Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
TEST BANK
Item 1
A 29-year-old G2P1 at 36 weeks’ gestation reports
sudden-onset severe, persistent headache and
visual disturbances. BP = 162/106 mm Hg, urine
dipstick = 3+ protein. Which nursing action has
highest priority?
A. Start magnesium sulfate per protocol for seizure
prophylaxis.
B. Encourage oral fluids and monitor intake and
output.
C. Give acetaminophen for headache and reassess
in 1 hour.
D. Perform a nonstress test (NST) and await the
result.
Answer: A
Rationale:
, • Correct (A): Presentation is consistent with
severe preeclampsia (BP ≥160/110, proteinuria,
neurologic symptoms). Magnesium sulfate for
seizure prophylaxis is the immediate priority to
reduce the risk of eclampsia — a life-
threatening complication. Initiating seizure
prophylaxis takes precedence before further
diagnostic tests.
• B (incorrect): Oral fluids are not the priority and
could worsen fluid balance; IV management and
seizure prevention are critical.
• C (incorrect): Treating the symptom (headache)
without addressing seizure risk is inadequate.
• D (incorrect): Fetal assessment is important but
secondary to immediate maternal stabilization
(seizure prevention).
NCLEX Test Plan tag: Safe & Effective Care
Environment / Physiological Integrity — Reduction
of Risk Potential (Apply). NGN focus: Recognize →
Respond.
,Item 2
A 28-week gestation client undergoes a nonstress
test (NST). The external monitor shows baseline 140
bpm and two accelerations of 20 bpm lasting 12
seconds within 20 minutes. How should the nurse
interpret the NST?
A. Reactive NST — reassuring fetal status.
B. Nonreactive NST — continue monitoring.
C. Category III tracing — immediate delivery
indicated.
D. Variable decelerations present — reposition
mother.
Answer: A
Rationale:
• Correct (A): For fetuses <32 weeks,
accelerations ≥10 bpm lasting ≥10 seconds
count. Two qualifying accelerations within 20
minutes indicate a reactive NST and suggest
adequate fetal oxygenation — reassuring.
, • B (incorrect): Nonreactive NST is when
qualifying accelerations are absent after
appropriate observation/stimulation. Here
accelerations are present.
• C (incorrect): Category III refers to intrapartum
FHR categories and includes absent variability
with recurrent decelerations or bradycardia; an
NST with accelerations does not fit Category III.
• D (incorrect): The tracing describes
accelerations, not variable decelerations.
NCLEX tag: Health Promotion & Maintenance /
Physiological Integrity (Apply). NGN: Recognize →
Analyze.
Item 3
During augmentation of labor with oxytocin, the
fetal monitor shows repetitive late decelerations
and uterine contractions occurring every 1.5–2
minutes and lasting 90 seconds. What is the nurse’s
first action?
PN® Examination
9th Edition
TEST BANK
Item 1
A 29-year-old G2P1 at 36 weeks’ gestation reports
sudden-onset severe, persistent headache and
visual disturbances. BP = 162/106 mm Hg, urine
dipstick = 3+ protein. Which nursing action has
highest priority?
A. Start magnesium sulfate per protocol for seizure
prophylaxis.
B. Encourage oral fluids and monitor intake and
output.
C. Give acetaminophen for headache and reassess
in 1 hour.
D. Perform a nonstress test (NST) and await the
result.
Answer: A
Rationale:
, • Correct (A): Presentation is consistent with
severe preeclampsia (BP ≥160/110, proteinuria,
neurologic symptoms). Magnesium sulfate for
seizure prophylaxis is the immediate priority to
reduce the risk of eclampsia — a life-
threatening complication. Initiating seizure
prophylaxis takes precedence before further
diagnostic tests.
• B (incorrect): Oral fluids are not the priority and
could worsen fluid balance; IV management and
seizure prevention are critical.
• C (incorrect): Treating the symptom (headache)
without addressing seizure risk is inadequate.
• D (incorrect): Fetal assessment is important but
secondary to immediate maternal stabilization
(seizure prevention).
NCLEX Test Plan tag: Safe & Effective Care
Environment / Physiological Integrity — Reduction
of Risk Potential (Apply). NGN focus: Recognize →
Respond.
,Item 2
A 28-week gestation client undergoes a nonstress
test (NST). The external monitor shows baseline 140
bpm and two accelerations of 20 bpm lasting 12
seconds within 20 minutes. How should the nurse
interpret the NST?
A. Reactive NST — reassuring fetal status.
B. Nonreactive NST — continue monitoring.
C. Category III tracing — immediate delivery
indicated.
D. Variable decelerations present — reposition
mother.
Answer: A
Rationale:
• Correct (A): For fetuses <32 weeks,
accelerations ≥10 bpm lasting ≥10 seconds
count. Two qualifying accelerations within 20
minutes indicate a reactive NST and suggest
adequate fetal oxygenation — reassuring.
, • B (incorrect): Nonreactive NST is when
qualifying accelerations are absent after
appropriate observation/stimulation. Here
accelerations are present.
• C (incorrect): Category III refers to intrapartum
FHR categories and includes absent variability
with recurrent decelerations or bradycardia; an
NST with accelerations does not fit Category III.
• D (incorrect): The tracing describes
accelerations, not variable decelerations.
NCLEX tag: Health Promotion & Maintenance /
Physiological Integrity (Apply). NGN: Recognize →
Analyze.
Item 3
During augmentation of labor with oxytocin, the
fetal monitor shows repetitive late decelerations
and uterine contractions occurring every 1.5–2
minutes and lasting 90 seconds. What is the nurse’s
first action?
