Preeclampsia nursing 211 Questions with
Correct Answers
1. The nurse knows that preeclampsia tends to occur during what time in a pregnancy?
A. before 20 weeks
B. in the third trimester and postpartum
C. after 20 weeks
D. in the first and second trimester
The answer is C. Preeclampsia tends to occur AFTER 20 weeks gestation.
The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks'
gestation. What is the priority nursing action for this client?
1.) Assess for signs and symptoms of labor.
2.)Assess the client's temperature every 2 hours.
3.)Schedule a daily ultrasound to assess fetal movement. 4.)Schedule a nonstress test
every 4 hours to assess fetal well-being.
1.) Assess for signs and symptoms of labor.
Rationale:As a result of the sedative effect of the magnesium sulfate, the client may not
perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not
necessary for this client. A nonstress test may be done, but not every 4 hours.
A 19-year-old gravida 1, para 0 patient at 40 weeks' gestation who is in labor is being
treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are
priority assessments with this medication? Select all that apply.
,1.) Check deep tendon reflexes.
2.) Observe for vaginal bleeding.
3.) Check the respiratory rate.
4.) Note the urine output.
5.) Monitor for calf pain.
1,3,4
1.) Check deep tendon reflexes.
3.) Check the respiratory rate.
4.) Note the urine output.
Rationale:Magnesium sulfate toxicity can cause fatal cardiovascular events or respiratory
depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is
excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep
tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding
is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein
thrombosis but is not associated with magnesium sulfate therapy.
The nurse prepares a plan of care for the client with preeclampsia and documents that
if the client progresses from preeclampsia to eclampsia, the nurse should take which
first action?
1.) Administer oxygen by face mask.
2.) Clear and maintain an open airway.
3.)Administer magnesium sulfate intravenously.
4.)Assess the blood pressure and fetal heart rate.
, 2.) Clear and maintain an open airway.
Rationale:The first action during a seizure (eclampsia) is to ensure a patent airway. All other
options are actions that follow.
A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is
being monitored at home. The home care nurse teaches the woman about the signs that
need to be reported to the health care provider (HCP). The nurse should tell the woman
to call the HCP if which occurs?
1.)Urine test is negative for protein.
2.)Fetal movements are more than 4 per hour.
3.)Weight increases by more than 1 pound in a week.
4.)The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.
3.)Weight increases by more than 1 pound in a week.
Rationale:The nurse should instruct the client to report any increase in blood pressure, protein
in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught
how to count fetal movements and is instructed that decreased fetal activity (3 or fewer
movements per hour) may indicate fetal compromise and should be reported.
The nurse is reviewing the medical record of a woman scheduled for her weekly
prenatal appointment. The nurse notes that the woman has been diagnosed with mild
preeclampsia. Which interventions should the nurse include in planning nursing care
for this client? Select all that apply.
Correct Answers
1. The nurse knows that preeclampsia tends to occur during what time in a pregnancy?
A. before 20 weeks
B. in the third trimester and postpartum
C. after 20 weeks
D. in the first and second trimester
The answer is C. Preeclampsia tends to occur AFTER 20 weeks gestation.
The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks'
gestation. What is the priority nursing action for this client?
1.) Assess for signs and symptoms of labor.
2.)Assess the client's temperature every 2 hours.
3.)Schedule a daily ultrasound to assess fetal movement. 4.)Schedule a nonstress test
every 4 hours to assess fetal well-being.
1.) Assess for signs and symptoms of labor.
Rationale:As a result of the sedative effect of the magnesium sulfate, the client may not
perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not
necessary for this client. A nonstress test may be done, but not every 4 hours.
A 19-year-old gravida 1, para 0 patient at 40 weeks' gestation who is in labor is being
treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are
priority assessments with this medication? Select all that apply.
,1.) Check deep tendon reflexes.
2.) Observe for vaginal bleeding.
3.) Check the respiratory rate.
4.) Note the urine output.
5.) Monitor for calf pain.
1,3,4
1.) Check deep tendon reflexes.
3.) Check the respiratory rate.
4.) Note the urine output.
Rationale:Magnesium sulfate toxicity can cause fatal cardiovascular events or respiratory
depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is
excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep
tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding
is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein
thrombosis but is not associated with magnesium sulfate therapy.
The nurse prepares a plan of care for the client with preeclampsia and documents that
if the client progresses from preeclampsia to eclampsia, the nurse should take which
first action?
1.) Administer oxygen by face mask.
2.) Clear and maintain an open airway.
3.)Administer magnesium sulfate intravenously.
4.)Assess the blood pressure and fetal heart rate.
, 2.) Clear and maintain an open airway.
Rationale:The first action during a seizure (eclampsia) is to ensure a patent airway. All other
options are actions that follow.
A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is
being monitored at home. The home care nurse teaches the woman about the signs that
need to be reported to the health care provider (HCP). The nurse should tell the woman
to call the HCP if which occurs?
1.)Urine test is negative for protein.
2.)Fetal movements are more than 4 per hour.
3.)Weight increases by more than 1 pound in a week.
4.)The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.
3.)Weight increases by more than 1 pound in a week.
Rationale:The nurse should instruct the client to report any increase in blood pressure, protein
in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught
how to count fetal movements and is instructed that decreased fetal activity (3 or fewer
movements per hour) may indicate fetal compromise and should be reported.
The nurse is reviewing the medical record of a woman scheduled for her weekly
prenatal appointment. The nurse notes that the woman has been diagnosed with mild
preeclampsia. Which interventions should the nurse include in planning nursing care
for this client? Select all that apply.
