A patient’s lab results are as follows: BUN level is 8 mg/dL, Hemoglobin is 15 g/dL, Hematocrit is 47%, WBC count is 9,000/mm, Platelet count is 140,000/mm, Creatinine is 1.3 mg/dL, Bilirubin is 20 mg/dL, Aspartate aminotransferase (AST) is 36 units/L, and Alanine aminotransferase (ALT) is 40 units/L. What actions should be taken?

Implement seizure precautions.

Check deep tendon reflexes every hour.

Review the daily logs of the patient.

Obtain a prescription for methyldopa.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Implementing seizure precautions is not necessary based on these lab results. Seizure precautions are typically implemented for patients with a known seizure disorder or those who are at risk for seizures, such as patients with severe preeclampsia or eclampsia, neither of which can be diagnosed based on these lab results.
Choice B rationale
Checking deep tendon reflexes every hour is not indicated based on these lab results. This action is typically taken for patients with altered neurological status or those receiving certain medications that can affect muscle tone.
Choice C rationale
Reviewing the daily logs of the patient is a good practice in general to monitor the patient’s progress and response to treatment. However, it is not a specific action that should be taken based on these lab results.
Choice D rationale
Obtaining a prescription for methyldopa is not indicated based on these lab results.
Methyldopa is a medication used to treat high blood pressure, and there is no indication from these lab results that the patient has high blood pressure.

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Correct Answer is B

Explanation

Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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 in a provider’s office is caring for a client who is pregnant. Which of the following assessment findings should the nurse report to the provider? (Select all that apply)

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 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?

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)

50 grams of Magnesium sulfate is added to 1L of Lactated Ringers. After giving an initial loading dose, the nurse is to infuse a maintenance dose of 2 gm/hr. What rate should the IV pump be set at?