Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
TEST BANK
1 — Antepartum: Preeclampsia warning signs
A 28-year-old primigravida at 36 weeks’ gestation
reports a new, severe frontal headache and the
sudden onset of visual spots. Her blood pressure is
160/102 mm Hg and urinalysis shows 3+ protein.
Which action should the nurse take first?
A. Encourage oral fluids and observe for 30 minutes.
B. Administer the prescribed IV hydralazine now.
C. Place the client in lateral position and call the
provider.
D. Give acetaminophen for the headache and
reassess.
Correct answer: C. Place the client in lateral
position and call the provider.
Rationale (correct): Sudden severe headache, visual
disturbances, and elevated BP plus proteinuria are
,signs of severe preeclampsia and risk for
cerebral/placental compromise and seizure.
Immediate nursing priorities are maternal safety
and fetal perfusion: place the mother in a lateral
position to improve uteroplacental blood flow and
immediately notify the provider for urgent orders
(antihypertensives, magnesium sulfate, labs, fetal
monitoring). Positioning is a rapid, low-risk
intervention that can be done while awaiting orders.
ACOG
Why other options are incorrect:
A — Encouraging oral fluids delays urgent treatment
and is not first priority in suspected severe
preeclampsia.
B — IV antihypertensive may be appropriate but
requires prescriber order and assessment; first
action is to optimize perfusion/notify.
D — Treating the symptom (headache) without
addressing underlying hypertensive emergency is
unsafe.
,2 — Antepartum: Rh incompatibility (timing)
A woman who is Rh-negative gives birth to an Rh-
positive neonate. Which postpartum action is
highest priority?
A. Obtain a direct Coombs test on the newborn.
B. Draw maternal blood for type and screen and
administer Rho(D) immune globulin within 72 hours
if indicated.
C. Start the mother on iron supplementation for
postpartum anemia.
D. Teach the mother about future pregnancy risks
but defer interventions to the pediatrician.
Correct answer: B. Draw maternal blood for type
and screen and administer Rho(D) immune
globulin within 72 hours if indicated.
Rationale (correct): Preventing maternal
alloimmunization is time-sensitive. If the mother is
Rh-negative and infant Rh-positive, Rho(D) immune
globulin (RhoGAM) should be given within 72 hours
postpartum (and sometimes earlier if indicated) to
prevent sensitization that could affect future
, pregnancies. Drawing maternal blood to confirm
status and administering Rho(D) immune globulin
are urgent nursing actions. NCSBN
Why other options are incorrect:
A — A direct Coombs on the newborn assesses
hemolysis but does not prevent maternal
sensitization.
C — Iron may be appropriate but is not the highest
priority related to Rh status.
D — Delaying RhoGAM risks future hemolytic
disease of the fetus/newborn (HDFN).
3 — Antepartum: Hyperemesis gravidarum
priorities
A client at 8 weeks’ gestation has severe nausea and
vomiting, 6% weight loss, and ketonuria. Which
order should the nurse implement first?
A. Start oral pyridoxine (vitamin B6) and ginger.
B. Insert an IV and begin fluid replacement with
electrolyte repletion.
C. Offer small, frequent meals and teach dietary
PN® Examination
9th Edition
TEST BANK
1 — Antepartum: Preeclampsia warning signs
A 28-year-old primigravida at 36 weeks’ gestation
reports a new, severe frontal headache and the
sudden onset of visual spots. Her blood pressure is
160/102 mm Hg and urinalysis shows 3+ protein.
Which action should the nurse take first?
A. Encourage oral fluids and observe for 30 minutes.
B. Administer the prescribed IV hydralazine now.
C. Place the client in lateral position and call the
provider.
D. Give acetaminophen for the headache and
reassess.
Correct answer: C. Place the client in lateral
position and call the provider.
Rationale (correct): Sudden severe headache, visual
disturbances, and elevated BP plus proteinuria are
,signs of severe preeclampsia and risk for
cerebral/placental compromise and seizure.
Immediate nursing priorities are maternal safety
and fetal perfusion: place the mother in a lateral
position to improve uteroplacental blood flow and
immediately notify the provider for urgent orders
(antihypertensives, magnesium sulfate, labs, fetal
monitoring). Positioning is a rapid, low-risk
intervention that can be done while awaiting orders.
ACOG
Why other options are incorrect:
A — Encouraging oral fluids delays urgent treatment
and is not first priority in suspected severe
preeclampsia.
B — IV antihypertensive may be appropriate but
requires prescriber order and assessment; first
action is to optimize perfusion/notify.
D — Treating the symptom (headache) without
addressing underlying hypertensive emergency is
unsafe.
,2 — Antepartum: Rh incompatibility (timing)
A woman who is Rh-negative gives birth to an Rh-
positive neonate. Which postpartum action is
highest priority?
A. Obtain a direct Coombs test on the newborn.
B. Draw maternal blood for type and screen and
administer Rho(D) immune globulin within 72 hours
if indicated.
C. Start the mother on iron supplementation for
postpartum anemia.
D. Teach the mother about future pregnancy risks
but defer interventions to the pediatrician.
Correct answer: B. Draw maternal blood for type
and screen and administer Rho(D) immune
globulin within 72 hours if indicated.
Rationale (correct): Preventing maternal
alloimmunization is time-sensitive. If the mother is
Rh-negative and infant Rh-positive, Rho(D) immune
globulin (RhoGAM) should be given within 72 hours
postpartum (and sometimes earlier if indicated) to
prevent sensitization that could affect future
, pregnancies. Drawing maternal blood to confirm
status and administering Rho(D) immune globulin
are urgent nursing actions. NCSBN
Why other options are incorrect:
A — A direct Coombs on the newborn assesses
hemolysis but does not prevent maternal
sensitization.
C — Iron may be appropriate but is not the highest
priority related to Rh status.
D — Delaying RhoGAM risks future hemolytic
disease of the fetus/newborn (HDFN).
3 — Antepartum: Hyperemesis gravidarum
priorities
A client at 8 weeks’ gestation has severe nausea and
vomiting, 6% weight loss, and ketonuria. Which
order should the nurse implement first?
A. Start oral pyridoxine (vitamin B6) and ginger.
B. Insert an IV and begin fluid replacement with
electrolyte repletion.
C. Offer small, frequent meals and teach dietary
