Question

A nurse is assisting in the care of a client at 35 weeks of gestation who has preeclampsia with severe features and is scheduled for an immediate induction of labor after the manifestations worsened. The client is upset because the provider has disregarded their birth plan. Which of the following considerations should the nurse implement for the client?

Answer 1

Correct Answers:

Shared decision-making

Rationale :

💎 Shared decision-making is the best consideration because the client is upset that the provider has disregarded the birth plan, and the nurse should help preserve the client’s involvement in care decisions whenever possible.

💎 In severe preeclampsia, delivery is indicated after 34 weeks when maternal or fetal status worsens, so the urgency of induction is medically appropriate.

💎 Even when immediate delivery is necessary, the client still has the right to be included in discussions about labor preferences, comfort measures, and what parts of the birth plan can still be honored safely.

💎 ACOG emphasizes informed consent and shared decision-making in obstetric care, including during labor and delivery.

💎 This approach supports client autonomy, reduces distress, and promotes respectful maternity care while still protecting maternal and fetal safety.

Expectant management protocols

💎 Expectant management is generally considered only when the condition is stable and gestational age is less than 34 weeks.

💎 This client has worsening severe features at 35 weeks, so immediate delivery is more appropriate than delaying birth.

Method of birth

💎 The immediate issue is not primarily choosing cesarean versus vaginal birth, because the provider has already planned induction of labor, which means vaginal birth is still being pursued if safe.

💎 The more important nursing focus is helping the client participate in decisions within the current medical plan through shared decision-making.

Antenatal steroid administration

💎 Antenatal corticosteroids may be considered in some late-preterm deliveries, but they do not address the client’s emotional concern about the birth plan being disregarded.

💎 The key nursing consideration in this question is preserving the client’s role in care decisions, not selecting a medication strategy.

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Answer 2

Correct Answers:

A 41 -year-old client who is pregnant and experiencing no fetal movement.

Rationale :

🔷 Absent or decreased fetal movement is the priority because it can indicate compromised fetal well-being and may precede fetal death.

🔷 This finding requires immediate evaluation, especially in the third trimester, because delayed assessment can place the fetus at serious risk.

🔷 Guidance on fetal surveillance recognizes maternal perception of reduced movement as a significant warning sign that should not be ignored.

🔷 Telephone reports of no fetal movement should prompt urgent follow-up and further assessment such as fetal heart rate evaluation or testing.

🔷 Using priority frameworks, this client should be called first because the complaint suggests a potential threat to fetal life.

A 35-year-old client who is pregnant and experiencing a cough

🔷 A cough may need evaluation, but by itself it is usually not as urgent as a report of no fetal movement.

🔷 Unless accompanied by severe respiratory distress, fever, or other alarming symptoms, it is not the top priority in this group.

A 29-year-old client who is pregnant and experiencing nausea

🔷 Nausea is common in pregnancy and is usually not the most urgent complaint unless it is severe or associated with dehydration.

🔷 In this comparison, it does not outrank a report that the fetus is not moving.

A 33-year-old client who is pregnant and experiencing dysuria

🔷 Dysuria can suggest a urinary tract infection, which should be addressed because UTIs in pregnancy can lead to complications.

🔷 However, it is still less immediately urgent than absent fetal movement, which may signal acute fetal compromise.

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Answer 3

Correct Answers:

Reduce cerebral vasospasm.

Rationale :

🟣 The primary purpose of magnesium sulfate in HELLP syndrome and severe preeclampsia is seizure prophylaxis.

🟣 It works by depressing the central nervous system and helping reduce neurologic irritability associated with preeclampsia.

🟣 Reduced cerebral vasospasm helps lower the risk of eclamptic seizures, making this the best answer among the options given.

🟣 Magnesium sulfate is not mainly used to lower blood pressure or increase urine output.

🟣 In severe preeclampsia and HELLP syndrome, preventing seizures is a major priority because neurologic complications can be life-threatening.

Enhance fetal lung maturity

🟣 Corticosteroids, not magnesium sulfate, are used to promote fetal lung maturity when preterm delivery is anticipated.

🟣 Magnesium sulfate in this setting is given for maternal neurologic protection against seizures.

Stabilize blood pressure

🟣 Antihypertensive medications are used to manage severe hypertension in preeclampsia.

🟣 Magnesium sulfate may have mild effects on neuromuscular activity, but it is not the primary drug for blood pressure control.

Increase urine output

🟣 Magnesium sulfate is not administered to improve renal perfusion or increase urinary output.

🟣 In fact, urine output must be monitored carefully during infusion because impaired excretion can increase the risk of magnesium toxicity.

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Answer 4

Correct Answers:

"This monitor provides me with information related to the duration and frequency of your contractions."

Rationale :

🟢 An external toco transducer is used to monitor uterine activity during labor.

🟢 It provides information about the frequency and duration of contractions by detecting changes at the maternal abdominal wall.

🟢 External monitoring does not accurately measure contraction intensity, which is why this answer is the most correct.

🟢 If exact contraction strength is needed, an internal uterine pressure catheter is more accurate.

🟢 Explaining the device correctly helps the client understand what the nurse can and cannot learn from the monitor.

"This monitor measures the intensity and frequency of your contractions so I can observe labor progress."

🟢 A toco transducer can identify frequency, but it does not reliably measure intensity.

🟢 Saying it measures strength is inaccurate and could mislead the client about the device’s purpose.

"This monitor gives me information related to fetal heart rate fluctuations during your labor."

🟢 Fetal heart rate is monitored by the ultrasound transducer, not by the TOCO device.

🟢 The TOCO transducer specifically evaluates uterine contractions.

"This monitor allows me to observe your labor progress. By observing the pattern, I can tell how strong your contractions are."

🟢 Although contraction patterns help assess labor, an external TOCO does not tell the nurse exactly how strong the contractions are.

🟢 That statement confuses contraction pattern monitoring with direct measurement of contraction intensity.

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Answer 5

Correct Answers:

Increased client cardiac output

Rationale :

🟠 During labor, maternal cardiac output increases, including during the first stage, as blood is autotransfused back into circulation with uterine contractions.

🟠 This rise in cardiac output helps support uteroplacental perfusion, which promotes fetal oxygen delivery.

🟠 Better maternal circulation improves the availability of oxygenated blood to the placenta between contractions.

🟠 This is a normal physiologic adaptation that helps the fetus tolerate labor.

🟠 For that reason, increased client cardiac output is the adaptation most associated with promoting fetal oxygenation.

Elevated client blood pressure during contractions

🟠 Blood pressure may rise somewhat during contractions, but that is not the key adaptive mechanism that most directly promotes fetal oxygenation.

🟠 Excessive maternal hypertension can actually worsen placental perfusion rather than improve it.

Decrease in client blood volume

🟠 A decreased maternal blood volume would reduce circulatory support to the placenta.

🟠 That change would impair, not promote, fetal oxygenation.

Client bradypnea

🟠 Bradypnea would decrease maternal ventilation and may reduce available oxygen.

🟠 Slower respirations do not support fetal oxygenation during labor.

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Answer 6

Correct Answers:

Blurred vision

Rationale :

🔴 Blurred vision is a warning sign of preeclampsia with severe features and should be reported promptly.

🔴 Visual disturbances occur because preeclampsia can affect the neurologic and vascular systems, including cerebral and retinal circulation.

🔴 ACOG identifies blurred vision and other visual changes as concerning symptoms in hypertensive disorders of pregnancy.

🔴 This finding is much more serious than common discomforts of late pregnancy such as constipation, leukorrhea, or low back pain.

🔴 Prompt reporting is necessary because worsening preeclampsia can rapidly progress to eclampsia, stroke, or fetal compromise.

Leukorrhea

🔴 Mild leukorrhea is a common physiologic finding in pregnancy due to hormonal changes and increased vaginal secretions.

🔴 It does not usually require urgent provider notification unless it has an abnormal odor, color, or is associated with infection symptoms.

Constipation

🔴 Constipation is common in pregnancy because progesterone slows gastrointestinal motility.

🔴 While it should be managed, it is not as urgent as blurred vision, which may indicate severe maternal disease.

Low back pain

🔴 Low back pain is also common in the third trimester due to postural changes and ligament relaxation.

🔴 It is expected discomfort unless accompanied by labor, neurologic deficits, or other concerning findings.

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Answer 7

Correct Answers:

"It helps me identify your baby's position in the uterus."

Rationale :

🟡 Leopold maneuvers are abdominal palpation techniques used to determine the fetus’s position, lie, and presentation.

🟡 Knowing the fetal position helps the nurse decide where to best auscultate the fetal heart rate.

🟡 These maneuvers also help anticipate labor considerations, such as whether the presenting part is cephalic or breech.

🟡 Although Leopold maneuvers may provide a rough idea about fetal size, their primary purpose is identifying fetal orientation in the uterus.

🟡 That makes the response about identifying the baby’s position the most accurate explanation.

"It helps me determine if you are having contractions."

🟡 Contractions are assessed mainly by palpation during the contraction itself or by uterine monitoring devices such as a TOCO transducer.

🟡 Leopold maneuvers are not primarily used to determine whether contractions are present.

"It helps me measure how high the top of your uterus is."

🟡 Measuring the height of the uterus is done with fundal height measurement, not Leopold maneuvers.

🟡 Leopold maneuvers focus on fetal presentation and position rather than uterine height.

"It helps me estimate how much your baby currently weighs."

🟡 Leopold maneuvers can contribute only a rough estimate of fetal size, but that is not their main purpose in this situation.

🟡 The major reason for performing them before auscultation is to locate the fetus’s position so heart tones can be found more accurately.

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Answer 8

Correct Answers:

Client dehydration

Rationale :

⚫ A fetal heart rate baseline of 180/min indicates fetal tachycardia.

⚫ Maternal dehydration is a recognized cause of fetal tachycardia because reduced maternal circulating volume can affect uteroplacental perfusion.

⚫ This client has had vomiting and diarrhea for 48 hours, making dehydration the most likely associated factor.

⚫ In this context, correcting maternal fluid status is an important part of managing the fetal heart rate abnormality.

⚫ The fetal tachycardia is therefore most consistent with maternal dehydration rather than prematurity or prolonged fetal activity.

Prematurity

⚫ At 36 weeks, the fetal baseline can be slightly higher than at term, but a sustained baseline of 180/min is still abnormal.

⚫ Prematurity alone does not best explain this tachycardia in a client with significant fluid losses.

Fetal cardiac anomalies

⚫ Cardiac anomalies can contribute to arrhythmias, but the question provides a much more obvious and immediate explanation through maternal vomiting and diarrhea.

⚫ The clinical picture points first to dehydration rather than congenital cardiac disease.

Prolonged fetal activity

⚫ Fetal activity can cause temporary accelerations, but it does not usually produce a sustained baseline tachycardia of 180/min.

⚫ A persistent elevated baseline is more concerning for a physiologic stressor such as maternal dehydration.

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Answer 9

Correct Answers:

Decreased fetal movement

Rationale :

⭐ Decreased fetal movement requires immediate follow-up because it may indicate reduced fetal oxygenation or other fetal compromise.

⭐ Maternal perception of reduced movement is an important clinical sign and is associated with increased risk of adverse fetal outcomes.

⭐ Professional guidance recommends prompt assessment when decreased movement is reported, often with fetal surveillance such as NST or BPP.

⭐ This is more urgent than common third-trimester findings like urinary frequency, leg edema, or periodic contractions.

⭐ Immediate follow-up is essential because timely evaluation may identify a fetus in distress before deterioration occurs.

Urinary frequency

⭐ Urinary frequency is common in late pregnancy because of fetal pressure on the bladder.

⭐ It is usually expected and does not require immediate follow-up unless there are signs of infection or urinary retention.

Edema in lower extremities

⭐ Mild dependent edema is a common finding in the third trimester.

⭐ It becomes more concerning when associated with facial edema, hypertension, or other signs of preeclampsia, but alone it is not as urgent as decreased fetal movement.

Periodic contractions

⭐ Intermittent contractions can occur in late pregnancy as Braxton Hicks contractions or with early labor changes.

⭐ Without other signs of labor or distress, they are not the most urgent finding in this list.

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Answer 10

Correct Answers:

Administer ondansetron.

Rationale :

✨ Nausea is a common adverse effect of opioid medications such as fentanyl.

✨ Ondansetron is an antiemetic that is used to treat nausea and vomiting by blocking serotonin activity at 5-HT3 receptors.

✨ Giving an antiemetic directly addresses the client’s symptom while allowing pain management to continue if otherwise appropriate.

✨ Oxygen is not indicated simply for nausea, and ambulation may worsen discomfort or create safety concerns in a laboring client who has received an opioid.

✨ Therefore, administering ondansetron is the most appropriate nursing intervention for opioid-related nausea in labor.

Switch the client to morphine

✨ Morphine is also an opioid and can cause similar gastrointestinal side effects, including nausea.

✨ Changing to another opioid does not directly solve the problem and may expose the client to additional adverse effects.

Apply oxygen

✨ Oxygen is used when there is evidence of maternal hypoxia or fetal compromise, not as routine treatment for medication-induced nausea.

✨ This intervention does not specifically address the cause of the client’s symptom.

Encourage the client to ambulate

✨ Ambulation is not the priority after opioid administration when the client is nauseated and in labor.

✨ Opioids can cause dizziness or sedation, so encouraging walking may increase the risk of falls rather than relieve the nausea.

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QLexNursing

2 :
A nurse in an obstetric clinic has received messages from four clients. Which of the following clients should the nurse call first?

3 :
A nurse is assisting in the care of a client who has HELLP syndrome and needs a magnesium sulfate infusion. Which of the following reasons should the nurse identify as the primary purpose of administering magnesium sulfate?

4 :
A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?

5 :
A nurse is discussing fetal oxygenation during labor of a client with the RN. As the client progresses through the first stage of labor, which of the following client physiologic adaptations should the nurse identify as promoting fetal oxygenation?

6 :
A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

7 :
A nurse is performing Leopold Maneuvers prior to auscultating the fetal heart rate for a client who is at 30 weeks of gestation. The client asks, "Why do you feel around on my belly first?" Which of the following responses should the nurse make?

9 :
A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following findings requires immediate follow-up?

10 :
A nurse administers fentanyl to a client in labor for pain management. The client reports nausea. Which of the following interventions should the nurse provide?

QLexNursing

2 : A nurse in an obstetric clinic has received messages from four clients. Which of the following clients should the nurse call first?

3 : A nurse is assisting in the care of a client who has HELLP syndrome and needs a magnesium sulfate infusion. Which of the following reasons should the nurse identify as the primary purpose of administering magnesium sulfate?

4 : A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?

5 : A nurse is discussing fetal oxygenation during labor of a client with the RN. As the client progresses through the first stage of labor, which of the following client physiologic adaptations should the nurse identify as promoting fetal oxygenation?

6 : A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

7 : A nurse is performing Leopold Maneuvers prior to auscultating the fetal heart rate for a client who is at 30 weeks of gestation. The client asks, "Why do you feel around on my belly first?" Which of the following responses should the nurse make?

9 : A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following findings requires immediate follow-up?

10 : A nurse administers fentanyl to a client in labor for pain management. The client reports nausea. Which of the following interventions should the nurse provide?

2 :
A nurse in an obstetric clinic has received messages from four clients. Which of the following clients should the nurse call first?

3 :
A nurse is assisting in the care of a client who has HELLP syndrome and needs a magnesium sulfate infusion. Which of the following reasons should the nurse identify as the primary purpose of administering magnesium sulfate?

4 :
A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?

5 :
A nurse is discussing fetal oxygenation during labor of a client with the RN. As the client progresses through the first stage of labor, which of the following client physiologic adaptations should the nurse identify as promoting fetal oxygenation?

6 :
A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

7 :
A nurse is performing Leopold Maneuvers prior to auscultating the fetal heart rate for a client who is at 30 weeks of gestation. The client asks, "Why do you feel around on my belly first?" Which of the following responses should the nurse make?

9 :
A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following findings requires immediate follow-up?

10 :
A nurse administers fentanyl to a client in labor for pain management. The client reports nausea. Which of the following interventions should the nurse provide?