The charge nurse is reviewing the physician's notes describing ...

[Redwolflake15]

The charge nurse is reviewing the physician's notes describing the diagnosis of abruptio placentae in a patient who is currently admitted. The physician describes the woman's placental separation as being central.
 
  Based upon this description, what can the nurse infer about the woman's condition?
  1. Blood is trapped between the woman's placenta and the uterine wall, and she may have concealed bleeding.
  2. The total separation of the woman's placenta from the uterine wall will lead to massive hemorrhage.
  3. Blood is passing between the fetal membranes and the woman's uterine wall, which will lead to some vaginal bleeding.
  4. The slight separation of the woman's placenta from the uterine wall will not produce any bleeding.

Question 2

The home health nurse is admitting a patient at 18 weeks who is pregnant with twins. Which nursing action is most important?
 
  1. Teach the patient about foods that are good sources of protein.
  2. Assess the patient's blood pressure in her upper right arm.
  3. Determine whether the pregnancy is a result of infertility treatment.
  4. Collect a cervicovaginal fetal fibronectin (fFN) specimen.

[onowka]

Answer to Question 1

Correct Answer: 1
Rationale 1: With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding.
Rationale 2: With marginal placental separation, blood passes between the fetal membranes and the uterine wall and escapes vaginally. With central placental separation, blood is trapped between the placenta and uterine wall, and bleeding is concealed. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.
Rationale 3: With marginal placental separation, blood passes between the fetal membranes and the uterine wall and escapes vaginally. With central placental separation, blood is trapped between the placenta and uterine wall, and bleeding is concealed. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.
Rationale 4: With marginal placental separation, blood passes between the fetal membranes and the uterine wall and escapes vaginally. With central placental separation, blood is trapped between the placenta and uterine wall, and bleeding is concealed. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.

Answer to Question 2

Correct Answer: 1
Rationale 1: A diet containing 3,500 kcal (minimum) and 175 g protein is recommended for a woman with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth.
Rationale 2: Pre-eclampsia is not diagnosed until the 20th week of gestation. This patient is only at 18 weeks. Further, blood pressure can be assessed in either arm when the patient is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm.
Rationale 3: Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those resulting from spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.
Rationale 4: Preterm labor is not diagnosed until 20 weeks. This patient is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time.