A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders.
Which of the following orders requires clarification?

Assess deep tendon reflexes every hour

Continuous fetal monitoring

Ambulate twice daily

Obtain a daily weight

Answer and Explanation

The Correct Answer is C

Choice A rationale
Assessing deep tendon reflexes every hour is a common practice in managing severe preeclampsia. Hyperreflexia can be a sign of worsening pre-eclampsia.
Choice B rationale
Continuous fetal monitoring is typically recommended for patients with severe pre-eclampsia. This allows for early detection of fetal distress.
Choice C rationale
Ambulating twice daily may not be appropriate for a patient with severe pre-eclampsia at 35 weeks of gestation. Bed rest is often recommended to help lower blood pressure and reduce the risk of complications.
Choice D rationale
Obtaining a daily weight is a common practice in managing severe pre-eclampsia. Sudden weight gain can be a sign of worsening pre-eclampsia.

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Correct Answer is B

Explanation

Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.

A. Monitor vital signs every 5 minutes. B. Elevate the patient’s legs. C. Notify the healthcare provider. D. Position the patient laterally. E. Position the patient laterally.

Correct Answer is D

Explanation

If a patient in labor who has received an epidural anesthesia block has a blood pressure reading of 80/40 mm Hg, the nurse’s immediate course of action should be to position the patient laterally. This helps to maximize venous return and cardiac output, thereby improving maternal blood pressure and fetal perfusion.

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A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders. Which of the following orders requires clarification?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?

Correct Answer is B

Explanation

A nurse is attending to a patient in labor who has received an epidural anesthesia block. The patient’s blood pressure reads 80/40 mm Hg and the fetal heart rate is 140/min. What should be the nurse’s immediate course of action?

Correct Answer is D

Explanation

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A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders. Which of the following orders requires clarification?

A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders.
Which of the following orders requires clarification?