Q&A: Placenta Abruption & Previa

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? A. Administration of blood B. Preparation of the woman for invasive hemodynamic monitoring C. Restriction of intravascular fluids D. Administration of steroids

A. Administration of blood Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement (not volume restriction), blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because it could contribute to more areas of bleeding. Steroids are not indicated for the management of DIC.

Which of the following is most likely indicated in a placenta previa pregnancy with an unstable fetus? A. C-section Delivery B. Vaginal Delivery Only C. Observation D. Moderate Exercise E. Cervical Cerclage F. Multiple Vaginal Examinations

A. C-section Delivery Cesarean delivery is necessary in practically all women with placenta previa as the placenta is at the cervix, and labor with cervical dilation could result in placental hemorrhage. Vaginal delivery may be attempted if a minor placenta previa of 2-3 cm from the cervical os is present, and one could proceed with an emergency cesarean if necessary.

Which of the following presentations is associated with early pregnancy loss, occurring in less than 12 weeks gestation? Select all that apply. A. Chromosomal abnormalities B. Infection C. Cystitis D. Antiphospholipid syndrome E. Hypothyroidism F. Caffeine use

A. Chromosomal abnormalities D. Antiphospholipid syndrome E. Hypothyroidism 50% of early pregnancy loss results from genetic abnormalities. Hypothyroidism and antiphospholipid syndrome are associated with early pregnancy loss. Caffeine use is associated with second-trimester losses as a result of maternal behavior. Infection is not a likely source of early pregnancy loss. Cystitis in not associated with early pregnancy loss.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At present she is at the greatest risk for: A. Hemorrhage. B. Infection. C. Urinary retention. D. Thrombophlebitis.

A. Hemorrhage. Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention or thrombophlebitis than does a normally implanted placenta.

Which of the following is an intervention for a stable fetus in a placenta previa pregnancy? A. Observation B. Multiple Rectal Examinations C. Multiple Vaginal Examinations D. Kegel Exercises E. Immediate Surgery F. Weight Bearing Exercises

A. Observation Close observation will be initiated to monitor blood loss, uterine tenderness, fetal activity, and vital signs. An external electronic fetal monitoring device may be applied to assess maternal and fetal heart rate. No vaginal or rectal exams are performed (pelvic rest - nothing in vagina).

3. A nurse is assessing a postpartum client who delivered via c-section for a placental abruption. What assessment finding would be the MOST concerning? A. Oozing from the IV site B. Abdominal cramping C. IV fluids running at 125 ml/hr D. Vaginal bleeding

A. Oozing from the IV site (correct) This is a major concern because of DIC, you bleed out of every orifice. Placental abduction puts a client at higher risk for DIC. IV fluids running at 125 ml/hr This is a normal post surgery. It would only be a concern if there was evidence this doesn't match the order or if the client is in heart failure. Abdominal cramping This is normal post delivery, the uterus is contracting to go back to pre pregnancy state. Vaginal bleeding Vaginal bleeding occurs after delivery as a normal finding. This is called lochia. It would be concerning if there was evidence of excessive bleeding, like saturating a pad every 15 minutes.

4. A 40-week pregnant client arrives to the L&D unit in labor. She admits to using cocaine this morning. The nurse knows this places the client at higher risk for which condition? A. Placental abruption B. Prolonged labor C. Placenta previa D. Miscarriage

A. Placental abruption Cocaine can cause a quick RISE in blood pressure and can cause placental abruption. Prolonged labor Precipitous delivery is the risk for cocaine use, which is a quick fast labor. Miscarriage At 40 weeks, cocaine is going to put the client at risk for abruption. Placenta previa Previa is when the placenta is located in the wrong spot and wouldn't occur from cocaine use.

A woman presents to the emergency department complaining of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary health care provider finds that the cervix is closed. The anticipated plan of care for this woman is based on a probable diagnosis of which type of spontaneous abortion? A. Incomplete B. Inevitable C. Threatened D. Septic

C. Threatened A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. Heavy bleeding, mild to severe cramping, and cervical dilation are the presentation for both incomplete abortion and inevitable abortion. A woman with a septic abortion presents with malodorous bleeding and, typically, a dilated cervix.

C-Section delivery is an intervention for which of the following? A. Baby is in Occiput Posterior Position B. Hemorrhage C. Unstable Fetus D. Preterm Labor Contractions E. Baby is in Occiput Anterior Position F. Stable Fetus

C. Unstable Fetus Excessive bleeding disrupts the uteroplacental blood flow, resulting in progressive deterioration of fetal status. A mature fetus (usually over 36 weeks gestation) should be prepared for immediate delivery.

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: A. Bleeding. B. Intense abdominal pain. C. Uterine activity. D. Cramping.

B. Intense abdominal pain. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding, uterine activity, and cramping may be present in varying degrees for both placental conditions.

Which of the following medications most likely may be used as an intervention for placenta previa? A. Misoprostol B. Magnesium Sulfate C. Oxytocin (Pitocin) D. Calcium Gluconate E. IV K+ Infusion at 5-10 mEq/hr F. Dinoprostone

B. Magnesium Sulfate Tocolytic drugs, such as magnesium sulfate, are medications that slow down or inhibit labor. In some cases, these may be given to the mother to promote the time for expectant management of symptomatic placenta previa

During your assessment of a patient with Placenta Previa, which of the following is a sign or symptom that is most likely to be seen? A. Foul smelling greenish frothy discharge B. Painless C. Increased Deep Tendon Reflexes (DTRs) D. Pain E. Decreased Deep Tendon Reflexes (DTRS) F. Leg Muscle Cramps

B. Painless The classic presentation of a placenta previa is painless uterine bleeding.

Which of the following is a consideration most likely associated with placenta previa? A. Increased Risk Hemorrhagic Stroke B. Risk for Shock C. Increased Risk of Thrombosis D. Increased Risk of Endometrial Cancer E. Increased Risk of Seizure F. Smoking Increases Risk

B. Risk for Shock Excessive bleeding places the mother at risk for hypovolemic shock. Monitor vital signs for increased pulse and respiratory rate and falling blood pressure every 5-15 minutes if active bleeding. Maintain IV access with a large-bore IV for a blood transfusion if needed.

For a placenta previa pregnancy with a stable fetus, which position, movement or direction advised for the mother? A. Activity at Tolerated B. Pelvic Tilt Exercise C. Bed Rest D. Exercise E. Elevate Legs F. Fowlers Position

C. Bed Rest Bed rest will be recommended as walking and other movements can induce contractions. A side lying position is ideal as this reduces the pressure of the uterus on the inferior vena cava and improves blood flow.

During your assessment of a patient with Placenta Previa, which of the following is a sign or symptom that is most likely to be seen? A. Dark Red/Brown Vaginal Bleeding B. Absent Bowel Sounds C. Bright Red Vaginal Bleeding D. No Vaginal Bleeding E. Boggy Uterus F. Absence of Hegar's Sign

C. Bright Red Vaginal Bleeding Bright red vaginal bleeding, usually near the end of the 2nd trimester or in the 3rd trimester of pregnancy, occurs due to placental separation from the internal cervical os or lower uterine segment and the inability of the uterus to contract at the vessel sites. It can range from light to heavy bleeding, and a vaginal exam is contraindicated as this can result in dislodgment of the placenta from maternal tissues.

A nurse is examining a patient who has been admitted for possible ectopic pregnancy who is approximately 8 weeks pregnant. Which finding would be a priority concern? A. No FHT heard via Doppler B. Scant vaginal bleeding noted on peri pad C. Ecchymosis noted around umbilicus D. Blood pressure 100/80

C. Ecchymosis noted around umbilicus Because this patient is most likely in the early stages of pregnancy, FHT would not be able to be auscultated at this time. Scant vaginal bleeding would not be a priority concern but should still be monitored by the nurse. Ecchymosis around the umbilicus indicates Cullen sign, which indicates hematoperitoneum, and may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.

Which of the following is most likely associated with Placenta Previa? A. Placenta adheres directly to myometrium B. Uteroplacental Insufficiency C. Placenta Covers Cervical Os D. Decreased Uteroplacental Perfusion E. Premature Separation of Placenta F. Retained Placenta

C. Placenta Covers Cervical Os Placenta previa occurs when the placenta covers the cervical os. The four classifications include: total (placenta completely covers the internal cervical os), partial (placenta partially covers the internal cervical os), marginal (placenta is at the margin of the internal cervical os), and low-lying placenta (placenta is implanted in the lower uterine segment in close proximity to the internal cervical os).

5. A 32-week pregnant client arrives to the emergency department with severe abdominal pain and vaginal bleeding. What condition should the nurse be concerned for? A. Miscarriage B. Cervical effacement C. Placental abruption D. Placenta previa

C. Placental abruption (correct) In the 3rd trimester, painful bleeding is indicative of possible placental abruption. Placenta previa This would be painless bleeding. Cervical effacement Effacement can cause some spotting but wouldn't be painful. Miscarriage A miscarriage would happen earlier in pregnancy.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? A. Prepare the woman for a dilation and curettage (D&C). B. Put the woman on bed rest for at least 1 week and reevaluate. C. Prepare the woman for an ultrasound and blood work. D. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.

C. Prepare the woman for an ultrasound and blood work. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine whether the fetus is alive and within the uterus. Bed rest is recommended for 48 hours initially. D&C is not considered until signs of the progress to inevitable abortion are noted or the contents are expelled and incomplete. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.

A nurse is evaluating several obstetric patients for their risk for cervical insufficiency. Which patient would be considered to be most at risk? A. Primipara B. Grandmultip who has previously had all vaginal deliveries without a problem C. Primip who undergoes a cervical cone biopsy for cervical dysplasia prior to the pregnancy D. Multip who had her previous delivery via C section due to cephalopelvic disproportion (CPD)

C. Primip who undergoes a cervical cone biopsy for cervical dysplasia prior to the pregnancy Any patient who has had previous surgical interventions (cone biopsy) is at greater risk for cervical insufficiency. There is no indication that a primip is at risk for cervical insufficiency. A grandmultip who has previously had vaginal deliveries without incidence is not necessarily at an increased risk for cervical insufficiency. A multip who has delivered via C section as a result of CPD would not necessarily be at an increased risk as the issue involves pelvic adequacy as determined by pelvic measurements in relationship to the fetus.

1. A nurse is caring for a 38-week pregnant client. The client is complaining of severe abdominal pain. What is your priority assessment? A. Check the contraction pattern B. Call for epidural orders C. Check for bleeding D. Assess fetal heart tones

D. Assess fetal heart tones (CORRECT) The priority is to check the fetal status so that we can know if the fetus is stable. This mom is showing signs of either a placental abruption or uterine infection, so we are concerned with the status of the fetus. We need to assess fetal stability to know if intervention is required. Check for bleeding There is no indication that the patient would be bleeding. Severe abdominal pain in pregnancy could be a symptom of placental abruption or infection. Our priority assessment would be to check fetal heart tones because that is our second patient and if the fetus is not stable then we need to know to intervene. Check the contraction pattern This patient has severe abdominal pain which is the main symptom of placental abruption or severe infection. The priority assessment is to assess the fetal status. Call for epidural orders We need to first assess the fetal heart tones to determine the status/stability of the fetus.

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 to every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: A. Eclamptic seizure. B. Rupture of the uterus. C. Placenta previa. D. Placental abruption.

D. Placental abruption. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests with hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain, and placenta previa with bright red, painless vaginal bleeding.

2. A nurse is assessing a pregnant client who is in labor. Which of the following symptoms would be indicative of a possible placental abruption? Select all that apply. A. Hypertension B. Maternal bradycardia C. Non reassuring FHR D. Abdominal pain E. Bleeding

E. Bleeding Bleeding occurs from the placenta being pulled from the uterus and leaving an open wound. C. Non reassuring FHR FHR is non-reassuring because the placenta that brings oxygen and nutrients from the mother becomes detached. D. Abdominal pain Severe abdominal pains from the placenta being ripped away from the uterus and blood filling up the uterus. INCORRECT Maternal bradycardia Maternal TACHYCARDIA would occur if shock symptoms start from blood loss. Hypertension This is not a symptom. It is more likely we would see HYPOTENSION due to blood loss.

Observation is an intervention (Placenta Previa) for which of the following? A. Abnormal Cord Position B. Stable Fetus C. Hemorrhage D. Ectopic Pregnancy E. Boggy Uterus F. Unstable Fetus

F. Unstable Fetus Prolonging pregnancy and delaying delivery may be possible when the maternal and fetal status is stable and bleeding is minimal. This expectant or conservative management occurs when the fetus is premature (less than 36 weeks gestation) to allow for fetal lung maturity. If indicated, corticosteroids may be given to facilitate fetal lung maturity.