A nurse is caring for a client who is in labor and experiences abruptio placenta.
Which of the following findings should the nurse expect?
Hypertension.
Uterine tenderness.
Fetal tachycardia.
Leukorrhea.
The Correct Answer is B
Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae.
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.
The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:
b. Uterine tenderness.
Here's why:
- Hypertension (a): While preeclampsia can increase the risk of abruptio placenta, it's not always present, and hypertension wouldn't be the immediate expected finding during the abruption event itself.
- Fetal tachycardia (c): This can occur in early stages of abruption to compensate for decreased oxygen supply, but as the abruption becomes more severe, fetal bradycardia is more likely due to oxygen deprivation.
- Leukorrhea (d): This is a white vaginal discharge and has no connection to abruptio placenta.
Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:
- Vaginal bleeding (bright red or dark)
- Abdominal pain or cramping
- Sudden, ongoing uterine tightening or irritability
- Fetal distress (decreased fetal heart rate movements)
Therefore, option b is the most expected finding in this scenario.
Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.
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