A nurse is assessing a patient with preeclampsia who delivered 12 hours ago. Which of the following assessments would indicate that the condition has not yet resolved?
a. blood pressure reading at prenatal baseline b. adequate urinary output and no proteinuria c. presence of 1-2+ deep tendon refle...
NUR 353 REP Questions and Complete
Solutions
A nurse is assessing a patient with preeclampsia who delivered 12 hours ago.
Which of the following assessments would indicate that the condition has not yet
resolved?
a. blood pressure reading at prenatal baseline
b. adequate urinary output and no proteinuria
c. presence of 1-2+ deep tendon reflexes
d. patient complaints of blurred vision and headache ✅D
A nurse is completing the admission assessment of a client who is at 38 weeks
gestation and has severe preeclampsia.
Which one of the following findings is consistent with the diagnosis of severe
preeclampsia?
a. Polyuria
b. Absence of clonus
c. Epigastric pain
d. Tachycardia ✅C
Why is magnesium sulfate is given to women with preeclampsia and eclampsia?
a. To improve patellar reflexes and increase respiratory efficiency
b. To prevent and treat convulsions
c. To decrease blood pressure readings
d. To prevent a boggy uterus and lessen lochial flow ✅B
A nurse in a prenatal clinic is reviewing results from recent one-hour oral glucose
tolerance tests.
Which one of the 4 pregnant clients needs to be scheduled for a follow-up, diagnostic
three-hour glucose tolerance test?
a. One hour GTT result: 115 mg/dl
b. One hour GTT result: 95 mg/dl
c. One hour GTT result: 125 mg/dl
d. One hour GTT result: 160 mg/dl ✅D
A nurse is caring for a client at 30 weeks gestation who has just been diagnosed with
gestational diabetes.
The client has a lot of questions about the risks to her baby with GDM.
What is the best explanation by the nurse for why her fetus is at risk for macrosomia
and hypoglycemia at delivery?
,a. To prevent macrosomia, you should only gain 11-20 lbs. total during this pregnancy.
b. When your blood sugar levels are too high, the insulin that you make can cross the
placenta and affect your baby's metabolism.
c. Extra sugar (glucose) can cross the placenta to your baby. This may cause your baby
to gain extra weight and to have sudden low blood glucose after birth.
d. Your baby may be born with diabetes. ✅C
A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia
for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity?
(Select all that apply.)
a. RR less than 12/min
b. Urinary output less than 30 mL/hr
c. Hyperreflexic deep-tendon reflexes
d. Decrease LOC
e. Flushing and sweating ✅A B D
The nurse is preparing to discharge a 30-year-old woman who has experienced a
miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a
correct understanding of the discharge instructions?
a. "I will not experience mood swings since I was only at 10 weeks of gestation."
b. "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months."
c. "I should eat foods that are high in iron and protein to help my body heal."
d. "I should expect the bleeding to be heavy and bright red for at least 1 week." ✅C
(After a miscarriage a woman may experience mood swings and depression from the
reduction of hormones and the grieving process. Sexual intercourse should be avoided
for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months.
A woman who has experienced a miscarriage should be advised to eat foods that are
high in iron and protein to help replenish her body after the loss. The woman should not
experience bright red, heavy, profuse bleeding; this should be reported to the health
care provider.)
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The
nurse becomes concerned after assessment when the woman exhibits:
a. a sleepy, sedated affect.
b. a respiratory rate of 10 breaths/min.
c. deep tendon reflexes of 2+.
d. absent ankle clonus. ✅B (Because magnesium sulfate is a central nervous system
(CNS) depressant, the client will most likely become sedated when the infusion is
initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing
respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of
2+ are a normal finding. Absent ankle clonus is a normal finding.)
, A woman with severe preeclampsia is being treated with an IV infusion of magnesium
sulfate. This treatment is considered successful if:
a. blood pressure is reduced to prepregnant baseline.
b. seizures do not occur.
c. deep tendon reflexes become hypotonic.
d. diuresis reduces fluid retention. ✅B (A temporary decrease in blood pressure can
occur; however, this is not the purpose of administering this medication. Magnesium
sulfate is a central nervous system (CNS) depressant given primarily to prevent
seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical
that calcium gluconate be on hand to counteract the depressant effects of magnesium
toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.)
A woman with severe preeclampsia has been receiving magnesium sulfate by IV
infusion for 8 hours. The nurse assesses the woman and documents the following
findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min,
blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The
nurse calls the physician, anticipating an order for:
a. hydralazine.
b. magnesium sulfate bolus
c. diazepam.
d. calcium gluconate. ✅A (Hydralazine is an antihypertensive commonly used to treat
hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be
ordered for increasing signs of central nervous system irritability related to severe
preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to
stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for
magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms
of magnesium toxicity.)
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta
previa) is:
a. bleeding.
b. intense abdominal pain.
c. uterine activity.
d. cramping. ✅B (Bleeding may be present in varying degrees for both placental
conditions. Pain is absent with placenta previa and may be agonizing with abruptio
placentae. Uterine activity may be present with both placental conditions. Cramping is a
form of uterine activity that may be present in both placental conditions.)
A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the
labor and birth unit. She suddenly experiences increased contraction frequency of every
1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse
suspects the onset of:
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