NURSING CARE OF A FAMILY EXPERIENCING A
SUDDEN PREGNANCY COMPLICATION: CHAPTER
21 EXAM QUESTIONS WITH ANSWERS
A nurse in the maternity triage unit is caring for a client with a suspected
ectopic pregnancy. Which nursing intervention should the nurse perform first? -
-CORRECT ANSWER--Assess the client's vital signs.
A suspected ectopic pregnancy can put the client at risk for hypovolemic shock.
The assessment of vital signs should be performed first, followed by any
procedures to maintain the ABCs. Providing emotional support would also
occur, as would obtaining a surgical consent, if needed, but these are not first
steps.
A pregnant client at 32 weeks' gestation is treated with magnesium sulfate for
seizure management. The nurse assesses which of the following for evidence of
magnesium toxicity? --CORRECT ANSWER--Absence of knee jerk response
Magnesium sulfate toxicity is characterized by absence of deep tendon reflexes
like the knee jerk reflex. Urinary retention, and not frequency of micturition, is
seen with magnesium sulfate toxicity. Magnesium sulfate is given to treat
seizures associated with hypertension and proteinuria in pregnancy, and
therefore decreases the blood pressure. It does not cause an increase in blood
pressure. There is respiratory depression, and not an increased rate of
respiration, with magnesium sulfate toxicity.
Page 1 of 33
,The nurse is appraising the medical record of a pregnant client who is resting in
a darkened room and receiving oxytocin and magnesium sulfate. The nurse will
continue to monitor this client for progression to which condition? --CORRECT
ANSWER--eclampsia
This woman is in severe preeclampsia and must be monitored for progression to
eclampsia. The administration of magnesium sulfate is to relax the skeletal
muscles and raise the threshold for a seizure. The administration of oxytocin is
to stimulate uterine contractions to hasten birth. The client has already
progressed from mild preeclampsia to severe preeclampsia, and the nurse need
to follow measures to prevent advancement of the disease process. Although
preeclampsia results in a high blood pressure, the scenario described does not
indicate a client with hypertension.
A client reporting she recently had a positive pregnancy test has reported to the
emergency department stating one-sided lower abdominal pain. The health care
provider has prescribed a series of tests. Which test will provide the most
definitive confirmation of an ectopic pregnancy? --CORRECT ANSWER--
Abdominal ultrasound
An ectopic pregnancy refers to the implantation of the fertilized egg in a
location other than the uterus. Potential sites include the cervix, uterus,
abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be
made by an ultrasound, which would confirm that there was no uterine
Page 2 of 33
,pregnancy. A quantitative hCG level may be completed in the diagnostic plan.
hCG levels in an ectopic pregnancy are traditionally reduced. While this would
be an indication, it would not provide a positive confirmation. The qualitative
hCG test would provide evidence of a pregnancy, but not the location of the
pregnancy. A pelvic exam would be included in the diagnostic plan of care. It
would likely show an enlarged uterus and cause potential discomfort to the
client but would not be a definitive finding.
A woman at 34 weeks' gestation presents to labor and delivery with vaginal
bleeding. Which finding from the obstetric examination would lead to a
diagnosis of placental abruption (abruptio placentae)? --CORRECT ANSWER--
Onset of vaginal bleeding was sudden and painful
Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that
does not relax are signs of a placental abruption (abruptio placentae). The other
findings are consistent with a diagnosis of placenta previa.
The nurse is caring for a woman at 32 weeks' gestation with severe
preeclampsia. Which assessment finding should the nurse prioritize after the
administration of hydralazine to this client? --CORRECT ANSWER--
Tachycardia
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 (halos around lights),
or sweating. Magnesium sulfate may cause sweating.
Page 3 of 33
, A 24-year-old client presents in labor. The nurse notes there is an order to
administer Rho(D) immune globulin after the birth of her infant. When asked by
the client the reason for this injection, which reason should the nurse point out?
--CORRECT ANSWER--prevent maternal D antibody formation.
Because Rho(D) immune globulin contains passive antibodies, the solution will
prevent the woman from forming long-lasting antibodies which may harm a
future fetus. The administration of Rho(D) immune globulin does not promote
the formation of maternal D antibodies; it does not stimulate maternal D
immune antigens or prevent fetal Rh blood formation.
A client with severe preeclampsia is receiving magnesium sulfate as part of the
treatment plan. To ensure the client's safety, which compound would the nurse
have readily available? --CORRECT ANSWER--calcium gluconate
The woman is at risk for magnesium toxicity. 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 client is diagnosed with gestational hypertension and is receiving magnesium
sulfate. The nurse determines that the medication is at a therapeutic level based
on which finding? --CORRECT ANSWER--deep tendons reflexes 2+
Page 4 of 33
SUDDEN PREGNANCY COMPLICATION: CHAPTER
21 EXAM QUESTIONS WITH ANSWERS
A nurse in the maternity triage unit is caring for a client with a suspected
ectopic pregnancy. Which nursing intervention should the nurse perform first? -
-CORRECT ANSWER--Assess the client's vital signs.
A suspected ectopic pregnancy can put the client at risk for hypovolemic shock.
The assessment of vital signs should be performed first, followed by any
procedures to maintain the ABCs. Providing emotional support would also
occur, as would obtaining a surgical consent, if needed, but these are not first
steps.
A pregnant client at 32 weeks' gestation is treated with magnesium sulfate for
seizure management. The nurse assesses which of the following for evidence of
magnesium toxicity? --CORRECT ANSWER--Absence of knee jerk response
Magnesium sulfate toxicity is characterized by absence of deep tendon reflexes
like the knee jerk reflex. Urinary retention, and not frequency of micturition, is
seen with magnesium sulfate toxicity. Magnesium sulfate is given to treat
seizures associated with hypertension and proteinuria in pregnancy, and
therefore decreases the blood pressure. It does not cause an increase in blood
pressure. There is respiratory depression, and not an increased rate of
respiration, with magnesium sulfate toxicity.
Page 1 of 33
,The nurse is appraising the medical record of a pregnant client who is resting in
a darkened room and receiving oxytocin and magnesium sulfate. The nurse will
continue to monitor this client for progression to which condition? --CORRECT
ANSWER--eclampsia
This woman is in severe preeclampsia and must be monitored for progression to
eclampsia. The administration of magnesium sulfate is to relax the skeletal
muscles and raise the threshold for a seizure. The administration of oxytocin is
to stimulate uterine contractions to hasten birth. The client has already
progressed from mild preeclampsia to severe preeclampsia, and the nurse need
to follow measures to prevent advancement of the disease process. Although
preeclampsia results in a high blood pressure, the scenario described does not
indicate a client with hypertension.
A client reporting she recently had a positive pregnancy test has reported to the
emergency department stating one-sided lower abdominal pain. The health care
provider has prescribed a series of tests. Which test will provide the most
definitive confirmation of an ectopic pregnancy? --CORRECT ANSWER--
Abdominal ultrasound
An ectopic pregnancy refers to the implantation of the fertilized egg in a
location other than the uterus. Potential sites include the cervix, uterus,
abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be
made by an ultrasound, which would confirm that there was no uterine
Page 2 of 33
,pregnancy. A quantitative hCG level may be completed in the diagnostic plan.
hCG levels in an ectopic pregnancy are traditionally reduced. While this would
be an indication, it would not provide a positive confirmation. The qualitative
hCG test would provide evidence of a pregnancy, but not the location of the
pregnancy. A pelvic exam would be included in the diagnostic plan of care. It
would likely show an enlarged uterus and cause potential discomfort to the
client but would not be a definitive finding.
A woman at 34 weeks' gestation presents to labor and delivery with vaginal
bleeding. Which finding from the obstetric examination would lead to a
diagnosis of placental abruption (abruptio placentae)? --CORRECT ANSWER--
Onset of vaginal bleeding was sudden and painful
Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that
does not relax are signs of a placental abruption (abruptio placentae). The other
findings are consistent with a diagnosis of placenta previa.
The nurse is caring for a woman at 32 weeks' gestation with severe
preeclampsia. Which assessment finding should the nurse prioritize after the
administration of hydralazine to this client? --CORRECT ANSWER--
Tachycardia
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 (halos around lights),
or sweating. Magnesium sulfate may cause sweating.
Page 3 of 33
, A 24-year-old client presents in labor. The nurse notes there is an order to
administer Rho(D) immune globulin after the birth of her infant. When asked by
the client the reason for this injection, which reason should the nurse point out?
--CORRECT ANSWER--prevent maternal D antibody formation.
Because Rho(D) immune globulin contains passive antibodies, the solution will
prevent the woman from forming long-lasting antibodies which may harm a
future fetus. The administration of Rho(D) immune globulin does not promote
the formation of maternal D antibodies; it does not stimulate maternal D
immune antigens or prevent fetal Rh blood formation.
A client with severe preeclampsia is receiving magnesium sulfate as part of the
treatment plan. To ensure the client's safety, which compound would the nurse
have readily available? --CORRECT ANSWER--calcium gluconate
The woman is at risk for magnesium toxicity. 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 client is diagnosed with gestational hypertension and is receiving magnesium
sulfate. The nurse determines that the medication is at a therapeutic level based
on which finding? --CORRECT ANSWER--deep tendons reflexes 2+
Page 4 of 33
