Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A woman who is 32 weeks pregnant presents to the clinic. The nurse suspects preeclampsia. Which of the following findings support this diagnosis? (Select All that Apply.)
A. Mild fatigue after walking
Mild fatigue after walking is a common symptom in normal pregnancy and is not specific to preeclampsia. Fatigue alone does not indicate hypertension or organ involvement.
B. Mild headache with blurred vision
Headache with blurred vision is a classic symptom of preeclampsia, indicating possible cerebral involvement due to elevated blood pressure and vasospasm. Persistent or severe headache should always be evaluated in the context of preeclampsia.
C. 150/95 mmHg blood pressure
Blood pressure ≥140/90 mmHg after 20 weeks gestation in a previously normotensive woman is one of the diagnostic criteria for preeclampsia. This patient’s reading of 150/95 mmHg supports the diagnosis.
D. Sudden weight loss
Sudden weight loss is not a feature of preeclampsia. On the contrary, rapid weight gain due to fluid retention is often seen in preeclampsia.
E. +2 protein in the urine
Proteinuria (+1 or higher on a urine dipstick or ≥300 mg/24 hours) is another hallmark of preeclampsia. +2 proteinuria indicates significant renal involvement, supporting the diagnosis.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Demsn 650 Pediatrics Proctored Exam. Take the full exam now
Full Explanation
A. Mild fatigue after walking is a common symptom in normal pregnancy and is not specific to preeclampsia. Fatigue alone does not indicate hypertension or organ involvement.
B. Headache with blurred vision is a classic symptom of preeclampsia, indicating possible cerebral involvement due to elevated blood pressure and vasospasm. Persistent or severe headache should always be evaluated in the context of preeclampsia.
C. Blood pressure ≥140/90 mmHg after 20 weeks gestation in a previously normotensive woman is one of the diagnostic criteria for preeclampsia. This patient’s reading of 150/95 mmHg supports the diagnosis.
D. Sudden weight loss is not a feature of preeclampsia. On the contrary, rapid weight gain due to fluid retention is often seen in preeclampsia.
E. Proteinuria (+1 or higher on a urine dipstick or ≥300 mg/24 hours) is another hallmark of preeclampsia. +2 proteinuria indicates significant renal involvement, supporting the diagnosis.
Similar Questions
A nurse is preparing to perform a heel-stick procedure on a 2-day-old newborn. Which intervention BEST represents nonpharmacologic pain management for neonates?
A. Applying EMLA cream immediately before the procedure without waiting
EMLA cream is a pharmacologic intervention because it contains local anesthetics (lidocaine and prilocaine) that numb the skin. It must be applied 30–60 minutes before the procedure under an occlusive dressing to achieve effective analgesia. Applying it immediately before a heel stick would not provide pain relief and does not qualify as nonpharmacologic.
B. Administering an intramuscular opioid prior to the procedure
Intramuscular opioids are systemic pharmacologic agents used for moderate to severe pain. They carry risks such as respiratory depression, sedation, and hypotension in neonates, so they are rarely used for minor procedures like heel sticks.
C. Distracting the newborn with toys and verbal explanations
Distraction with toys or verbal explanations is ineffective for neonates because infants at 2 days old cannot process or respond to visual or verbal cues. Cognitive engagement strategies work only in older infants and children.
D. Giving a small dose of oral sucrose solution and providing nonnutritive sucking
Oral sucrose combined with nonnutritive sucking (e.g., using a pacifier) is a safe and evidence-based nonpharmacologic method for reducing procedural pain in neonates. Sucrose triggers the release of endogenous opioids in the central nervous system, which decreases the perception of pain. Nonnutritive sucking provides comfort and a calming effect, further reducing physiological stress responses such as increased heart rate, blood pressure, and crying. Studies show that this intervention effectively lowers behavioral and physiological indicators of pain during minor procedures such as heel sticks, venipuncture, or immunizations. This method is preferred for routine procedures in neonates because it is simple, safe, and effective without the risks associated with pharmacologic agents.
Full Explanation
A. EMLA cream is a pharmacologic intervention because it contains local anesthetics (lidocaine and prilocaine) that numb the skin. It must be applied 30–60 minutes before the procedure under an occlusive dressing to achieve effective analgesia. Applying it immediately before a heel stick would not provide pain relief and does not qualify as nonpharmacologic.
B. Intramuscular opioids are systemic pharmacologic agents used for moderate to severe pain. They carry risks such as respiratory depression, sedation, and hypotension in neonates, so they are rarely used for minor procedures like heel sticks.
C. Distraction with toys or verbal explanations is ineffective for neonates because infants at 2 days old cannot process or respond to visual or verbal cues. Cognitive engagement strategies work only in older infants and children.
D. Oral sucrose combined with nonnutritive sucking (e.g., using a pacifier) is a safe and evidence-based nonpharmacologic method for reducing procedural pain in neonates. Sucrose triggers the release of endogenous opioids in the central nervous system, which decreases the perception of pain. Nonnutritive sucking provides comfort and a calming effect, further reducing physiological stress responses such as increased heart rate, blood pressure, and crying. Studies show that this intervention effectively lowers behavioral and physiological indicators of pain during minor procedures such as heel sticks, venipuncture, or immunizations. This method is preferred for routine procedures in neonates because it is simple, safe, and effective without the risks associated with pharmacologic agents.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's urine output for the past hour is 25 mL and deep-tendon reflexes are absent. Which of the following actions should the nurse take? (Select all that apply)
A. Prepare for an emergency cesarean birth.
The client shows signs of magnesium sulfate toxicity: oliguria (urine output <30 mL/hr) and absent deep-tendon reflexes. These are potentially life-threatening signs that require immediate intervention, including preparing for emergent delivery if maternal or fetal status is unstable. Stopping the magnesium infusion and preparing for emergency interventions is critical.
B. Administer Vitamin k. per protocol.
Administering Vitamin K is not indicated in this scenario. Vitamin K is used to treat or prevent coagulopathy, such as in newborns or clients on certain anticoagulants, but it does not counteract magnesium toxicity.
C. Increase the magnesium sulfate infusion.
Increasing the magnesium sulfate infusion would worsen toxicity. The correct action is to stop the infusion immediately and prepare to administer calcium gluconate as an antidote if prescribed.
D. Assess maternal glucose levels
Assessing maternal glucose levels is unrelated to the immediate concern of magnesium toxicity. While glucose monitoring may be part of overall prenatal care, it is not a priority in this emergent situation.
E. Place the client in Trendelenburg position.
Placing the client in Trendelenburg position is not indicated. Positioning does not treat magnesium toxicity and could worsen respiratory compromise in a client with severe preeclampsia. The priority is stopping magnesium, assessing maternal and fetal status, and preparing for emergency delivery if necessary.
Full Explanation
A. The client shows signs of magnesium sulfate toxicity: oliguria (urine output <30 mL/hr) and absent deep-tendon reflexes. These are potentially life-threatening signs that require immediate intervention, including preparing for emergent delivery if maternal or fetal status is unstable. Stopping the magnesium infusion and preparing for emergency interventions is critical.
B. Administering Vitamin K is not indicated in this scenario. Vitamin K is used to treat or prevent coagulopathy, such as in newborns or clients on certain anticoagulants, but it does not counteract magnesium toxicity.
C. Increasing the magnesium sulfate infusion would worsen toxicity. The correct action is to stop the infusion immediately and prepare to administer calcium gluconate as an antidote if prescribed.
D. Assessing maternal glucose levels is unrelated to the immediate concern of magnesium toxicity. While glucose monitoring may be part of overall prenatal care, it is not a priority in this emergent situation.
E. Placing the client in Trendelenburg position is not indicated. Positioning does not treat magnesium toxicity and could worsen respiratory compromise in a client with severe preeclampsia. The priority is stopping magnesium, assessing maternal and fetal status, and preparing for emergency delivery if necessary.
A 5-year-old child is scheduled for a venipuncture and is anxious about pain. Which intervention BEST reduces procedural pain at the insertion site?
A. Applying EMLA cream 30-60 minutes before the procedure under an occlusive dressing
EMLA cream (a eutectic mixture of local anesthetics) applied 30–60 minutes before a procedure under an occlusive dressing provides effective topical anesthesia, reducing pain at the venipuncture site. This is evidence-based practice for minimizing procedural pain in children and is particularly effective for needle insertions.
B. Giving the child a sugar solution after the procedure
Administering a sugar solution (sucrose) is effective primarily for infants under 12 months and is most beneficial when given before or during painful procedures, not after. In a 5-year-old, it has minimal analgesic effect.
C. Placing a cold pack on the site immediately before the needle
Applying a cold pack can provide some temporary numbing, but it is less effective than topical anesthetic creams for reducing pain during venipuncture. Additionally, short-duration cold application may not penetrate deep enough to anesthetize the vein adequately.
D. Distracting the child with toys during the procedure
Distraction with toys can reduce anxiety and perceived pain but does not directly numb the insertion site. While helpful as a complementary measure, it is not as effective as topical anesthesia in reducing procedural pain.
Full Explanation
A. EMLA cream (a eutectic mixture of local anesthetics) applied 30–60 minutes before a procedure under an occlusive dressing provides effective topical anesthesia, reducing pain at the venipuncture site. This is evidence-based practice for minimizing procedural pain in children and is particularly effective for needle insertions.
B. Administering a sugar solution (sucrose) is effective primarily for infants under 12 months and is most beneficial when given before or during painful procedures, not after. In a 5-year-old, it has minimal analgesic effect.
C. Applying a cold pack can provide some temporary numbing, but it is less effective than topical anesthetic creams for reducing pain during venipuncture. Additionally, short-duration cold application may not penetrate deep enough to anesthetize the vein adequately.
D. Distraction with toys can reduce anxiety and perceived pain but does not directly numb the insertion site. While helpful as a complementary measure, it is not as effective as topical anesthesia in reducing procedural pain.