A nurse is caring for a client who is at 34 weeks of gestation.

The client reports headache, dizziness, and blurred vision for 1 week.

The nurse notes 3+ edema in lower extremities and deep tendon reflexes (DTRs) 3+ with positive clonus.

The fetal heart rate (FHR) is 140 with minimal variability.

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

Which condition is the client most likely experiencing, what are two actions the nurse should take to

Preeclampsia

Chronic hypertension

Neurologic status

Liver function studies

Answer and Explanation

The Correct Answer is A

Choice A rationale
The client’s symptoms of headache, dizziness, blurred vision, 3+ edema in lower extremities, deep tendon reflexes (DTRs) 3+ with positive clonus, and a fetal heart rate (FHR) of 140 with minimal variability are indicative of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious complications for both the mother and baby. To address this condition, the nurse should: Monitor the client’s blood pressure regularly. Administer prescribed medications to control blood pressure and prevent seizures. 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
Chronic hypertension is a possibility, but it does not fully explain the client’s symptoms. While chronic hypertension can cause headaches and dizziness, it does not typically cause 3+ edema in the lower extremities or positive clonus. Furthermore, chronic hypertension would have been present before the pregnancy or diagnosed before the client reached 20 weeks of gestation.
Choice C rationale
While the client’s symptoms of headache, dizziness, and blurred vision could suggest a neurologic issue, the presence of 3+ edema in the lower extremities and positive clonus are more indicative of preeclampsia. Neurologic status would be monitored as part of the care for a client with preeclampsia.
Choice D rationale
Liver function studies would be relevant if there were symptoms or signs suggesting liver involvement such as upper right abdominal pain, nausea or vomiting, or jaundice. However, the client’s symptoms are more indicative of preeclampsia.

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Correct Answer is D

Explanation

Choice A rationale
Hypomagnesemia, or low magnesium levels, is not typically a primary concern for newborns of mothers with diabetes mellitus. While it can occur, it is not the priority focus of care.
Choice B rationale
Hyperbilirubinemia, or high bilirubin levels, can lead to jaundice in newborns. However, it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
Choice C rationale
Hypocalcemia, or low calcium levels, can occur in newborns, but it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.

A. Amniotic fluid present in the vaginal vault. B. Cervical dilation observed. C. Brownish vaginal discharge noted. D. Patient reports pain above the umbilicus.

Correct Answer is B

Explanation

Cervical dilation is a key sign that a patient is in labor. As labor progresses, the cervix dilates to allow the baby to pass through the birth canal. Other signs of labor can include regular contractions, rupture of membranes (amniotic fluid present in the vaginal vault), and changes in vaginal discharge.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

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 is caring for a client who is at 36 weeks of gestation and suspected of having placenta previa. Which of the following symptoms would support this diagnosis?

A nurse is attending to a patient in labor who has received an epidural anesthesia block. The patient’s blood pressure reads 80/40 mm Hg and the fetal heart rate is 140/min. What should be the nurse’s immediate course of action?

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?