High-Risk Pregnancy: 2026 Complication Protocols
Examination Questions
1. A 32-week gestation patient presents to the triage unit with a blood pressure of 162/114 mmHg,
severe frontal headache, and visual scotoma. Which of the following is the priority first-line nursing
intervention?
A. Administer oral nifedipine 10 mg immediately
B. Initiate a loading dose of intravenous Magnesium Sulfate per protocol
C. Obtain a 24-hour urine collection for protein assessment
D. Perform a non-stress test (NST) to evaluate fetal well-being
Correct Answer: B. Initiate a loading dose of intravenous Magnesium Sulfate per protocol
Rationale: The patient exhibits preeclampsia with severe features (headache, visual changes, and blood pressure
≥160/110 mmHg). The immediate priority is seizure prophylaxis using Magnesium Sulfate. Antihypertensives are
critical but secondary to safety/seizure prevention, and oral nifedipine is not the primary choice if IV access is
established for urgent control.
2. During the administration of Magnesium Sulfate for a preeclamptic patient, the nurse notes a
respiratory rate of 9 breaths per minute, absent deep tendon reflexes (DTRs), and a urine output of 15
mL over the last hour. What is the immediate action?
A. Increase the intravenous fluid maintenance rate to flush the kidneys
B. Stop the Magnesium Sulfate infusion and prepare to administer Calcium Gluconate
C. Draw a stat serum magnesium level and await laboratory results
D. Place the patient in a high-Fowler's position and administer supplemental oxygen
Correct Answer: B. Stop the Magnesium Sulfate infusion and prepare to administer Calcium Gluconate
Rationale: Absent DTRs, bradypnea, and oliguria are classic signs of magnesium toxicity. The infusion must be
stopped immediately, and the antidote, Calcium Gluconate (typically 1 g IV over 5-10 minutes), should be
administered to prevent cardiac arrest.
3. What is the therapeutic target range for serum magnesium levels during seizure prophylaxis in
preeclampsia?
A. 2.0 to 4.0 mEq/L
B. 4.8 to 8.4 mg/dL (4.0 to 7.0 mEq/L)
C. 9.0 to 12.0 mg/dL
D. 1.5 to 2.5 mg/dL
Correct Answer: B. 4.8 to 8.4 mg/dL (4.0 to 7.0 mEq/L)
,Rationale: The therapeutic range for seizure prevention is 4.8 to 8.4 mg/dL (or 4 to 7 mEq/L). Levels above 9
mg/dL are associated with toxicity (loss of DTRs), and levels above 12 mg/dL can cause respiratory depression.
4. According to 2026 ACOG and SMFM guidelines, which dose of aspirin should be initiated for a
pregnant patient with high risk for preeclampsia, and when should it start?
A. 81 mg daily starting at 20 weeks gestation
B. 150 mg daily starting at 28 weeks gestation
C. 81 to 162 mg daily starting between 12 and 28 weeks gestation (ideally before 16 weeks)
D. 325 mg daily starting in the first trimester
Correct Answer: C. 81 to 162 mg daily starting between 12 and 28 weeks gestation (ideally before 16 weeks)
Rationale: Current protocols recommend low-dose aspirin (81 to 162 mg/day, commonly prescribed as 162
mg/day or two 81 mg tablets in high-risk patients) initiated between late first trimester/early second trimester (12-
16 weeks) to optimize placental vascular development and prevent preeclampsia.
5. A patient with gestational hypertension at 38 weeks gestation has a blood pressure of 144/92 mmHg
and no severe features. What is the recommended management plan?
A. Maintain outpatient expectant management with twice-weekly NSTs until 40 weeks
B. Recommend induction of labor, as delivery is recommended at 37 0/7 weeks for gestational hypertension
C. Initiate oral labetalol 100 mg twice daily to normalize blood pressure
D. Admit for continuous inpatient monitoring and schedule a Cesarean delivery
Correct Answer: B. Recommend induction of labor, as delivery is recommended at 37 0/7 weeks for
gestational hypertension
Rationale: For both gestational hypertension and preeclampsia without severe features, delivery is recommended
at 37 0/7 weeks. Prolonging pregnancy beyond this increases maternal-fetal risks without improving outcomes.
Antihypertensive therapy is not routinely recommended for mild range hypertension (systolic <160 and diastolic
<110 mmHg).
6. Which diagnostic lab criteria is indicative of HELLP Syndrome?
A. Platelets < 150,000/mcL, AST < 40 U/L, Bilirubin < 1.0 mg/dL
B. Platelets < 100,000/mcL, LDH ≥ 600 U/L, and AST/ALT ≥ twice the upper limit of normal
C. Fibrinogen < 150 mg/dL, elevated BUN, and creatinine > 1.1 mg/dL
D. Hemoglobin < 8 g/dL, WBC > 20,000/mcL, and elevated alkaline phosphatase
Correct Answer: B. Platelets < 100,000/mcL, LDH ≥ 600 U/L, and AST/ALT ≥ twice the upper limit of
normal
Rationale: HELLP stands for Hemolysis (indicated by LDH ≥ 600 U/L or schistocytes), Elevated Liver enzymes
(AST/ALT twice normal), and Low Platelets (<100,000/mcL).
,7. A patient at 29 weeks gestation with preeclampsia with severe features is being managed expectantly.
Which clinical finding would necessitate immediate delivery?
A. Mild proteinuria of 500 mg per 24 hours
B. Fetal growth restriction at the 8th percentile with normal umbilical artery Doppler flow
C. Repeated readings of severe range blood pressure controlled by oral medication
D. Uncontrolled severe right upper quadrant/epigastric pain or progressive renal dysfunction
Correct Answer: D. Uncontrolled severe right upper quadrant/epigastric pain or progressive renal
dysfunction
Rationale: Indications for delivery during expectant management of preeclampsia with severe features include
maternal indicators (uncontrolled severe hypertension, eclampsia, placental abruption, pulmonary edema, renal
failure, persistent severe RUQ/epigastric pain indicating hepatic risk) or fetal indicators (abnormal Doppler, non-
reassuring NST, or fetal death).
8. What is the mechanism of action of Magnesium Sulfate in preventing eclamptic seizures?
A. It is a potent systemic vasodilator that decreases cerebral arterial pressure
B. It acts as a central nervous system depressant by blocking neuromuscular transmission and acting as an
NMDA receptor antagonist
C. It directly sedates the patient and reduces metabolic activity in the occipital lobe
D. It stimulates GABA receptors to hyperpolarize postsynaptic membranes
Correct Answer: B. It acts as a central nervous system depressant by blocking neuromuscular transmission
and acting as an NMDA receptor antagonist
Rationale: Magnesium sulfate works by decreasing acetylcholine release at the neuromuscular junction and
blocking calcium influx into NMDA receptors in the brain, thereby raising the seizure threshold. It is not primarily
a vasodilator or sedative.
9. When managing a hypertensive emergency in pregnancy (BP ≥ 160/110 mmHg), which of the
following represents the correct administration protocol for intravenous hydralazine?
A. Give 20 mg IV bolus over 1 minute; repeat with 40 mg in 5 minutes if BP remains elevated
B. Give 5 to 10 mg IV slow bolus over 2 minutes; repeat in 20 minutes if threshold remains exceeded
(maximum cumulative dose of 20 mg)
C. Administer 100 mg IV over 10 minutes and initiate a continuous infusion at 10 mg/hr
D. Hydralazine is contraindicated in pregnancy and should only be given postpartum
Correct Answer: B. Give 5 to 10 mg IV slow bolus over 2 minutes; repeat in 20 minutes if threshold remains
exceeded (maximum cumulative dose of 20 mg)
Rationale: Standard emergency protocols dictate IV hydralazine 5-10 mg slow bolus. If BP is still elevated, repeat
10 mg in 20 minutes. The maximum dose is 20 mg. Excessively rapid reduction in blood pressure can compromise
placental perfusion.
, 10. A postpartum patient who had preeclampsia with severe features is preparing for discharge. What
is the essential 2026 teaching protocol regarding blood pressure monitoring?
A. Blood pressure should be checked once at the 6-week postpartum visit
B. The patient should monitor blood pressure daily, and contact the provider if BP is ≥ 140/90 mmHg or for
any severe preeclampsia symptoms
C. Antihypertensive medications should be stopped immediately upon delivery
D. Postpartum preeclampsia does not occur, so no blood pressure tracking is required after discharge
Correct Answer: B. The patient should monitor blood pressure daily, and contact the provider if BP is ≥
140/90 mmHg or for any severe preeclampsia symptoms
Rationale: Postpartum preeclampsia can present up to 6 weeks after delivery. Discharged patients require explicit
education to monitor blood pressure and report signs (headache, vision changes, epigastric pain) or a BP ≥140/90
mmHg. High-risk patients should have their BP checked 72 hours and 7-10 days postpartum.
11. A pregnant patient with chronic hypertension is prescribed labetalol. What is a key maternal
contraindication to the use of beta-blockers like labetalol?
A. Gestational diabetes mellitus
B. Asthma or reactive airway disease
C. History of twin gestations
D. Mild proteinuria
Correct Answer: B. Asthma or reactive airway disease
Rationale: Labetalol is a non-selective beta-blocker that also blocks alpha-1 receptors. It can cause
bronchoconstriction and is contraindicated in patients with asthma, chronic obstructive pulmonary disease
(COPD), or severe reactive airway disease.
12. A patient at 36 weeks gestation with preeclampsia presents with sudden onset of hypertonic, painful
uterine contractions, dark red vaginal bleeding, and fetal heart rate decelerations. What complication
is suspected?
A. Placenta previa
B. Uterine atony
C. Placental abruption
D. Vasa previa rupture
Correct Answer: C. Placental abruption
Rationale: Preeclampsia is a major risk factor for placental abruption. Classic symptoms of abruption include
painful vaginal bleeding, uterine rigidity/tenderness, hypertonic contractions, and non-reassuring fetal status.
Placenta previa presents with painless vaginal bleeding.
Examination Questions
1. A 32-week gestation patient presents to the triage unit with a blood pressure of 162/114 mmHg,
severe frontal headache, and visual scotoma. Which of the following is the priority first-line nursing
intervention?
A. Administer oral nifedipine 10 mg immediately
B. Initiate a loading dose of intravenous Magnesium Sulfate per protocol
C. Obtain a 24-hour urine collection for protein assessment
D. Perform a non-stress test (NST) to evaluate fetal well-being
Correct Answer: B. Initiate a loading dose of intravenous Magnesium Sulfate per protocol
Rationale: The patient exhibits preeclampsia with severe features (headache, visual changes, and blood pressure
≥160/110 mmHg). The immediate priority is seizure prophylaxis using Magnesium Sulfate. Antihypertensives are
critical but secondary to safety/seizure prevention, and oral nifedipine is not the primary choice if IV access is
established for urgent control.
2. During the administration of Magnesium Sulfate for a preeclamptic patient, the nurse notes a
respiratory rate of 9 breaths per minute, absent deep tendon reflexes (DTRs), and a urine output of 15
mL over the last hour. What is the immediate action?
A. Increase the intravenous fluid maintenance rate to flush the kidneys
B. Stop the Magnesium Sulfate infusion and prepare to administer Calcium Gluconate
C. Draw a stat serum magnesium level and await laboratory results
D. Place the patient in a high-Fowler's position and administer supplemental oxygen
Correct Answer: B. Stop the Magnesium Sulfate infusion and prepare to administer Calcium Gluconate
Rationale: Absent DTRs, bradypnea, and oliguria are classic signs of magnesium toxicity. The infusion must be
stopped immediately, and the antidote, Calcium Gluconate (typically 1 g IV over 5-10 minutes), should be
administered to prevent cardiac arrest.
3. What is the therapeutic target range for serum magnesium levels during seizure prophylaxis in
preeclampsia?
A. 2.0 to 4.0 mEq/L
B. 4.8 to 8.4 mg/dL (4.0 to 7.0 mEq/L)
C. 9.0 to 12.0 mg/dL
D. 1.5 to 2.5 mg/dL
Correct Answer: B. 4.8 to 8.4 mg/dL (4.0 to 7.0 mEq/L)
,Rationale: The therapeutic range for seizure prevention is 4.8 to 8.4 mg/dL (or 4 to 7 mEq/L). Levels above 9
mg/dL are associated with toxicity (loss of DTRs), and levels above 12 mg/dL can cause respiratory depression.
4. According to 2026 ACOG and SMFM guidelines, which dose of aspirin should be initiated for a
pregnant patient with high risk for preeclampsia, and when should it start?
A. 81 mg daily starting at 20 weeks gestation
B. 150 mg daily starting at 28 weeks gestation
C. 81 to 162 mg daily starting between 12 and 28 weeks gestation (ideally before 16 weeks)
D. 325 mg daily starting in the first trimester
Correct Answer: C. 81 to 162 mg daily starting between 12 and 28 weeks gestation (ideally before 16 weeks)
Rationale: Current protocols recommend low-dose aspirin (81 to 162 mg/day, commonly prescribed as 162
mg/day or two 81 mg tablets in high-risk patients) initiated between late first trimester/early second trimester (12-
16 weeks) to optimize placental vascular development and prevent preeclampsia.
5. A patient with gestational hypertension at 38 weeks gestation has a blood pressure of 144/92 mmHg
and no severe features. What is the recommended management plan?
A. Maintain outpatient expectant management with twice-weekly NSTs until 40 weeks
B. Recommend induction of labor, as delivery is recommended at 37 0/7 weeks for gestational hypertension
C. Initiate oral labetalol 100 mg twice daily to normalize blood pressure
D. Admit for continuous inpatient monitoring and schedule a Cesarean delivery
Correct Answer: B. Recommend induction of labor, as delivery is recommended at 37 0/7 weeks for
gestational hypertension
Rationale: For both gestational hypertension and preeclampsia without severe features, delivery is recommended
at 37 0/7 weeks. Prolonging pregnancy beyond this increases maternal-fetal risks without improving outcomes.
Antihypertensive therapy is not routinely recommended for mild range hypertension (systolic <160 and diastolic
<110 mmHg).
6. Which diagnostic lab criteria is indicative of HELLP Syndrome?
A. Platelets < 150,000/mcL, AST < 40 U/L, Bilirubin < 1.0 mg/dL
B. Platelets < 100,000/mcL, LDH ≥ 600 U/L, and AST/ALT ≥ twice the upper limit of normal
C. Fibrinogen < 150 mg/dL, elevated BUN, and creatinine > 1.1 mg/dL
D. Hemoglobin < 8 g/dL, WBC > 20,000/mcL, and elevated alkaline phosphatase
Correct Answer: B. Platelets < 100,000/mcL, LDH ≥ 600 U/L, and AST/ALT ≥ twice the upper limit of
normal
Rationale: HELLP stands for Hemolysis (indicated by LDH ≥ 600 U/L or schistocytes), Elevated Liver enzymes
(AST/ALT twice normal), and Low Platelets (<100,000/mcL).
,7. A patient at 29 weeks gestation with preeclampsia with severe features is being managed expectantly.
Which clinical finding would necessitate immediate delivery?
A. Mild proteinuria of 500 mg per 24 hours
B. Fetal growth restriction at the 8th percentile with normal umbilical artery Doppler flow
C. Repeated readings of severe range blood pressure controlled by oral medication
D. Uncontrolled severe right upper quadrant/epigastric pain or progressive renal dysfunction
Correct Answer: D. Uncontrolled severe right upper quadrant/epigastric pain or progressive renal
dysfunction
Rationale: Indications for delivery during expectant management of preeclampsia with severe features include
maternal indicators (uncontrolled severe hypertension, eclampsia, placental abruption, pulmonary edema, renal
failure, persistent severe RUQ/epigastric pain indicating hepatic risk) or fetal indicators (abnormal Doppler, non-
reassuring NST, or fetal death).
8. What is the mechanism of action of Magnesium Sulfate in preventing eclamptic seizures?
A. It is a potent systemic vasodilator that decreases cerebral arterial pressure
B. It acts as a central nervous system depressant by blocking neuromuscular transmission and acting as an
NMDA receptor antagonist
C. It directly sedates the patient and reduces metabolic activity in the occipital lobe
D. It stimulates GABA receptors to hyperpolarize postsynaptic membranes
Correct Answer: B. It acts as a central nervous system depressant by blocking neuromuscular transmission
and acting as an NMDA receptor antagonist
Rationale: Magnesium sulfate works by decreasing acetylcholine release at the neuromuscular junction and
blocking calcium influx into NMDA receptors in the brain, thereby raising the seizure threshold. It is not primarily
a vasodilator or sedative.
9. When managing a hypertensive emergency in pregnancy (BP ≥ 160/110 mmHg), which of the
following represents the correct administration protocol for intravenous hydralazine?
A. Give 20 mg IV bolus over 1 minute; repeat with 40 mg in 5 minutes if BP remains elevated
B. Give 5 to 10 mg IV slow bolus over 2 minutes; repeat in 20 minutes if threshold remains exceeded
(maximum cumulative dose of 20 mg)
C. Administer 100 mg IV over 10 minutes and initiate a continuous infusion at 10 mg/hr
D. Hydralazine is contraindicated in pregnancy and should only be given postpartum
Correct Answer: B. Give 5 to 10 mg IV slow bolus over 2 minutes; repeat in 20 minutes if threshold remains
exceeded (maximum cumulative dose of 20 mg)
Rationale: Standard emergency protocols dictate IV hydralazine 5-10 mg slow bolus. If BP is still elevated, repeat
10 mg in 20 minutes. The maximum dose is 20 mg. Excessively rapid reduction in blood pressure can compromise
placental perfusion.
, 10. A postpartum patient who had preeclampsia with severe features is preparing for discharge. What
is the essential 2026 teaching protocol regarding blood pressure monitoring?
A. Blood pressure should be checked once at the 6-week postpartum visit
B. The patient should monitor blood pressure daily, and contact the provider if BP is ≥ 140/90 mmHg or for
any severe preeclampsia symptoms
C. Antihypertensive medications should be stopped immediately upon delivery
D. Postpartum preeclampsia does not occur, so no blood pressure tracking is required after discharge
Correct Answer: B. The patient should monitor blood pressure daily, and contact the provider if BP is ≥
140/90 mmHg or for any severe preeclampsia symptoms
Rationale: Postpartum preeclampsia can present up to 6 weeks after delivery. Discharged patients require explicit
education to monitor blood pressure and report signs (headache, vision changes, epigastric pain) or a BP ≥140/90
mmHg. High-risk patients should have their BP checked 72 hours and 7-10 days postpartum.
11. A pregnant patient with chronic hypertension is prescribed labetalol. What is a key maternal
contraindication to the use of beta-blockers like labetalol?
A. Gestational diabetes mellitus
B. Asthma or reactive airway disease
C. History of twin gestations
D. Mild proteinuria
Correct Answer: B. Asthma or reactive airway disease
Rationale: Labetalol is a non-selective beta-blocker that also blocks alpha-1 receptors. It can cause
bronchoconstriction and is contraindicated in patients with asthma, chronic obstructive pulmonary disease
(COPD), or severe reactive airway disease.
12. A patient at 36 weeks gestation with preeclampsia presents with sudden onset of hypertonic, painful
uterine contractions, dark red vaginal bleeding, and fetal heart rate decelerations. What complication
is suspected?
A. Placenta previa
B. Uterine atony
C. Placental abruption
D. Vasa previa rupture
Correct Answer: C. Placental abruption
Rationale: Preeclampsia is a major risk factor for placental abruption. Classic symptoms of abruption include
painful vaginal bleeding, uterine rigidity/tenderness, hypertonic contractions, and non-reassuring fetal status.
Placenta previa presents with painless vaginal bleeding.
