High Risk Pregnancy NCLEX Questions

High Risk Pregnancy NCLEX Questions ScienceMedicineObstetrics brittbarnwell91 Save

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38 terms nelvehjemPreview Pregna 109 term Bro A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

• Urinary output of 20 mL per hour
• Respiratory rate of 10 breaths/minute
• Deep tendons reflexes 2+
• Difficulty in arousing

Ans: C

With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the woman's increased risk?

• Oligohydramnios
• Preeclampsia
• Post-term labor
• Chorioamnionitis

Ans: B

Women with multiple gestations are at high risk for preeclampsia, preterm labor, hydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.

A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which of the following would the lead the nurse to suspect that the client is having an adverse effect associated with this drug?

• Gastrointestinal bleeding
• Blurred vision
• Tachycardia
• Sweating

Ans: C

Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision, or sweating. Magnesium sulfate may cause sweating.After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension?

• Mother had gestational hypertension during pregnancy.
• Client has a twin sister.
• Sister-in-law had gestational hypertension.
• This is the client's second pregnancy.

Ans: A

A family history of gestational hypertension, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy.The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome?

• Hyperglycemia
• Elevated platelet count
• Leukocytosis
• Elevated liver enzymes

Ans: D

HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome.Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?

• Calcium gluconate
• Potassium chloride
• Ferrous sulfate
• Calcium carbonate

Ans: A

The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.

A nurse is teaching a pregnant woman with preterm premature rupture of membranes who is about to be discharged home about caring for herself. Which statement by the woman indicates a need for additional teaching?

• "I need to keep a close eye on how active my baby is each day."
• "I need to call my doctor if my temperature increases."
• "It's okay for my husband and me to have sexual intercourse."
• "I can shower but I shouldn't take a tub bath."

Ans: C

Feedback:

The woman with preterm premature rupture of membranes should monitor her baby's activity by performing fetal kick counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and avoid sitting in a tub bath.A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia?

• Urine protein 300 mg/24 hours
• Blood pressure 150/96 mm Hg
• Mild facial edema
• Hyperreflexia

Ans: D

Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild preeclampsia.A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment of which of the following? (Select all that apply.)

• Dark red vaginal bleeding
• Insidious onset
• Absence of pain
• Rigid uterus
• Absent fetal heart tones

Ans: A, D, E

Feedback:

Assessment findings associated with abruption placenta include a sudden onset, with concealed or visible bleeding, dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones.

A nursing student is reviewing an article about preterm premature rupture of membranes. Which of the following would the student expect to find as factor placing a woman at high risk for this condition? (Select all that apply.)

• High body mass index
• Urinary tract infection
• Low socioeconomic status
• Single gestations
• Smoking

Ans: B, C, E

High-risk factors associated with preterm PROM include low socioeconomic status, multiple gestation, low body mass index, tobacco use, preterm labor history, placenta previa, abruptio placenta, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?

• "My mother lives next door and can drive me here if necessary."
• "I have a toddler and preschooler at home who need my attention."
• "I know to call my health care provider right away if I start to bleed again."
• "I realize the importance of following the instructions for my care."

Ans: B

Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home.Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions.A woman with gestational hypertension experiences a seizure. Which of the following would be the priority?

• Fluid replacement
• Oxygenation
• Control of hypertension
• Delivery of the fetus

Ans: B

As with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable.