A primigravida who is 28 weeks pregnant visits the clinic fearing she is experiencing preeclampsia. Which of the following assessments would the nurse make to confirm or negate these thoughts? Select all that apply.

Right Sided Epigastric pain

Uterine contractions

Bright red painless vaginal bleeding

Severe headache

Visual disturbances

Dull back ache

Answer and Explanation

Correct Answer : A,D,E

A. Right-sided epigastric pain. Epigastric pain, especially on the right side, is a concerning sign of preeclampsia and may indicate liver involvement due to elevated liver enzymes or HELLP syndrome. This symptom should be assessed further as it suggests worsening disease progression.

B. Uterine contractions. Uterine contractions are not a defining feature of preeclampsia. They are more commonly associated with preterm labor rather than hypertension-related complications. While preeclampsia can lead to preterm birth, contractions alone do not confirm or negate the condition.

C. Bright red painless vaginal bleeding. Bright red painless vaginal bleeding is more indicative of placenta previa or another obstetric complication rather than preeclampsia. Preeclampsia primarily presents with hypertension, proteinuria, and systemic symptoms rather than vaginal bleeding.

D. Severe headache. A severe headache is a classic symptom of preeclampsia, often due to elevated blood pressure and cerebral edema. Persistent headaches that do not resolve with usual interventions should be evaluated promptly as they may indicate worsening hypertension or an impending seizure.

E. Visual disturbances. Visual disturbances such as blurred vision, photophobia, or seeing spots are common in preeclampsia and can signal cerebral edema or increased intracranial pressure. This is a significant warning sign requiring immediate assessment.

F. Dull backache. A dull backache is more commonly associated with musculoskeletal strain, labor, or a urinary tract infection rather than preeclampsia. While discomfort can be present in pregnancy, it is not a defining symptom of preeclampsia.

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Correct Answer is D

Explanation

A. Call for a STAT magnesium level. While obtaining a magnesium level is important to confirm magnesium toxicity, the priority action is to stop or reduce the infusion immediately to prevent further toxicity and respiratory depression.

B. Do nothing, this is the expected action of magnesium. Absent deep tendon reflexes, lethargy, and respiratory depression (RR 9) are signs of magnesium toxicity, not expected therapeutic effects. Immediate intervention is necessary to prevent worsening respiratory and cardiac complications.

C. Prepare to administer hydralazine. Hydralazine is used to treat hypertension in preeclampsia, but this patient’s blood pressure is not critically high, and the primary concern is magnesium toxicity, not hypertension. Administering hydralazine would not address the immediate life-threatening issue.

D. Decrease or Discontinue the magnesium sulfate infusion. The first action in magnesium toxicity is to stop or reduce the infusion to prevent further accumulation. If symptoms worsen, calcium gluconate, the antidote for magnesium toxicity, may be administered to reverse its effects, especially if respiratory depression progresses.

A. True B. False

Correct Answer is A

Explanation

True.

When supporting a woman who has just experienced a fetal demise, it is appropriate and compassionate to:

Offer supportive care.
Allow and encourage space and time to grieve.
Offer the services of a chaplain, especially if the patient expresses a desire for spiritual or emotional support.

Chaplains are typically trained to be non-denominational and sensitive to a wide range of beliefs, and they can provide comforting words and presence regardless of the patient’s faith or lack thereof. This approach aligns with holistic and patient-centered care.

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A primigravida who is 28 weeks pregnant visits the clinic fearing she is experiencing preeclampsia. Which of the following assessments would the nurse make to confirm or negate these thoughts? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

When working with a woman who has just experienced a fetal demise you should offer supportive care, give her the opportunity to grieve, and provide for a chaplain to come in if the patient wants one. You know that the Chaplain is non-denominational and can also provide comforting words.

Correct Answer is A

Explanation

A woman who is 26 weeks pregnant has just found out that she has gestational diabetes. Which of the following therapies will most likely be ordered first for this patient?

A pregnant woman is just admitted to the emergency room after a head on auto accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which complication(s) of pregnancy? (Select all that apply)

A 26-year old having her first baby is 28 weeks pregnant. She experiences bright red, painless vaginal bleeding, soaking one pad. Upon her arrival at the hospital, after placing her on the FHR Monitor, what would be an expected diagnostic procedure?

A patient is 3 days post c-section delivery for eclampsia. The client is receiving hydralazine (Apresoline). Which of the following would indicate that the medication is effective?

A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary health care practitioner?

A client has been admitted to the labor and delivery suite for induction of labor for post-term pregnancy. Misoprostol (Cytotec) has been inserted. Which of the following findings would warrant stopping the Cytotec treatment?

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to:

A client is receiving (Pitocin) oxytocin to induce labor. The nurse should monitor for which of the following adverse maternal effects?