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 D

Explanation

Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a newborn. Macrosomic newborns, or those with a high birth weight, may have increased fat deposits, but this is not the primary cause of respiratory distress.
Choice B rationale
A brachial plexus injury is a type of birth injury that can occur due to difficulties during delivery, such as a prolonged labor or a breech presentation. It involves damage to the bundle of nerves that supply the arms and hands. However, it does not directly cause respiratory distress syndrome.
Choice C rationale
Increased blood viscosity could potentially contribute to respiratory distress, but it is not the most likely cause in a macrosomic newborn whose mother has poorly controlled type 2 diabetes. High blood sugar levels in the mother can lead to high insulin levels in the newborn, which is a more direct cause of respiratory distress.
Choice D rationale
Hyperinsulinemia, or high levels of insulin in the blood, is the most likely cause of respiratory distress in this case. When a mother has poorly controlled diabetes, the baby’s pancreas may respond to high glucose levels by producing extra insulin. After birth, the baby may have hypoglycemia (low blood sugar) and increased red blood cell production, both of which can contribute to respiratory distress.

A. Administer a magnesium sulfate infusion. B. Initiate pushing. C. Prepare for a cesarean birth. D. Examination to determine cervical status.

Correct Answer is C

Explanation

If a patient in labor at 40 weeks of gestation reports saturating two perineal pads in the past 30 minutes, and placenta previa is suspected, an appropriate nursing action would be to prepare for a cesarean birth. Placenta previa, where the placenta partially or completely covers the cervical opening, can cause significant bleeding and is typically managed with a cesarean delivery to prevent further bleeding and ensure the safety of the mother and baby.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. What would be an appropriate nursing action in this situation?

Correct Answer is C

Explanation

A nurse is caring for a client who is 39 weeks pregnant and in active labor. The nurse detects the fetal heart tones above the client’s umbilicus at the midline. Which of the following positions should the nurse suspect the fetus is in?

A nurse is caring for a client in the first stage of labor who is undergoing external fetal monitoring and receiving IV fluids. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is the correct interpretation of this finding

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse has received an order to administer Morphine 5mg IV once immediately. The available concentration is 2.5 mg/mL. How many mL of morphine should the nurse prepare for administration?

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. Which of the following explanations about this test should the nurse provide to the client?