Practice 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 Choices:
Correct Answer:
Dark red vaginal bleeding
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.
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This question is from RN ATI Maternal &Newborn Care Exam III which contains 43 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 5