Nokea
Which data support a diagnosis of abruptio placenta in a pregnant woman?
- A. Uterine rigidity and abdominal pain
- B. Painless bleeding with soft abdomen
- C. Premature rupture of membranes and uterine contractions
- D. Bright red blood loss and elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Uterine rigidity and abdominal pain. Abruptio placenta is characterized by premature separation of the placenta from the uterine wall. Uterine rigidity indicates the presence of a hypertonic uterus due to the sudden hemorrhage, leading to severe abdominal pain. This is a classic presentation of abruptio placenta. Choices B, C, and D do not align with the typical clinical features of abruptio placenta. Painless bleeding with a soft abdomen does not suggest an acute and painful condition like abruptio placenta. Premature rupture of membranes and uterine contractions are more indicative of preterm labor or premature rupture of membranes, not abruptio placenta. Bright red blood loss and elevated blood pressure are more characteristic of placenta previa or preeclampsia, respectively, not abruptio placenta.
You may also like to solve these questions
At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?
- A. The skin is wrinkled and fat is being formed.
- B. The eyelids are open and he can see.
- C. The kidneys are making urine.
- D. The heart is being developed.
Correct Answer: C
Rationale: Correct Answer: C - The kidneys are making urine.
Rationale: At 10 weeks gestation, the kidneys of the developing fetus begin to form and function, producing urine. This is a crucial milestone in fetal development as it indicates proper organ formation and functionality. The formation of urine by the kidneys plays a significant role in maintaining the amniotic fluid levels and supporting overall fetal growth and development.
Summary of other choices:
A: The skin is wrinkled and fat is being formed - Incorrect. Skin and fat formation typically occur later in gestation, not at 10 weeks.
B: The eyelids are open and he can see - Incorrect. Eye development is still in progress at 10 weeks, and the eyelids remain fused.
D: The heart is being developed - Incorrect. While the heart is forming at 10 weeks, it is not the most accurate response to the question posed by the primigravida.
During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of 'pain related to perineal sutures.' Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?
- A. Instruct the client to use petroleum jelly on the episiotomy after voiding.
- B. Encourage the client to practice Kegel exercises.
- C. Advise the client to take a warm sitz bath every four hours.
- D. Apply ice packs to the perineum.
Correct Answer: D
Rationale: The correct answer is D: Apply ice packs to the perineum. Ice packs help reduce swelling and provide numbing relief, which can help alleviate pain in the immediate postpartum period. Applying ice packs during the first 24 hours can also promote vasoconstriction, reducing the risk of bleeding and infection.
Incorrect options:
A: Using petroleum jelly can increase the risk of infection and hinder wound healing.
B: Kegel exercises are beneficial for pelvic floor strengthening but are not the most appropriate intervention for immediate pain relief.
C: While sitz baths can be soothing, they may not be suitable within the first 24 hours post-episiotomy as they can increase blood flow and potentially worsen swelling.
Overall, ice packs are the most effective and appropriate intervention for pain management in the immediate postpartum period.
A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?
- A. Weak, ineffective suck, and scalp edema
- B. Molding of the head and jitteriness
- C. Shrill, high pitched cry, and tachypnea
- D. Hypothermia and hemoglobin of 12.5 g/dL
Correct Answer: A
Rationale: The correct answer is A: Weak, ineffective suck, and scalp edema. Forceps delivery can cause head trauma leading to facial nerve injury, resulting in weak suck and scalp edema. Molding of the head (choice B) is a normal finding after vaginal birth. Jitteriness (choice B) may be due to immaturity rather than a complication of forceps delivery. A shrill, high-pitched cry and tachypnea (choice C) are more indicative of respiratory distress, not specific to forceps delivery. Hypothermia and hemoglobin of 12.5 g/dL (choice D) are not directly related to complications of forceps delivery.
A client comes to the clinic to confirm that she is pregnant. Her last menstrual period was January 31st. According to Naegele's rule, when should the client expect to deliver?
- A. November 31
- B. December 7
- C. November 7
- D. December 24
Correct Answer: C
Rationale: The correct answer is C: November 7. Naegele's rule estimates the due date by adding 7 days to the first day of the last menstrual period (LMP), subtracting 3 months, and adding 1 year. LMP is January 31, so adding 7 days gives February 7. Subtracting 3 months gives November 7. Other choices are incorrect as there is no November 31, December 7 is too far ahead, and December 24 is also too far from the estimated due date.
A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?
- A. Contractions that are irregular and decrease in intensity when walking
- B. Abdominal pain that starts at the fundus and progresses to the lower back
- C. Increased pressure on the bladder and urinary frequency
- D. Expulsion of pink-tinged mucous and contractions that start in the lower back
Correct Answer: D
Rationale: The correct answer is D because the expulsion of pink-tinged mucous (bloody show) and contractions starting in the lower back are indicative of true labor. This is due to the release of the mucus plug and the initiation of true uterine contractions. Contractions that start in the lower back and progress to the front are characteristic of true labor.
Choice A is incorrect because contractions that are irregular and decrease in intensity with walking are characteristic of false labor (Braxton Hicks contractions).
Choice B is incorrect as abdominal pain starting at the fundus and progressing to the lower back is not a specific sign of true labor.
Choice C is incorrect as increased pressure on the bladder and urinary frequency are common throughout pregnancy and not specific to the onset of true labor.
In summary, the correct answer D provides specific and characteristic signs of true labor, while the other choices do not accurately reflect the onset of true labor.