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

Rationale: preeclampsia occur after 20 weeks of gestation up to 72 hours of postpartum

2. A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the
development of preeclampsia in this patient that would need to be reported to the physician? Select all
that apply:*

A. 1600: blood pressure 144/100, 1700: blood pressure 120/80

B. 3+ dipstick urine protein

C. 1 hour glucose tolerance test 90 mg/dL

D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98

E. <300 mg/dL 24-hour urine protein

Rationale: the answer is B and D because it’s the sign and symptoms and preeclampsia, letter B had
the presence of proteinuria and letter D because you need to check the blood pressure twice but 4-
6hrs apart.

3. You're providing an in-service to a group of new labor and delivery nurse graduates about the
pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they
understood how this condition develops?*

A. "The basal arteries of the myometrium fail to widen to support blood flow to the placenta."

B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and
increase in diameter."

C. "The cardiovascular system of the mother fails to compensate for the increased blood flow from the
fetus and placental ischemia occurs."

D. "If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to
the placenta and leads to preeclampsia."

Rationale: the answer is letter B because preeclampsia occurs because the spiral arteries did not
dilated 5 to 10 times
4. A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The
nurse will include what information in the patient’s education? Select all that apply:*

A. Report weight gain of >4 lbs in one week to physician

B. Incorporate foods like eggs, nuts, fish, meat in your diet

C. Follow a no salt diet

D. Headache and vision changes are expected side effects of this condition and cause no reason for
concern.

E. Importance of monitoring urine protein at home

F. Lying on left-side is recommended along with rest

G. Report a decrease in fetal activity immediately

Rationale: the answer is B, E, F, G because these options are some of the nurse teachings with
preeclampsia and option A is wrong because weight gain of 2 in one week should be reported not 4
and option C, it should be low salt diet, and option D is wrong because it may be serious complications

5. Fill-in-the-blank: The signs and symptoms of preeclampsia are mainly occurring because substances
released by the ischemic placenta cause damage to the _________________ in mom's body, which
injures organs.*

A. spiral arteries

B. epithelial cells

C. endothelial cells

D. juxtaglomerular cells

Rationale: the answer is C because from the ischemic placenta causes the damage of the bloodvessels

6. Select all the risk factors below that increases a woman’s risk for developing preeclampsia:*

A. Nulligravida

B. Primigravida

C. BMI 34

D. Pregnant with twins

E. Maternal history of preeclampsia

F. Age: 25-years-old

G. History of Lupus and Diabetes

Rationale: the answer is B,C,D,E, and G because the risk factors of preeclampsia are those people less
than 18 yrs old or 35 yrs above, first pregnancy, multiple gestation, who has history of preeclampsia,
BMI of more than 30, and has diseases like diabetes and also lupus.

7. Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to
assess for HELLP Syndrome. Which findings on the patient’s lab results correlate with HELLP Syndrome?*

A. Hemoglobin 12 g/dL

B. Platelets 90,000 μL

C. ALT 100 IU/L

D. AST 90 IU/L

E. Glucose 350 mg/dL

F. Abnormal RBC peripheral smear

Rationale: the answers are B, C, D, and F because option B has showed low platelet count, option C
and D showed elevated liver enzyme. And option F because of HELLP syndrome.

8. Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what
medication on standby?*

A. Acetylcysteine

B. Calcium carbonate

C. Oxytocin

D. Calcium gluconate

Rationale: the answer is letter D because calcium gluconate is the antidote for magnesium sulfate

9. A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV
Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify
the physician?*

A. Deep tendon reflex 4+

B. Respiratory rate of 13 breaths per minute

C. Urinary output of 600 mL over 12 hours

D. Clonus presenting in the lower extremities

E. Patient reports flushing or feeling hot

Rationale: the answer is letter E because it’s the signs and symptoms for magnesium sulfate toxicity.
Option A is normal and the option C and D is not a sign of magnesium sulfate toxicity.

10. In a patient with preeclampsia, what signs and symptoms indicate that the patient has a high risk of
experiencing a seizure due to central nervous system irritability? Select all that apply:*

A. You note bouncing of the foot when it is quickly dorsiflexed.

B. Patellar and bicep deep tendon reflexes are graded 4+.

C. Platelet count 200,000

D. Patient reports a decrease in headache pain.

Rationale: the answer is A and B because option A has a positive clonus and the score to deep tendon
reflex to option B is also positive in hyperreflexia

11. How would the nurse check for clonus in a patient with preeclampsia?*

A. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction.

B. Assess for muscular rigidity by having the patient extend the arms and place resistance against the
arms.

C. Assess for beating of the foot when the foot is quickly dorsiflexed.

D. Assess for dorsiflexion of the foot by quickly plantar flexing the foot.

Rationale: the answer is letter C because to check clonus the nurse will perform a deep tendon reflex
to see the beating of the foot. If the foot beat for more than 3 times, it is positive for clonus.

12. A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences
a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure?*

A. Placing the patient in a supine position

B. Holding down the patient’s head to prevent injury

C. Staying with the patient and activating the emergency response team

D. Timing the seizure

E. Providing 8 to 10 L of oxygen
Rationale: the answer is A and B because patient should be position on their side and not in supine
position and during seizure, the patient should NOT be touched to prevent any injuries. The option C,
D, and E are the things that should be done while seizure.