A nurse is collecting data from a client who is at 35 weeks of gestation. The nurse should identify that which of the following findings indicates abruptio placentae?
Uterine atony
Polyhydramnios
Painless vaginal bleeding
Board-like abdomen
None
None
The Correct Answer is D
A. Uterine atony
Uterine atony refers to the lack of muscle tone in the uterus after delivery, leading to excessive bleeding. This is not typically associated with abruptio placentae, which involves the premature separation of the placenta from the uterine wall during pregnancy, typically presenting with different symptoms such as painful contractions and bleeding.
B. Polyhydramnios
Polyhydramnios refers to an excessive amount of amniotic fluid during pregnancy and is not a characteristic of abruptio placentae. Polyhydramnios can be associated with various conditions but is not directly linked to placental abruption.
C. Painless vaginal bleeding
Painless vaginal bleeding is more characteristic of placenta previa, a condition where the placenta is abnormally positioned over the cervix. Abruptio placentae, on the other hand, typically presents with painful vaginal bleeding due to the detachment of the placenta from the uterine wall.
D. Board-like abdomen
A board-like abdomen is a classic sign of abruptio placentae, indicating significant uterine muscle contraction and possible internal hemorrhage. The sudden separation of the placenta can cause blood to accumulate behind the placenta, leading to a rigid, "board-like" feeling of the abdomen, which is a hallmark symptom of this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased muscle tone is not typically associated with neonatal abstinence syndrome.
B. Exaggerated Moro reflex, which is a startle response that causes the baby to fling their arms and legs out and then curl them in, is a common signof neonatal abstinence
C. Consoling easily is not a characteristic feature of neonatal abstinence syndrome; these infants are often difficult to console.
D. A high pitched cry is a common symptom of neonatal abstinence syndrome. A weak cry is not anticipated.
Correct Answer is A
Explanation
A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.
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