QUIZ 2 Flashcards
A patient at 32 weeks gestation is diagnosed with preeclampsia with severe features. Which lab value would the nurse prioritize?
A. Hemoglobin: 10 g/dL
B. Platelets: 90,000/mm³
C. WBC: 12,000/mm³
D. Uric Acid: 4 mg/dL
Answer: B. Platelets: 90,000/mm³
Rationale: Low platelets suggest HELLP syndrome, a severe complication of preeclampsia.
Question: A nurse is administering magnesium sulfate to a patient with preeclampsia. What is the priority assessment?
A. Reflexes
B. Urine output
C. Respiratory rate
D. Blood pressure
Answer: C. Respiratory rate
Rationale: Magnesium toxicity can cause respiratory depression; this is the priority.
Question: Which symptom is most indicative of ectopic pregnancy?
A. Shoulder pain
B. Painless vaginal bleeding
C. Lower abdominal cramping
D. Severe nausea
Answer: A. Shoulder pain
Rationale: Shoulder pain is referred pain from diaphragmatic irritation caused by ruptured ectopic pregnancy.
Question: A patient with placenta previa presents with bleeding. What is the most appropriate nursing action?
A. Perform a vaginal examination.
B. Monitor fetal heart rate.
C. Administer oxytocin.
D. Position the patient in a high Fowler’s position.
Answer: B. Monitor fetal heart rate
Rationale: Vaginal exams are contraindicated in placenta previa due to risk of further bleeding.
Question: A pregnant patient has iron-deficiency anemia. Which teaching point is correct?
A. Take iron supplements with meals.
B. Increase calcium intake while taking iron.
C. Avoid taking iron with milk.
D. Take iron at bedtime with a full glass of water.
Answer: C. Avoid taking iron with milk
Rationale: Calcium in milk inhibits iron absorption.
Question: A nurse is caring for a patient with PROM. Which intervention is most important?
A. Perform a sterile vaginal exam.
B. Assess for signs of infection.
C. Encourage frequent ambulation.
D. Administer a tocolytic.
Answer: B. Assess for signs of infection
Rationale: PROM increases the risk of infection (chorioamnionitis).
Question: A pregnant patient has a positive rubella titer. What is the correct nursing action?
A. Administer MMR vaccine immediately.
B. Advise the patient to avoid contact with others.
C. Administer MMR vaccine postpartum.
D. Inform the patient that no intervention is needed.
Answer: C. Administer MMR vaccine postpartum
Rationale: The live vaccine is contraindicated during pregnancy.
Question: A patient has an ABO incompatibility. Which neonatal condition is most likely?
A. Respiratory distress
B. Neonatal jaundice
C. Sepsis
D. Hypoglycemia
Answer: B. Neonatal jaundice
Rationale: ABO incompatibility increases the risk of hemolysis and subsequent jaundice.
Question: A fetal heart rate strip shows early decelerations. What is the nurse’s priority action?
A. Document the findings.
B. Administer oxygen at 10 L/min.
C. Change the patient’s position.
D. Prepare for an emergency cesarean section.
Answer: A. Document the findings
Rationale: Early decelerations are benign and associated with head compression.
Question: A fetal heart rate tracing shows absent variability with recurrent late decelerations. What is the priority nursing action?
A. Increase IV fluids.
B. Reassess in 30 minutes.
C. Administer terbutaline.
D. Notify the provider.
Answer: D. Notify the provider
Rationale: These findings indicate fetal distress and require immediate attention.
Question: A patient is receiving magnesium sulfate for preterm labor. The nurse notes a respiratory rate of 10 breaths/min. What is the first action?
A. Stop the infusion.
B. Notify the provider.
C. Administer oxygen.
D. Check the magnesium level.
Answer: A. Stop the infusion
Rationale: Magnesium sulfate toxicity requires immediate discontinuation.
Question: A patient with preeclampsia is prescribed labetalol. What side effect should the nurse monitor for?
A. Hypoglycemia
B. Tachycardia
C. Dizziness
D. Hyperkalemia
Answer: C. Dizziness
Rationale: Labetalol can cause hypotension, leading to dizziness.
Question: A patient with preeclampsia is receiving a continuous magnesium sulfate infusion. Which finding indicates the medication is effective?
A. Deep tendon reflexes are absent.
B. Urine output is 20 mL/hr.
C. The patient reports no more headaches or visual changes.
D. Respiratory rate is 10 breaths/min.
Answer: C. The patient reports no more headaches or visual changes
Rationale: Resolution of symptoms such as headache and visual changes indicates improved preeclampsia management.
Question: What is the primary nursing action for a patient experiencing eclampsia?
A. Administer oxygen at 2 L/min via nasal cannula.
B. Turn the patient to her side.
C. Administer an antihypertensive medication.
D. Perform a vaginal examination.
Answer: B. Turn the patient to her side
Rationale: During a seizure, turning the patient to her side prevents aspiration and ensures airway patency.
Question: A patient with preeclampsia is receiving a continuous magnesium sulfate infusion. Which finding indicates the medication is effective?
A. Deep tendon reflexes are absent.
B. Urine output is 20 mL/hr.
C. Respiratory rate is 10 breaths/min.
D. The patient reports no more headaches or visual changes.
Answer: D. The patient reports no more headaches or visual changes
Rationale: Resolution of symptoms such as headache and visual changes indicates improved preeclampsia management.
Question: Which patient is most at risk for placental abruption?
A. A 35-year-old with chronic hypertension.
B. A 22-year-old with gestational diabetes.
C. A 27-year-old with hyperemesis gravidarum.
D. A 30-year-old with a history of a spontaneous abortion.
Answer: A. A 35-year-old with chronic hypertension
Rationale: Chronic hypertension is a significant risk factor for placental abruption.
Question: A patient with cervical insufficiency has a cerclage placed at 14 weeks gestation. What is a priority nursing teaching point?
A. “Avoid sexual intercourse for 3 months.”
B. “Notify the provider immediately if you experience any cramping or back pain.”
C. “You will need weekly cervical checks starting at 20 weeks.”
D. “Stay on complete bedrest until delivery.”
Answer: B. Notify the provider immediately if you experience any cramping or back pain.
Rationale: Cramping or back pain may indicate preterm labor or cerclage failure.
Question: A patient with suspected PROM is admitted. Which diagnostic test result confirms the diagnosis?
A. Negative fetal fibronectin test.
B. Positive nitrazine paper test.
C. Negative Ferning test.
D. Elevated WBC count.
Answer: B. Positive nitrazine paper test
Rationale: A positive nitrazine paper test indicates the presence of amniotic fluid.
Question: A nurse is educating a pregnant patient about the risks of caffeine consumption. Which statement indicates effective teaching?
A. “Excessive caffeine intake may increase the risk of miscarriage.”
B. “Caffeine has no effect on pregnancy outcomes.”
C. “I should limit caffeine to 500 mg per day.”
D. “Caffeine causes preterm labor.”
Answer: A. Excessive caffeine intake may increase the risk of miscarriage.
Rationale: High caffeine consumption has been linked to an increased risk of miscarriage.
Question: A pregnant patient with Rh-negative blood requires RhoGAM. When is the appropriate time for administration?
A. At 12 weeks gestation.
B. At 28 weeks gestation and within 72 hours postpartum if the baby is Rh-positive.
C. Only if the baby is Rh-positive after delivery.
D. At 20 weeks gestation and again at delivery.
Answer: B. At 28 weeks gestation and within 72 hours postpartum if the baby is Rh-positive.
Rationale: RhoGAM is routinely administered at 28 weeks and after delivery if the newborn is Rh-positive.
Question: A patient’s prenatal lab results show elevated AST and ALT. What condition does this suggest?
A. Gestational diabetes.
B. HELLP syndrome.
C. Placenta previa.
D. Iron-deficiency anemia.
Answer: B. HELLP syndrome
Rationale: Elevated liver enzymes are characteristic of HELLP syndrome.
Question: The nurse notes late decelerations on the fetal monitor. What is the initial nursing intervention?
A. Notify the provider.
B. Reposition the patient to the left side.
C. Administer IV fluids.
D. Apply oxygen via non-rebreather mask.
Answer: B. Reposition the patient to the left side
Rationale: Repositioning can improve placental blood flow and oxygenation.
Question: Which fetal heart rate variability pattern requires immediate intervention?
A. Moderate variability.
B. Minimal variability with accelerations.
C. Absent variability with late decelerations.
D. Marked variability with no decelerations.
Answer: C. Absent variability with late decelerations
Rationale: This pattern suggests severe fetal distress and hypoxia.
Question: A patient receiving nifedipine for preterm labor reports feeling dizzy and flushed. What is the nurse’s priority action?
A. Check the patient’s blood pressure.
B. Discontinue the medication.
C. Administer oxygen.
D. Reassess in 30 minutes.
Answer: A. Check the patient’s blood pressure
Rationale: Dizziness and flushing may indicate hypotension, a side effect of nifedipine.
Question: A patient receiving betamethasone for fetal lung maturity asks about side effects. What is the best response?
A. “This medication has no side effects.”
B. “You may experience an increase in blood sugar levels.”
C. “This medication will cause mild uterine contractions.”
D. “You might feel drowsy after receiving this medication.”
Answer: B. You may experience an increase in blood sugar levels.
Rationale: Betamethasone can cause hyperglycemia in some patients.
Question: Which vaccine is safe to administer during pregnancy?
A. MMR
B. Influenza (inactivated)
C. Varicella
D. HPV
Answer: B. Influenza (inactivated)
Rationale: Inactivated vaccines are safe in pregnancy.
Question: A patient with hyperemesis gravidarum is receiving IV fluids. Which electrolyte imbalance is most likely?
A. Hypercalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypermagnesemia
Answer: B. Hypokalemia
Rationale: Severe vomiting often causes hypokalemia.
Question: A patient is experiencing a prolonged deceleration. What is the nurse’s priority?
A. Administer terbutaline.
B. Prepare for immediate delivery.
C. Reposition the patient.
D. Increase the Pitocin infusion.
Answer: C. Reposition the patient
Rationale: Repositioning can relieve cord compression or improve oxygenation.
Question: A nurse is reviewing a fetal heart rate tracing with variable decelerations. What intervention should the nurse perform?
A. Administer oxygen at 10 L/min.
B. Perform an amnioinfusion.
C. Reposition the patient.
D. Increase IV fluids.
Answer: C. Reposition the patient.
Rationale: Variable decelerations are often due to cord compression, which can be relieved by repositioning.
H in HELLP serious obstetric complication?
H: Hemolysis (destruction of red blood cells)
EL in HELLP serious obstetric complication?
EL: Elevated Liver enzymes (indicating liver dysfunction)
LP in HELLP serious obstetric complication?
LP: Low Platelet count (thrombocytopenia)
PROM stands for?
Premature Rupture of Membranes. Refers to the rupture of the amniotic sac (commonly known as the “water breaking”) before the onset of labor.
When does PROM occur?
Before 37 weeks of gestation but before labor begins
Question: A pregnant patient presents with BP 150/92 mmHg after 20 weeks of gestation without proteinuria. Which condition is most likely?
A. Chronic hypertension
B. Gestational hypertension
C. Preeclampsia
D. HELLP syndrome
Answer: B. Gestational hypertension
Rationale: Hypertension after 20 weeks without proteinuria or severe features is classified as gestational hypertension.
Question: A patient reports severe nausea and vomiting with a weight loss of 5% of her pre-pregnancy weight. What is the primary concern?
A. Hyperemesis gravidarum
B. Placenta previa
C. Polyhydramnios
D. Preterm labor
Answer: A. Hyperemesis gravidarum
Rationale: Severe nausea, vomiting, and weight loss are hallmarks of hyperemesis gravidarum.
Question: A patient with cervical insufficiency is scheduled for a cerclage. What should the nurse include in patient teaching?
A. Avoid sexual intercourse until delivery
B. Call the provider if contractions or cramping occur
C. Restrict fluid intake
D. Begin ambulating immediately after the procedure
Answer: B. Call the provider if contractions or cramping occur
Rationale: Cramping or contractions may indicate preterm labor or cerclage failure.
Question: A patient with suspected ectopic pregnancy reports shoulder pain and light vaginal bleeding. What is the priority nursing intervention?
A. Administer methotrexate
B. Prepare for surgery
C. Monitor vital signs
D. Perform a vaginal exam
Answer: C. Monitor vital signs
Rationale: Shoulder pain and bleeding may indicate rupture; monitoring vital signs is crucial for assessing shock.
Question: What condition is most associated with elevated AST and ALT in pregnancy?
A. Gestational diabetes
B. Iron-deficiency anemia
C. Placenta previa
D. HELLP syndrome
Answer: D. HELLP syndrome
Rationale: Elevated liver enzymes are diagnostic criteria for HELLP syndrome.
Question: What is the significance of a positive Group B Streptococcus (GBS) culture in a pregnant patient?
A. Increased risk of chorioamnionitis
B. Need for IV antibiotics during labor
C. Risk of preterm labor
D. Requirement for cesarean delivery
Answer: B. Need for IV antibiotics during labor
Rationale: IV antibiotics reduce the risk of neonatal GBS infection.
Question: A fetal heart rate tracing shows absent variability with recurrent late decelerations. What is the nurse’s priority?
A. Notify the provider immediately
B. Reassess in 30 minutes
C. Perform an amnioinfusion
D. Administer oxygen at 2 L/min
Answer: A. Notify the provider immediately
Rationale: Absent variability with late decelerations indicates fetal distress requiring urgent action.
Question: A fetal heart tracing shows early decelerations. What is the most appropriate nursing action?
A. Reposition the patient
B. Apply oxygen via mask
C. Continue to monitor
D. Prepare for cesarean delivery
Answer: C. Continue to monitor
Rationale: Early decelerations are benign and associated with head compression.
Question: A patient receiving magnesium sulfate has a serum level of 10 mEq/L. What is the priority action?
A. Continue infusion
B. Administer calcium gluconate
C. Increase infusion rate
D. Notify the provider
Answer: B. Administer calcium gluconate
Rationale: Levels >7 mEq/L indicate toxicity; calcium gluconate is the antidote.
Question: What is the purpose of betamethasone in pregnancy?
A. Promote fetal lung maturity
B. Reduce BP
C. Prevent seizures
D. Treat preterm labor
Answer: A. Promote fetal lung maturity
Rationale: Betamethasone enhances surfactant production in preterm fetuses.
Question: A patient with preeclampsia has a urine output of 20 mL/hr and persistent headache. What is the priority action?
A. Administer antihypertensives
B. Increase IV fluids
C. Notify the provider
D. Perform a neurological assessment
Answer: C. Notify the provider
Rationale: Reduced urine output and neurological symptoms may indicate worsening preeclampsia or impending eclampsia.
Question: A pregnant patient with chronic hypertension develops proteinuria at 32 weeks gestation. What condition should the nurse suspect?
A. Gestational hypertension
B. Preeclampsia superimposed on chronic hypertension
C. HELLP syndrome
D. Chronic hypertension with worsening symptoms
Answer: B. Preeclampsia superimposed on chronic hypertension
Rationale: The addition of proteinuria in a patient with pre-existing hypertension is diagnostic of superimposed preeclampsia.
Question: A nurse administers magnesium sulfate to a patient with preeclampsia. Which assessment finding requires immediate intervention?
A. Deep tendon reflexes +1
B. Respiratory rate of 14 breaths/min
C. Urine output of 50 mL/hr
D. BP 150/90 mmHg
Answer: A. Deep tendon reflexes +1
Rationale: Diminished reflexes may indicate early magnesium toxicity.
Question: What is the priority nursing intervention for a patient with placenta previa experiencing active bleeding?
A. Perform a sterile vaginal exam
B. Administer oxytocin
C. Monitor maternal vital signs and fetal heart rate
D. Prepare for immediate cesarean delivery
Answer: C. Monitor maternal vital signs and fetal heart rate
Rationale: Monitoring is essential to assess maternal and fetal stability, but vaginal exams are contraindicated.
Question: A nurse is caring for a patient with suspected placental abruption. Which symptom is most concerning?
A. Painless vaginal bleeding
B. Rigid, tender uterus
C. Normal fetal heart rate
D. Increased fetal movement
Answer: B. Rigid, tender uterus
Rationale: A rigid, tender uterus is indicative of placental abruption, which is a medical emergency.
Question: A patient with preterm premature rupture of membranes (PPROM) at 34 weeks gestation asks why she is receiving antibiotics. What is the nurse’s best response?
A. “Antibiotics are given to prevent preterm labor.”
B. “Antibiotics are only for preventing fever.”
C. “Antibiotics help your baby’s lungs mature.”
D. “Antibiotics reduce your risk of infection.”
Answer: D. Antibiotics reduce your risk of infection.
Rationale: Antibiotics in PPROM help reduce the risk of chorioamnionitis.
Question: Which prenatal vaccine is contraindicated during pregnancy?
A. Influenza (inactivated)
B. Tdap
C. Rubella (live)
D. Hepatitis B
Answer: C. Rubella (live)
Rationale: Live vaccines, such as rubella, are contraindicated during pregnancy due to teratogenic risks.
Question: A patient’s prenatal lab results show a hemoglobin level of 9.5 g/dL. Which nursing intervention is most appropriate?
A. Advise the patient to increase red meat intake
B. Administer RhoGAM
C. Administer IV fluids
D. Prepare the patient for a blood transfusion
Answer: A. Advise the patient to increase red meat intake
Rationale: A hemoglobin level of 9.5 g/dL indicates mild anemia, which can often be treated with dietary changes and supplements.
Question: A nurse is reviewing a patient’s labs for HELLP syndrome. Which findings would confirm this diagnosis? (Select all that apply.)
A. Platelets 80,000/mm³
B. AST 70 U/L
C. Hemoglobin 12 g/dL
D. LDH 650 U/L
E. Proteinuria 1+
Answer: A, B, D
Rationale: HELLP syndrome involves low platelets, elevated liver enzymes, and elevated LDH levels due to hemolysis.
Question: A fetal heart rate tracing shows late decelerations. What is the nurse’s priority action?
A. Administer oxygen via non-rebreather mask
B. Decrease the IV Pitocin rate
C. Notify the provider immediately
D. Reposition the patient to the left side
Answer: D. Reposition the patient to the left side
Rationale: Repositioning may improve uteroplacental blood flow and reduce late decelerations.
A nurse observes variable decelerations on a fetal monitor. What should the nurse suspect as the cause?
A. Uteroplacental insufficiency
B. Cord compression
C. Fetal head compression
D. Maternal hypotension
Answer: B. Cord compression
Rationale: Variable decelerations are caused by umbilical cord compression.
Question: A patient with preeclampsia asks why she is receiving magnesium sulfate. What is the nurse’s best response?
A. “It prevents seizures during labor.”
B. “It helps reduce your blood pressure.”
C. “It promotes fetal lung maturity.”
D. “It relieves your headache.”
Answer: A. It prevents seizures during labor.
Rationale: Magnesium sulfate is used for seizure prophylaxis in preeclamptic patients.
Question: A patient at 32 weeks gestation has a positive fetal fibronectin test. What is the nurse’s priority intervention?
A. Administer corticosteroids
B. Reassure the patient that labor is not imminent
C. Schedule the patient for induction
D. Perform a sterile vaginal exam
Answer: A. Administer corticosteroids
Rationale: A positive fetal fibronectin test indicates an increased risk of preterm labor; corticosteroids promote fetal lung maturity.
A patient at 34 weeks gestation with preeclampsia reports a severe headache, blurred vision, and right upper quadrant pain. Which nursing intervention is the priority?
A. Administer acetaminophen for the headache.
B. Turn the patient to the left lateral position.
C. Assess deep tendon reflexes and clonus.
D. Prepare for immediate cesarean delivery.
Answer: C. Assess deep tendon reflexes and clonus.
Rationale: These symptoms suggest severe preeclampsia and possible progression to eclampsia. Assessing for hyperreflexia and clonus can indicate increased neurological irritability, a precursor to seizures.
A pregnant patient begins to experience tonic-clonic seizures while in labor. What is the nurse’s priority action?
A. Notify the provider.
B. Protect the patient from injury and maintain a patent airway.
C. Administer antihypertensive medication.
D. Check fetal heart rate and variability.
Answer: B. Protect the patient from injury and maintain a patent airway.
Rationale: During an eclamptic seizure, ensuring airway patency and protecting the patient from injury are critical steps.
A patient with severe preeclampsia is receiving magnesium sulfate. Which assessment finding indicates the medication is effective?
A. BP decreases to 120/80 mmHg.
B. Seizures are absent.
C. Urine output increases to 60 mL/hr.
D. Deep tendon reflexes are absent.
Answer: B. Seizures are absent.
Rationale: Magnesium sulfate is primarily used to prevent seizures in preeclampsia. Its effectiveness is indicated by the absence of seizures, not necessarily by BP reduction or urine output.
