Maternal Newborn Nursing Test High-Risk Pregnancy Complications 1 — Questions and Answers
Question 1: A client at 32 weeks gestation presents with a blood pressure of 158/106 mmHg, proteinuria of 2+, and severe headache. Which condition does the nurse suspect?
- Severe preeclampsia (Correct answer)
- Chronic hypertension
- Gestational hypertension
- HELLP syndrome
Correct answer: Severe preeclampsia
Severe preeclampsia is characterized by BP ≥160/110 mmHg on two occasions, significant proteinuria, and severe features such as headache, visual changes, or right upper quadrant pain.
Question 2: A nurse is caring for a client with severe preeclampsia receiving magnesium sulfate. Which assessment finding indicates magnesium toxicity?
- Respiratory rate of 10 breaths per minute and absent deep tendon reflexes (Correct answer)
- Blood pressure of 150/95 mmHg
- Urinary output of 35 mL/hr
- Serum magnesium level of 5 mEq/L
Correct answer: Respiratory rate of 10 breaths per minute and absent deep tendon reflexes
Magnesium toxicity causes respiratory depression (<12 breaths/min) and loss of deep tendon reflexes (DTRs); the antidote is calcium gluconate.
Question 3: Which laboratory finding is characteristic of HELLP syndrome?
- Elevated liver enzymes, low platelets, and hemolysis (Correct answer)
- Elevated platelets and decreased liver enzymes
- Normal platelets with markedly elevated blood pressure
- Decreased white blood cell count and low hemoglobin
Correct answer: Elevated liver enzymes, low platelets, and hemolysis
HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and Low Platelets — a severe variant of preeclampsia that can be life-threatening.
Question 4: A client at 28 weeks gestation is diagnosed with placenta previa. She reports painless, bright red vaginal bleeding. What is the priority nursing action?
- Initiate continuous electronic fetal monitoring and establish IV access (Correct answer)
- Perform a vaginal examination to assess cervical dilation
- Prepare the client for immediate cesarean delivery
- Apply external uterine pressure to slow bleeding
Correct answer: Initiate continuous electronic fetal monitoring and establish IV access
Placenta previa presents with painless bright red bleeding; the priority is maternal-fetal assessment with continuous EFM and IV access — vaginal exams are contraindicated.
Question 5: Which symptom distinguishes placental abruption from placenta previa?
- Painful, dark red vaginal bleeding with uterine rigidity (Correct answer)
- Painless bright red vaginal bleeding
- Absent fetal movement without bleeding
- Rupture of membranes with a gush of fluid
Correct answer: Painful, dark red vaginal bleeding with uterine rigidity
Placental abruption presents with painful, dark red vaginal bleeding (may be concealed) and a rigid, board-like uterus due to retroplacental hemorrhage.
Question 6: A nurse is caring for a client at 34 weeks with preterm premature rupture of membranes (PPROM). Which intervention is a priority?
- Assess for signs of infection (fever, uterine tenderness, foul-smelling discharge) and notify provider (Correct answer)
- Encourage ambulation to stimulate labor
- Administer tocolytics to stop all contractions indefinitely
- Perform digital cervical exam to assess dilation
Correct answer: Assess for signs of infection (fever, uterine tenderness, foul-smelling discharge) and notify provider
PPROM carries a high risk of chorioamnionitis; the nurse must assess for infection (maternal fever, uterine tenderness, leukocytosis, foul discharge) and report findings promptly.
