Exam 1: High Risk Antepartum NCLEX Questions and Correct Solutions Graded A+

a 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? a. assess deep tendon reflexes b. obtain complete blood count c. assess baseline weight d. obtain routine urinalysis c A nurse is counseling a preeclamptic client about her diet. Which should the nurse encourage the woman to do? a. restrict sodium intake b. increase intake of fluids c. eat a well-balanced diet d. avoid simple sugars a 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? a. weight loss b. 2+ proteinuria c. decrease in plasma proteins d. 3+ patellar reflexes b 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? a. inquire whether or not the client has allergies b. take the woman's blood pressure c. assess the woman's fundal height d. ask the woman about stressors at work a 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? a. altered glomerular filtration b. cardiac failure c. hepatic insufficiency d. altered splenic circulation d 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? a. severe anemia b. hypoprothrombinemia c. craniosynostosis d. intrauterine growth restriction a A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following? a. grand mal seizure b. high platelet count c. explosive diarrhea d. fractured pelvis c A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? a. strike the woman's patellar tendon b. palpate the woman's ankle c. dorsiflex the woman's foot d. position the woman's feet flat on the floor c The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? a. +1 b. +2 c. +3 d. +4 d A 26 week gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? a. low serum creatinine b. high serum protein c. bloody stools d. epigastric pain b 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 past 2 days. Which of the following signs/symptoms would the nurse also expect to see? a. fundal height of 32cm b. papilledema c. patellar reflex of +2 d. nystagmus c A client with mild preeclampsia who has been advised to be on bed rest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give to the client? a. "bed rest will help you to conserve energy for your labor" b. "bed rest will help to relieve your nausea and anorexia" c. "reclining will increase the amount of oxygen that your baby gets" d. "the position change will prevent the placenta from separating" a In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18 week gravid client to call the office if she experiences which of the following? a. headache and decreased output b. puffy feet c. hemorrhoids and vaginal discharge d. backache