A nurse is caring for a client who is pregnant and has suspected placenta previa. Which of the following should the nurse monitor the client for?
Large amount of bright red vaginal bleeding
Severe pain with no bleeding
High-grade fever
Sudden sharp pain in the lower abdomen
The Correct Answer is A
Choice A rationale:
Large amount of bright red vaginal bleeding is the cardinal sign of placenta previa. This is because the placenta is abnormally positioned low in the uterus, covering the cervix partially or completely. When the cervix starts to dilate in preparation for labor, it can detach from the uterine wall, leading to significant bleeding. The blood is typically bright red, indicating fresh bleeding, and can be painless.
Severity of bleeding: The amount of bleeding can vary from spotting to massive hemorrhage, and it may start suddenly or gradually. Even a small amount of bleeding can be a sign of placenta previa and should not be ignored.
Risks of hemorrhage: Prompt recognition and management of bleeding are crucial to prevent potentially life-threatening hemorrhage for both the mother and the fetus.
Choice B rationale:
Severe pain with no bleeding is not a typical presentation of placenta previa. While some women with placenta previa may experience mild abdominal pain or cramping, severe pain without bleeding is more suggestive of placental abruption, a condition where the placenta prematurely separates from the uterine wall.
Choice C rationale:
High-grade fever is not a direct symptom of placenta previa. However, if a woman with placenta previa develops a fever, it could indicate an infection, which can further complicate the condition and require immediate medical attention.
Choice D rationale:
Sudden sharp pain in the lower abdomen can be a sign of placental abruption but is not characteristic of placenta previa.
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Correct Answer is B
Explanation
Choice A rationale:
A heart rate of 60/min is a sign of bradycardia, which can be a side effect of magnesium sulfate toxicity. Magnesium sulfate slows down neuromuscular transmission, which can lead to a decrease in heart rate. If the heart rate drops too low, it can compromise blood flow to vital organs, including the brain and heart. Therefore, a heart rate of 60/min is not a safe finding that would indicate the nurse should continue the infusion.
Choice C rationale:
A urine output of 50 ml in 4 hours is indicative of oliguria, which is a decreased urine output. Oliguria can be a sign of magnesium sulfate toxicity, as magnesium is primarily excreted through the kidneys. If the kidneys are not functioning properly, magnesium can build up in the body and lead to toxic levels. Therefore, a urine output of 50 ml in 4 hours is not a safe finding that would indicate the nurse should continue the infusion.
Choice D rationale:
Diminished deep-tendon reflexes are another sign of magnesium sulfate toxicity. Magnesium sulfate suppresses the nervous system, which can lead to decreased reflexes. If the reflexes are too diminished, it can indicate that the magnesium level in the body is too high. Therefore, diminished deep-tendon reflexes are not a safe finding that would indicate the nurse should continue the infusion.
Choice B rationale:
A respiratory rate of 16/min is within the normal range for an adult. It does not indicate any respiratory depression, which can be a side effect of magnesium sulfate toxicity. Therefore, a respiratory rate of 16/min is a safe finding that would indicate the nurse can continue the infusion.
Correct Answer is A
Explanation
Choice A rationale:
Large amount of bright red vaginal bleeding is the cardinal sign of placenta previa. This is because the placenta is abnormally positioned low in the uterus, covering the cervix partially or completely. When the cervix starts to dilate in preparation for labor, it can detach from the uterine wall, leading to significant bleeding. The blood is typically bright red, indicating fresh bleeding, and can be painless.
Severity of bleeding: The amount of bleeding can vary from spotting to massive hemorrhage, and it may start suddenly or gradually. Even a small amount of bleeding can be a sign of placenta previa and should not be ignored.
Risks of hemorrhage: Prompt recognition and management of bleeding are crucial to prevent potentially life-threatening hemorrhage for both the mother and the fetus.
Choice B rationale:
Severe pain with no bleeding is not a typical presentation of placenta previa. While some women with placenta previa may experience mild abdominal pain or cramping, severe pain without bleeding is more suggestive of placental abruption, a condition where the placenta prematurely separates from the uterine wall.
Choice C rationale:
High-grade fever is not a direct symptom of placenta previa. However, if a woman with placenta previa develops a fever, it could indicate an infection, which can further complicate the condition and require immediate medical attention.
Choice D rationale:
Sudden sharp pain in the lower abdomen can be a sign of placental abruption but is not characteristic of placenta previa.
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