Question

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

Answer 1

Correct Answers:

Report of headache

Rationale :

⚠️ Severe preeclampsia is characterized by hypertension, proteinuria, and end-organ dysfunction, with neurologic symptoms such as a severe headache being a classic finding.

⚠️ The headache results from cerebral edema and vasospasm, indicating worsening disease and potential progression to eclampsia (seizures).

⚠️ Other expected findings in severe preeclampsia include hyperreflexia, clonus, visual disturbances, epigastric pain, and oliguria, not polyuria.

⚠️ Tachycardia is not a hallmark of preeclampsia; instead, blood pressure is elevated, and bradycardia may even occur due to vagal stimulation.

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Answer 2

Correct Answers:

Continuous contraction lasting 2 min

Rationale :

🚨 A continuous contraction lasting 2 minutes or longer is considered uterine tachysystole, which can compromise uteroplacental blood flow and lead to fetal hypoxia and distress. This is an emergent finding that requires immediate provider notification.

🚨 Expulsion of clear fluid indicates rupture of membranes, which is expected in labor but requires monitoring for infection and FHR, not immediate emergency action.

🚨 Pressure on the perineum causing the urge to bear down suggests labor progression but is expected in active labor.

🚨 Expulsion of a blood-tinged mucus plug is a normal sign of cervical dilation and effacement, not a complication.

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Answer 3

Correct Answers:

"l will reduce my intake of vitamin K-rich foods."

Rationale :

🦴 Vitamin K plays a role in bone metabolism by aiding in the activation of osteocalcin, a protein essential for bone mineralization. Reducing vitamin K intake is not recommended for osteoporosis prevention.

🦴 Limiting soft drinks (high in phosphates), sodium, and caffeine is appropriate because excessive intake can lead to calcium loss and decreased bone density.

🦴 Therefore, the statement about reducing vitamin K intake shows a misunderstanding and indicates a need for further teaching.

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Answer 4

Correct Answers:

Abruptio placentae

Rationale :

🔴Abruptio placentae is the premature separation of the placenta from the uterine wall, which presents with sudden onset of continuous abdominal pain and vaginal bleeding.

🔴 It is commonly associated with hypertensive disorders of pregnancy, such as pregnancy-induced hypertension, due to vascular damage leading to placental separation.

🔴 Placenta previa typically causes painless, bright red vaginal bleeding, while prolapsed cord presents with fetal distress and visible/palpable cord, not continuous pain.

🔴 Incompetent cervix results in painless cervical dilation, not acute abdominal pain and bleeding.

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Answer 5

Correct Answers:

Dryness with intercourse

Rationale :

🌷 Vaginal dryness during intercourse is a common early manifestation of menopause, caused by decreased estrogen levels, which lead to thinning and atrophy of vaginal tissues and reduced lubrication.

🌷 Other early symptoms of menopause include hot flashes, night sweats, mood changes, and irregular menses.

🌷 Decreased blood pressure is not typical; in fact, postmenopausal women are at increased risk for hypertension due to hormonal changes.

🌷 Elevated body temperature during hot flashes is transient and does not persistently exceed 37.8°C (100°F).

🌷 Urinary retention is not common; instead, women may experience urinary frequency or stress incontinence due to estrogen-related pelvic tissue changes.

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Answer 6

Correct Answers:

Insulin

Rationale :

💉 Insulin is the treatment of choice for gestational diabetes mellitus (GDM) that cannot be controlled by diet and exercise because it does not cross the placenta, making it safe for the fetus.

💉 Maintaining strict blood glucose control reduces the risk of macrosomia, neonatal hypoglycemia, and birth trauma.

💉 Oral hypoglycemics such as repaglinide, glipizide, and acarbose are generally avoided in pregnancy because many cross the placenta, and their safety profiles are not fully established for fetal use.

💉 Insulin dosages are adjusted based on frequent blood glucose monitoring to maintain target levels throughout pregnancy.

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Answer 7

Correct Answers:

Consume foods fortified with folic acid

Rationale :

🌿 Folic acid is essential in preventing neural tube defects (NTDs) such as spina bifida and anencephaly, as it supports proper closure of the neural tube in early embryonic development.

🌿 Women planning pregnancy should consume 400–600 mcg of folic acid daily, beginning before conception and continuing through the first trimester.

🌿 Foods rich in folic acid include fortified cereals, leafy green vegetables, citrus fruits, and legumes.

🌿 While limiting alcohol, increasing iron, and avoiding aspartame contribute to overall maternal health, they do not directly prevent NTDs.

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Answer 8

Correct Answers:

Hypertension

Rationale :

🔴 Hypertension (chronic or pregnancy-induced) is the most common risk factor for placental abruption, as it causes vascular damage and compromised placental perfusion, leading to premature separation of the placenta.

🔴 Other risk factors include cocaine use, cigarette smoking, trauma, and multiparity, but none are as strongly associated as hypertensive disorders of pregnancy.

🔴 Placental abruption presents with painful vaginal bleeding, uterine tenderness, and abdominal pain, which can lead to fetal hypoxia and maternal hemorrhage.

🔴 Early detection and management of hypertension reduce the risk of severe complications.

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Answer 9

Correct Answers:

Changes in the cervix

Rationale :

🔴 Hypertension (chronic or pregnancy-induced) is the most common risk factor for placental abruption, as it causes vascular damage and compromised placental perfusion, leading to premature separation of the placenta.

🔴 Other risk factors include cocaine use, cigarette smoking, trauma, and multiparity, but none are as strongly associated as hypertensive disorders of pregnancy.

🔴 Placental abruption presents with painful vaginal bleeding, uterine tenderness, and abdominal pain, which can lead to fetal hypoxia and maternal hemorrhage.

🔴 Early detection and management of hypertension reduce the risk of severe complications.

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Answer 10

Correct Answers

Collect a urine specimen of culture and sensitivity [ Anticipated ]
Administer magnesium sulfate 4 g IV bolus [ Anticipated ]
Tell the client to lie in a supine position [ contraindicated ]
Monitor blood pressure and respiratory status every 15 min [ Anticipated ]

Rationale :

1. Collect a urine specimen for culture and sensitivity

✔️ Anticipated

🔹 In a client with severe preeclampsia, urine analysis is essential to monitor proteinuria, which is a key diagnostic indicator of renal involvement and disease progression.

🔹 Although the current findings already show 3+ proteinuria, continued assessment helps monitor worsening renal function and guides treatment decisions.

🔹 It also helps rule out urinary tract infection, which can worsen hypertensive complications.

2. Administer magnesium sulfate 4 g IV bolus

✔️ Anticipated

🔹 Magnesium sulfate is the drug of choice to prevent seizures (eclampsia) in clients with severe preeclampsia.

🔹 The client’s symptoms—headache, blurred vision, hyperreflexia (DTRs 3+), and hypertension (172/104 mmHg)—indicate severe CNS irritability and risk for seizures.

🔹 A 4 g IV bolus followed by maintenance infusion helps stabilize neuromuscular excitability and reduce cerebral edema.

3. Tell the client to lie in a supine position

❌ Contraindicated

🔹 The supine position can compress the inferior vena cava, leading to supine hypotensive syndrome, which reduces placental perfusion and worsens fetal oxygenation.

🔹 The preferred position is the left lateral (side-lying) to enhance uteroplacental blood flow and reduce edema.

4. Monitor blood pressure and respiratory status every 15 min

✔️ Anticipated

🔹 Frequent monitoring is critical for early detection of complications such as hypertensive crisis or magnesium sulfate toxicity (respiratory depression <12 breaths/min).

🔹 The client already has severe hypertension and abnormal labs (low platelets, elevated creatinine & uric acid, and proteinuria), making close monitoring essential for maternal and fetal safety.

🔹 Continuous observation also guides timely interventions, including antihypertensives or preparation for possible emergency delivery.

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Potential Prescription	Anticipated	nonessential	contraindicated
Collect a urine specimen of culture and sensitivity
Administer magnesium sulfate 4 g IV bolus
Tell the client to lie in a supine position
Monitor blood pressure and respiratory status every 15 min

QLexNursing

1 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

2 :
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

3 :
A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching

4 :
A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

5 :
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause?

6 :
A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

7 :
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

8 :
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

9 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

10 :
A nurse is caring for a client who is at 32 weeks of gestation.

Correct Answers

QLexNursing

1 : A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

2 : A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

3 : A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching

4 : A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

5 : A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause?

6 : A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

7 : A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

8 : A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

9 : A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

10 : A nurse is caring for a client who is at 32 weeks of gestation.

Correct Answers

1 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

2 :
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

3 :
A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching

4 :
A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

5 :
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause?

6 :
A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

7 :
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

8 :
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

9 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

10 :
A nurse is caring for a client who is at 32 weeks of gestation.