A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Elevated blood pressure

Increased urine output

Joint pain

Vaginal discharge

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevated blood pressure is a hallmark sign of preeclampsia, which is a hypertensive disorder of pregnancy that can cause serious complications, such as eclampsia, HELLP syndrome, or placental abruption. The nurse should monitor the client's blood pressure regularly and report any readings above 140/90 mm Hg to the provider.

Choice B reason: Increased urine output is not a sign of preeclampsia, but rather a normal physiological change of pregnancy, as the renal blood flow and glomerular filtration rate increase. A client with preeclampsia may have decreased urine output, which can indicate renal impairment or oligohydramnios.

Choice C reason: Joint pain is not a sign of preeclampsia, but rather a common discomfort of pregnancy, as the hormones relaxin and progesterone loosen the ligaments and joints. A client with preeclampsia may have epigastric pain, which can indicate liver involvement or impending eclampsia.

Choice D reason: Vaginal discharge is not a sign of preeclampsia, but rather a normal occurrence of pregnancy, as the cervical glands secrete more mucus to protect the uterus from infection. A client with preeclampsia may have vaginal bleeding, which can indicate placental abruption or disseminated intravascular coagulation.

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Correct Answer is A

Explanation

Choice A reason: Respiratory rate is the priority nursing assessment for this client, because magnesium sulfate can cause respiratory depression, which is a life-threatening complication. The nurse should monitor the client's respiratory rate closely, and discontinue the infusion if it falls below 12 breaths per minute.

Choice B reason: Bowel sounds is not a priority nursing assessment for this client, because magnesium sulfate does not have a significant effect on the gastrointestinal system. The nurse should assess the client's bowel sounds as part of the routine physical examination, but it is not a critical parameter for this medication.

Choice C reason: Time of last food intake is not a priority nursing assessment for this client, because magnesium sulfate does not interact with food or affect the absorption of nutrients. The nurse should inquire about the client's dietary intake and preferences, but it is not a vital factor for this medication.

Choice D reason: Temperature is not a priority nursing assessment for this client, because magnesium sulfate does not cause fever or hypothermia. The nurse should measure the client's temperature as part of the vital signs, but it is not a key indicator for this medication.

A. Primigravida in spontaneous labor with preterm twins B. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress C. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor D. Woman with severe preeclampsia on magnesium sulfate whose labor is being induced

Correct Answer is C

Explanation

Choice A reason: Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.

Choice B reason: Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.

Choice C reason: Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.

Choice D reason: Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.

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A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is A

Explanation

Which client is at greatest risk for early postpartum hemorrhage (PPH)?

Correct Answer is C

Explanation

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

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A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?