COMPREHENSIVE TEST
1. Ms. Rowan comes into the clinic for her prenatal checkup. Her blood pressure is 150/86 and she has gained 2.27 kg in the last
... [Show More] 2
weeks. The nurse should:
1. Take her temperature and pulse
2. Prepare her for a vaginal examination
3. Give her another appointment in 2 weeks
4. Test her urine for the presence of albumin
Answer: 4
4 Albumin in the urine is a sign of pregnancy induced hypertension, as are an elevated BP and a weight gain of more than 1 kg per
week.
1 BP and weight are more relative; changes in the pulse rate and temperature are not associated with pregnancy-induced hypertension.
2 These signs indicate pregnancy-induced hypertension; treatment of this does not require vaginal examination.
3 The signs indicate that pregnancy-induced hypertension may be present; the client may be seen more frequently than every 2 weeks.
2. Preeclampsia is first suspected in Ms. Rowan’s pregnancy when she has:
1. Fluctuation of the BP
2. Excessive weight gain
3. Presence of albuminuria
4. Progressive ankle edema
Answer: 2
2Weight gain caused by fluid retention is the earliest objective sign of mild Preeclampsia.
1 Continued elevations are significant; emotional upset, anxiety, and other factors may cause fluctuations or variations in blood
pressure.
3 This may occur; however, it usually becomes evident after weight gain and a progressive increase in BP.
4 Edema progresses as the signs of Preeclampsia worsen because of abnormal retention of fluid.
3. Ms. Rowan is diagnosed with pregnancy-induced hypertension. The nurse would know that dietary teaching is effective when Ms.
Rowan says, “I should follow a diet that includes:
1. High sodium and calories and low protein.
2. Low sodium and calories and high protein.
3. Normal sodium with ample calories and protein.
4. Moderate sodium, low calories, and ample protein.
Answer: 3
3 The latest concept concerning pregnancy induced hypertension is that this condition is a consequent of salt loss during pregnancy
and poor protein intake. The recommendations therefore call for a diet containing normal sodium, high protein, and a sufficient
number of calories.
1 Low protein is contraindicated for normal fetal growth; there is no indication for increasing sodium.
2 Lowering the intake of calories and sodium is detrimental to both fetus and mother.
4 There is an additional daily requirement of 500 calories during pregnancy.
4. Ms. Rowan is hospitalized and is receiving magnesium sulphate (MgSO4) by IV push. Before administering each dose, the nurse
should assess her:
1. Temperature and pulse rate.
2. Respirations and patellar reflex.
3. Blood pressure and apical pulse
4. Urinary output relative to fluid intake
Answer: 2
2 The cumulative effects of magnesium sulphate include depressed respirations and an absent or weak knee jerk reflex.
1 Temperature and pulse are not affected by administration of MgSO4.
3 The BP is monitored after administration f MgSO4; the apical pulse is not relevant.
4 Urinary output is increased after administration of MgSO4.
5. What would the nurse place at Ms. Rowan’s bed-side in preparation for the possibility of magnesium sulphate toxicity?
1. Nalline
2. Oxygen
3. Calcium gluconate
4. Suction equipment
Answer: 3
3 The antagonist for magnesium sulphate is calcium gluconate and it needs to be at the bedside.
1 This is a narcotic antagonist.
2 This would be ineffective if the action of magnesium is not reversed. [Show Less]