Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
TEST BANK
A 29-year-old at 36 weeks' gestation presents with
new onset severe headache and blood pressure
166/108 mm Hg. Which assessment should the
nurse perform first?
A. Auscultate fetal heart rate pattern.
B. Check deep tendon reflexes and test for clonus.
C. Obtain a urine specimen for protein.
D. Prepare to start magnesium sulfate infusion.
Correct answer: B
Rationale: Severe preeclampsia can progress to
eclampsia; hyperreflexia and clonus are immediate
indicators of cerebral irritability and seizure risk, so
assessing DTRs/clonus guides urgency of seizure
prophylaxis.
, • A — Fetal status is important but maternal
neurologic signs determine immediate seizure
risk.
• C — Proteinuria supports diagnosis but is not
the most urgent bedside assessment for seizure
risk.
• D — Magnesium may be indicated, but initiating
it safely follows assessment and appropriate IV
access/orders.
2 — Preterm labor (Medication purpose)
A woman at 30 weeks' gestation presents in
preterm labor. The provider orders betamethasone,
nifedipine, and magnesium sulfate. Which
medication’s primary purpose is to accelerate fetal
lung maturity?
A. Nifedipine
B. Betamethasone
C. Magnesium sulfate
D. Oxytocin
,Correct answer: B
Rationale: Betamethasone (corticosteroid)
accelerates fetal surfactant production and lung
maturation prior to preterm birth.
• A — Nifedipine is a tocolytic to reduce uterine
activity.
• C — Magnesium sulfate is used for maternal
seizure prophylaxis and fetal neuroprotection
(in very preterm deliveries), not lung
maturation.
• D — Oxytocin induces/augments labor; it is not
used to mature fetal lungs.
(Test plan focus: Physiological Integrity — Reduction
of Risk Potential.) ncsbn.org
3 — Fetal monitoring (Decelerations
interpretation)
Continuous fetal monitoring shows repeated late
decelerations during contractions. The nurse’s best
immediate action is:
, A. Reposition the woman to left lateral and
administer oxygen via face mask.
B. Prepare for immediate emergency cesarean
delivery.
C. Encourage pushing to speed delivery.
D. Increase oxytocin infusion.
Correct answer: A
Rationale: Late decelerations indicate
uteroplacental insufficiency; first actions are to
improve maternal cardiac output and oxygenation
(lateral positioning, oxygen, IV bolus if ordered) to
enhance fetal oxygenation.
• B — Cesarean may be required if interventions
fail or fetal compromise persists, but immediate
bedside measures come first.
• C — Pushing can worsen fetal stress during
compromised oxygenation.
• D — Increasing oxytocin would worsen uterine
perfusion.
PN® Examination
9th Edition
TEST BANK
A 29-year-old at 36 weeks' gestation presents with
new onset severe headache and blood pressure
166/108 mm Hg. Which assessment should the
nurse perform first?
A. Auscultate fetal heart rate pattern.
B. Check deep tendon reflexes and test for clonus.
C. Obtain a urine specimen for protein.
D. Prepare to start magnesium sulfate infusion.
Correct answer: B
Rationale: Severe preeclampsia can progress to
eclampsia; hyperreflexia and clonus are immediate
indicators of cerebral irritability and seizure risk, so
assessing DTRs/clonus guides urgency of seizure
prophylaxis.
, • A — Fetal status is important but maternal
neurologic signs determine immediate seizure
risk.
• C — Proteinuria supports diagnosis but is not
the most urgent bedside assessment for seizure
risk.
• D — Magnesium may be indicated, but initiating
it safely follows assessment and appropriate IV
access/orders.
2 — Preterm labor (Medication purpose)
A woman at 30 weeks' gestation presents in
preterm labor. The provider orders betamethasone,
nifedipine, and magnesium sulfate. Which
medication’s primary purpose is to accelerate fetal
lung maturity?
A. Nifedipine
B. Betamethasone
C. Magnesium sulfate
D. Oxytocin
,Correct answer: B
Rationale: Betamethasone (corticosteroid)
accelerates fetal surfactant production and lung
maturation prior to preterm birth.
• A — Nifedipine is a tocolytic to reduce uterine
activity.
• C — Magnesium sulfate is used for maternal
seizure prophylaxis and fetal neuroprotection
(in very preterm deliveries), not lung
maturation.
• D — Oxytocin induces/augments labor; it is not
used to mature fetal lungs.
(Test plan focus: Physiological Integrity — Reduction
of Risk Potential.) ncsbn.org
3 — Fetal monitoring (Decelerations
interpretation)
Continuous fetal monitoring shows repeated late
decelerations during contractions. The nurse’s best
immediate action is:
, A. Reposition the woman to left lateral and
administer oxygen via face mask.
B. Prepare for immediate emergency cesarean
delivery.
C. Encourage pushing to speed delivery.
D. Increase oxytocin infusion.
Correct answer: A
Rationale: Late decelerations indicate
uteroplacental insufficiency; first actions are to
improve maternal cardiac output and oxygenation
(lateral positioning, oxygen, IV bolus if ordered) to
enhance fetal oxygenation.
• B — Cesarean may be required if interventions
fail or fetal compromise persists, but immediate
bedside measures come first.
• C — Pushing can worsen fetal stress during
compromised oxygenation.
• D — Increasing oxytocin would worsen uterine
perfusion.
