QUESTION: "Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruptio placenta? "
CHOICES
( X ) a.) Excessive vaginal bleeding.
( O ) b.) Rigid, boardlike abdomen.
( X ) c.) Tetanic uterine contractions.
( X ) d.) Premature rupture of membranes.
RATIONALE: The most common assessment finding in a client with abruptio placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. Typically, bleeding is usually heavy but it may not be visible or readily apparent depending on the area of separation. Tetanic uterine contractions are contractions that are excessively strong and last longer than 90 seconds. This type of contraction is usually associated with oxytocin toxicity. With abruptio placenta, the membranes usually do not rupture prematurely. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
