A 37 weeks' gestation patient with a scheduled nonstress test (NST) has the following vital signs recorded over two days: 2/10 1535: BP 162/100, HR 78, SpO2 100%; 2/10 1600: BP 168/100, HR 76, SpO2 100%; 2/11 1200: BP 166/100, HR 84, SpO2 99%; 2/11 1818: BP 152/86, HR 78, SpO2 99%. The nurse anticipates needing to administer Magnesium Sulfate to prevent which of the following complications?

Preterm labor.

Gestational diabetes.

Seizures.

Fetal growth restriction.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Preterm labor is defined as labor that occurs between 20 and 37 weeks of gestation. The patient is already at 37 weeks' gestation, so preterm labor is not a complication to prevent.

Choice B rationale

Gestational diabetes is glucose intolerance that develops during pregnancy. While elevated blood pressure can sometimes be associated with gestational diabetes, magnesium sulfate is not a primary treatment or preventative measure for this condition. Management typically involves dietary changes, exercise, and sometimes insulin.

Choice C rationale

Magnesium sulfate is commonly administered in the setting of preeclampsia with severe features or eclampsia to prevent seizures. The patient's consistently elevated blood pressure readings (above 160/110 mmHg on multiple occasions) indicate severe hypertension, a key diagnostic criterion for preeclampsia with severe features, placing her at high risk for seizures (eclampsia). Magnesium sulfate acts as a central nervous system depressant, reducing neuronal excitability and thus the risk of seizures.

Choice D rationale

Fetal growth restriction (FGR) is a condition where the fetus does not grow at the expected rate in utero. While severe preeclampsia can contribute to FGR due to placental insufficiency, magnesium sulfate is not directly used to prevent fetal growth restriction. The primary focus of magnesium sulfate in this scenario is maternal seizure prophylaxis.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E"]

Explanation

The correct answer is Choice A, Choice D, Choice E.

Choice A rationale

Pain during intercourse, also known as dyspareunia, is a common symptom of endometriosis. Endometrial tissue growing outside the uterus can infiltrate the pelvic organs and ligaments, causing pain and discomfort during sexual activity due to pressure and inflammation in these areas.

Choice B rationale

Painless heavy menstrual bleeding is not typically associated with endometriosis. Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus, which responds to hormonal fluctuations of the menstrual cycle, often leading to painful periods (dysmenorrhea) and potentially heavy bleeding accompanied by pain.

Choice C rationale

Unexplained weight gain is not a typical symptom directly linked to endometriosis. While hormonal imbalances can occur with endometriosis, they do not usually manifest as unexplained weight gain. Other factors are more likely to contribute to weight changes.

Choice D rationale

Infertility is a significant concern for many individuals with endometriosis. The presence of endometrial implants, adhesions, and scarring in the pelvic cavity can distort the anatomy of the reproductive organs, interfering with ovulation, fertilization, and implantation of a fertilized egg.

Choice E rationale

Pain during the menstrual period, known as dysmenorrhea, is a hallmark symptom of endometriosis. The ectopic endometrial tissue undergoes cyclical bleeding and shedding, similar to the uterine lining, but this occurs outside the uterus, causing inflammation, pain, and potentially the formation of scar tissue and adhesions.

A. Your cervix is open a little and the baby is very low. B. Your cervix is all thinned out and the baby is very low. C. Your cervix is open a little, but the baby is still high in the pelvis. D. Your cervix is open a little, but still needs to thin out.

Correct Answer is B

Explanation

Choice A rationale

While a dilation of 3 cm indicates some cervical opening, stating the baby is "very low" with a station of -2 is inaccurate. A negative station indicates the presenting part is above the ischial spines, not low in the pelvis.

Choice B rationale

A cervical effacement of 100% means the cervix has fully thinned out. A fetal station of -2 indicates the presenting part of the fetus is 2 cm above the ischial spines. Therefore, the cervix is completely thinned, and the baby's head is relatively high in the pelvis.

Choice C rationale

Although the cervix is dilated to 3 cm, indicating some opening, the fetal station of -2 signifies that the baby is still high in the pelvis, not low. This statement correctly identifies the dilation but inaccurately describes the fetal descent.

Choice D rationale

A cervical dilation of 3 cm indicates the cervix is open to some extent. However, the 100% effacement indicates that the cervix is already completely thinned out, so the statement that it "still needs to thin out" is incorrect.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings might raise the nurse's suspicion of endometriosis in the client they are evaluating?

Correct Answer is ["A","D","E"]

Explanation

A first-time mother presents for a labor check.She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is educating a pregnant client about the differences between Braxton Hicks contractions and true labor contractions.Which statement should the nurse include?

A nurse is caring for a client in the first trimester of pregnancy and discovers that the client lacks immunity to rubella based on her blood work.When is the recommended time for administering rubella immunization?

A nurse is monitoring a client in active labor who has an epidural in place.Which of the following findings should be reported to the anesthesiologist immediately?

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed.Which of the following findings indicate mastitis?

A teenager presents to the clinic with complaints of painful lesions, fever, headache, and vaginal discharge.After testing she is diagnosed with Herpes simplex virus type 2. What education should the nurse include in a teaching plan? (Select All that Apply.)