A primigravida who is 28 weeks pregnant visits the clinic fearing she is experiencing preeclampsia. Which of the following assessments would the nurse make to confirm or negate these thoughts? Select all that apply.

Right Sided Epigastric pain

Uterine contractions

Bright red painless vaginal bleeding

Severe headache

Visual disturbances

Dull back ache

Answer and Explanation

Correct Answer : A,D,E

A. Right-sided epigastric pain. Epigastric pain, especially on the right side, is a concerning sign of preeclampsia and may indicate liver involvement due to elevated liver enzymes or HELLP syndrome. This symptom should be assessed further as it suggests worsening disease progression.

B. Uterine contractions. Uterine contractions are not a defining feature of preeclampsia. They are more commonly associated with preterm labor rather than hypertension-related complications. While preeclampsia can lead to preterm birth, contractions alone do not confirm or negate the condition.

C. Bright red painless vaginal bleeding. Bright red painless vaginal bleeding is more indicative of placenta previa or another obstetric complication rather than preeclampsia. Preeclampsia primarily presents with hypertension, proteinuria, and systemic symptoms rather than vaginal bleeding.

D. Severe headache. A severe headache is a classic symptom of preeclampsia, often due to elevated blood pressure and cerebral edema. Persistent headaches that do not resolve with usual interventions should be evaluated promptly as they may indicate worsening hypertension or an impending seizure.

E. Visual disturbances. Visual disturbances such as blurred vision, photophobia, or seeing spots are common in preeclampsia and can signal cerebral edema or increased intracranial pressure. This is a significant warning sign requiring immediate assessment.

F. Dull backache. A dull backache is more commonly associated with musculoskeletal strain, labor, or a urinary tract infection rather than preeclampsia. While discomfort can be present in pregnancy, it is not a defining symptom of 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 D

Explanation

A. Enteral nutrition (TPN) to correct nutritional deficits. Total parenteral nutrition (TPN) is only considered in severe cases where oral and IV hydration fail. The initial treatment focuses on correcting dehydration and electrolyte imbalances before considering more invasive nutritional support.

B. Small frequent meals. While small, frequent meals may help manage nausea in mild cases of pregnancy-related nausea and vomiting, they are not sufficient for treating hyperemesis gravidarum, which involves severe, persistent vomiting leading to dehydration and electrolyte imbalances.

C. Corticosteroids to reduce inflammation. Corticosteroids are not the first-line treatment for hyperemesis gravidarum. They may be used in refractory cases where standard treatments fail, but IV fluids and antiemetics are prioritized initially.

D. IV therapy to correct fluid and electrolyte imbalances. The primary concern in hyperemesis gravidarum is severe dehydration and electrolyte disturbances due to excessive vomiting. IV fluids, often with electrolytes and thiamine, are the first step in stabilizing the patient before introducing oral intake.

A. Occiput anterior position. B. Breech presentation. C. Cervical dilation 5 cm. D. Station-4.

Correct Answer is ["B","D"]

Explanation

A. Occiput anterior position. The occiput anterior (OA) position is the ideal fetal position for vaginal delivery, where the baby’s head is well-engaged in the pelvis. This positioning reduces the risk of a prolapsed cord since the presenting part (the fetal head) effectively blocks the cord from slipping through.

B. Breech presentation. In a breech presentation, the buttocks or feet are the presenting part, leaving more space in the birth canal. This increases the risk of cord prolapse, especially if the feet or buttocks do not fully block the cervix, allowing the umbilical cord to slip past and become compressed.

C. Cervical dilation 5 cm. While cervical dilation is important in labor progression, it does not directly increase the risk of cord prolapse. The risk is more dependent on fetal position and station rather than the degree of cervical dilation.

D. Station -4. A high fetal station (e.g., -4) means the baby’s presenting part has not yet descended into the pelvis, leaving more room for the umbilical cord to slip through once the membranes rupture. A well-engaged fetus at station 0 or lower helps prevent prolapse by blocking the cervix.

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

A primigravida who is 28 weeks pregnant visits the clinic fearing she is experiencing preeclampsia. Which of the following assessments would the nurse make to confirm or negate these thoughts? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for a woman hospitalized for hyperemesis gravidarum would expect that the initial treatment would involve:

Correct Answer is D

Explanation

A patient has just spontaneously ruptured her membranes. Which of the following factors makes her especially high risk for having a prolapsed cord? Select all that apply.

Correct Answer is ["B","D"]

Explanation

The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.

A woman at 39 weeks gestation with a history of preeclampsia is admitted to the labor and delivery. She suddenly experiences increased contraction frequency of every 1 to 2 minutes, dark red bleeding and a tense, very painful abdomen. The nurse suspects the onset of:

The nurse is caring for a pregnant woman who is HIV positive. While teaching her about the use of antiretroviral drugs, the nurse explains that these medications will

The nurse would include which of the following statements when describing the pathophysiology of gestational diabetes?

A 26-year old having her first baby is 28 weeks pregnant. She experiences bright red, painless vaginal bleeding, soaking one pad. Upon her arrival at the hospital, after placing her on the FHR Monitor, what would be an expected diagnostic procedure?

A woman with preeclampsia gave birth vaginally 1 hour ago. She is still receiving a magnesium sulfate infusion at 1 gm/hr. A major concern regarding the administration of magnesium sulfate at this time would be:

A woman who is 26 weeks pregnant has just found out that she has gestational diabetes. Which of the following therapies will most likely be ordered first for this patient?

A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary health care practitioner?