A nurse is providing care for a patient who is at 34 weeks of gestation. The nurse is reviewing the patient’s electronic medical record to develop a plan of care. Which condition is the patient most likely experiencing, what are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the patient’s progress?

Preeclampsia, initiate seizure precautions, monitor neurological status and liver function studies.

Hypertension, prepare for bed rest, monitor blood pressure and heart rate.

Gestational diabetes, administer insulin, monitor blood glucose levels and fetal heart rate.

Preterm labor, administer tocolytics, monitor contraction pattern and cervical dilation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Preeclampsia is a condition that can occur during pregnancy, characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. If a patient is experiencing preeclampsia, the nurse should initiate seizure precautions, as seizures can occur in severe cases. The nurse should also monitor the patient’s neurological status and liver function studies, as these can be affected by preeclampsia.
Choice B rationale
Hypertension, or high blood pressure, can occur during pregnancy, but the actions listed do not fully address the condition. While bed rest was once commonly recommended for high blood pressure during pregnancy, research has not shown it to be effective. Monitoring blood pressure and heart rate is important, but other interventions, such as medication, may also be necessary.
Choice C rationale
Gestational diabetes is a condition characterized by high blood sugar that develops during pregnancy. Insulin may be administered to help control blood glucose levels. The nurse should monitor blood glucose levels and fetal heart rate, as gestational diabetes can affect both the mother and the baby. However, the condition the patient is most likely experiencing, given the gestational age and symptoms, is preeclampsia.
Choice D rationale
Preterm labor refers to labor that begins before the 37th week of pregnancy. Tocolytics may be administered to slow or stop contractions. The nurse should monitor the contraction pattern and cervical dilation to assess for progression of labor. However, the condition the patient is most likely experiencing, given the gestational age and symptoms, is preeclampsia.

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Correct Answer is D

Explanation

The correct answer is D. Slightly above the umbilicus. At 22 weeks of gestation, the fundus, or top of the uterus, is typically located slightly above the umbilicus.

A. G4 T1 P2 A0 L3 B. G4 T2 P1 A0 L3 C. G4 T3 P1 A0 L3 D. G4 T1 P1 A0 L4

Correct Answer is D

Explanation

G (Gravida): Total number of pregnancies → 4
T (Term births): Delivered at 37 weeks or more → One (39 weeks) → T = 1
P (Preterm births): Delivered between 20–36 weeks → Twins (34 weeks, 1 pregnancy) + One at 35 weeks = 2 preterm pregnancies → P = 2
A (Abortions): Pregnancies ending before 20 weeks → 0
L (Living children): One from term birth, two from twins, and one from the other preterm = 4 living children → L = 4

Correct Answer: D. G4 T1 P2 A0 L4

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

Correct Answer: D. G4 T1 P2 A0 L4

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