A nurse is caring for a client who is 34 weeks pregnant.

The nurse is reviewing the client’s electronic medical record to develop a care plan.

The nurse should take which of the following actions to address the condition the client is most likely experiencing, and monitor which parameters to assess the client’s progress.

Implement seizure precautions.

Check deep tendon reflexes every hour.

Administer prescribed methyldopa.

Monitor neurologic status.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.

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Correct Answer is B

Explanation

Choice A rationale
While cigarette smoking can increase the risk of many complications during pregnancy, including placental abruption, it is not the most common risk factor. Smoking can cause constriction and damage to the blood vessels in the placenta, but other factors, such as hypertension, are more commonly associated with placental abruption.
Choice B rationale
Hypertension is the most common risk factor for placental abruption. High blood pressure can cause damage to the blood vessels in the placenta, leading to abruption. Chronic hypertension, gestational hypertension, and preeclampsia can all increase a woman’s risk of experiencing a placental abruption.
Choice C rationale
Blunt force trauma, such as that experienced in a car accident or a fall, can cause placental abruption, but it is not the most common risk factor. Any trauma to the abdomen during pregnancy should be evaluated by a healthcare provider to assess for potential complications, including placental abruption.
Choice D rationale
Cocaine use can increase the risk of placental abruption. Cocaine causes intense vasoconstriction, which can compromise the blood flow to the placenta and lead to abruption. However, it is not the most common risk factor for this condition.

Correct Answer is []

Explanation

The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.

Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.

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Naxlex Comprehensive Predictor Exams

A nurse in a healthcare provider’s office is caring for a patient 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?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. Which of the following newborn complications should the nurse recognize as the priority focus of care?

A nurse in labor and delivery is caring for a client. Following the delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

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

A nurse is caring for a group of patients on an intrapartum unit. Which of the following findings should be reported to the healthcare provider immediately?

A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia. Which of the following observations should the nurse report to the healthcare provider?

A nurse is attending to a first-time pregnant woman who is at term. She is experiencing contractions but is unsure if she is in labor. Which of the following should the nurse identify as a labor sign?