A nurse is assessing a client who has placenta previa and is receiving fetal monitoring.
Which of the following clinical findings should the nurse expect?
Variable decelerations.
Painless vaginal bleeding.
Rigid abdomen.
Uterine tachysystole.
The Correct Answer is B
Choice A rationale
Variable decelerations are typically caused by umbilical cord compression, which can occur in various obstetric scenarios but are not a specific expected finding for placenta previa. In placenta previa, the primary issue is placental implantation over or near the cervical os, leading to distinct clinical manifestations.
Choice B rationale
Painless vaginal bleeding is the hallmark clinical finding of placenta previa. This occurs because the placenta is implanted in the lower uterine segment, potentially covering the internal cervical os. As the cervix effaces or dilates, the placenta separates from the uterine wall, leading to bleeding without the associated pain of uterine contractions.
Choice C rationale
A rigid abdomen is a classic sign of abruptio placentae, where the placenta prematurely detaches from the uterine wall. This causes internal bleeding and uterine spasm, leading to a board-like, tender abdomen, which is distinct from the typical presentation of placenta previa.
Choice D rationale
Uterine tachysystole, characterized by excessive uterine contractions, is a common finding in conditions like abruptio placentae or during labor induction. It is not typically associated with placenta previa, where the primary concern is the placental position and the risk of hemorrhage rather than abnormal contraction patterns.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
During labor, the body experiences physiological stress and an inflammatory response, leading to an increase in white blood cell count. This leukocytosis is a normal physiological adaptation to the physical demands of labor and tissue remodeling, not a decrease. A normal WBC count is typically 4,500-11,000 cells/µL, and it can rise to 15,000-20,000 cells/µL during labor.
Choice B rationale
Labor is an energy-intensive process that increases metabolic demands, leading to greater glucose utilization by uterine muscles and other tissues. This increased consumption of glucose can result in a decrease in blood glucose levels as the body expends energy to fuel contractions and other physiological activities. A normal blood glucose range is 70-100 mg/dL.
Choice C rationale
The pain and physiological stress of labor typically cause an increase in respiratory rate, not a decrease. The body tries to compensate for the increased metabolic demand and oxygen consumption by increasing ventilation. A decrease in respiratory rate would be an unexpected and potentially concerning finding, indicating respiratory depression. A normal respiratory rate is 12-20 breaths per minute.
Choice D rationale
While slight fluctuations can occur, a significant decrease in temperature is not an expected finding during labor. The metabolic activity and physical exertion of labor can slightly elevate body temperature, or it may remain stable. A decrease in temperature could indicate hypothermia or a systemic issue, which is not a normal physiological response to labor. A normal temperature is 36.5-37.5°C.
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit can inadvertently convey a message of displacement to the older sibling. This is due to the older child's developing cognitive understanding of parental attention and resources. The immediate focus on the new baby might lead to feelings of jealousy or being replaced, potentially hindering positive sibling bonding.
Choice B rationale
Spending individual time with the older sibling reinforces their continued importance within the family structure. This dedicated attention helps mitigate feelings of neglect or competition, promoting a sense of security and love. It allows the older child to process the family change and feel valued, fostering a more positive acceptance of the newborn.
Choice C rationale
While involving the older sibling in purchasing a gift can be a positive step, it might not fully address the emotional and psychological adjustments required. The act itself is a superficial gesture and doesn't substitute for direct parental reassurance and quality time, which are crucial for true sibling acceptance and emotional well-being.
Choice D rationale
Postponing the introduction can create anxiety and resentment in the older sibling. Children often perceive delays as exclusion or secrecy, which can foster negative feelings towards the new baby. An early, supervised introduction, with parental guidance, allows for a more natural and integrated family adjustment.
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