Author Question: A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment ... (Read 129 times)

beccaep · **on:** Jun 27, 2018

A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment of which of the following? (Select all that apply.)

A) Dark red vaginal bleeding
B) Insidious onset
C) Absence of pain
D) Rigid uterus
E) Absent fetal heart tones

Question 2

The nurse assists while a pregnant patient has an amniotomy. Which action should the nurse take immediately at the conclusion of the procedure?

A) Assess fetal heart rate.
B) Adjust intravenous fluid infusion rate.
C) Assist the patient to wash the perineum.
D) Provide clean gown and linens for the patient.

frre432 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

A, D, E
Feedback:
Assessment findings associated with abruption placenta include a sudden onset, with concealed or visible bleeding, dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones.

Answer to Question 2

A
Feedback:
Amniotomy is the artificial rupturing of membranes during labor. A disadvantage of amniotomy is it puts a fetus momentarily at risk for cord prolapse if a loop of cord escapes into the vagina with the fluid. Always measure the fetal heart rate immediately after the rupture of membranes to determine this did not occur. The nurse can assist the patient with washing and applying a clean gown and linens after the fetal heart rate is assessed. The patient may or may not have an intravenous infusion at this time.