A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain.

Which of the following findings is most consistent with abruptio placenta?

Low uterine tone with mild vaginal bleeding.

Rigid uterine tone with dark vaginal bleeding.

Soft uterine tone with painless vaginal bleeding.

Low uterine tone with absence of vaginal bleeding.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Low uterine tone with mild vaginal bleeding is more indicative of placenta previa rather than abruptio placenta. Placenta previa involves the placenta covering the cervix, leading to painless bleeding. Uterine tone remains soft as there is no detachment of the placenta from the uterine wall. Abruptio placenta, however, is characterized by uterine rigidity due to blood accumulation between the placenta and uterine wall.

Choice B rationale: Rigid uterine tone with dark vaginal bleeding is a hallmark of abruptio placenta. The rigidity arises from blood pooling behind the placenta, causing uterine muscle contraction. Dark vaginal bleeding occurs as the blood is often concealed and clotted before expulsion. This condition is a medical emergency due to the risk of maternal hemorrhage and fetal hypoxia. Prompt diagnosis and intervention are critical to prevent severe complications.

Choice C rationale: Soft uterine tone with painless vaginal bleeding is characteristic of placenta previa, not abruptio placenta. Placenta previa involves the placenta partially or completely covering the cervix, leading to painless bleeding as the placenta detaches from the lower uterine segment. The uterine tone remains soft because there is no significant blood accumulation or uterine muscle contraction, unlike in abruptio placenta.

Choice D rationale: Low uterine tone with absence of vaginal bleeding does not align with abruptio placenta. While concealed abruptio placenta can occur without visible bleeding, the uterine tone is typically rigid due to blood accumulation. Low uterine tone suggests a lack of uterine contraction or detachment, which is inconsistent with the pathophysiology of abruptio placenta. This finding may indicate other obstetric conditions rather than abruptio placenta.

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Correct Answer is C

Explanation

Choice A rationale

Gravida refers to total pregnancies, not live births, thus excluding the client's current pregnancy inaccurately lowers her gravida count from 4 to 3 in this documentation.

Choice B rationale

Para reflects live births, not pregnancies, thus inaccurately including her spontaneous abortion as a parity increases her para count from 2 to 3, which contradicts obstetric standards.

Choice C rationale

Gravida 4 reflects the client’s total pregnancies, including the current one and her abortion, while Para 2 accounts for her two full-term live births, accurately documenting her obstetrical history.

Choice D rationale

Para 3 includes the abortion, contradicting obstetric definitions that exclude non-viable pregnancies from parity, making this documentation scientifically incorrect in context. .

A. Administering prophylactic antibiotics to prevent infection. B. Assessing for signs of jaundice in the newborn. C. Monitoring the client's vital signs for stability. D. Educating the client on breastfeeding techniques.

Correct Answer is B

Explanation

Choice A rationale

Administering prophylactic antibiotics is essential when there is infection risk, but this intervention is not directly related to managing hemorrhage or neonatal nerve palsy.

Choice B rationale

Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.

Choice C rationale

Monitoring vital signs ensures maternal stability, though it does not directly address hemorrhage risk or neonatal complications like nerve palsy.

Choice D rationale

Educating the client on breastfeeding techniques provides essential support but does not focus on managing cephalohematoma-related neonatal conditions.

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A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain. Which of the following findings is most consistent with abruptio placenta?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is pregnant for the fourth time.The client delivered two full-term newborns and had one spontaneous abortion at 10 weeks of gestation.The nurse should document the client's obstetrical history as which of the following?

Correct Answer is C

Explanation

Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy.What additional care should the nurse consider?

Correct Answer is B

Explanation

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A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain.

Which of the following findings is most consistent with abruptio placenta?