A nurse is caring for a female client who is at 30 weeks of gestation in the labor and delivery unit.
Vaginal bleeding
Uterine contractions
Cervical dilation
Abdominal tenderness
Client report of low back pain
The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B,C"}}
Vaginal bleeding
Bleeding occurs in placenta previa due to partial or total implantation of the placenta over the cervical os, leading to painless bright red bleeding from disrupted placental vessels. It also occurs in preterm labor when cervical effacement and dilation disrupt small cervical vessels, producing light bleeding or spotting. In abruptio placenta, bleeding is dark red and may be concealed or apparent, resulting from premature placental detachment and rupture of maternal vessels in the decidua basalis.
Uterine contractions
Regular uterine contractions every 2 to 3 minutes with cervical change are diagnostic of preterm labor, resulting from premature activation of uterine oxytocin receptors and prostaglandin release before 37 weeks. In abruptio placenta, contractions are often strong and sustained (hypertonic uterus) due to myometrial irritability from bleeding into the decidual layer. Placenta previa, however, typically presents with painless bleeding and a soft, relaxed uterus without contractions because the uterine muscle tone remains unaffected.
Cervical dilation
Cervical dilation indicates preterm labor, as biochemical changes in the cervix from increased prostaglandin and relaxin activity cause collagen breakdown and effacement before term. This process reflects uterine activation sequence initiation leading to potential preterm birth. In placenta previa, the cervix may remain closed despite bleeding because bleeding originates from placental implantation, not cervical change. Abruptio placenta rarely involves dilation unless labor progresses secondarily after placental separation, thus cervical dilation is not a key feature.
Abdominal tenderness
Abdominal tenderness is characteristic of abruptio placenta, caused by bleeding between the uterine wall and placenta leading to myometrial irritability, uterine rigidity, and ischemic pain. The trapped blood increases intrauterine pressure, stimulating pain receptors in the myometrium and stretching the uterine serosa. Placenta previa presents with a soft, nontender abdomen because bleeding is external and not associated with uterine muscle involvement. Preterm labor generally causes back discomfort or cramping, not localized abdominal tenderness.
Client report of low back pain
Low back pain is prominent in preterm labor, resulting from referred pain due to rhythmic uterine contractions transmitted through the lumbosacral plexus and pelvic nerves. It reflects early cervical change and uterine irritability. In abruptio placenta, the back pain may occur secondary to uteroplacental separation and posterior placental bleeding irritating the parietal peritoneum. Placenta previa typically lacks pain or back discomfort since bleeding occurs without uterine or peritoneal irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
True labor contractions persist and often intensify with activity, such as walking, because physical exertion promotes the release of oxytocin. In contrast, Braxton Hicks or false labor contractions typically diminish or cease with ambulation. Therefore, contractions persisting with walking indicate the cervical changes characteristic of progression into the active phase of labor.
Choice B rationale
Urinary frequency is a common discomfort throughout the third trimester of pregnancy due to the pressure of the enlarged uterus on the bladder. While present, it is not a specific indicator of the progression of labor from the latent to the active phase, which is characterized by measurable changes in cervical dilation and effacement.
Choice C rationale
Increased blood-tinged vaginal mucus, known as "bloody show," results from the cervical capillaries breaking as the cervix effaces and dilates. While this indicates cervical change, the most definitive sign of labor progression is a change in the frequency, duration, and intensity of contractions coupled with measurable descent or cervical dilation increase.
Choice D rationale
The station is the relationship of the presenting part to the ischial spines (zero station). The client's initial station was -1 cm. A change to -3 cm station indicates the fetus has moved up and away from the ischial spines, which signifies regression, or higher negative numbers, in the engagement, not the desired progression into the maternal pelvis.
Correct Answer is B
Explanation
Choice A rationale
Erb-Duchenne palsy, a form of brachial plexus injury (C5-C6), primarily affects the nerves controlling the shoulder and upper arm muscles. It generally does not affect cranial nerves (such as IX and X, which control swallowing) or the muscles of the mouth, thus typically preserving the ability to suck and swallow.
Choice B rationale
The Moro (startle) reflex involves symmetrical extension and abduction of the arms followed by adduction and flexion. An injury to the brachial plexus on one side impairs the motor function of that arm, resulting in the characteristic absence of the reflex in the affected extremity, which is a key diagnostic finding.
Choice C rationale
The Babinski reflex is a normal neurological finding in infants up to about 2 years old, reflecting immature corticospinal tracts. It is a foot reflex and is unrelated to a brachial plexus injury in the neck and shoulder area; thus, its presence is not a specific finding for Erb-Duchenne palsy.
Choice D rationale
Cleft palate is a congenital craniofacial malformation resulting from incomplete fusion of the palatine shelves during fetal development. It is a structural anomaly of the mouth and is not a finding or complication associated with Erb-Duchenne palsy, which is a neuromuscular injury sustained, most commonly, during birth.
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