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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

The correct answers are Choices C, D, and E.
Choice A rationale
Fetal neck translucency is not typically evaluated during a biophysical profile. It is usually assessed during a first trimester ultrasound to screen for chromosomal abnormalities.
Choice B rationale
Fetal gender is not typically evaluated during a biophysical profile. The focus of a biophysical profile is on assessing the health and well-being of the fetus.
Choice C rationale
Fetal motion is one of the aspects evaluated during a biophysical profile. It is assessed to determine the activity level of the fetus.
Choice D rationale
Fetal breathing is one of the aspects evaluated during a biophysical profile. It is assessed to determine the respiratory function of the fetus.
Choice E rationale
Amniotic fluid volume is one of the aspects evaluated during a biophysical profile. It is assessed to determine the amount of amniotic fluid surrounding the fetus.

A. Assess deep tendon reflexes every hour B. Continuous fetal monitoring C. Ambulate twice daily D. Obtain a daily weight

Correct Answer is C

Explanation

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

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?

Correct Answer is C

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?

50 grams of Magnesium sulfate is added to 1L of Lactated Ringers. After giving an initial loading dose, the nurse is to infuse a maintenance dose of 2 gm/hr. What rate should the IV pump be set at?

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?

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

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.

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