A nurse is caring for a client who is 34 weeks pregnant.

The nurse is reviewing the client’s electronic medical record to develop a care plan.

The nurse should take which of the following actions to address the condition the client is most likely experiencing, and monitor which parameters to assess the client’s progress.

Implement seizure precautions.

Check deep tendon reflexes every hour.

Administer prescribed methyldopa.

Monitor neurologic status.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.

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Correct Answer is A

Explanation

The correct answer is A. Shoulder dystocia. Retraction of the fetal head against the maternal perineum as the head is birthed is a classic sign of shoulder dystocia. This is a birth complication where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery.

A. Change the client’s position. B. Apply a fetal scalp electrode. C. Administer oxygen at 10 L/min via a nonrebreather mask. D. Increase the rate of the IV infusion. E. Increase the rate of the IV infusion.

Correct Answer is A

Explanation

Choice A rationale
Late decelerations in the Fetal Heart Rate (FHR) are a type of FHR pattern observed during labor, indicating a potential compromise of fetal well-being. They often begin just after a contraction, with their lowest point occurring after the peak of the contraction. These decelerations are associated with maternal and fetal conditions. Changing the client’s position can help alleviate the pressure on the fetus and improve blood flow, potentially reducing the occurrence of late decelerations. Therefore, the first action the nurse should take when noting late decelerations in the FHR is to change the client’s position.
Choice B rationale
Applying a fetal scalp electrode is a method used to monitor the FHR more accurately. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice C rationale
Administering oxygen can help increase the oxygen supply to the fetus. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice D rationale
Increasing the rate of the IV infusion can help improve uteroplacental perfusion. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which condition is the client most likely experiencing?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

The nurse caring for the pregnant patient understands that which hormone is essential for maintaining pregnancy?

A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor. What should be the nurse’s priority action?

A nurse midwife is examining a patient who is at 42 weeks of gestation and believes she is in labor. Which of the following findings would confirm to the nurse that the patient is in labor?

A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia. Which of the following observations should the nurse report to the healthcare provider?

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse in a healthcare provider’s office is caring for a patient who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?