The clinic nurse’s patient is 21 weeks pregnant. Her blood pressure is 168/100. Blood pressures in prior visits have all been normal. Her urine sample shows trace protein. What other questions or procedures might you ask/perform to determine if your patient is pre-eclamptic. (Select all that apply)

Do you have any headaches or blurry vision?

I am going to check your reflexes now

Have you been having trouble with urinary incontinence?

Do you have any right upper quadrant pain?

Have you had any nausea or vomiting recently?

Do you feel safe at home?

Answer and Explanation

Correct Answer : A,B,D

A. Do you have any headaches or blurry vision? Headaches and blurry vision are common neurological symptoms of preeclampsia. These occur due to cerebral edema and hypertension-related vascular changes. Persistent headaches or visual disturbances (such as seeing spots or flashing lights) warrant further evaluation.

B. I am going to check your reflexes now. Hyperreflexia (brisk deep tendon reflexes) is a key neurological sign of worsening preeclampsia. Severe hyperreflexia can indicate impending eclampsia and increased seizure risk. Checking for clonus (involuntary rhythmic muscle contractions) is also important.

C. Have you been having trouble with urinary incontinence? Urinary incontinence is not a sign of preeclampsia. However, decreased urine output (oliguria) would be concerning as it may indicate worsening renal impairment, but incontinence itself is unrelated.

D. Do you have any right upper quadrant pain? Right upper quadrant or epigastric pain is a concerning sign of liver involvement in severe preeclampsia or HELLP syndrome. It occurs due to liver swelling and can be a precursor to serious complications such as hepatic rupture.

E. Have you had any nausea or vomiting recently? While nausea and vomiting are common in pregnancy, they are not defining symptoms of preeclampsia unless they are sudden and severe. If present in the third trimester, they may suggest worsening disease, but they are not primary indicators.

F. Do you feel safe at home? Screening for domestic violence is important in pregnancy, but it is not a diagnostic question for preeclampsia. While stress and abuse can impact blood pressure, this question does not help in determining preeclampsia.

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Correct Answer is A

Explanation

A. The cervix is effacing and dilated to 2 cm. Cervical changes, including effacement and dilation, are the most definitive signs of preterm labor. Uterine contractions alone do not confirm preterm labor unless they result in cervical dilation, indicating that labor is progressing.

B. Irregular, mild uterine contractions are occurring every 15-30 minutes. Irregular contractions, known as Braxton Hicks contractions, can be common in pregnancy and do not necessarily indicate preterm labor. True preterm labor involves regular contractions that lead to cervical changes.

C. Estriol is not found in maternal saliva. The absence of estriol in maternal saliva does not confirm or rule out preterm labor. Salivary estriol testing is not a widely used or reliable diagnostic tool for determining the onset of preterm labor.

D. Fetal fibronectin is present in vaginal secretion. Fetal fibronectin (fFN) is a protein found in vaginal secretions between 22-34 weeks of pregnancy and can indicate a risk of preterm labor, but its presence alone does not confirm that labor is actively occurring. A positive fFN test means the patient may be at increased risk for preterm labor, but cervical changes remain the best indicator of actual labor.

A. The type of uterine incision used for the cesarean. B. The client's blood type and Rh status. C. The client's response to anesthesia used for the last delivery. D. Lab values, especially hemoglobin and hematocrit

Correct Answer is A

Explanation

A. The type of uterine incision used for the cesarean. This is the most important information because the type of uterine incision determines whether a trial of labor after cesarean (TOLAC) is safe. A low transverse incision is the safest and has the lowest risk of uterine rupture, while a classical (vertical) incision carries a high risk of rupture and contraindicates vaginal birth after cesarean (VBAC).

B. The client's blood type and Rh status. While blood type and Rh status are important for managing potential complications such as Rh incompatibility, they do not determine the safety of a VBAC attempt. The uterine incision type is the key factor in assessing the risk of uterine rupture.

C. The client's response to anesthesia used for the last delivery. Although anesthesia history is relevant for planning pain management, it is not the most critical factor in determining whether the patient can safely attempt a vaginal delivery after a prior cesarean.

D. Lab values, especially hemoglobin and hematocrit. Hemoglobin and hematocrit levels help assess for anemia or blood loss risk, but they do not affect the safety of a VBAC attempt. The primary concern is uterine integrity, which is determined by the type of previous cesarean incision.

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Naxlex Comprehensive Predictor Exams

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which finding is most indicative that preterm labor is occurring?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

Professor Proctor: Always wants us to be safe while traveling anywhere- especially when coming to class. This is prioritized even over being on time.

A woman is admitted due to a suspected ectopic pregnancy. While explaining treatment the patient asks if she will be able to get pregnant again. You answer that she absolutely will get pregnant again. Is this the correct thing to say?

During augmentation of labor with intravenous oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic and complains of severe lower abdominal pain with a tearing sensation. An abnormal FHR tracing is noted on the monitor. The nurse should suspect:

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?

A laboring woman with Type 1 diabetes is on an IV insulin drip, and the nurse is monitoring her glucose levels hourly. The woman's partner asks why the glucose needs to remain between 70-110 mg/dL. The nurse's response is based on which of the following information?

If the nurse suspects a patient has experienced anaphylactoid syndrome of pregnancy (amniotic fluid embolus), which of the following is the priority nursing intervention?

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?