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

A WBC count of 35,000/mm² exceeds the normal newborn range of 9,000 to 30,000/mm². This elevated count typically indicates infection rather than cephalohematoma-related complications.

Choice B rationale

A glucose level of 35 mg/dL falls below the normal range of greater than 40 to 45 mg/dL. Hypoglycemia is not directly associated with cephalohematoma but may occur in stressed or premature neonates.

Choice C rationale

A bilirubin level of 14.0 mg/dL is above the newborn normal range of 1.0 to 12.0 mg/dL. This indicates hyperbilirubinemia, commonly seen due to red blood cell breakdown in cephalohematoma.

Choice D rationale

A platelet count of 350,000/mm³ is above the normal newborn range of 150,000 to 300,000/mm³. Elevated levels are less likely due to cephalohematoma and often suggest other hematologic conditions.

A. "You will receive a medication through an IV for this test.”. B. "You should expect the test to take about 30 minutes.”. C. "You should not eat or drink for 4 hours prior to the test.”. D. "This test will help determine if your baby's lungs are mature.”.

Correct Answer is B

Explanation

Choice A rationale

Intravenous medications are not administered for a nonstress test, which evaluates fetal heart rate response to movement using external monitoring. No pharmacological intervention is needed.

Choice B rationale

Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.

Choice C rationale

There are no dietary restrictions for a nonstress test, as the procedure involves non-invasive external monitoring and does not affect digestion or metabolic processes.

Choice D rationale

A nonstress test does not assess fetal lung maturity but evaluates fetal heart rate accelerations in response to fetal movement to ensure fetal well-being.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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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?