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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While weight gain is crucial during pregnancy, a blanket statement of 2 pounds per week is not universally appropriate. The recommended rate of weight gain varies based on the client's pre-pregnancy BMI and the trimester. Excessive or insufficient weight gain can lead to adverse maternal and fetal outcomes, including macrosomia or intrauterine growth restriction, highlighting the need for individualized nutritional guidance rather than a fixed weekly gain.
Choice B rationale
Dieting during pregnancy, especially restrictive calorie intake, can significantly compromise the nutrient supply to the developing fetus. Fetal growth and organogenesis are highly dependent on adequate maternal nutritional stores and daily nutrient intake. Inadequate nutrition can lead to low birth weight, premature birth, and long-term health complications for the infant, emphasizing the dangers of unguided dietary restrictions.
Choice C rationale
A dietitian possesses specialized knowledge in medical nutrition therapy and can provide personalized recommendations based on the adolescent's specific nutritional needs, gestational age, and pre-pregnancy weight. This collaborative approach ensures optimal maternal and fetal health by addressing any deficiencies, managing appropriate weight gain, and promoting healthy eating habits throughout the pregnancy, which is crucial for adolescent development and pregnancy outcomes.
Choice D rationale
The caloric needs of a pregnant adolescent increase in the second and third trimesters, but a fixed additional 700 calories per day may not be accurate for all individuals. Caloric requirements are dynamic and depend on pre-pregnancy weight, activity level, and the specific stage of gestation. Overestimation can lead to excessive weight gain, while underestimation can result in inadequate fetal growth, necessitating individualized assessment.
Correct Answer is A
Explanation
Choice A rationale
Magnesium sulfate toxicity causes central nervous system depression, including respiratory depression. A respiratory rate of 12 breaths/min indicates that the respiratory depression has resolved, suggesting the calcium gluconate, a magnesium antagonist, has effectively reversed the neuromuscular blockade caused by magnesium. A normal respiratory rate is 12-20 breaths/min.
Choice B rationale
Absent deep tendon reflexes (DTRs) are a sign of magnesium sulfate toxicity due to its depressant effect on neuromuscular transmission. If calcium gluconate were effective, DTRs would return to normal or become less diminished, indicating resolution of magnesium's inhibitory effects on the nervous system.
Choice C rationale
Slurred speech is a neurological symptom associated with magnesium sulfate toxicity, reflecting central nervous system depression. If calcium gluconate were effective in reversing the toxicity, slurred speech would improve or resolve as the central nervous system depression diminishes.
Choice D rationale
Urine output of 22 mL/hr indicates oliguria, which can be a sign of worsening preeclampsia or kidney dysfunction, and is not an indicator of effective calcium gluconate administration for magnesium toxicity. Adequate urine output (typically >30 mL/hr) is essential for magnesium excretion and overall renal function.
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