A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

dark red vaginal bleeding

absence of pain

insidious onset

absent fetal heart tones

Answer and Explanation

Correct Answer : A,D

A. Dark red vaginal bleeding is often seen in placental abruption. The blood from an abruption is typically dark red (indicating that it is older blood) and may be mixed with amniotic fluid, making it more challenging to assess. However, the bleeding can sometimes be concealed, especially in complete abruption or retroplacental hemorrhage, where blood accumulates behind the placenta.

B. Absence of pain is incorrect. In fact, placental abruption is typically associated with abdominal pain, which can be severe and often comes on suddenly. Pain occurs due to the detachment of the placenta from the uterine wall and subsequent irritation or bleeding into the uterine cavity.

C. Insidious onset is incorrect. Placental abruption usually has a sudden or acute onset of symptoms, such as vaginal bleeding and abdominal pain. An insidious onset would be more suggestive of other conditions, such as placenta previa.

D. Absent fetal heart tones is a critical finding. Placental abruption can cause fetal distress or fetal death, especially if the abruption is severe. Absent fetal heart tones are a sign of fetal compromise or death resulting from the disruption of placental blood flow.

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Correct Answer is C

Explanation

A. Ferning is a test to detect ferning patterns in amniotic fluid under a microscope. A positive result indicates the presence of amniotic fluid but does not suggest infection.

B. Yellow-green fluid may suggest meconium-stained amniotic fluid, which is often associated with fetal distress, but it does not directly indicate infection. However, it can increase the risk of infection if the meconium is aspirated by the baby.

C. Foul odor is a key sign that infection may be present, particularly in the case of chorioamnionitis, an infection of the fetal membranes. A foul odor in the amniotic fluid suggests the presence of bacteria and should raise concern for infection, requiring prompt intervention.

D. Blue color on Nitrazine testing indicates that the amniotic fluid is alkaline, which is expected and normal, as amniotic fluid typically has a pH of 7-7.5. This test is used to confirm the rupture of membranes, not infection.

A. 8.4 mEq/L B. 6.1 mEq/L C. 10.8 mEq/L D. 3.3 mEq/L

Correct Answer is B

Explanation

A. 8.4 mEq/L is above the therapeutic range and may indicate magnesium toxicity. Levels greater than 7.5–8 mEq/L can lead to loss of deep tendon reflexes, and higher levels can cause respiratory depression and cardiac arrest.
B. 6.1 mEq/L falls within the therapeutic range for magnesium sulfate when used to treat severe preeclampsia, which is generally 4.8–8.4 mEq/L (or 4–7 mEq/L depending on the source and unit of measurement). This level is considered safe and effective for preventing seizures.
C. 10.8 mEq/L is too high and indicates magnesium toxicity, placing the patient at risk for serious complications like respiratory or cardiac arrest.
D. 3.3 mEq/L is below the therapeutic range, suggesting that the dose may be inadequate to prevent eclamptic seizures in a woman with severe preeclampsia.

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A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

Correct Answer is C

Explanation

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?

Correct Answer is B

Explanation

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