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
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

A. Increased deposits of fat in the chest and shoulder area. B. Brachial plexus injury. C. Increased blood viscosity. D. Hyperinsulinemia.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse in an antepartum unit performing triage, which client should be prioritized?

Correct Answer is B

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?

Correct Answer is D

Explanation

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?

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?

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?

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 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 client is due to receive a subcutaneous injection of enoxaparin, 30 mg. How many mL should the nurse administer if the answer is to be rounded to the nearest tenth? (Use a leading zero if applicable.