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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypotonicity is not a feature of neonatal opioid withdrawal syndrome. These newborns often display hypertonicity or an increased muscle tone due to overactive autonomic responses.
Choice B rationale
Moderate tremors result from central nervous system irritability during withdrawal. Elevated norepinephrine levels lead to excessive stimulation, causing tremors and jitteriness.
Choice C rationale
Axillary temperature of 36.1°C (96.9°F) reflects hypothermia, which is uncommon in opioid withdrawal. Thermoregulation issues typically present as fevers or temperature instability.
Choice D rationale
Neonatal opioid withdrawal increases arousal and irritability, leading to difficulty sleeping. Excessive sleeping is not characteristic of withdrawal and suggests an alternative cause.
Correct Answer is C
Explanation
Choice A rationale
Postpartum depression involves persistent sadness and impaired functioning, typically lasting longer than two weeks. This client’s symptoms suggest a more transient condition.
Choice B rationale
The taking-in phase refers to the period immediately postpartum when the mother focuses on her own needs, not emotional instability as described.
Choice C rationale
Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
Choice D rationale
The taking-hold phase involves active learning about infant care and maternal adjustment, not the emotional lability described in this scenario.
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