Abruptio Placenta Nursing Care Plan and Management

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Notes

Description

Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage.

Etiology

The cause of abruptio placenta is unknown.
Risk factors include:
- Uterine anomalies
- Multiparity
- Preeclampsia
- Previous cesarean delivery
- Renal or vascular disease
- Trauma to the abdomen
- Previous third trimester bleeding
- Abnormally large placenta
- Short umbilical cord

Pathophysiology

The placenta detaches in whole or in par from the implantation site. This occurs in the area of the deciduas basalis.

Assessment Findings

Associated findings. Severe abruption placentae may produce such complications as:
1. Renal failure
2. Disseminated intravascular coagulation
3. Maternal and fetal death
Common clinical manifestation include:
1. Intense, localized uterine pain, with or without vaginal bleeding.
2. Concealed or external dark red bleeding
3. Uterus firm to boardlike, with severe continuous pain
4. Uterine contractions
5. Uterine outline possibly enlarged or changing shape
6. FHR present or absent.
7. Fetal presenting part may be engaged.
Laboratory and diagnostic study findings.
- Ultrasound may be able to identify the extent of abruption. However, the absence of an ultrasound finding does not rule out the presence of abruption.

Nursing Management

Continuously evaluate maternal and fetal physiologic status, particularly:
- Vital signs
- Bleeding
- Electronic fetal and maternal monitoring tracings
- Signs of shock-rapid pulse, pallor, cold and most skin, decrease in blood pressure
- Decreasing urine output
- Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity.
Assess the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated.
Provide appropriate management.
- On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava.
- Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample for fibrinogen level.
- Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen to the mother by mask.
- Prepare for cesarean section, which is the method of choice for the birth.
Provide client and family teaching.
Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of the separation, amount of fetal hypoxia, and amount of bleeding.

Exam

Welcome to your MCHN Exam for Abruptio Placentae! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

✔ Exam Details

Number of Questions: 10 items
Mode: Practice Mode

✔ Exam Instructions

Practice Mode: This mode aims to facilitate effective learning and review.
Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

✔ Tips For Success

Read each question carefully. Take your time and don't rush.
Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
Take breaks if you need them. It's not a race, and your understanding is what's most important.
Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Consider the blood dyscrasia that is often associated with obstetric emergencies and involves widespread activation of clotting leading to bleeding.

1 / 10

1. Nurse Reynolds is attending to a pregnant woman who has been rushed to the emergency department with a diagnosis of abruptio placentae at 34 weeks' gestation. Recognizing the potential complications associated with this condition, Nurse Reynolds is particularly vigilant for signs of certain blood dyscrasias. Which blood condition is the patient at increased risk for developing due to abruptio placentae?

A. Thrombocytopenia.

B. Disseminated intravascular coagulation (DIC).

C. Heparin-associated thrombosis and thrombocytopenia (HATT).

D. Idiopathic thrombocytopenic purpura (ITP).

EXPLANATION

✔Correct answer:

Disseminated intravascular coagulation (DIC). Abruptio placentae is a serious condition where the placenta prematurely detaches from the uterine wall, leading to significant maternal and fetal complications. One of the critical complications associated with abruptio placentae is disseminated intravascular coagulation (DIC). DIC is a complex condition characterized by widespread activation of the clotting cascade, leading to the formation of small blood clots throughout the bloodstream, which can deplete clotting factors and platelets, resulting in severe bleeding.

In the case of abruptio placentae, the detachment of the placenta can cause the release of thromboplastin into the maternal bloodstream, which triggers the coagulation cascade. This widespread activation of clotting factors can result in the formation of microthrombi in the blood vessels, consumption of clotting factors and platelets, and ultimately lead to bleeding and hemorrhage.

Imagine a city where all fire hydrants suddenly burst open (clotting cascade activation), leading to a severe water shortage (depletion of clotting factors and platelets). This shortage makes it difficult to fight any new fires (stop bleeding) effectively.

Nurse Reynolds should monitor the patient closely for signs of DIC and be prepared to intervene promptly.

Monitor for signs of bleeding, such as petechiae, ecchymoses, or oozing from venipuncture sites.
Assess for signs of organ dysfunction due to microthrombi, such as altered mental status, chest pain, or decreased urine output.
Check laboratory values including platelet count, fibrinogen levels, prothrombin time (PT), activated partial thromboplastin time (aPTT), and D-dimer levels.
Prepare for potential administration of blood products, such as fresh frozen plasma, platelets, or cryoprecipitate, as indicated.
Collaborate with the healthcare team to manage the underlying cause of DIC and stabilize the patient.

✘Incorrect answer options:

Thrombocytopenia. While thrombocytopenia (a low platelet count) can occur as part of DIC, it is not the primary condition associated with abruptio placentae. DIC involves a broader coagulopathy.

Heparin-associated thrombosis and thrombocytopenia (HATT). This condition is related to heparin administration and is not specifically linked to abruptio placentae.

Idiopathic thrombocytopenic purpura (ITP). ITP is an autoimmune condition characterized by isolated thrombocytopenia without the systemic clotting and bleeding abnormalities seen in DIC.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Think about the immediate actions needed to assess the condition of both the mother and fetus in a potential emergency situation.

2 / 10

2. A pregnant patient at 32 weeks gestation presents to the emergency department with severe abdominal pain, vaginal bleeding, and a tense, board-like abdomen. The nurse suspects abruptio placentae. Which initial intervention is the priority?

A. Start an intravenous infusion of oxytocin.

B. Administer pain medication as prescribed.

C. Monitor maternal vital signs and fetal heart rate.

D. Prepare the patient for an emergency cesarean section.

EXPLANATION

✔Correct answer:

Monitor maternal vital signs and fetal heart rate. In the case of suspected abruptio placentae, it is critical to assess both the maternal and fetal status to determine the severity of the situation and guide further interventions. Monitoring maternal vital signs and fetal heart rate provides essential information about the well-being of both the mother and the fetus, which helps in making timely decisions regarding the need for emergency interventions, such as a cesarean section if indicated.

Abruptio placentae, or placental abruption, is a serious condition where the placenta detaches from the uterine wall prematurely. This can lead to severe maternal hemorrhage and fetal distress or demise. Immediate assessment of maternal and fetal status is crucial for prioritizing subsequent steps, such as emergency delivery or stabilization of the mother.

Imagine a sudden, severe car malfunction while driving. The first step is to check the dashboard for warning lights (maternal vital signs and fetal heart rate) to understand the immediate issue before deciding on further actions, such as calling for emergency services (preparing for a cesarean section) or making other interventions.

Nurse's initial priority should be to stabilize the patient and continuously monitor vital signs to detect any signs of shock, and to monitor the fetal heart rate to assess fetal distress.

Place the patient on continuous fetal monitoring to assess the fetal heart rate and contractions.
Measure maternal vital signs frequently, including blood pressure, heart rate, and respiratory rate.
Assess the amount and type of vaginal bleeding.
Prepare for potential rapid intervention, including establishing IV access and ensuring blood products are available.
Notify the obstetric team immediately for further assessment and potential emergency delivery if indicated.

✘Incorrect answer options:

Prepare the patient for an emergency cesarean section. While this may become necessary, it is not the initial priority. The need for an emergency cesarean section depends on the maternal and fetal assessment findings.

Administer pain medication as prescribed. Pain management is important but not the initial priority. It is more critical to assess maternal and fetal status first.

Start an intravenous infusion of oxytocin. Oxytocin is contraindicated in cases of suspected placental abruption as it could exacerbate the condition by increasing uterine contractions and potentially worsening the abruption.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Identify the condition that specifically refers to the premature and often sudden detachment of the placenta from the uterine wall, a scenario frequently associated with severe bleeding.

3 / 10

3. Nurse Miller is reviewing obstetric complications with her team and focuses on conditions characterized by the premature separation of the placenta. She describes a specific condition that involves the early detachment of a normally implanted placenta during the latter part of pregnancy, often leading to significant bleeding. Which condition is Nurse Miller discussing?

A. Abruptio placentae.

B. Placenta previa.

C. Ectopic pregnancy.

D. Incompetent cervix.

EXPLANATION

✔Correct answer:

Abruptio placentae. Nurse Miller is discussing abruptio placentae, a condition characterized by the premature separation of a normally implanted placenta from the uterine wall, typically during the latter part of pregnancy. This condition can lead to significant maternal and fetal complications, including heavy bleeding, uterine tenderness, and fetal distress.

Abruptio placentae occurs when the blood vessels in the placenta or the area of the uterine wall to which it is attached rupture, causing the placenta to partially or completely detach. The detachment impairs the exchange of oxygen and nutrients between the mother and fetus and can result in significant bleeding. Risk factors include hypertension, trauma, smoking, and a history of placental abruption.

Imagine the placenta as a lifeline attached to a boat (the uterus). Abruptio placentae is like this lifeline being severed prematurely, causing both the boat and the lifeline to lose connection, leading to a critical situation for both.

Nurse Miller and her team should be prepared to recognize and manage the symptoms of abruptio placentae, providing prompt intervention to ensure the safety of both mother and baby.

Monitor the patient's vital signs and fetal heart rate continuously to detect signs of maternal or fetal distress.
Prepare for potential emergency delivery if the condition is severe, to prevent further complications.
Provide IV fluids and blood products as needed to manage hemorrhage and stabilize the patient.
Offer emotional support and clear communication to the patient and her family about the condition and necessary interventions.
Collaborate with the obstetric team to determine the best course of action based on the severity of the abruption and the gestational age of the fetus.

✘Incorrect answer options:

Ectopic pregnancy. This condition involves the implantation of a fertilized egg outside the uterine cavity, often in the fallopian tube, and is not related to placental separation within the uterus.

Incompetent cervix. This refers to a condition where the cervix dilates prematurely without contractions, leading to potential preterm birth, but it does not involve placental detachment.

Placenta previa. This condition occurs when the placenta is implanted low in the uterus, covering or near the cervical os. It causes painless vaginal bleeding and is not characterized by placental separation from the uterine wall.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Think about which option represents a localized effect rather than the systemic coagulopathy seen in DIC.

4 / 10

4. Maria is a maternity nurse caring for Barbara, a client diagnosed with abruptio placentae. To monitor for disseminated intravascular coagulation (DIC), Maria checks Barbara's lab results and assessments. Which of the following findings would Maria recognize as least indicative of DIC?

A. Unilateral calf swelling.

B. Thrombocytopenia

C. Prolonged clotting times.

D. Petechiae, injection site oozing, hematuria.

EXPLANATION

✔Correct answer:

Unilateral calf swelling. Unilateral calf swelling is least indicative of disseminated intravascular coagulation (DIC). While calf swelling may suggest a deep vein thrombosis (DVT), it is not a direct sign of DIC. DIC is a systemic condition characterized by widespread clotting and bleeding throughout the body, not localized symptoms. Key indicators of DIC include thrombocytopenia (low platelet count), petechiae, oozing from injection sites, hematuria (blood in urine), and prolonged clotting times due to the consumption of clotting factors.

DIC involves the activation of the coagulation cascade leading to the formation of small blood clots in the blood vessels throughout the body. These clots consume platelets and clotting factors, resulting in bleeding in other areas. The systemic nature of DIC means it presents with generalized symptoms of clotting and bleeding, rather than localized swelling.

Imagine a city's water supply system where pipes burst all over, causing both flooding (bleeding) and blockages (clotting). A single clogged pipe (unilateral calf swelling) doesn't indicate the widespread issue, but water pooling everywhere (generalized clotting and bleeding) does.

Maria should focus on recognizing the systemic signs of DIC and ensure timely intervention to manage the condition.

Monitor platelet count for thrombocytopenia, which is common in DIC.
Check for petechiae, oozing from injection sites, and hematuria as signs of bleeding.
Assess clotting times, such as prothrombin time (PT) and activated partial thromboplastin time (aPTT), which are typically prolonged in DIC.
Prepare for the potential administration of blood products, such as platelets and fresh frozen plasma, to manage clotting deficiencies.
Collaborate with the healthcare team to address the underlying cause of DIC and provide comprehensive care.

✘Incorrect answer options:

Thrombocytopenia. Thrombocytopenia, or a low platelet count, is a common finding in DIC due to the consumption of platelets in widespread clot formation.

Petechiae, injection site oozing, hematuria. These are classic signs of bleeding associated with DIC, indicative of the consumption of clotting factors and platelets.

Prolonged clotting times. Prolonged clotting times, such as increased prothrombin time (PT) and activated partial thromboplastin time (aPTT), are indicative of DIC as they reflect the depletion of clotting factors.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Focus on conditions that can impact placental health and blood pressure during pregnancy.

5 / 10

5. Which patient history would most likely indicate a higher risk for developing abruptio placentae?

A. A patient with a history of anemia.

B. A patient with a history of preeclampsia.

C. A patient with a history of gestational diabetes.

D. A patient with a history of urinary tract infections.

EXPLANATION

✔Correct answer:

A patient with a history of preeclampsia. Preeclampsia is a significant risk factor for abruptio placentae. Preeclampsia involves high blood pressure and often proteinuria and can affect the placental blood vessels, leading to placental abruption. The compromised blood flow and increased vascular pressure associated with preeclampsia can predispose the placenta to detach prematurely from the uterine wall.

Preeclampsia causes endothelial dysfunction, increased vascular resistance, and hypertension. These changes can damage the placental attachment and lead to abruptio placentae. The risk is especially high if preeclampsia is severe or poorly controlled.

Imagine a tree (placenta) with roots (blood vessels) that are tightly holding on to the soil (uterus). If the ground becomes unstable due to a storm (preeclampsia), the roots can be damaged, and the tree may uproot (placental abruption).

Nurse should monitor patients with a history of preeclampsia closely for signs of placental abruption and provide appropriate interventions to manage preeclampsia and reduce the risk of complications.

Monitor blood pressure regularly and manage hypertension as per medical guidelines.
Assess for signs of placental abruption, such as sudden onset of abdominal pain, uterine tenderness, and vaginal bleeding.
Educate the patient about the importance of regular prenatal check-ups and adherence to prescribed medications.
Ensure that the patient understands the signs and symptoms of both preeclampsia and placental abruption and knows when to seek immediate medical attention.
Collaborate with the healthcare team to develop a comprehensive care plan that includes monitoring and managing preeclampsia to minimize the risk of placental abruption.

✘Incorrect answer options:

A patient with a history of gestational diabetes. While gestational diabetes can lead to other complications such as macrosomia and birth trauma, it is not directly linked to an increased risk of abruptio placentae.

A patient with a history of urinary tract infections. Urinary tract infections, if recurrent and severe, can lead to preterm labor but are not a known risk factor for abruptio placentae.

A patient with a history of anemia. Anemia can complicate pregnancy but is not specifically a risk factor for placental abruption. It can exacerbate outcomes if abruption occurs but does not directly cause it.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Consider the seriousness of abruptio placentae, especially at term gestation, and the standard immediate intervention to prevent further complications for both the mother and the fetus.

6 / 10

6. Nurse Brown is caring for a client at term gestation who is experiencing moderate vaginal bleeding. An ultrasound confirms the presence of abruptio placentae. Understanding the urgency and potential complications of this condition, Nurse Brown prepares the client for the immediate next steps in management. What should Nurse Brown anticipate as the most appropriate course of action for this client?

A. Implementing strict monitoring of the client's intake and output.

B. Prescribing complete bed rest for the rest of the pregnancy.

C. Preparing the client for the delivery of the fetus.

D. Conducting weekly coagulation studies until delivery.

EXPLANATION

✔Correct answer:

Preparing the client for the delivery of the fetus. Abruptio placentae is a serious condition where the placenta detaches prematurely from the uterine wall, leading to significant maternal and fetal risks, including severe hemorrhage and fetal distress. In a client at term gestation with confirmed abruptio placentae and moderate vaginal bleeding, the priority is to prepare for immediate delivery. This course of action is necessary to prevent further complications and ensure the safety of both the mother and the fetus.

The detachment of the placenta compromises fetal oxygenation and can lead to rapid maternal blood loss. Immediate delivery is often required to stabilize the condition and minimize risks. The mode of delivery (vaginal vs. cesarean) will depend on the severity of the abruption, the status of the mother and fetus, and the clinical judgment of the healthcare team.

Imagine a car (the mother) carrying precious cargo (the baby) suddenly having severe engine trouble (abruptio placentae). The immediate priority is to get to a safe destination (delivery) as quickly as possible to prevent further damage and ensure safety.

Nurse Brown should focus on preparing the client for delivery while ensuring maternal and fetal well-being through continuous monitoring and supportive care.

Prepare the client for immediate delivery, whether vaginal or cesarean, based on the healthcare team's assessment.
Monitor maternal vital signs and fetal heart rate continuously to detect any signs of distress.
Establish and maintain IV access for potential fluid and blood product administration.
Ensure that the surgical team, anesthesia, and neonatal resuscitation team are informed and ready.
Provide emotional support and clear communication to the client and her family about the urgency and steps being taken.

✘Incorrect answer options:

Conducting weekly coagulation studies until delivery. While monitoring coagulation status is important, it is not the immediate priority in the setting of confirmed abruptio placentae with active bleeding. Immediate delivery takes precedence.

Prescribing complete bed rest for the rest of the pregnancy. Bed rest is not an appropriate response in the context of confirmed abruptio placentae with active bleeding at term. This condition requires urgent delivery to address the immediate risks.

Implementing strict monitoring of the client's intake and output. While monitoring intake and output is part of comprehensive care, it is not the most critical action in the immediate management of abruptio placentae. The priority is to deliver the fetus to prevent further complications.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Focus on the factor that has a documented association with a recurrent risk of the same obstetric complication in subsequent pregnancies.

7 / 10

7. Nurse Rogers is leading a prenatal class and discussing various risk factors for obstetric complications. When the topic of placental abruption comes up, she wants to emphasize a particular factor that significantly increases the likelihood of this serious condition. Which factor should Nurse Rogers highlight as increasing the risk of placental abruption?

A. Having a history of placental abruption.

B. Being younger than 35 years of age.

C. Having gestational diabetes.

D. Engaging in strenuous exercise.

EXPLANATION

✔Correct answer:

Having a history of placental abruption. One of the most significant risk factors for placental abruption is having a history of the condition in a previous pregnancy. Women who have experienced placental abruption before are at a higher risk of it occurring again in subsequent pregnancies. This risk is due to underlying factors that may predispose the individual to placental abnormalities, such as uterine scarring or chronic conditions that affect placental attachment and stability.

Placental abruption involves the premature separation of the placenta from the uterine wall, which can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and preterm birth. The exact cause is often multifactorial, involving both maternal and placental factors. A previous occurrence of abruption indicates a potential predisposition to these factors.

Think of it like a weak spot in a piece of fabric that has already torn once. Once there's been a tear, the fabric (uterus) is more likely to tear again at that spot (previous abruption) because it’s already been weakened.

Nurse Rogers should educate the class about the importance of disclosing previous obstetric history to their healthcare provider, as it can influence prenatal care and monitoring strategies.

Emphasize the importance of a detailed medical and obstetric history to identify those at increased risk.
Encourage regular prenatal visits for monitoring and early detection of potential complications.
Discuss the importance of avoiding risk factors such as smoking, drug use, and uncontrolled hypertension, which can further increase the risk of placental abruption.
Educate about the signs and symptoms of placental abruption, such as sudden onset of abdominal pain, vaginal bleeding, and uterine tenderness, and advise seeking immediate medical attention if they occur.

✘Incorrect answer options:

Having gestational diabetes. While gestational diabetes can lead to other complications, it is not a significant risk factor specifically for placental abruption.

Being younger than 35 years of age. Age younger than 35 is not a recognized risk factor for placental abruption. Advanced maternal age (older than 35) is more commonly associated with increased risks of various obstetric complications.

Engaging in strenuous exercise. Strenuous exercise is not typically linked to an increased risk of placental abruption. Moderate exercise is generally recommended and beneficial during pregnancy unless contraindicated by specific medical conditions.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Consider the symptoms specifically associated with abruptio placenta, particularly in terms of the nature and appearance of vaginal bleeding.

8 / 10

8. Nurse Taylor is caring for a client with a suspected diagnosis of abruptio placenta. She knows it's crucial to conduct a thorough assessment to identify the key signs of this condition. Which finding is Nurse Taylor most likely to observe in a client experiencing abruptio placenta?

A. A soft and non-tender abdomen upon palpation.

B. Bright red, painless bleeding from the vagina.

C. Easily felt fetal outline through the abdominal wall.

D. Concealed or externally visible dark red bleeding.

EXPLANATION

✔Correct answer:

Concealed or externally visible dark red bleeding. Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall. This condition often presents with dark red vaginal bleeding, which may be either concealed (bleeding trapped behind the placenta) or externally visible. The bleeding is usually accompanied by uterine tenderness and abdominal pain, as well as a tense, board-like abdomen due to the accumulation of blood within the uterine muscle.

The detachment of the placenta from the uterine wall disrupts blood vessels and leads to hemorrhage. The blood may collect behind the placenta (concealed) or flow out through the cervix (external). The dark red color of the blood is due to its venous origin, as opposed to the bright red arterial blood seen in conditions like placenta previa.

Think of abruptio placentae like a water balloon (the uterus) that has a tear inside (the placental detachment). Water (blood) can either stay trapped inside the balloon (concealed) or leak out (externally visible).

Nurse Taylor should monitor the client closely for these key symptoms and be prepared to take immediate action if abruptio placentae is confirmed.

Monitor maternal vital signs and fetal heart rate continuously to detect any signs of distress.
Assess the amount, color, and type of vaginal bleeding.
Palpate the abdomen for tenderness and evaluate for a tense, board-like uterus.
Prepare for potential emergency delivery if the condition is severe, to prevent further complications.
Provide emotional support and clear communication to the client and her family about the condition and necessary interventions.

✘Incorrect answer options:

Easily felt fetal outline through the abdominal wall. In cases of abruptio placentae, the abdomen is typically tense and tender, making it difficult to palpate and outline the fetus.

A soft and non-tender abdomen upon palpation. This finding is not consistent with abruptio placentae, as the condition usually involves a tense, board-like abdomen due to uterine irritability and trapped blood.

Bright red, painless bleeding from the vagina. This description is more characteristic of placenta previa, where the placenta is abnormally implanted near or over the cervical os, causing painless, bright red bleeding.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Consider the characteristic symptoms of abruptio placentae, including the nature of the pain and the type of bleeding.

9 / 10

9. A nurse is caring for a patient diagnosed with abruptio placentae. Which of the following assessment findings should the nurse expect?

A. Painless, dark brown vaginal bleeding.

B. Painful, dark red vaginal bleeding.

C. Painless, bright red vaginal bleeding.

D. Painful, bright red vaginal bleeding.

EXPLANATION

✔Correct answer:

Painful, dark red vaginal bleeding. Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which often leads to painful, dark red vaginal bleeding. The bleeding is usually dark red due to its venous origin and the presence of clotted blood behind the placenta. The associated pain and tenderness result from the uterine contractions and irritation caused by the bleeding.

In abruptio placentae, the detachment of the placenta causes blood to accumulate between the placenta and the uterine wall. This can lead to significant pain, uterine tenderness, and a rigid, board-like abdomen due to the irritation and pressure from the accumulated blood. The dark red color of the bleeding is indicative of older, clotted blood.

Think of the uterus as a water balloon with a thick layer inside representing the placenta. If a portion of that inner layer peels away suddenly, water (blood) will start to gather and press against the sides of the balloon. This pressure makes the balloon feel very tight and painful, and the trapped water becomes darker as it stagnates and clots.

Nurse should closely monitor the patient for the key signs of abruptio placentae and be prepared to take immediate action to manage the condition and prevent complications.

Monitor maternal vital signs and fetal heart rate continuously to detect any signs of distress.
Assess the amount, color, and type of vaginal bleeding.
Palpate the abdomen for tenderness and evaluate for a tense, board-like uterus.
Prepare for potential emergency delivery if the condition is severe, to prevent further complications.
Provide emotional support and clear communication to the patient and her family about the condition and necessary interventions.

✘Incorrect answer options:

Painless, bright red vaginal bleeding. This description is more characteristic of placenta previa, where the placenta is abnormally implanted near or over the cervical os, causing painless, bright red bleeding.

Painless, dark brown vaginal bleeding. Dark brown bleeding might indicate old blood, but it is typically painless and not characteristic of abruptio placentae, which involves painful bleeding.

Painful, bright red vaginal bleeding. While the bleeding in abruptio placentae is painful, it is usually dark red rather than bright red. Bright red bleeding is more indicative of arterial bleeding, such as in placenta previa.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

💡 Hint

Consider which option reflects a common symptom of placental abruption resulting from concealed bleeding into the uterus.

10 / 10

10. Jenna is a nurse caring for Sarah, a client in her second trimester who was admitted with suspected abruptio placentae. As part of her assessment, Jenna needs to identify key clinical manifestations of this condition. Which of the following would Jenna expect to observe if Sarah has abruptio placentae?

A. No abdominal pain.

B. Uterine tenderness and pain.

C. Painless bright red vaginal bleeding.

D. A soft, nontender abdomen.

EXPLANATION

✔Correct answer:

Uterine tenderness and pain. Abruptio placentae, also known as placental abruption, is characterized by the premature separation of the placenta from the uterine wall. Key clinical manifestations of this condition include uterine tenderness, pain, and often a tense, board-like abdomen. These symptoms result from the bleeding that occurs behind the placenta, causing irritation and contractions of the uterine muscle.

In abruptio placentae, the separation of the placenta leads to bleeding in the decidual layer between the placenta and the uterus. This bleeding can cause significant pain and tenderness as blood accumulates and the uterus becomes increasingly irritable. The condition can also lead to complications such as fetal distress and maternal hemorrhage.

Imagine a band-aid being pulled off from a wound. As it detaches, it causes discomfort and the wound beneath it can bleed, leading to pain and tenderness in the surrounding area, similar to how the placenta detaching causes pain and tenderness in the uterus.

Jenna should closely monitor Sarah for these key symptoms and be prepared to take immediate action if placental abruption is confirmed.

Monitor vital signs, including maternal heart rate and blood pressure, to assess for signs of shock or hemorrhage.
Continuously assess fetal heart rate to detect any signs of fetal distress.
Document the intensity, location, and duration of uterine pain and tenderness.
Prepare for potential emergency interventions, including immediate delivery if the condition worsens.
Provide emotional support and education to Sarah and her family about the condition and its potential complications.

✘Incorrect answer options:

A soft, nontender abdomen. A soft, nontender abdomen is not indicative of abruptio placentae. In this condition, the abdomen is typically tense and tender due to the irritation and bleeding in the uterine wall.

No abdominal pain. Absence of abdominal pain is not characteristic of abruptio placentae. Pain is a common and significant symptom of this condition due to the separation and associated bleeding.

Painless bright red vaginal bleeding. Painless bright red vaginal bleeding is more characteristic of placenta previa, not abruptio placentae. In abruptio placentae, bleeding is usually accompanied by significant pain and uterine tenderness.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. Lippincott Williams & Wilkins.

Nursing Care Plan

Ineffective Tissue Perfusion

Related to:

Excessive blood loss

Possibly evidenced by:

Loss of blood
FHR pattern
Altered BP compared to baseline
Altered PR Severe abdominal pain and rigidity
Pallor
Changes in LOC
Decrease urine output
Edema
Delay in wound healing
Positive Homan’s sign
Skin temperature changes

Desired outcome:

Nursing Interventions	Rationale
Assess patient’s vital signs, O2 saturation, and skin color.	For baseline data.
Monitor for restlessness, anxiety, hunger and changes in LOC	These conditions may indicate decreased cerebral perfusion
Monitor accurately I&O	To obtain data about renal perfusion and function and the extent of blood loss.
Monitor FHT continuously	To provide information regarding fetal distress and/or worsening of condition
Assess uterine irritability, abdominal pain and rigidity.	To determine the severity of the placental abruptio and bleeding
Assess skin color, temperature, moisture, turgor, capillary refill	To determine peripheral tissue perfusion like hypervolemia.
Elevate extremity above the level of the heart	Helps promote circulation.
Teach patient not to apply uterine pressure	Uterine pressure can cause pooling of venous blood in lower extremities
Instruct patient and/or SO to report immediately signs and symptoms of thrombosis: (1) pain in leg, groin (2) unilateral leg swelling (3) pale skin	To immediately provide additional interventions

Risk for Shock

Related to:

Significant blood loss of about 10% of the blood volume
Separation of the placenta
External or internal bleeding

Possibly evidenced by:

Vaginal bleeding
Couvelaire uterus or a tense and rigid uterus
Increased pulse rate
Decreased blood pressure
Increased respiratory rate
Decreased central venous pressure
Decreased urine output
Decreasing level of consciousness
Cold, clammy skin
Fetal bradycardia

Desired outcomes:

Patient will display hemodynamic stability.
Patient will regain vital signs within the normal range.
Patient will be able to verbalize understanding of disease process, risk factors, and treatment plan.
Patient will display a normal central venous pressure.
Patient’s skin is warm and dry.
Fetal heart rate is within normal range.
Patient will exhibit an adequate amount of urine output with normal specific gravity.
Patient will display the usual level of mentation.

Nursing Interventions	Rationale
Assess for history or presence of conditions leading to hypovolemic shock.	The condition may deplete the body’s circulating blood volume and the ability to maintain organ perfusion and function.
Monitor for persistent or heavy fluid or blood loss.	The amount of fluid or blood loss must be noted to determine the extent of shock.
Assess vital signs and tissue and organ perfusion.	For changes associated with shock states
Review laboratory data.	To identify potential sources of shock and degree of organ involvement.
Collaborate in prompt treatment of underlying conditions and prepare for or assist with medical and surgical interventions.	To maximize systemic circulation and tissue and organ perfusion.
Administer oxygen by appropriate route.	To maximize oxygenation of tissues.
Administer blood or blood products as indicated.	To rapidly restore or sustain circulating volume and electrolyte balance.
Monitor uterine contractions and fetal heart rate by external monitor.	Assesses whether labor is present and fetal status; external system avoids cervical trauma.
Withhold oral fluid.	Anticipates need for emergency surgery.
Measure intake and output.	Enables assessment of renal function.
Measure maternal blood loss by weighing perineal pads and save any tissue that has passed.	Provides objective evidence of amount bleeding.
Maintain a positive attitude about fetal outcome.	Supports mother-child bonding.
Provide emotional support to the woman and her support person.	Assists problem solving which is lessened by poor self-esteem.

Acute Pain

Related to:

Sudden separation of placenta from the uterine wall
Pain accompanying labor contractions during initial separation

Possibly evidenced by:

Sharp, stabbing pain high in the uterine fundus
Uterine tenderness

Desired outcomes:

Patient will report relief or control of pain.
Patient will follow prescribed pharmacological regimen.
Patient will verbalize non pharmacological methods that provide relief.
Patient will demonstrate use of relaxation skills and diversional activities as indicated.

Nursing Interventions	Rationale
Assess for referred pain as appropriate.	To help determine the possibility of underlying condition or organ dysfunction requiring treatment.
Note client’s locus of control.	Individuals with external locus of control may take little or no responsibility for pain management.
Note and investigate changes from previous reports of pain.	To rule out worsening of underlying condition or development of complications.
Acknowledge the client’s description of pain and convey acceptance of client’s response to pain.	Pain is a subjective experience and cannot be felt by others.
Monitor skin color and temperature and vital signs.	These are usually altered in acute pain.
Note when pain occurs.	To medicate as appropriate.
Provide comfort measures, quiet environment, and calm activities.	To promote non pharmacological pain management.
Administer analgesics as indicated.	To maintain an acceptable level of pain.
Encourage adequate rest periods.	To prevent fatigue.

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Notes

Description

Etiology

Pathophysiology

Assessment Findings

Nursing Management

Exam

Nursing Care Plan

Ineffective Tissue Perfusion

Related to:

Possibly evidenced by:

Desired outcome:

Risk for Shock

Related to:

Possibly evidenced by:

Desired outcomes:

Acute Pain

Related to:

Possibly evidenced by:

Desired outcomes:

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