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Exam (elaborations)

nursing 135 midterm study guide

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Ans *classification of abruptio placenta: class 0: asymptomatic; diagnosed after birth. -class 1: mild; most common, occurring 50% of cases -Class 2: moderate; both mother and fetus show signs of destress. (occur 30 5 of cases) -class 3: severe; maternal shock and fetal death likely; (occur 24% cases) Abruptio placentae Ans description: Premature separation of a normally implanted placenta from the uterine wall; may be a catastrophic event depending on the severity of the resulting hemorrhage, which may be vaginal or may be unseen because it collects in the uterus or abdomen. manifest: rigid and painful abdomen can occur any time during pregnancy bleeding can be apparent or occult uterine tension without rest interventions/ therapies:

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Institution
Nurs 135
Course
Nurs 135

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nursing 135 midterm study guide
Ans✓✓✓ *classification of abruptio placenta:
class 0: asymptomatic; diagnosed after birth.
-class 1: mild; most common, occurring 50% of cases
-Class 2: moderate; both mother and fetus show signs of destress.
(occur 30
5 of cases)
-class 3: severe; maternal shock and fetal death likely; (occur 24%
cases)


Abruptio placentae Ans✓✓✓ description:
Premature separation of a normally implanted placenta from the
uterine wall; may be a catastrophic event depending on the severity of
the resulting hemorrhage, which may be vaginal or may be unseen
because it collects in the uterus or abdomen.


manifest:
rigid and painful abdomen
can occur any time during pregnancy
bleeding can be apparent or occult
uterine tension without rest


interventions/ therapies:

, -Monitor uterine resting tone, which is frequently increased with
abruptio placentae (uterine resting tone is the pressure within the
uterus btw contractions. in a term woman is less than or equal to 20
mm Hg , and is assessed by palpating the uterus during and btw
contractions).


-Monitor abdominal girth measurements to determine internal blood
collection. (Uterine size increases as bleeding occurs at the separation
site. use a measuring tape at the umbilicus area to measure q 15
minutes)


-Monitor vital signs, hemoglobin and hematocrit, and urine output.


(amjor cause is HTN)


alterations in perfusion Ans✓✓✓ alterations in perfusion due to
(whatever reason) can lead to acute ventilation failure, which leads to
acute respiratory acidosis; which can be due to drug induces respiratory
depression, inadequate ventilation due to neuromuscular disease or
paralysis ,and airway obstruction.


alterations due to clotting disorders:
clotting disorders can result in excessive bleeding (in disseminated
intravascular coagulation) or excessive clotting (deep vein thrombosis).
-clotting can occur only if body have enough platelets and clotting
factors.

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Institution
Nurs 135
Course
Nurs 135

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