The clinic nurse’s patient is 21 weeks pregnant. Her blood pressure is 168/100. Blood pressures in prior visits have all been normal. Her urine sample shows trace protein. What other questions or procedures might you ask/perform to determine if your patient is pre-eclamptic. (Select all that apply)

Do you have any headaches or blurry vision?

I am going to check your reflexes now

Have you been having trouble with urinary incontinence?

Do you have any right upper quadrant pain?

Have you had any nausea or vomiting recently?

Do you feel safe at home?

Answer and Explanation

Correct Answer : A,B,D

A. Do you have any headaches or blurry vision? Headaches and blurry vision are common neurological symptoms of preeclampsia. These occur due to cerebral edema and hypertension-related vascular changes. Persistent headaches or visual disturbances (such as seeing spots or flashing lights) warrant further evaluation.

B. I am going to check your reflexes now. Hyperreflexia (brisk deep tendon reflexes) is a key neurological sign of worsening preeclampsia. Severe hyperreflexia can indicate impending eclampsia and increased seizure risk. Checking for clonus (involuntary rhythmic muscle contractions) is also important.

C. Have you been having trouble with urinary incontinence? Urinary incontinence is not a sign of preeclampsia. However, decreased urine output (oliguria) would be concerning as it may indicate worsening renal impairment, but incontinence itself is unrelated.

D. Do you have any right upper quadrant pain? Right upper quadrant or epigastric pain is a concerning sign of liver involvement in severe preeclampsia or HELLP syndrome. It occurs due to liver swelling and can be a precursor to serious complications such as hepatic rupture.

E. Have you had any nausea or vomiting recently? While nausea and vomiting are common in pregnancy, they are not defining symptoms of preeclampsia unless they are sudden and severe. If present in the third trimester, they may suggest worsening disease, but they are not primary indicators.

F. Do you feel safe at home? Screening for domestic violence is important in pregnancy, but it is not a diagnostic question for preeclampsia. While stress and abuse can impact blood pressure, this question does not help in determining preeclampsia.

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Correct Answer is B

Explanation

A. "An ectopic pregnancy does not need major treatment and can be delivered vaginally." This statement is incorrect. An ectopic pregnancy involves the fertilized ovum implanting outside the uterus, most commonly in a fallopian tube, which poses serious risks to the mother. The pregnancy cannot be carried to term, and it requires prompt medical intervention, such as medication or surgery, to prevent life-threatening complications.
B. "An ectopic pregnancy involves a fertilized ovum outside the uterus that cannot be transferred to the uterus." This is an accurate explanation of an ectopic pregnancy. The fertilized egg implants outside the uterus, most commonly in the fallopian tubes, and cannot develop into a viable pregnancy. The condition requires immediate treatment to prevent tube rupture and internal bleeding.
C. "An ectopic pregnancy involves a cancerous fertilized ovum in either fallopian tube." This is incorrect. An ectopic pregnancy is not cancerous. It refers to a pregnancy where the fertilized ovum implants in an abnormal location outside the uterus, most commonly the fallopian tubes, not involving cancerous growth.
D. "An ectopic pregnancy involves a fertilized ovum in the vagina." This statement is incorrect. An ectopic pregnancy occurs when the fertilized ovum implants outside the uterus, but it does not implant in the vagina. The condition most commonly involves the fallopian tubes but can also occur in other locations such as the cervix, ovary, or abdominal cavity.

A. Uterine prolapse. B. Uterine rupture. C. Precipitous labor. D. Amniotic fluid embolus.

Correct Answer is B

Explanation

A. Uterine prolapse. Uterine prolapse occurs when the uterus descends into or outside the vagina, usually postpartum due to weakened pelvic support. It does not present with sudden, severe pain or fetal heart rate abnormalities during labor.

B. Uterine rupture. A tearing sensation, sudden severe pain, fetal heart rate abnormalities, pallor, and diaphoresis are hallmark signs of uterine rupture. This is a life-threatening emergency where the uterine wall tears, often due to prior cesarean scars, excessive oxytocin use, or grand multiparity. Immediate intervention, including emergency surgery, is required to prevent maternal and fetal death.

C. Precipitous labor. Precipitous labor is rapid labor and delivery within three hours and is not associated with severe, tearing pain. While it can cause fetal distress, it does not typically involve uterine rupture symptoms.

D. Amniotic fluid embolus. An amniotic fluid embolus presents with sudden respiratory distress, hypotension, and cardiovascular collapse due to amniotic fluid entering the maternal circulation. It does not typically cause localized severe abdominal pain or fetal distress due to uterine rupture.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been admitted to the emergency department with a suspected diagnosis of ectopic pregnancy. How should the nurse explain this condition to the patient?

Correct Answer is B

Explanation

During augmentation of labor with intravenous oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic and complains of severe lower abdominal pain with a tearing sensation. An abnormal FHR tracing is noted on the monitor. The nurse should suspect:

Correct Answer is B

Explanation

The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.

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 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)

To assist with an induction of labor which of these medications can be used? Select all that apply

During a vaginal delivery the midwife tells you that a shoulder dystocia has occurred. Which of the following initial nursing actions is appropriate at this time?

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 comes in to her physician’s office at 16 weeks of pregnancy complaining of headache. On examination her Blood Pressure is 169/94. As the physician looks over her record he notices that she has a prior history of hypertension. He explains to her that she has