Sarah, a 34-year-old pregnant woman, has had a blood pressure consistently ranging from 140/90 to 160/98 since she was 26. Her weight gain and urinalysis have been normal.

What is this condition called? At 32 weeks’ gestation, Sarah experiences a seizure.

Her blood pressure has been elevated since 28 weeks, her urine dipstick shows 4+ protein, and she exhibits generalized edema.

What is this condition called?

Gestational hypertension; preeclampsia

Chronic hypertension; eclampsia

Gestational hypertension; eclampsia

Chronic hypertension; HELLP Syndrome

Answer and Explanation

The Correct Answer is B

Choice A rationale
Gestational hypertension is characterized by high blood pressure that develops after 20 weeks of pregnancy and typically resolves within a few weeks postpartum. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage.
However, Sarah’s condition does not fit this description because her blood pressure has been consistently high since she was 26, not just during pregnancy.
Choice B rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. Given Sarah’s history of consistent high blood pressure since age 26 and her recent seizure at 32 weeks’ gestation, this choice fits her condition.
Choice C rationale
Gestational hypertension refers to high blood pressure that begins during pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. However, Sarah’s high blood pressure did not begin during pregnancy, making this choice incorrect.
Choice D rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. HELLP Syndrome (Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels) is a serious health condition that can affect pregnant women3. However, Sarah’s symptoms do not indicate HELLP Syndrome, making this choice incorrect.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale
The nurse should be concerned about a client with an 18kg (4 lb) weight gain in her first trimester. This is because the expected weight gain for a client in the first trimester is usually around 1.8 kg (4 lb)1. A weight gain of 18 kg in the first trimester significantly exceeds this expectation, which could indicate a potential health issue such as gestational diabetes or multiple pregnancies. It’s important for the nurse to report this finding to the healthcare provider for further evaluation and management.
Choice B rationale
A client with a 68 kg (15 lb) weight gain in her second trimester does not necessarily pose a concern. Weight gain during pregnancy varies among individuals and can be influenced by factors such as the mother’s body mass index (BMI) before pregnancy, the baby’s growth rate, and the mother’s diet and lifestyle. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice C rationale
A client with a 13 kg (25 lb) weight gain in her third trimester does not necessarily pose a concern. Weight gain during the third trimester can be influenced by factors such as the baby’s growth rate, amniotic fluid volume, and the mother’s increased blood volume. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice D rationale
A client with a 3.6 kg (8 lb) weight gain in her first trimester does not necessarily pose a concern. This is within the expected weight gain range for the first trimester. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.

A. Low birth weight B. Appropriate for gestational age C. Large for gestational age D. Small for gestational age

Correct Answer is B

Explanation

Choice A rationale
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is attending to a group of clients. Which client’s weight gain should the nurse be concerned about?

Correct Answer is A

Explanation

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. How should the nurse classify this neonate based on the weight and gestational age?

Correct Answer is B

Explanation

A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor. What should be the nurse’s initial course of action?

A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?

A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight. What actions should the nurse plan to take? (Select all that apply.)

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

A nurse is caring for a laboring patient with an external fetal monitor. The nurse notices late decelerations on the monitor strip. What does the nurse interpret this as indicating?

A nurse is completing a newborn assessment and notices small white nodules on the roof of the newborn’s mouth. This finding is characteristic of which of the following conditions?