The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Complaints of feeling hot when the room is cold.

Evidence of bleeding, such as in gums, petechiae, and purpura.

Edema of the lower extremities.

Periods of fetal movement followed by quiet periods.

Answer and Explanation

The Correct Answer is B

A. Feeling hot when the room is cold is not a typical sign or complication of severe preeclampsia. This symptom is more related to general temperature sensitivity and does not indicate the hematologic or vascular complications associated with preeclampsia.

B. Evidence of bleeding, including gums bleeding, petechiae, and purpura, may indicate thrombocytopenia or a progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe complication of preeclampsia. These findings suggest impaired coagulation and increased risk of bleeding, which are life-threatening if not promptly managed. Monitoring for such hematologic complications is essential in severe preeclampsia.

C. Edema of the lower extremities is common in normal pregnancy and mild preeclampsia, but it is not a specific sign of a serious complication. While generalized edema can indicate worsening preeclampsia, isolated lower-extremity edema is not as closely associated with life-threatening complications as bleeding or hematologic abnormalities.

D. Periods of fetal movement followed by quiet periods are typical fetal behavior and do not indicate a maternal complication of preeclampsia. Monitoring for changes in fetal movement is important, but this finding alone does not reflect maternal complications of severe preeclampsia.

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Correct Answer is ["A"]

Explanation

A. The client shows signs of magnesium sulfate toxicity: oliguria (urine output <30 mL/hr) and absent deep-tendon reflexes. These are potentially life-threatening signs that require immediate intervention, including preparing for emergent delivery if maternal or fetal status is unstable. Stopping the magnesium infusion and preparing for emergency interventions is critical.

B. Administering Vitamin K is not indicated in this scenario. Vitamin K is used to treat or prevent coagulopathy, such as in newborns or clients on certain anticoagulants, but it does not counteract magnesium toxicity.

C. Increasing the magnesium sulfate infusion would worsen toxicity. The correct action is to stop the infusion immediately and prepare to administer calcium gluconate as an antidote if prescribed.

D. Assessing maternal glucose levels is unrelated to the immediate concern of magnesium toxicity. While glucose monitoring may be part of overall prenatal care, it is not a priority in this emergent situation.

E. Placing the client in Trendelenburg position is not indicated. Positioning does not treat magnesium toxicity and could worsen respiratory compromise in a client with severe preeclampsia. The priority is stopping magnesium, assessing maternal and fetal status, and preparing for emergency delivery if necessary.

A. Directional trends B. Developmental pace C. Sensitive periods D. Sequential trends

Correct Answer is B

Explanation

A. Directional trends describe the general patterns of growth, such as cephalocaudal (head-to-toe) or proximodistal (center-to-periphery) development. The scenario focuses on differences in the rate of skill acquisition, not the direction of development.

B. Developmental pace refers to the rate at which different skills or abilities emerge, which can vary among domains. In this scenario, the toddler’s language skills are advancing rapidly, while gross motor skills like running show little change, illustrating that different areas of development progress at different rates.

C. Sensitive periods refer to specific windows of time during which a child is particularly responsive to certain types of learning or stimuli, such as language acquisition. The scenario does not specify a critical timing for development, but rather differences in progression across skills, so sensitive periods are not the primary principle illustrated.

D. Sequential trends refer to the orderly and predictable progression of developmental milestones, such as crawling before walking. While the toddler is developing language, the scenario emphasizes rate differences, not the order in which skills emerge.

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The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's urine output for the past hour is 25 mL and deep-tendon reflexes are absent. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A"]

Explanation

During a well-child visit, a nurse notes that a toddler has recently started speaking in short sentences, but gross motor skills such as running have shown little change. Which principle does this BEST illustrate?

Correct Answer is B

Explanation

The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

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