A nurse is caring for a client in labor who is experiencing abruptio placentae. What findings should the nurse expect?

Leukorrhea

Hypertension

Uterine tenderness

Fetal tachycardia

Answer and Explanation

The Correct Answer is C

Choice A rationale
Leukorrhea, or vaginal discharge, is a common occurrence in pregnancy due to hormonal changes, but it is not a specific sign of abruptio placentae.
Choice B rationale

Hypertension can be a risk factor for abruptio placentae, but it is not a direct sign of the condition.
Choice C rationale
Uterine tenderness is a common symptom of abruptio placentae. This condition, which involves the premature separation of the placenta from the uterus, can cause the uterus to become irritable and sensitive to touch.
Choice D rationale
Fetal tachycardia can be a sign of fetal distress, which could be a result of various complications in pregnancy, including abruptio placentae. However, it is not a specific sign of abruptio placentae.

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Correct Answer is D

Explanation

Choice A rationale
Administering a 500 mL lactated Ringer’s IV bolus is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice B rationale
Documenting urinary output is important, but it is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice C rationale

Replacing the surgical dressing is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice D rationale
Notifying the healthcare provider is the correct action. Persistent vaginal bleeding after a cesarean birth could indicate a postpartum hemorrhage, which is a medical emergency

A. Check the newborn’s identification using the crib card. B. Require visitors to wear an identification band. C. Replace the infant’s identification band after his name has been recorded. D. Obtain an imprint of the infant’s feet prior to taking him to the nursery.

Correct Answer is D

Explanation

Choice A rationale
Checking the newborn’s identification using the crib card is not the most reliable method. The crib card could be misplaced or switched accidentally.
Choice B rationale
Requiring visitors to wear an identification band does not directly ensure the proper identification of newborns. While it can enhance the security of the unit, it does not link the newborn to their correct parents.
Choice C rationale
Replacing the infant’s identification band after his name has been recorded is not the most effective method. The identification band should be placed on the newborn immediately after birth to prevent mix-ups.

Choice D rationale
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is the correct answer. This method is a reliable way to identify newborns. The footprints, along with the mother’s fingerprints, are often taken within the first hour after birth. This can be used for identification throughout the hospital stay.

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A nurse is caring for a client in labor who is experiencing abruptio placentae. What findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse manager is revising a policy in the maternal unit to ensure proper identification of newborns. What should the nurse include in the policy?

Correct Answer is D

Explanation

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