OB Final HTN & Beetus nclex practice
A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? 1. Altered glomerular filtration. 2. Cardiac failure. 3. Hepatic insufficiency. 4. Altered splenic circulation.
1. Altered GFR Rationale: Altered glomerular filtration leads to protein loss and fluid retention, which leads to swelling
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.
1. Assess deep tendon reflexes. Rationale: assessing the patellar reflexes determines severity of preeclampsia. Ex: if reflexes are +2, the client would be much less likely to become eclamptic than someone w/ +4 reflexes + clonus.
A 12-week-gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. Which of the following signs/symptoms should the nurse assess this client for? Select all that apply. 1. Tachycardia. 2. Referred shoulder pain. 3. Headache. 4. Fetal heart dysrhythmias. 5. Hypertension.
1. Tachycardia. 3. Headache. 4. Fetal heart dysrhythmias. 5. Hypertension.
A 32-week-gestation client was last seen in the prenatal client at 2 8 weeks' gestation. Which of the following changes should the nurse bring to the attention of the midwife? 1. Weight change from 128 pounds to 138 pounds. 2. Pulse rate change from 88 bpm to 92 bpm. 3. Blood pressure change from 120/80 to 118/78. 4. Respiratory rate change from 16 rpm to 20 rpm
1. Weight change from 128 pounds to 138 pounds. Rationale: A weight gain of 10 pounds in a 4-week period is worrisome. The recommended weight gain during the second and third trimesters is approximately 1 pound per week. A weight gain above that which is recommended can be related to a few things, including preeclampsia, exces- sive food intake, or multiple gestations
A 25-week-pregnant client, who had eaten a small breakfast, has been notified that her glucose challenge test results were 142 mg/dL 1 hour after ingesting the glucose. Which of the following is appropriate for the nurse to say at this time? 1. "Because you ate before the test, the results are invalid and will need to be repeated." 2. "Because your test results are higher than normal, you will have to have another, more specific test." 3. "Because of the results you will have to have weekly glycohemoglobin testing done." 4. "Because your results are within normal limits you need not worry about gestational diabetes."
2. "Because your test results are higher than normal, you will have to have another, more specific test." Rationale: GCT is only a screen, not a dx test. If the GCT results are 130 mg/dL or higher (or 140 mg/dL or higher, the client will be referred for a 3-hour glucose tolerance test..
A client, G2 P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? 1. "When did you have your pregnancy test done?" 2. "When was the first day of your last menstrual period?" 3. "Did you have any complications with your first pregnancy?" 4. "How old were you when you first got your period?"
2. "When was the first day of your last menstrual period?" Rationale: LMP date will assist the nurse in determining how many weeks pregnant the client is. Ectopic pregnancies are usually diagnosed btw 8th and 9th week of gestation bc @ that age, conceptus has reached a size that is too large for the fallopian tube to hold.
Which of the following pregnant clients is most high risk for preterm prematurerupture of the membranes (PPROM)? Select all that apply. 1. 31 weeks' gestation with prolapsed mitral valve (PMV). 2. 32 weeks' gestation with urinary tract infection (UTI). 3. 33 weeks' gestation with twins post-in vitro fertilization (IVF). 4. 34 weeks' gestation with gestational diabetes (GDM). 5. 35 weeks' gestation with deep vein thrombosis (DVT).
2. 32 weeks' gestation with urinary tract infection (UTI). 3. 33 weeks' gestation with twins post-in vitro fertilization (IVF).
A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus
2. Papilledema.
A client, G8 P3406, 14 weeks' gestation, is being seen in the prenatal clinic. During the nurse's prenatal teaching session, the nurse will emphasize that the woman should notify the obstetric office immediately if she notes which of the following? 1. Change in fetal movement. 2. Signs and symptoms of labor. 3. Swelling of feet and ankles. 4. Appearance of spider veins.
2. Signs and symptoms of labor. Rationale: The client in the scenario, therefore, has had 8 pregnancies (she is currently pregnant) with 3 full-term deliveries, 4 preterm deliveries, no abortions, and she has 6 living children
The nurse caring for a type 1 diabetic client who wishes to become pregnant notes that the client's HgbA1C , result was 15% today and the fasting blood glucose result was 100 mg/dL. Which of the following interpretations by the nurse is correct in relation to these data? 1. The client has been hyperglycemic for the past 3 months and is hyperglycemic today. 2. The client has been normoglycemic for the past 3 months and is normoglycemic today 3. The client has been hyperglycemic for the past 3 months and is normoglycemic today. 4. The client has been normoglycemic for the past 3 months and is hyperglycemic today.
3. The client has been hyperglycemic for the past 3 months and is normoglycemic today. Rationale: Because the RBC lives for approximately 120 days, the health care practitioner can estimate the glucose control of the client over the preceding 3 months time by analyzing the glycohe- moglobin. Up to 5% glycohemoglobin is considered normal. A1c level of 15%, therefore, indicates that the client has been hyperglycemic for the past 3 months. Since her fasting blood glucose level of 100 mg/dL is normal, but, she is normoglycemic today.
A gravid client, G6 P5005, 24 weeks' gestation, has been admitted to the hospital for placenta previa. Which of the following is an appropriate long-term goal for this client? 1. The client will state an understanding of need for complete bed rest. 2. The client will have a reactive nonstress test on day 2 of hospitalization. 3. The client will be symptom free until at least 37 weeks' gestation. 4. The client will call her children shortly after admission.
3. The client will be symptom free until at least 37 weeks' gestation. Rationale: all the rest are short term goals
A gravid woman, who is 42 weeks' gestation, has just had a 20-minute nonstress test (NST). Which of the following results would the nurse interpret as a reactive test? 1. Moderate fetal heart baseline variability. 2. Maternal heart rate accelerations to 140 bpm lasting at least 20 seconds. 3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds. 4. Absence of maternal premature ventricular contractions.
3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds.
A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? 1. Cervical cerclage. 2. Amniocentesis. 3. Nonstress testing. 4. Dilation and curettage. 5. Emergency abortion
4. Dilation and curettage. Rationale: Dilation and curettage (D&C) is performed on a client with an incomplete abortion. Patient has incomplete abortion. It is important for the remaing products of conception to be removed to prevent hemorrhage and infection. Dr. dilates the cervix and scrapes the lining of the uterus with a curette
A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.
4. Epigastric pain. Rationale: Epigastric pain is associated w/ the liver involvement of HELLP syndrome. When the liver is deprived of sufficient blood supply, the organ becomes ischemic. The client experiences pain at the site of the liver as a result of the hypoxia in the liver.
A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.
4. Intrauterine growth restriction. Rationale: Perfusion to placenta drops when clients are preeclamptic bc the client's hypertension impairs adequate blood flow. When the placenta is poorly perfused, the baby is poorly nourished. Without the nourishment provided by the mother through the umbilical vein, the fetus's growth is affected.
The client has been on magnesium sulfate for 20 hours for the treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings does the nurse expect to observe or assess in this client? a. Absence of uterine bleeding in the postpartum period b. Fundus firm below the level of the umbilicus c. Scant lochia flow d. Boggy uterus with heavy lochia flow
d. Boggy uterus with heavy lochia flow Rationale: High serum levels of magnesium can cause a relaxation of smooth muscle such as the uterus. Dt this tocolytic effect, the client likely has a boggy uterus w/ increased amounts of bleeding. All women experience uterine bleeding in the postpartum period, especially those who have received magnesium therapy. Rather than scant lochial flow, however, this client will most likely have a heavy flow attributable to the relaxation of the uterine wall caused by the magnesium
An ultrasound has identified that a client's pregnancy is complicated by oligohydramnios. The nurse would expect that an ultrasound may show that the baby has which of the following structural defects? 1. Dysplastic kidneys. 2. Coarctation of the aorta. 3. Hydrocephalus. 4. Hepatic cirrhosis.
1. Dysplastic kidneys. Rationale: The majority of amniotic fluid is produced by the fetal kidneys. When a pregnancy is complicated by oligohydramnios, ultrasounds may be performed to check for defects in the fetal renal system.
A pregnant diabetic has been diagnosed with hydramnios. Which of the following would explain this finding? 1. Excessive fetal urination. 2. Recurring hypoglycemic episodes. 3. Fetal sacral agenesis. 4. Placental vascular damage.
1. Excessive fetal urination. Rationale: The majority of amniotic fluid is created as urine by the fetal kidneys. Fetuses of diabetic mothers often experience polyuria as a result of hyperglycemia. If the mother's diabetes is out of control, excess glucose diffuses across the placental membrane, making the fetus hyperglycemic. As a result, the fetus exhibits the classic sign of diabetes—polyuria.
Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? 1. G1 P0000, age 44 with history of diabetes mellitus. 2. G2 P0101, age 27 with history of rheumatic fever. 3. G3 P1102, age 25 with history of scoliosis. 4. G3 P1011, age 20 with history of celiac disease.
1. G1 P0000, age 44 with history of diabetes mellitus. Rationale: women @ highest risk for preeclampsia are primigravidas, multiple gestations, women under 17 or older than 34, those who had preeclampsia with first pregnancy, and those diagnosed w/ a vascular disease like diabetes mellitus or chronic
A gravid woman, 36 weeks' gestation with type 1 diabetes, has just had a biophysical profile (BPP). Which of the following results should be reported to the obstetrician? 1. One fetal heart acceleration in 20 minutes. 2. Three episodes of fetal rhythmic breathing in 30 minutes. 3. Two episodes of fetal extension and flexion of 1 arm. 4. One amniotic fluid pocket measuring 3 cm.
1. One fetal heart acceleration in 20 minutes. Rationale: There should be a minimum of 2 fetal heart accelerations in 20 minutes (approximately 1 every 10 minutes).
The physician has ordered a nonstress test (NST) to be done on a 41-week-gestation client. During the half-hour test, the nurse observed three periods of fetal heart accelerations that were 15 beats per minute above the baseline and that lasted 15 seconds each. No contractions were observed. Based on these results, what should the nurse do next? 1. Send the client home and report positive results to the MD. 2. Perform a nipple stimulation test to assess the fetal heart in response to contractions. 3. Prepare the client for induction with IV oxytocin or endocervical prostaglandins. 4. Place the client on her side with oxygen via face mask.
1. Send the client home and report positive results to the MD. Rationale: This client is postdates. The NST is being performed to assess the well-being of the fetus. The results of the reactive NST results—are evidence that the fetus is well and will likely be well for another few days. There is no need to provide emergent care.
The nurse is caring for a 32-week G8 P7007 with placenta previa. Which of the following interventions would the nurse expect to perform? Select all that apply. 1. Daily contraction stress tests. 2. Blood type and cross match. 3. Bed rest with passive range-of-motion exercises. 4. Daily serum electrolyte assessments. 5. Weekly biophysical profiles.
2. Blood type and cross match. 3. Bed rest with passive range-of-motion exercises. 5. Weekly biophysical profiles. Rationale: Because clients with placenta previa are at high risk for bleeding from the placental site, it is essential that they be limited in their activity and have blood on hand in case of hemorrhage. In addition, their babies must be monitored carefully for signs of fetal well-being. It would be inapprpriate to stimulate contractions because dilation of the cervix would stimulate bleeding.
A baby has been admitted to the neonatal intensive care unit with a diagnosis of symmetrical intrauterine growth restriction (IUGR). Which of the following pregnancy complications would be consistent with this diagnosis? 1. Severe preeclampsia. 2. Chromosomal defect. 3. Infarcts in an aging placenta. 4. Premature rupture of the membrane
2. Chromosomal defect. Rationale: 1. Severe preeclampsia is associated with asymmetrical IUGR. 2. Chromosomal abnormalities are associated with symmetrical IUGR. 3. An aging placenta is associated with asymmetrical IUG 4. PPROM is associated with asymmetrical IUGR.
A client is being admitted to the labor suite with a diagnosis of eclampsia. The fetal heart rate tracing shows moderate variability with early decelerations. Which of the following actions by the nurse is appropriate at this time? 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails and head of the bed. 3. Provide the client with needed stimulation. 4. Provide the client with grief counseling.
2. Pad the side rails and head of the bed. Rationale: When a client has been diagnosed with eclampsia, she has already had at least one seizure. The nurse must be prepare for another seizure. The most important action during the seizure is to protect the client from injury. Padding the side rails and headboard will provide that protection. This client's fetus is exhibiting a normal heart rate pattern.
A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the client and documents the following findings: Temp 37.1 C, HR 96, RR 24, BP of 155/112 mm Hg, 3+ DTRs, and no ankle clonus. The nurse calls the provider with an update. The nurse should anticipate an order for which medication? a. Hydralazine b. Magnesium sulfate bolus c. Diazepam d. Calcium gluconate
a. Hydralazine Rationale: Hydralazine is an antihypertensive medication commonly used to treat hypertension in severe preeclampsia. Typically, it is administered for a systolic BP higher than 160 mm Hg or a diastolic BP higher than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of CNS irritability rt severe preeclampsia (e.g., clonus) or if eclampsia develops.
Which intervention is most important when planning care for a client with severe gestational hypertension? a. Induction of labor is likely, as near term as possible. b. If at home, the woman should be confined to her bed, even with mild gestational hypertension. c. Special diet low in protein and salt should be initiated. d. Vaginal birth is still an option, even in severe cases.
a. Induction of labor is likely, as near term as possible. Rationale: By 34 weeks of gestation, the risk of continuing the pregnancy may be considered greater than the risks of a preterm birth. Women with severe gestational hypertension should expect a cesarean delivery.
Which neonatal complications are associated with hypertension in the mother? a. Intrauterine growth restriction (IUGR) and prematurity b. Seizures and cerebral hemorrhage c. Hepatic or renal dysfunction d. Placental abruption and DI
a. Intrauterine growth restriction (IUGR) and prematurity Rationale: Neonatal complications are rt to placental insufficiency & include IUGR, prematurity, and necrotizing enterocolitis. Seizures and cerebral hemorrhage are maternal complications. Hepatic & renal dysfunction are maternal complications of hypertensive disorders in pregnancy. Placental abruption and DIC are conditions rt maternal morbidity and mortality.
Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the client mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. This fetus is at the greatest risk for which condition? a. Macrosomia b. Congenital anomalies of the central nervous system c. Preterm birth d. Low birth weight
a. Macrosomia Rationale: Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this fetus.
Which adverse prenatal outcomes are associated with the HELLP syndrome? (Select all that apply.) a. Placental abruption b. Placenta previa c. Renal failure d. Cirrhosis e. Maternal and fetal death
a. Placental abruption c. Renal failure e. Maternal and fetal death Rationale: HELLP is associated w/ increased risk for adverse perinatal outcomes: placental abruption, acute renal failure, hepatic hematoma, hepatic rupture, recurrent preeclampsia, preterm birth, fetal and maternal death.
One of the most important components of the physical assessment of the pregnant client is the determination of BP. Consistency in measurement techniques must be maintained to ensure that the nuances in the variations of the BP readings are not the result of provider error. Which techniques are important in obtaining accurate BP readings? (Select all that apply.) a. The client should be seated. b. The clients arm should be placed at the level of the heart. c. An electronic BP device should be used. d. The cuff should cover a minimum of 60% of the upper arm. e. The same arm should be used for every reading
a. The client should be seated. b. The clients arm should be placed at the level of the heart. e. The same arm should be used for every reading Rationale: BP readings are easily affected by maternal position. Ideally, the client should be seated. An alternative position is left lateral recumbent with the arm at the level of the heart. The arm should always be held in a horizontal position at approximately the level of the heart. The same arm should be used at every visit. The manual sphygmomanometer is the most accurate device. If manual and electronic devices are used in the care setting, then the nurse must use caution when interpreting the readings. A proper size cuff should cover at least 80% of the upper arm or be approximately 1.5 times the length of the upper arm.
A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. Which nursing diagnosis is most appropriate for the client at this time? a. Deficient fluid volume b. Imbalanced nutrition: less than body requirements c. Imbalanced nutrition: more than body requirements d. Disturbed sleep pattern
b. Imbalanced nutrition: less than body requirements
A new mother with a thyroid disorder has come for a lactation follow-up appointment. Which thyroid disorder is a contraindication for breastfeeding? a. Hyperthyroidism b. PKU c. Hypothyroidism d. Thyroid storm
b. PKU Rationale: PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine and therefore should elect not to breastfeed. A woman with either hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism and is not a contraindication to breastfeeding.
A client with maternal phenylketonuria (PKU) has come to the obstetrical clinic to begin prenatal care. Why would this preexisting condition result in the need for closer monitoring during pregnancy? a. PKU is a recognized cause of preterm labor. b. The fetus may develop neurologic problems. c. A pregnant woman is more likely to die without strict dietary control. d. Women w/ PKU are usually mentally handicapped & should not reproduce.
b. The fetus may develop neurologic problems. Rationale: Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of an uncertain cause, or who have given birth to microcephalic infants.
The ACOG has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors? a. 30-year-old obese Caucasian with her third pregnancy b. 41-year-old Caucasian primigravida c. 19-year-old African American who is pregnant with twins d. 25-year-old Asian American whose pregnancy is the result of donor insemination
c. 19-year-old African American who is pregnant with twins Rationale: Three risk factors are present in the 19-year-old African-American client. She has African- American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy. All others only exhibit 1-2
A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse? a. Blood pressure (BP) increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. Dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day
c. Dipstick value of 3+ for protein in her urine
A number of metabolic changes occur throughout pregnancy. Which physiologic adaptation of pregnancy will influence the nurses plan of care? a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester bc they're consuming more sugar. c. During the 2nd & 3rd trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d. Maternal insulin requirements steadily decline during pregnancy.
c. During the 2nd & 3rd trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. Rationale: Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own around the 10th week.
The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin (Pitocin) infusion, the nurse reviews the womans latest laboratory test findings, which reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level, and a falling hematocrit. The laboratory results are indicative of which condition? a. Eclampsia b. (DIC) c. HELLP syndrome d. Idiopathic thrombocytopenia
c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome Rationale: HELLP syndrome is a lab dx for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver (EL) enzymes, and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.
A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature 37.3 C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute, BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client complains, Im so thirsty and warm. What is the nurses immediate action? a. To call for an immediate magnesium sulfate level b. To administer oxygen c. To discontinue the magnesium sulfate infusion d. To prepare to administer hydralazine
c. To discontinue the magnesium sulfate infusion Rationale: Patient is showing signs of mag toxicity. Discontinue mag drip & call provider to confirm before admin of antidote (calcium gluconate)
A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates? a. 75 mg/dl before lunch. This is low; better eat now. b. 115 mg/dl 1 hour after lunch. This is a little high; eat a little less next time. c. 115 mg/dl 2 hours after lunch. This is too high; time for insulin. d. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snackbefore going to sleep.
d. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snackbefore going to sleep. Rationale: 50 mg/dl after waking from a nap is too low. During sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.
A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes, dark red vaginal bleeding, and a tense, painful abdomen. Which clinical change does the nurse anticipate? a. Eclamptic seizure b. Rupture of the uterus c. Placenta previa d. Abruptio placentae
d. Abruptio placentae Rationale: Uterine tenderness in the presence of increasing tone may be the earliest sign of abruptio placentae. Women with preeclampsia are at increased risk for an abruption attributable to decreased placental perfusion. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture exhibits hypotonic uterine activity, signs of hypovolemia, and, in many cases, the absence of pain. Placenta previa exhibits bright red, painless vaginal bleeding.
