Question

A nurse is caring for a client at 34 weeks of gestation who has been diagnosed with preeclampsia without severe features. When reviewing the client's prenatal laboratory values, the nurse discovers the client's clotting factors have slowly decreased during the pregnancy. What pathophysiologic responses are responsible for the client's current laboratory values? (Select All that Apply.)

Answer 1

Correct Answers:

Vasoconstriction
Vasospasms
Client end-organ damage

Rationale :

Vasoconstriction

🔷 Vasoconstriction is correct because preeclampsia involves widespread endothelial dysfunction that leads to increased vascular tone and narrowing of blood vessels.

🔷 This abnormal vasoconstriction decreases organ perfusion and contributes to platelet activation and coagulation changes.

🔷 As the disease progresses, clotting factors and platelets can be consumed in the damaged vascular system.

🔷 This helps explain why coagulation-related laboratory values may gradually worsen during pregnancy.

🔷 Because vasoconstriction is a central pathophysiologic feature of preeclampsia, it is responsible for the abnormal laboratory trend.

Vasospasms

🔷 Vasospasms are correct because preeclampsia is classically associated with widespread vasospasm and reduced perfusion to maternal organs and the placenta.

🔷 Vasospasm causes tissue hypoxia and endothelial injury, which promote platelet consumption and coagulation abnormalities.

🔷 These vascular changes are part of why preeclampsia is considered a multisystem disorder.

🔷 Persistent vasospasm can progressively worsen maternal laboratory values even before severe complications appear.

🔷 Therefore, vasospasms are an important cause of the client’s current clotting-factor changes.

Client end-organ damage

🔷 Client end-organ damage is correct because preeclampsia affects organs such as the kidneys, liver, brain, and hematologic system through abnormal vascular injury and reduced perfusion.

🔷 End-organ involvement contributes to laboratory abnormalities, including thrombocytopenia and deranged coagulation in worsening disease.

🔷 Even without severe features, the disease process is still based on multisystem endothelial injury.

🔷 The slow change in clotting-related labs reflects the underlying systemic pathophysiology rather than a normal pregnancy adaptation.

🔷 For that reason, end-organ damage is appropriately associated with the client’s abnormal values.

Proteinuria

🔷 Proteinuria is a manifestation of renal involvement in preeclampsia, not the underlying pathophysiologic cause of decreasing clotting factors.

🔷 It reflects glomerular injury rather than being the process that drives the coagulation abnormalities.

Cardiac dysfunction

🔷 Cardiac dysfunction is not the primary pathophysiologic response used to explain the typical clotting-factor decline in preeclampsia.

🔷 The major mechanism is widespread endothelial injury with vasoconstriction and vasospasm.

Pulmonary edema

🔷 Pulmonary edema is a serious complication or severe feature of preeclampsia, not the main mechanism causing gradual clotting-factor changes.

🔷 It reflects disease severity rather than the underlying vascular cause of the abnormal labs.

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Answer 2

Correct Answers:

The muscles are still developing.

Rationale :

🟣 The correct finding for an infant born at 33 weeks is that the muscles are still developing.

🟣 Preterm infants commonly have low muscle tone and less mature muscle bulk than term infants.

🟣 At this gestation, many organ systems are still maturing, and muscle development is not yet complete.

🟣 This is why premature infants may appear weak, have less flexion, and tire easily.

🟣 Therefore, incomplete muscle development is the best answer for a 33-week infant.

The eyes are still developing.

🟣 Premature infants can have ongoing visual-system immaturity, but this option is less specific and less classically used than poor muscle development for a 33-week assessment question.

🟣 The clearest expected physical finding here is immature muscle tone and development.

The skin is smooth.

🟣 Preterm infants usually have thin, fragile, immature skin, not the more mature smooth appearance expected closer to term.

🟣 Their skin is often thin, pink, and less fully developed.

The pancreas is not producing insulin.

🟣 This is incorrect because the pancreas is producing insulin before 33 weeks of gestation.

🟣 Problems in preterm infants are related more to immaturity and regulation than complete absence of insulin production.

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Answer 3

Correct Answers:

Decrease in placental blood flow

Rationale :

🟢 Decrease in placental blood flow is the correct pathophysiologic response associated with gestational hypertension and intrauterine growth restriction (IUGR).

🟢 Hypertensive disorders in pregnancy reduce uteroplacental perfusion because abnormal placental vascular remodeling leads to high-resistance blood flow.

🟢 Reduced placental blood flow decreases oxygen and nutrient delivery to the fetus.

🟢 This chronic placental insufficiency is a major cause of IUGR.

🟢 Therefore, decreased placental perfusion is the best answer.

Decreased trophoblast necrosis

🟢 Abnormal placentation in hypertensive disease is associated with placental dysfunction and injury, not a beneficial decrease in trophoblast injury.

🟢 This option does not explain IUGR in gestational hypertension.

Acute uteroplacental ischemia

🟢 The placental process related to IUGR is more often chronic uteroplacental insufficiency/ischemia rather than an acute event.

🟢 The decrease in ongoing placental blood flow is the more accurate answer.

Reduced placental hypoxia

🟢 Placental dysfunction in gestational hypertension leads to increased, not reduced, placental hypoxia.

🟢 This option is opposite of the expected pathophysiology.

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Answer 4

Correct Answers:

Discontinue the medication infusion.

Rationale :

🟠 The nurse should discontinue the magnesium sulfate infusion because a respiratory rate of 10/min and absent deep-tendon reflexes are classic signs of magnesium toxicity.

🟠 Magnesium sulfate is used to prevent seizures in preeclampsia, but excessive levels can depress the central nervous system and respirations.

🟠 Loss of reflexes is an early warning sign, and respiratory depression signals potentially dangerous toxicity.

🟠 The infusion should be stopped immediately, and the provider should be notified while preparing for antidote administration if prescribed.

🟠 Because the assessment findings strongly indicate magnesium toxicity, stopping the infusion is the priority action.

Assess maternal blood glucose.

🟠 Blood glucose assessment does not address the immediate life-threatening findings of magnesium toxicity.

🟠 The urgent issue is respiratory depression with absent reflexes.

Prepare for an emergency cesarean birth.

🟠 The immediate problem is maternal medication toxicity, not an automatic need for emergency cesarean birth.

🟠 The nurse must first stabilize the client by stopping the magnesium infusion.

Place the client in Trendelenburg position.

🟠 Trendelenburg position does not treat magnesium toxicity and may worsen respiratory function.

🟠 The priority is to stop the drug causing the toxic response.

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Answer 5

Correct Answers:

Chronic uteroplacental ischemia

Rationale :

🔴 Chronic uteroplacental ischemia is the primary cause of oligohydramnios in a client with preeclampsia.

🔴 Poor placental perfusion reduces fetal blood flow and fetal renal perfusion.

🔴 When fetal kidney perfusion decreases, fetal urine output falls, and fetal urine is the main source of amniotic fluid in later pregnancy.

🔴 This leads to low amniotic fluid volume.

🔴 Therefore, chronic uteroplacental ischemia best explains the oligohydramnios.

Release of inflammatory factors

🔴 Inflammatory and antiangiogenic factors are involved in preeclampsia, but they do not directly explain oligohydramnios as clearly as chronic placental ischemia does.

🔴 The immediate mechanism is reduced placental perfusion and fetal urine production.

Client kidney damage

🔴 Maternal kidney involvement can occur in preeclampsia, but oligohydramnios is mainly linked to decreased fetal urine output from poor placental perfusion.

🔴 The primary cause is uteroplacental insufficiency, not maternal renal damage alone.

Vascular resistance

🔴 Increased vascular resistance is part of the broader disease process, but it is not as specific as chronic uteroplacental ischemia for explaining oligohydramnios.

🔴 The best answer is the direct placental perfusion problem.

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Answer 6

Correct Answers:

Decreased fetal movement

Rationale :

🟡 Decreased fetal movement at 36 weeks of gestation requires immediate follow-up because it can indicate fetal compromise or hypoxia.

🟡 Fetal movement is a key marker of fetal well-being in late pregnancy.

🟡 A reduction in normal movement patterns may signal placental insufficiency or worsening fetal status.

🟡 This requires prompt evaluation, often with fetal assessment such as nonstress testing or biophysical profile.

🟡 Among the findings listed, decreased fetal movement is the most urgent.

Periodic contractions

🟡 Periodic contractions can occur in late pregnancy and are not always abnormal.

🟡 They do not automatically indicate urgent fetal compromise the way decreased fetal movement can.

Edema in lower extremities

🟡 Mild dependent edema is common in late pregnancy.

🟡 By itself, it is less urgent than reduced fetal movement.

Urinary frequency

🟡 Urinary frequency is a common physiologic change in late pregnancy due to uterine pressure on the bladder.

🟡 It does not require the same immediate follow-up as decreased fetal movement.

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Answer 7

Correct Answers:

"The blood transfusion will help correct your anemia."

Rationale :

🟤 This is the correct teaching because packed red blood cells (PRBCs) are given to improve oxygen-carrying capacity and treat anemia.

🟤 In HELLP syndrome, hemolysis can significantly reduce red blood cell levels.

🟤 PRBC transfusion does not fix the underlying syndrome, but it can improve the anemia caused by red blood cell destruction or blood loss.

🟤 This helps stabilize the client and improve tissue oxygen delivery.

🟤 Therefore, the nurse should explain that the transfusion will help correct anemia.

"The blood transfusion will improve your liver's blood flow."

🟤 PRBC transfusion is not given to directly improve hepatic perfusion.

🟤 Its primary purpose is correction of anemia and oxygen delivery.

"The blood transfusion will improve damage to your kidneys."

🟤 Blood transfusion does not directly reverse kidney damage.

🟤 It supports circulation and anemia, but it is not a renal repair treatment.

"The blood transfusion will help correct cerebral hemorrhage."

🟤 PRBCs do not correct cerebral hemorrhage.

🟤 This statement inaccurately describes the purpose of the transfusion.

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Answer 8

Correct Answers:

Lanugo on back and buttocks
Fully developed internal ear
Hormonal response to pain

Rationale :

Lanugo on back and buttocks

⚫ Lanugo on back and buttocks is correct because preterm infants commonly have soft body hair (lanugo), especially when born well before term.

⚫ Lanugo is a normal developmental feature that is more noticeable in preterm infants.

⚫ Its presence on the back and buttocks is consistent with an infant born around 32 weeks.

⚫ This is one of the classic physical findings of prematurity.

⚫ Therefore, this option should be selected.

Fully developed internal ear

⚫ Fully developed internal ear is correct because the internal ear structures develop earlier in gestation and are present by this stage.

⚫ This contrasts with systems such as the lungs and muscle tone, which remain more immature at 32 weeks.

⚫ The question asks for findings consistent with a 32-week infant, and internal ear development fits that pattern better than fully developed lungs or bones.

⚫ This makes the option appropriate in comparison with the others given.

⚫ Therefore, this option should be selected.

Hormonal response to pain

⚫ Hormonal response to pain is correct because preterm infants are capable of a physiologic and hormonal response to painful stimuli by this gestation.

⚫ They do not lack pain response simply because they are premature.

⚫ In fact, premature infants can demonstrate significant stress responses to painful procedures.

⚫ This makes a hormonal pain response consistent with a 32-week infant.

⚫ Therefore, this is also a correct finding.

Fully developed lungs

⚫ Lungs are not fully mature at 32 weeks, and preterm infants at this age remain at risk for respiratory distress.

⚫ Pulmonary immaturity is one of the major concerns in premature birth.

Bones are fully developed

⚫ Bone development and mineralization are still incomplete in preterm infants.

⚫ This option is not the best description of a 32-week infant.

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Answer 9

Correct Answers:

Unexpected placental implantation

Rationale :

⭐ The nurse should recognize unexpected/abnormal placental implantation as being associated with eclampsia.

⭐ The underlying disease process begins with abnormal placentation and poor spiral artery remodeling early in pregnancy.

⭐ This leads to placental ischemia, endothelial dysfunction, vasospasm, and the maternal syndrome of preeclampsia, which can progress to eclampsia.

⭐ The other options describe the opposite of what occurs in this disorder.

⭐ Therefore, abnormal placental implantation is the best answer.

Increased uterine spiral artery remodeling

⭐ Preeclampsia and eclampsia are associated with inadequate, not increased, spiral artery remodeling.

⭐ Failed remodeling contributes to placental ischemia.

Vasodilation

⭐ The maternal vascular state in eclampsia is characterized by vasoconstriction/vasospasm, not vasodilation.

⭐ Vasodilation would be the opposite of the typical disease mechanism.

Decreased arterial resistance

⭐ Preeclampsia is associated with increased vascular resistance, not decreased arterial resistance.

⭐ This option does not fit the known pathophysiology.

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Answer 10

Correct Answers:

Shared decision-making

Rationale :

💎 Shared decision-making is the most appropriate nursing consideration because the client is upset that the provider has disregarded the birth plan.

💎 Even when immediate induction is medically necessary for preeclampsia with severe features at 35 weeks, the client should still be included in decisions about care whenever safely possible.

💎 Shared decision-making helps preserve autonomy, improve understanding, and support emotional coping during an unexpected change in the plan of birth.

💎 The nurse can advocate for the client by ensuring clear communication about the reason for induction and what choices still remain.

💎 Therefore, shared decision-making is the best consideration to implement.

Method of birth

💎 The exact method of birth may still need to be individualized, but the question focuses on how to support the upset client after the birth plan changed.

💎 The most therapeutic nursing response is to promote shared decision-making within the medically necessary plan.

Antenatal steroid administration

💎 Antenatal steroids may be considered in some preterm situations, but that is not the primary psychosocial and ethical consideration in this question.

💎 The issue presented is the client’s distress about the provider disregarding the birth plan.

Expectant management protocols

💎 Expectant management is not the key issue once severe features have worsened and immediate induction is planned.

💎 The better nursing consideration is to preserve client involvement through shared decision-making.

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QLexNursing

2 :
A nurse is assessing a pre-term infant. Which of the following assessment findings is consistent with an infant born at 33 weeks?

3 :
A nurse is caring for a client at 32 weeks of gestation who has been diagnosed with gestational hypertension and intrauterine growth restriction (IUGR). Which of the following pathophysiological responses should the nurse associate with this diagnosis?

4 :
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client at 36 weeks of gestation and who has preeclampsia with mild features and oligohydramnios. Which of the following elements should the nurse recognize as the primary cause of oligohydramnios?

6 :
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings requires immediate follow-up?

7 :
A nurse is providing education to a client who has HELLP syndrome and who will receive a transfusion of packed red blood cells. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is assessing a pre-term infant. Which of the following assessment findings is consistent with an infant born at 32 weeks? (Select All that Apply.)

9 :
A nurse is caring for a client who has eclampsia. Which of the following changes should the nurse recognize as being associated with eclampsia?

QLexNursing

2 : A nurse is assessing a pre-term infant. Which of the following assessment findings is consistent with an infant born at 33 weeks?

3 : A nurse is caring for a client at 32 weeks of gestation who has been diagnosed with gestational hypertension and intrauterine growth restriction (IUGR). Which of the following pathophysiological responses should the nurse associate with this diagnosis?

4 : A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

5 : A nurse is caring for a client at 36 weeks of gestation and who has preeclampsia with mild features and oligohydramnios. Which of the following elements should the nurse recognize as the primary cause of oligohydramnios?

6 : A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings requires immediate follow-up?

7 : A nurse is providing education to a client who has HELLP syndrome and who will receive a transfusion of packed red blood cells. Which of the following statements should the nurse include in the teaching?

8 : A nurse is assessing a pre-term infant. Which of the following assessment findings is consistent with an infant born at 32 weeks? (Select All that Apply.)

9 : A nurse is caring for a client who has eclampsia. Which of the following changes should the nurse recognize as being associated with eclampsia?

2 :
A nurse is assessing a pre-term infant. Which of the following assessment findings is consistent with an infant born at 33 weeks?

3 :
A nurse is caring for a client at 32 weeks of gestation who has been diagnosed with gestational hypertension and intrauterine growth restriction (IUGR). Which of the following pathophysiological responses should the nurse associate with this diagnosis?

4 :
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client at 36 weeks of gestation and who has preeclampsia with mild features and oligohydramnios. Which of the following elements should the nurse recognize as the primary cause of oligohydramnios?

6 :
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings requires immediate follow-up?

7 :
A nurse is providing education to a client who has HELLP syndrome and who will receive a transfusion of packed red blood cells. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is assessing a pre-term infant. Which of the following assessment findings is consistent with an infant born at 32 weeks? (Select All that Apply.)

9 :
A nurse is caring for a client who has eclampsia. Which of the following changes should the nurse recognize as being associated with eclampsia?