Question

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

Answer 1

Correct Answers:

Dark red vaginal bleeding
Rigid uterus
Absent fetal heart tones

Rationale :

Dark red vaginal bleeding 🩸

❄In placental abruption, the placenta prematurely separates from the uterine wall, often resulting in dark red vaginal bleeding.

❄The blood tends to be darker because it accumulates behind the placenta before being expelled.

❄Unlike placenta previa, which often presents with painless, bright red bleeding, abruption involves darker blood and is typically accompanied by pain.

❄The presence of this type of bleeding is a significant clinical indicator of concealed or visible hemorrhage, posing risks to both maternal and fetal health and requiring immediate evaluation and intervention.

Rigid uterus 🧱

🧱 A rigid or board-like uterus is a hallmark sign of placental abruption.

🧱The accumulation of blood within the uterine wall (concealed hemorrhage) leads to a constant state of uterine tone and tension.

🧱Unlike normal labor contractions that come and go, the uterus in abruption remains firm continuously, even between contractions.

🧱This rigidity is concerning because it indicates ongoing internal bleeding and a lack of normal uterine relaxation, significantly increasing the risk for fetal distress, disseminated intravascular coagulation (DIC), and maternal hypovolemic shock.

Absent fetal heart tones 💔

❄ Absent fetal heart tones in the context of suspected placental abruption indicate severe fetal compromise or intrauterine fetal demise.

❄When a significant portion of the placenta detaches, the fetus loses its oxygen and nutrient supply, leading rapidly to hypoxia and death if not intervened upon immediately.

❄This finding underscores the urgency of rapid emergency delivery to attempt to save the fetus if viable or to stabilize the mother if fetal demise has already occurred.

❄ It highlights how severe abruption is an obstetric emergency requiring prompt action.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Hemodilution of pregnancy

Rationale :

💧 During pregnancy, plasma volume increases disproportionately to red blood cell mass, resulting in a physiologic hemodilution known as "physiologic anemia of pregnancy."

💧 A hemoglobin of 11 g/dL in the second trimester is expected and considered normal because of this natural plasma expansion.

💧 This dilution is protective, helping to decrease blood viscosity and maintain placental perfusion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

36 weeks' gestation

Rationale :

📆 Screening for Group B Streptococcus (GBS) is recommended between 36–37 weeks' gestation to assess colonization risk before delivery.

📆 Positive GBS colonization requires intrapartum antibiotic prophylaxis to prevent neonatal sepsis, pneumonia, and meningitis.

📆 Early screening ensures timely treatment planning without premature exposure to antibiotics.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Prenatal vitamins will meet your need for increased folic acid during pregnancy.

Rationale :

🍀 Folic acid supplementation is critical to prevent neural tube defects such as spina bifida and anencephaly during fetal development.

🍀 Prenatal vitamins are specifically designed to provide the higher folic acid needs of pregnancy, typically 400–600 mcg daily.

🍀 Dietary sources alone are often insufficient; thus prenatal vitamin use is essential for fetal neural health.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

linea nigra

Rationale :

➖ Linea nigra refers to the dark vertical line that appears along the midline of the abdomen during pregnancy due to hormonal changes (increased melanin production).

➖ It is harmless and typically fades after birth without treatment.

➖ This hyperpigmentation is common and expected during mid to late pregnancy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

nothing by mouth

Rationale :

🚫 In hyperemesis gravidarum, severe vomiting risks dehydration, electrolyte imbalance, and malnutrition; thus, NPO status allows the gastrointestinal tract to rest.

🚫 After stabilization, treatment progresses to IV hydration and electrolyte correction before reintroducing oral intake.

🚫 Early aggressive management prevents progression to more serious maternal and fetal complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

I'm sorry you lost your baby.

Rationale :

🕊️ Expressing empathy and acknowledgment of loss is the most appropriate therapeutic response in cases of spontaneous abortion.

🕊️ It validates the client’s grief and fosters open emotional expression without minimizing or judging feelings.

🕊️ Therapeutic communication should always be supportive, nonjudgmental, and compassionate in loss situations.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

pica

Rationale :

🍦 Pica is the compulsive craving and consumption of non-nutritive substances like ice, dirt, or starch during pregnancy.

🍦 It is often associated with iron-deficiency anemia, and assessment should include evaluation of hemoglobin levels.

🍦 Addressing pica behavior early helps prevent nutritional deficiencies and potential ingestion of harmful substances.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Gestational diabetes; glucose

Rationale :

🍬 An elevated glucose level in pregnancy raises suspicion for gestational diabetes mellitus (GDM), a condition that increases maternal and fetal risks.

🍬 Early diagnosis and tight glucose control reduce complications such as macrosomia, preeclampsia, and neonatal hypoglycemia.

🍬 Routine screening for gestational diabetes usually occurs between 24–28 weeks, but high glucose earlier warrants immediate attention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Hemorrhage

Rationale :

🩸 A ruptured ectopic pregnancy leads to massive internal hemorrhage into the peritoneal cavity, causing life-threatening hypovolemic shock.

🩸 Prioritizing hemorrhage management prevents rapid cardiovascular collapse and maternal mortality.

🩸 Clinical signs include shoulder pain, abdominal tenderness, and hypotension due to internal bleeding.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse suspects that a pregnant client may be experiencing placenta abruption based on the assessment of which finding? Select all that apply.

2 :
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating

3 :
A nurse is providing prenatal care to a pregnant client. At which time would the nurse expect to screen the client for group B streptococcus infection?

4 :
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

5 :
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?

6 :
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

7 :
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?

8 :
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as

9 :
After reviewing the information provided in the client's medical record, which of the following complications should the nurse identify that the client is at risk of developing?

10 :
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

QLexNursing

1 : A nurse suspects that a pregnant client may be experiencing placenta abruption based on the assessment of which finding? Select all that apply.

2 : A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating

3 : A nurse is providing prenatal care to a pregnant client. At which time would the nurse expect to screen the client for group B streptococcus infection?

4 : A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

5 : Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?

6 : A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

7 : Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?

8 : Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as

9 : After reviewing the information provided in the client's medical record, which of the following complications should the nurse identify that the client is at risk of developing?

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

1 :
A nurse suspects that a pregnant client may be experiencing placenta abruption based on the assessment of which finding? Select all that apply.

2 :
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating

3 :
A nurse is providing prenatal care to a pregnant client. At which time would the nurse expect to screen the client for group B streptococcus infection?

4 :
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

5 :
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?

6 :
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

7 :
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?

8 :
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as

9 :
After reviewing the information provided in the client's medical record, which of the following complications should the nurse identify that the client is at risk of developing?

10 :
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?