The nurse prepares prescribed oxytocin, which is to be added to the client's IV fluid when the placenta has been delivered. The nurse determines the placenta has separated and is about to be delivered when which of the following happens?
Abdominal wall relaxes noticeably and the cord shortens
Uterus falls below the level of the symphysis pubis and becomes globular
Cord lengthens outside the vagina with a gush of blood
Client complains of the urge to push and you see the uterus shrink
The Correct Answer is C
A. Abdominal wall relaxes noticeably and the cord shortens
Cord shortening is not a sign of placental separation; it should lengthen.
B. Uterus falls below the level of the symphysis pubis and becomes globular
The uterus rises slightly and becomes globular, not falls.
C. Cord lengthens outside the vagina with a gush of blood
Classic signs of placental separation include a sudden gush of blood and visible cord lengthening.
D. Client complains of the urge to push and you see the uterus shrink
Urge to push may occur in labor but does not indicate placental separation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypoglycemia: Would not necessarily be position-related.
B. Vena cava syndrome: Compression of the inferior vena cava by the uterus reduces venous return, causing hypotension and dizziness.
C. A rise in BP due to position: BP actually drops in this position, not rises.
D. A cardiac arrhythmia: Could cause dizziness, but not typically position-dependent in pregnancy.
Correct Answer is D
Explanation
A. An enlarged uterus: Presumptive or probable sign; can occur in non-pregnancy conditions.
B. Quickening: Subjective, felt by mother; not definitive.
C. Positive pregnancy test: Probable sign, not definitive (false positives possible).
D. Fetal heart tones: A definitive (positive) sign of pregnancy.
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