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 B

Explanation

A. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

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

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

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?

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

An ultrasound is performed on a client at term who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on this finding, what would be the next action?

A nurse is teaching a postpartum client how to do muscle-clenching (Kegel) exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production?

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?