A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?
In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.
A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority?
The priority is to monitor the fetal heart rate.
A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?
Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vaginal), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping.
A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor:
In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s orders and would question which order?
Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and Placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage.
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?
When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred?
Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.
An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for:
The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?
DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.
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