A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?
Soft abdomen
Heart rate 120/min
A fetal heart of 150/min with moderate variability
Painless vaginal bleeding
The Correct Answer is B
A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Double-flush the toilet with the lid closed – Methotrexate is a hazardous medication that is excreted in body fluids. The client should be instructed to double-flush the toilet with the lid closed for 48 hours to prevent exposure to others.
B. Avoid sexual intercourse until the β-hCG level is undetectable – This reduces the risk of rupture or bleeding and prevents confusion with another pregnancy. Abstinence is recommended until the ectopic pregnancy is fully resolved.
C. Take aspirin as needed for pain – Aspirin is contraindicated as it increases the risk of bleeding and can interact adversely with methotrexate, enhancing toxicity.
D. Avoid exposure to the sun – Methotrexate can cause photosensitivity, and the client should use sunscreen and protective clothing when outdoors.
E. Expect a transient fever and chills – Fever and chills are not expected side effects of methotrexate. These symptoms may indicate infection or rupture and should be reported immediately.
Correct Answer is D
Explanation
A. Fentanyl citrate is a potent opioid, typically reserved for severe pain and usually administered in controlled settings, not first-line postpartum analgesia.
B. Meperidine is less commonly used due to side effects and safety concerns.
C. Aspirin is generally avoided postpartum due to bleeding risks.
D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used postpartum for pain relief and inflammation control with a safer profile for breastfeeding mothers.
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