NCLEX QUESTIONS FOR OB EXAM 2
QUESTIONS WITH CORRECT DETAILED
ANSWERS
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 --ANSWER--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 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
Page 1 of 20
,D.Increased respirations --ANSWER--A and C. The three classic signs of
preeclampsia are hypertension, generalized edema, and protenuria. Increased
respirations are not a sign of preeclampsia
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 --ANSWER--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.
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 --ANSWER--1. Severe
Preeclampsia can trigger disseminated intravascular coagulation (DIC;
Page 2 of 20
, 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 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 --ANSWER--3. If the client complains of a
headache and blurred vision, the physician should be notified because these are
signs of worsening Preeclampsia.
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 --ANSWER--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
Page 3 of 20
QUESTIONS WITH CORRECT DETAILED
ANSWERS
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 --ANSWER--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 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
Page 1 of 20
,D.Increased respirations --ANSWER--A and C. The three classic signs of
preeclampsia are hypertension, generalized edema, and protenuria. Increased
respirations are not a sign of preeclampsia
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 --ANSWER--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.
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 --ANSWER--1. Severe
Preeclampsia can trigger disseminated intravascular coagulation (DIC;
Page 2 of 20
, 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 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 --ANSWER--3. If the client complains of a
headache and blurred vision, the physician should be notified because these are
signs of worsening Preeclampsia.
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 --ANSWER--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
Page 3 of 20
