A nurse in a provider's office is caring for a client who is at 30 weeks of gestation
For each assessment finding below, click to specify if the finding is consistent with placenta previa, preterm labor, or abruptio placenta Each finding may be consistent with more than one condition or none at all
Cervical dilation
Uterine contractions
Vaginal bleeding
Client reports low back pain
Abdominal tenderness
The Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B,C"},"E":{"answers":"C"}}
|
Assessment findings |
Placenta previa |
Preterm labor |
Abruption placenta |
|
Cervical dilation |
|
✓ |
✓ |
|
Uterine contractions |
|
✓ |
✓ |
|
Vaginal bleeding |
✓ |
|
✓ |
|
Client reports low back pain |
|
✓ |
✓ |
|
Abdominal tenderness |
|
|
✓ |
Rationale
- Cervical dilation: Present in preterm labor and abruption due to uterine activity and cervical changes; not typical in placenta previa unless labor begins.
- Uterine contractions: Present in preterm labor and abruption; placenta previa usually painless without contractions.
- Vaginal bleeding: In placenta previa, bleeding is usually painless; in abruption, bleeding is often accompanied by pain; preterm labor usually does not involve bleeding.
- Low back pain: Common in preterm labor and abruption due to contractions or placental separation; not typical in placenta previa.
- Abdominal tenderness: Present in abruption because of bleeding behind the placenta causing uterine irritation; absent in placenta previa and preterm labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.
Correct Answer is B
Explanation
A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.
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