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 B

Explanation

The correct answer is Choice B.
Choice A rationale
Variable decelerations are not related to fetal head compression. Fetal head compression typically results in early decelerations, not variable ones.
Choice B rationale
Variable decelerations are indeed due to umbilical cord compression. They are quick decreases in fetal heart rate that vary with uterine contractions. This can be a sign that the baby’s blood flow is reduced if variable decelerations happen over and over.
Choice C rationale
Uteroplacental insufficiency typically results in late decelerations, not variable ones. Late decelerations are a sign of fetal hypoxia and are associated with uteroplacental insufficiency.
Choice D rationale
While certain medications can affect the fetal heart rate, variable decelerations are not typically a result of the administration of narcotic analgesics.

A. A patient at 28 weeks of gestation receiving terbutaline reports fine tremors. B. A tearful patient at 32 weeks of gestation is experiencing irregular, frequent contractions. C. A patient diagnosed with preeclampsia reports epigastric pain and an unresolved headache. D. A patient diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes.

Correct Answer is C

Explanation

Choice A rationale
A patient at 28 weeks of gestation receiving terbutaline may report fine tremors. This is a common side effect of terbutaline, which is a medication used to relax the muscles in the uterus to prevent premature labor. However, while it may be uncomfortable for the patient, it is not typically a cause for immediate concern.
Choice B rationale
A tearful patient at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing Braxton Hicks contractions, which are often referred to as “false labor.”. These contractions are usually irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of pregnancy and do not typically require immediate medical attention. Choice C rationale
A patient diagnosed with preeclampsia reporting epigastric pain and an unresolved headache should be reported to the healthcare provider immediately. These symptoms could indicate severe preeclampsia, which can lead to serious complications if not treated promptly. Epigastric pain may suggest liver involvement, and a persistent headache could be a sign of neurological involvement, both of which require immediate medical attention.
Choice D rationale
A patient diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes is expected. Proteinuria is a common symptom of preeclampsia, and hyperreflexia can be a sign of increased neurological excitability, a common feature of preeclampsia. However, these findings alone do not typically require immediate medical attention.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the first stage of labor who is undergoing external fetal monitoring and receiving IV fluids. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is the correct interpretation of this finding

Correct Answer is B

Explanation

A nurse is caring for a group of patients on an intrapartum unit. Which of the following findings should be reported to the healthcare provider immediately?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. Which of the following medications should the nurse anticipate a prescription from the provider for the client?

A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders. Which of the following orders requires clarification?

A nurse in a prenatal clinic is caring for a pregnant client who inquires about her estimated date of birth (EDB). If the client’s last menstrual period started on July 27, what would be the client’s EDB? (Provide the date in MMDD format. For example, July 27 is 0727) .

A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)

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?

A nurse is preparing to administer methylergonovine IM to a client who has just had a vaginal delivery. The nurse should inform the client that this medication is intended to prevent which of the following conditions?