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 D

Explanation

A. Increase in dietary protein is not the appropriate response based on the results of the glucose challenge test. Protein intake may be adjusted for other health reasons but is not typically a first-line intervention after an abnormal GCT result.

B. Schedule a repeat Glucose Challenge Test (GCT) is not typically the next step. If the initial GCT is abnormal (usually a result >130-140 mg/dL), a repeat test is not recommended. Instead, a 3-hour glucose tolerance test (GTT) is used to confirm or rule out gestational diabetes.

C. Restrict carbohydrate intake might be part of managing gestational diabetes if it is diagnosed, but it is not the immediate next step after an abnormal GCT result. The focus is on further testing with a 3-hour GTT to confirm gestational diabetes.

D. Return for a fasting 3-hour glucose tolerance test (GTT) is the correct next step. If a client’s GCT result is ≥130-140 mg/dL, a 3-hour GTT is typically scheduled. The 3-hour GTT is a more comprehensive test that involves fasting and measuring blood glucose levels after consuming a larger dose of glucose (100 g). This test is used to diagnose gestational diabetes.

A. saturated with clots and mucus B. about the same as after a vaginal birth. C. greater than after a vaginal birth. D. less than after a vaginal birth.

Correct Answer is D

Explanation

A. Saturated with clots and mucus is not typical of lochia in either vaginal or cesarean births unless there is excessive bleeding or other complications. While clots are normal in the early days postpartum, lochia should not be saturated with them in a healthy postpartum recovery.

B. About the same as after a vaginal birth is incorrect because lochia after a cesarean birth tends to be less due to the surgical procedure. The uterus does not expel as much tissue or blood from the vaginal canal as in a vaginal delivery.

C. Greater than after a vaginal birth is incorrect. Although there is a possibility of more bleeding initially from the incision site in a cesarean birth, the amount of lochia is typically less due to the nature of the surgical delivery.

D. Less than after a vaginal birth is correct. After a cesarean birth, the lochia typically is less because the surgical delivery method does not involve the same physical exertion or vaginal tearing that occurs with a vaginal birth. Additionally, the surgical incision prevents some of the natural expulsion of blood and tissue.

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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 26-week pregnant client has a Glucose challenge test (GCT) with 50 g of glucola, her results are 150mg/dl. What would be expected next step when caring for this client?

Correct Answer is D

Explanation

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

Correct Answer is D

Explanation

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