Nclex questions for OB exam 2

The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2+ proteinuria. 3. Decrease in plasma protein. 4. 3 + patellar reflexes.

1. Weight loss is a positive sign. The key to answering this question is the test taker's ability to interpret the meaning of mild preeclampsia and to realize that this is an evaluation question. There are two levels of preeclampsia. Mild preeclampsia is characterized by the following signs/symptoms: blood pressure 140/90, urine protein +2, patellar reflexes + 3, and weight gain. As can be seen, the values included in answers 2 and 4 are the same as those in the diagnosis. They, therefore, are not signs that the preeclampsia is resolving. Similarly, loss of protein is not a sign of resolution of the disease.

When counseling a preeclamptic client about her diet, what should the nurse encourage the woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars.

3. It is important for the client to eat a well-balanced diet. Clients with preeclampsia are losing albumin through their urine. They should eat a well-balanced diet with sufficient protein to replace the lost protein. Even though preeclamptic clients are hypertensive, it is not recommended that they restrict salt-they should have a normal salt intake-because during pregnancy the kidney is salt sparing. When salt is restricted, the kidneys become stressed.

A home care nurse visits a pregnant client who ad a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician? 1. Urinary output as increased 2. Dependent edema has resolved 3. BP reading is at the prenatal baseline 4. The client complains of a headache and blurred vision.

4. The client complains of a headache and blurred vision.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse review the physican's prescriptions and would question which prescription? 1. Prepare the client for an ultrasound 2. Obtain equipment for a manual pelvic examination 3. Prepare to draw a hemoglobin and hematocrit blood sample 4. Obtain equipment for external electronic FHR monitoring.

2. Obtain equipment for a manual pelvic examination

A 32-week gestation client was last seen in the prenatal clinic at 28 weeks' gestation. Which of the following changes should the nurse bring to the attention of the Certified Nurse's Midwife? 1. Weight change from 128 pounds to 132 pounds 2. Pulse changes from 88 bpm to 92 bpm 3. Blood pressure changes from 110/70 to 140/90 4. Respiratory change from 16 rpm to 20 rpm

3. Blood pressure changes from 110/70 to 140/90 A blood pressure elevation to 140/90 is a sign of mild pre-eclampsia

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? 1.Blood pressure reading is at the prenatal baseline 2.Urinary output has increased 3.The client complains of a headache and blurred vision 4.Dependent edema has resolved

3. If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening Preeclampsia.

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? A.Elevated blood pressure B.Negative urinary protein C.Facial edema D.Increased respirations

A and C. The three classic signs of preeclampsia are hypertension, generalized edema, and protenuria. Increased respirations are not a sign of preeclampsia

The antagonist for magnesium sulfate should be readily available to any client receiving IV magnesium. Which of the following drugs is the antidote for magnesium toxicity? A.Calcium gluconate B.Hydralazine (Apresoline) C.Narcan D.RhoGAM

A. Calcium gluconate is the antidote for magnesium toxicity. Ten ml of 10% calcium gluconate is given IV push over 3-5 minutes. Hydralazine is given for sustained elevated blood pressures in preeclamptic clients.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A.Ankle clonus in noted B.The blood pressure decreases C.Seizures do not occur D.Scotoma's are present

C. For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Ankle clonus indicated hyperrelexia and may precede the onset of eclampsia. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure.

A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A.Administer magnesium sulfate intravenously B.Assess the blood pressure and fetal heart rate C.Clean and maintain an open airway D.Administer oxygen by face mask

C. The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.

A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? 1. Altered glomerular filtration. 2. Cardiac failure. 3. Hepatic insufficiency. 4. Altered splenic circulation.

1. Altered glomerular filtration leads to protein loss and, subsequently, to fluid retention, which can lead to swelling in the face and hands. The hypertension associated with preeclampsia results in poor perfusion of the kidneys. When the kidneys are poorly perfused, the glomerlular filtration is altered, allowing large molecules, most notably the protein albumin, to be lost through the urine. With the loss of protein, the colloidal pressure drops in the vascular tree, allowing fluid to third space. The body gets the message to retain fluids, exacerbating the problem. One of the early signs of the third spacing is the swelling of a client's hands and face.

A client with 4+ protein and 4+ reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1. Clients with severe preeclampsia are high risk for seizure. A client who is diagnosed with severe preeclampsia is high risk for becoming eclamptic. Clients who become eclamptic have had at least one seizure.

A client who is 32 weeks pregnant is being monitored in the antepartum unit for PIH. She suddenly complains of continuous abdominal pain and vaginal bleeding. Which of the following nursing internventions should be included in the care of this client? Check all that apply 1. Evaluate VS 2. Prepare for vaginal delivery 3. Reassure client that she'll be able to continue pregnancy 4. Evaluate FHT 5. Monitor amt of vaginal bleed 6. Monitor I&O

1. Evaluate VS 4. Evaluate FHT 5. Monitor amt of vaginal bleed 6. Monitor I&O The clients Sx indicate that she's experiencing abruptio placenta. The nurse must immed eval the moms well being by eval VS, FWB, by auscultation of heart tones, monitoring amt of blood loss and eval the vol status by measuring I&O. After the severity of the abruption has been determined and blood and fluid have been replaced, prompt C-SECTION delivery of the fetus (not vaginal) is indicated if the fetus is in distress

A home care nurse is monitoring a pregnant client with gestational HTN who is at risk for preeclampsia. At each home care visit, the nurse assess the client for which classic signs of preeclampsia? SELECT ALL THAT APPLY. 1. Proteinuria 2. HTN 3. Low grade fever 4. Generalized edema 5. Increased pulse rate 6. Increased respirator rate

1. Proteinuria 2. HTN 4. Generalized edema

A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

2. The nurse should assess the client's blood pressure. Headache is a symptom of preeclampsia. Preeclampsia, a serious complication, is a hypertensive disease of pregnancy. In order to determine whether or not the client is preeclamptic, the next action by the nurse would be to assess the woman's blood pressure.

A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the last 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus.

2. The nurse would expect to see papilledema. TEST-TAKING TIP: Intracranial pressure (ICP) is present in a client with severe preeclampsia because she is third spacing large quantities of fluid. As a result of the ICP, the optic disk swells and papilledema is seen when the disk is viewed through an ophthalmoscope.

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: 1.Any bleeding, such as in the gums, petechiae, and purpura. 2.Enlargement of the breasts 3.Periods of fetal movement followed by quiet periods 4.Complaints of feeling hot when the room is cool

1. Severe Preeclampsia can trigger disseminated intravascular coagulation (DIC; remember the Peds lecture?) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D

A nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? SELECT ALL THAT APPLY. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age.

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age.

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

4. Epigastric pain is associated with the liver involvement of HELLP syndrome. TEST-TAKING TIP: When the liver is deprived of sufficient blood supply, as can occur with severe preeclampsia, the organ becomes ischemic. The client experiences pain at the site of the liver as a result of the hypoxia in the liver.

A client with a 4+ protein and 4+ reflexes is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. High leukocyte count 2. Explosive diarrhea 3. Fractured pelvis 4. Low platelet count

4. Low platelet count Low platelet count is one of the signs associated with HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)

A primagravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A.Urinary output of 20 ml since the previous assessment B.Deep tendon reflexes of 2+ C.Respiratory rate of 10 BPM D.Fetal heart rate of 120 BPM

C. Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A.Presence of deep tendon reflexes B.Serum magnesium level of 6 mEq/L C.Proteinuria of +3 D.Respirations of 10 per minute

D. Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden drop in the fetal heart rate and maternal heart rate and blood pressure. Therapeutic levels of magnesium are 4-7 mEq/L. Proteinuria of +3 would be noted in a client with preeclampsia.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. Based on these findings, the nurse would prepare the client for: 1. Delivery of the fetus 2. Strict monitoring of I/O 3. Complete bedrest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1. Delivery of the fetus

Which of the following S&S would the nurse expect to see in a woman with concealed abruption placentae? 1. Increasing abdominal girth measurements 2. Profuse vaginal bleeding 3. Bradycardia with an aortic thrill 4. Hypothermia with chills

1. Increasing abdominal girth measurements The nurse would expect to see increasing abdominal girth measurements Profuse vaginal bleeding rarely seen in abruption placentae and is never seen when abruption is concealed With excessive blood loss, the nurse would expect to see tachycardia Temp would be stable

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is-to-assess the patellar reflexes. Preeclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the urinalysis. By assessing the patellar reflexes first, however, the nurse can make a preliminary assessment of the severity of the preeclampsia. For example, if the reflexes are +2, the client would be much less likely to become eclamptic than a client who has +4 reflexes with clonus.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic HTN 4. DIC

2. Hemorrhage

A client's 32-week clinic assessment was: BP 90/60; TPR 98.6°F, P 92, R 20; weight 145 lb; and urine negative for protein. Which of the following findings at the 34-week appointment should the nurse highlight for the certified nurse midwife? 1. BP 110/70; TPR 99.2°F, 88, 20. 2. Weight 155 lb; urine protein +2. 3. Urine protein trace; BP 88/56. 4. Weight 147 lb; TPR 99.0°F, 76,

2. There has been a 10-lb weight gain in 2 weeks and a significant amount of protein is being spilled in the urine. This client should be brought to the attention of the primary caregiver. There is a great deal of information included in this question. The test taker must methodically assess each of the pieces of data. Important things to attend to are the timing of the appointments-2 weeks apart; changes in vital signs-it is normal for pulse and respiratory rate to increase slightly and BP to drop slightly; changes in urinary protein-trace is normal, +2 is not normal; and changes in weight-2-lb increase over 2 weeks is normal, a 10-lb increase is not normal.

A nurse is assessing a pregant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2. Uterine tenderness

The nurse has assessed four primigravid clients in the prenatal clinic. Which of the women would the nurse refer to the nurse midwife for further assessment? 1. 10 weeks' gestation, complains of fatigue with nausea and vomiting. 2. 26 weeks' gestation, complains of ankle edema and chloasma. 3. 32 weeks' gestation, complains of epigastric pain and facial edema. 4. 37 weeks' gestation, complains of bleeding gums and urinary frequency

3. Epigastric pain and facial edema are not normal. This client should be referred to the nurse midwife. The nurse must be prepared to identify clients with symptoms that are unexpected. This question requires the test taker to differentiate between normal signs and symptoms of pregnancy at a variety of gestational ages and those that could indicate a serious complication of pregnancy.

Which finding should the nurse expect when assessing a client with placenta previa? 1. Severe occipital headache. 2. History of renal disease. 3. Previous premature delivery. 4. Painless vaginal bleeding.

4. Painless vaginal bleeding is often the only symptom of placenta previa. There are three different forms of placenta previa: low-lying placenta-one that lies adjacent to, but not over, the internal cervical os; partial-one that partially covers the internal cervical os; and complete-a placenta that completely covers the internal cervical os. There is no way to deliver a live baby vaginally when a client has a complete previa, although there are cases when live babies have been delivered when the clients had low-lying or partial previas.

A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.

4. The fetus should be assessed for intrauterine growth restriction. TIP: Perfusion to the placenta drops when clients are preeclamptic because the client's hypertension impairs adequate blood flow. When the placenta is poorly perfused, the baby is poorly nourished. Without the nourishment provided by the mother through the umbilical vein, the fetus' growth is affected.

A client with mild preeclampsia, who has been advised to be on bed rest at home, asks why it is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bed rest will help you to conserve energy for your labor." 2. "Bed rest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."

3. Bed rest, especially side-lying, helps to improve perfusion to the placenta. TEST-TAKING TIP: This question requires the nurse to have a clear understanding of the pathology of preeclampsia. Only with an understanding of the underlying disease, can the test taker be able to remember the rationale for many aspects of client care. The vital organs of preeclamptic clients are being poorly perfused as a result of the abnormally high blood pressure. When a woman lies on her side, blood return to the heart is improved and the cardiac output is also improved. With improved cardiac output, perfusion to the placenta and other organs is improved

nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. 1.Monitor maternal vital signs every 2 hours 2.Notify the physician if respirations are less than 18 per minute. 3.Monitor renal function and cardiac function closely 4.Keep calcium gluconate on hand in case of a magnesium sulfate overdose 5.Monitor deep tendon reflexes hourly 6.Monitor I and O's hourly 7.Notify the physician if urinary output is less than 30 ml per hour.

3, 4, 5, 6, and 7. When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.