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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.

A. Insert an indwelling urinary catheter. B. Evaluate deep tendon reflexes. C. Determine motor function of lower extremities. D. Administer meperidine hydrochloride IV.

Correct Answer is C

Explanation

A. Catheterization may be necessary if the client cannot void but is not the first step before ambulation.
B. Evaluating deep tendon reflexes is more relevant for clients receiving magnesium sulfate, not primarily for epidural assessment.
C. Assessing motor function of the lower extremities ensures the client has adequate strength and sensation to safely ambulate after an epidural.
D. Administering meperidine is for pain management and does not relate to safety before ambulation.

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A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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