Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
TEST BANK
1
A 28-year-old G1P0 at 34 weeks’ gestation presents with a
sudden, severe headache, blurred vision, and epigastric pain.
Her BP is 168/104 mm Hg and urine dipstick shows 3+ protein.
Which nursing action should be your priority?
A. Start magnesium sulfate infusion per protocol.
B. Encourage oral fluids and monitor intake/output.
C. Administer a dose of oral labetalol and discharge home with
follow-up.
D. Position the client on the left side and obtain a clean-catch
urine for culture.
Answer: A
Rationale:
• Correct (A): These findings (BP ≥160/110, proteinuria,
headache, visual changes, epigastric pain) indicate severe
preeclampsia with neurologic symptoms. Magnesium
, sulfate is indicated to prevent eclamptic seizures and is a
priority to protect maternal neurologic status. Start
magnesium per protocol while preparing for further
evaluation and definitive management.
• B (incorrect): Encouraging oral fluids is inappropriate as an
immediate priority; fluid management is careful in severe
preeclampsia and seizure prophylaxis takes precedence.
• C (incorrect): Labetalol may be used to lower severe BP,
but seizure prophylaxis (magnesium) is the immediate
priority; outpatient discharge is contraindicated.
• D (incorrect): Left lateral position can improve
uteroplacental perfusion and is reasonable, but it is not
sufficient as the primary immediate action when seizure
risk is present; urine culture is not urgent here.
2
A pregnant client at 28 weeks with gestational diabetes is
scheduled for a nonstress test (NST). The external fetal monitor
tracing shows baseline 140 bpm with two accelerations of 20
bpm lasting 10 seconds in a 20-minute period. How should the
nurse interpret this result?
A. Reactive NST — reassuring fetal status.
B. Nonreactive NST — possible fetal compromise.
C. Category III — immediate delivery indicated.
D. Variable decelerations — check maternal position.
,Answer: A
Rationale:
• Correct (A): Reactive NST criteria: ≥2 accelerations within
20 minutes, each ≥15 bpm above baseline lasting ≥15
seconds for ≥32 weeks; for fetuses <32 weeks threshold is
≥10 bpm × ≥10 seconds. The tracing shown (two
accelerations 20×10 sec at 28 weeks) meets criteria for a
reactive test for <32 weeks, indicating fetal well-being.
• B (incorrect): Nonreactive is when these accelerations are
absent after 40 minutes (or after stimulation). Here
accelerations are present.
• C (incorrect): Category III applies to intrapartum fetal heart
rate tracings (late decels, severe bradycardia, or sinusoidal
pattern), not to NST results; immediate delivery is not
indicated.
• D (incorrect): Variable decelerations would be transient
drops in FHR often related to cord compression; the tracing
describes accelerations, not variables.
3
A laboring client’s external fetal monitor shows recurrent late
decelerations with minimal variability. Uterine activity shows
contractions every 2 minutes, duration 90 seconds. The client is
receiving oxytocin. Which nursing action is highest priority?
, A. Discontinue oxytocin infusion and administer oxygen via face
mask.
B. Encourage the client to push with each contraction to speed
delivery.
C. Increase oxytocin infusion rate to shorten labor.
D. Perform a vaginal exam and, if 10 cm, begin immediate
pushing.
Answer: A
Rationale:
• Correct (A): Recurrent late decelerations + minimal
variability indicate uteroplacental insufficiency and
Category II/III pattern; with oxytocin augmentation, the
first priority is to stop uterotonics to reduce contraction
frequency/intensity, improve uteroplacental perfusion, and
apply oxygen and reposition client to left lateral. These
actions aim to reverse fetal hypoxia.
• B (incorrect): Encouraging pushing will increase fetal stress
during hypoxic patterns and is unsafe.
• C (incorrect): Increasing oxytocin will worsen uterine
hyperstimulation and fetal hypoxia — contraindicated.
• D (incorrect): Vaginal exam may be appropriate later, but
immediate priorities are to correct reversible causes (stop
oxytocin, oxygenate, reposition).
PN® Examination
9th Edition
TEST BANK
1
A 28-year-old G1P0 at 34 weeks’ gestation presents with a
sudden, severe headache, blurred vision, and epigastric pain.
Her BP is 168/104 mm Hg and urine dipstick shows 3+ protein.
Which nursing action should be your priority?
A. Start magnesium sulfate infusion per protocol.
B. Encourage oral fluids and monitor intake/output.
C. Administer a dose of oral labetalol and discharge home with
follow-up.
D. Position the client on the left side and obtain a clean-catch
urine for culture.
Answer: A
Rationale:
• Correct (A): These findings (BP ≥160/110, proteinuria,
headache, visual changes, epigastric pain) indicate severe
preeclampsia with neurologic symptoms. Magnesium
, sulfate is indicated to prevent eclamptic seizures and is a
priority to protect maternal neurologic status. Start
magnesium per protocol while preparing for further
evaluation and definitive management.
• B (incorrect): Encouraging oral fluids is inappropriate as an
immediate priority; fluid management is careful in severe
preeclampsia and seizure prophylaxis takes precedence.
• C (incorrect): Labetalol may be used to lower severe BP,
but seizure prophylaxis (magnesium) is the immediate
priority; outpatient discharge is contraindicated.
• D (incorrect): Left lateral position can improve
uteroplacental perfusion and is reasonable, but it is not
sufficient as the primary immediate action when seizure
risk is present; urine culture is not urgent here.
2
A pregnant client at 28 weeks with gestational diabetes is
scheduled for a nonstress test (NST). The external fetal monitor
tracing shows baseline 140 bpm with two accelerations of 20
bpm lasting 10 seconds in a 20-minute period. How should the
nurse interpret this result?
A. Reactive NST — reassuring fetal status.
B. Nonreactive NST — possible fetal compromise.
C. Category III — immediate delivery indicated.
D. Variable decelerations — check maternal position.
,Answer: A
Rationale:
• Correct (A): Reactive NST criteria: ≥2 accelerations within
20 minutes, each ≥15 bpm above baseline lasting ≥15
seconds for ≥32 weeks; for fetuses <32 weeks threshold is
≥10 bpm × ≥10 seconds. The tracing shown (two
accelerations 20×10 sec at 28 weeks) meets criteria for a
reactive test for <32 weeks, indicating fetal well-being.
• B (incorrect): Nonreactive is when these accelerations are
absent after 40 minutes (or after stimulation). Here
accelerations are present.
• C (incorrect): Category III applies to intrapartum fetal heart
rate tracings (late decels, severe bradycardia, or sinusoidal
pattern), not to NST results; immediate delivery is not
indicated.
• D (incorrect): Variable decelerations would be transient
drops in FHR often related to cord compression; the tracing
describes accelerations, not variables.
3
A laboring client’s external fetal monitor shows recurrent late
decelerations with minimal variability. Uterine activity shows
contractions every 2 minutes, duration 90 seconds. The client is
receiving oxytocin. Which nursing action is highest priority?
, A. Discontinue oxytocin infusion and administer oxygen via face
mask.
B. Encourage the client to push with each contraction to speed
delivery.
C. Increase oxytocin infusion rate to shorten labor.
D. Perform a vaginal exam and, if 10 cm, begin immediate
pushing.
Answer: A
Rationale:
• Correct (A): Recurrent late decelerations + minimal
variability indicate uteroplacental insufficiency and
Category II/III pattern; with oxytocin augmentation, the
first priority is to stop uterotonics to reduce contraction
frequency/intensity, improve uteroplacental perfusion, and
apply oxygen and reposition client to left lateral. These
actions aim to reverse fetal hypoxia.
• B (incorrect): Encouraging pushing will increase fetal stress
during hypoxic patterns and is unsafe.
• C (incorrect): Increasing oxytocin will worsen uterine
hyperstimulation and fetal hypoxia — contraindicated.
• D (incorrect): Vaginal exam may be appropriate later, but
immediate priorities are to correct reversible causes (stop
oxytocin, oxygenate, reposition).
