Preeclampsia and postpartum hemorrhage are the two obstetric emergencies the NCLEX returns to again and again, because both test rapid assessment and medication safety under pressure. Preeclampsia questions revolve around hypertension with proteinuria after 20 weeks, seizure prophylaxis with magnesium sulfate, and recognizing progression to HELLP syndrome or eclampsia. Postpartum hemorrhage questions test the four T's — tone, trauma, tissue, thrombin — and the priority sequence of fundal massage, uterotonics, and escalating intervention. Both demand that you know which findings are expected, which require provider notification, and which require immediate action to protect the mother.
Quick Study Tips
Magnesium sulfate prevents seizures; it does not treat blood pressure.
Hold criteria: respirations under 12, urine under 30 mL/hr, absent reflexes.
Calcium gluconate is the magnesium antidote — keep it at the bedside.
Boggy uterus: massage first, then empty the bladder.
Check the blood pressure before methylergonovine; check asthma history before carboprost.
Practice Quiz: Preeclampsia & Postpartum Hemorrhage NCLEX Questions
Answer these exam-style questions to test your knowledge. Detailed rationales are shown after each answer.
Preeclampsia Assessment and Magnesium Sulfate Safety
Preeclampsia is new-onset hypertension (140/90 mmHg or higher) with proteinuria after 20 weeks of gestation; severe features include blood pressure of 160/110 or higher, headache, visual disturbances, epigastric or right upper quadrant pain, and hyperreflexia. Magnesium sulfate is given for seizure prophylaxis, not blood pressure control, and the NCLEX tests its safety parameters relentlessly: respiratory rate at or above 12 per minute, urine output at or above 30 mL/hour, and present deep tendon reflexes. Therapeutic serum magnesium is roughly 4.8 to 8.4 mg/dL; toxicity shows as absent reflexes, respiratory depression, and decreased level of consciousness. Calcium gluconate is the antidote and must be at the bedside. Warning signs of worsening disease — headache, blurred vision, epigastric pain — require immediate provider notification because they precede seizure.
HELLP Syndrome and Eclampsia
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant marked by right upper quadrant or epigastric pain, nausea, and malaise, and it can occur without dramatic blood pressure elevation — a classic NCLEX trap. Eclampsia is preeclampsia plus a seizure. During a seizure, the priorities are safety and airway: stay with the client, protect from injury, maintain a side-lying position, suction secretions as needed, and administer oxygen after the seizure; do not force an airway or restrain. Most eclamptic seizures are self-limiting, and magnesium sulfate remains the drug of choice for prevention and recurrence. Fetal monitoring is continuous throughout, because uteroplacental perfusion drops during the seizure and late decelerations are common immediately after.
Postpartum Hemorrhage: The Four T's and Priority Actions
Postpartum hemorrhage is blood loss of 1,000 mL or more, or any loss causing hemodynamic instability, and uterine atony — a soft, boggy, displaced fundus — causes roughly 70 to 80 percent of cases. The first action for a boggy uterus is fundal massage while supporting the lower uterine segment, followed by emptying the bladder, because a full bladder displaces the uterus and prevents contraction. Uterotonics follow in order: oxytocin first-line, then methylergonovine (contraindicated in hypertension — a frequent NCLEX trap given preeclampsia overlap), carboprost (contraindicated in asthma), and misoprostol. If the fundus is firm but bleeding continues, think trauma (lacerations) or retained tissue (fragments prevent contraction), and if clotting fails, think thrombin (DIC). Saturating one pad in 15 minutes or less, or passing large clots with a firm fundus, demands immediate escalation.
Review each question with its correct answer and a rationale for every choice.
1. A client at 36 weeks has BP 168/110, severe headache, and 3+ protein. Which action is FIRST?
A. Place in a quiet room with seizure precautionsThis client is exhibiting classic signs and symptoms of severe preeclampsia (BP >160/110, severe headache, proteinuria >3+). Severe preeclampsia places the client at significant risk for eclampsia, which is characterized by generalized tonic-clonic seizures. Placing the client in a quiet room minimizes external stimuli that could trigger a seizure, while implementing seizure precautions (e.g., padding side rails, suction and oxygen readily available) prepares the healthcare team to manage a potential seizure event, ensuring client safety and prompt intervention. This action addresses the immediate life-threatening complication of severe preeclampsia.
B. Obtain a 24-hour urine collectionWhile a 24-hour urine collection is crucial for quantifying proteinuria and confirming the diagnosis of preeclampsia, it is not the *first* action in a client presenting with severe, acute symptoms suggestive of impending eclampsia. The immediate priority is to stabilize the client and prevent life-threatening complications. Obtaining a 24-hour urine collection is a diagnostic test that takes an extended period and does not address the acute risk of seizure or other severe preeclampsia complications.
C. Encourage ambulationEncouraging ambulation is contraindicated for a client with severe preeclampsia. Activity can increase blood pressure and the risk of complications such as placental abruption, stroke, or seizures. Bed rest or restricted activity is typically recommended to decrease blood pressure and reduce maternal and fetal risks. This intervention would exacerbate the client's condition rather than improve it, potentially increasing the risk of adverse outcomes.
D. Schedule a nonstress test for tomorrowA nonstress test (NST) assesses fetal well-being by monitoring fetal heart rate accelerations in response to fetal movement and is an important component of managing preeclampsia. However, scheduling an NST for *tomorrow* delays critical assessment of fetal status and does not address the immediate maternal life-threatening risks associated with severe preeclampsia. The priority in this scenario is to stabilize the mother and prevent maternal complications like seizures, and fetal well-being assessment, if not immediately done, should be performed as soon as possible after maternal stabilization, not postponed until the next day.
Correct answer: A. Option A: This client is exhibiting classic signs and symptoms of severe preeclampsia (BP >160/110, severe headache, proteinuria >3+). Severe preeclampsia places the client at significant risk for eclampsia, which is characterized by generalized tonic-clonic seizures. Placing the client in a quiet room minimizes external stimuli that could trigger a seizure, while implementing seizure precautions (e.g., padding side rails, suction and oxygen readily available) prepares the healthcare team to manage a potential seizure event, ensuring client safety and prompt intervention. This action addresses the immediate life-threatening complication of severe preeclampsia.
Option B: While a 24-hour urine collection is crucial for quantifying proteinuria and confirming the diagnosis of preeclampsia, it is not the *first* action in a client presenting with severe, acute symptoms suggestive of impending eclampsia. The immediate priority is to stabilize the client and prevent life-threatening complications. Obtaining a 24-hour urine collection is a diagnostic test that takes an extended period and does not address the acute risk of seizure or other severe preeclampsia complications.
Option C: Encouraging ambulation is contraindicated for a client with severe preeclampsia. Activity can increase blood pressure and the risk of complications such as placental abruption, stroke, or seizures. Bed rest or restricted activity is typically recommended to decrease blood pressure and reduce maternal and fetal risks. This intervention would exacerbate the client's condition rather than improve it, potentially increasing the risk of adverse outcomes.
Option D: A nonstress test (NST) assesses fetal well-being by monitoring fetal heart rate accelerations in response to fetal movement and is an important component of managing preeclampsia. However, scheduling an NST for *tomorrow* delays critical assessment of fetal status and does not address the immediate maternal life-threatening risks associated with severe preeclampsia. The priority in this scenario is to stabilize the mother and prevent maternal complications like seizures, and fetal well-being assessment, if not immediately done, should be performed as soon as possible after maternal stabilization, not postponed until the next day.
2. A client on a magnesium sulfate drip has absent patellar reflexes and RR 10. The nurse should…
A. Increase the infusion rateIncreasing the infusion rate of magnesium sulfate would exacerbate the client's signs of magnesium toxicity. Absent patellar reflexes indicate a severe depression of the central nervous system and neuromuscular transmission, while a respiratory rate of 10 breaths per minute signifies significant respiratory depression. Escalating the dose would further depress the respiratory drive, potentially leading to respiratory arrest, and intensify CNS depression, jeopardizing maternal and fetal well-being. Therefore, this action is contraindicated as it directly worsens the client's critical condition.
B. Reposition and reassess in 30 minutesRepositioning the client and reassessing in 30 minutes is an inadequate and potentially dangerous response given the severe signs of magnesium toxicity. Absent deep tendon reflexes and a respiratory rate of 10 are critical findings that indicate an immediate life-threatening situation requiring prompt intervention, not a delayed reassessment. Delaying intervention could lead to complete respiratory arrest, cardiac arrest, or severe neurological complications for the client. The nurse must act decisively to reverse the toxicity, not merely observe or reposition.
C. Stop the infusion and give calcium gluconateStopping the magnesium sulfate infusion immediately and administering calcium gluconate is the correct and most critical intervention for managing severe magnesium toxicity. Magnesium sulfate primarily acts as a central nervous system depressant and neuromuscular blocker; calcium gluconate is the direct antidote, competitively antagonizing magnesium at the neuromuscular junction, thereby reversing respiratory depression and restoring deep tendon reflexes. This prompt action is essential to prevent further progression of toxicity, such as respiratory arrest, and to stabilize the client's condition. Administering calcium gluconate rapidly reverses the life-threatening effects while discontinuing the magnesium removes the source of the problem.
D. Give an extra bolus for seizure prophylaxisGiving an extra bolus of magnesium for seizure prophylaxis is an extremely dangerous and inappropriate action in a client exhibiting severe signs of magnesium toxicity. The client's absent reflexes and respiratory depression clearly indicate supratherapeutic magnesium levels, meaning the medication is causing harm rather than providing therapeutic benefit. Administering an additional bolus would dangerously elevate magnesium levels even further, leading to a higher risk of complete respiratory arrest, cardiac conduction abnormalities, and profound CNS depression. The priority is to reverse the toxicity, not to increase the dose.
Correct answer: C. Option A: Increasing the infusion rate of magnesium sulfate would exacerbate the client's signs of magnesium toxicity. Absent patellar reflexes indicate a severe depression of the central nervous system and neuromuscular transmission, while a respiratory rate of 10 breaths per minute signifies significant respiratory depression. Escalating the dose would further depress the respiratory drive, potentially leading to respiratory arrest, and intensify CNS depression, jeopardizing maternal and fetal well-being. Therefore, this action is contraindicated as it directly worsens the client's critical condition.
Option B: Repositioning the client and reassessing in 30 minutes is an inadequate and potentially dangerous response given the severe signs of magnesium toxicity. Absent deep tendon reflexes and a respiratory rate of 10 are critical findings that indicate an immediate life-threatening situation requiring prompt intervention, not a delayed reassessment. Delaying intervention could lead to complete respiratory arrest, cardiac arrest, or severe neurological complications for the client. The nurse must act decisively to reverse the toxicity, not merely observe or reposition.
Option C: Stopping the magnesium sulfate infusion immediately and administering calcium gluconate is the correct and most critical intervention for managing severe magnesium toxicity. Magnesium sulfate primarily acts as a central nervous system depressant and neuromuscular blocker; calcium gluconate is the direct antidote, competitively antagonizing magnesium at the neuromuscular junction, thereby reversing respiratory depression and restoring deep tendon reflexes. This prompt action is essential to prevent further progression of toxicity, such as respiratory arrest, and to stabilize the client's condition. Administering calcium gluconate rapidly reverses the life-threatening effects while discontinuing the magnesium removes the source of the problem.
Option D: Giving an extra bolus of magnesium for seizure prophylaxis is an extremely dangerous and inappropriate action in a client exhibiting severe signs of magnesium toxicity. The client's absent reflexes and respiratory depression clearly indicate supratherapeutic magnesium levels, meaning the medication is causing harm rather than providing therapeutic benefit. Administering an additional bolus would dangerously elevate magnesium levels even further, leading to a higher risk of complete respiratory arrest, cardiac conduction abnormalities, and profound CNS depression. The priority is to reverse the toxicity, not to increase the dose.
3. A client on magnesium sulfate for preeclampsia has absent deep tendon reflexes and a respiratory rate of 10. The nurse should…
A. Increase the infusion rateIncreasing the magnesium sulfate infusion rate would exacerbate the client's current signs of magnesium toxicity, which include absent deep tendon reflexes (DTRs) and respiratory depression. Magnesium acts as a central nervous system depressant, and an increased dose would further suppress neurological and respiratory function, leading to a critical and potentially fatal outcome such as respiratory arrest. The nurse's priority in this situation is to reverse the magnesium effects, not intensify them, to ensure client safety and prevent further complications.
B. Stop the infusion and give calcium gluconateAbsent deep tendon reflexes and a respiratory rate of 10 breaths per minute are classic signs of severe magnesium toxicity, indicating a dangerously high serum magnesium level that is depressing the central nervous system. Stopping the magnesium sulfate infusion immediately halts further administration of the toxic agent, while administering calcium gluconate acts as a direct antagonist to magnesium, rapidly reversing its neuromuscular and respiratory depressant effects. This intervention is critical and life-saving, directly addressing the underlying overdose and preventing progression to respiratory arrest or cardiac complications.
C. Reposition and recheck in 30 minutesRepositioning the client and rechecking in 30 minutes would delay critical intervention for a life-threatening condition. Absent DTRs and a respiratory rate of 10 are clear indications of magnesium toxicity requiring immediate action, not observation. Magnesium toxicity can rapidly progress to severe respiratory depression and cardiac arrest, making a "wait and see" approach extremely dangerous and negligent. The nurse's responsibility is to intervene promptly to mitigate harm and stabilize the client.
D. Administer an additional bolusAdministering an additional bolus of magnesium sulfate would drastically worsen the client's condition, as it would increase the already toxic serum magnesium levels. This action would further depress the central nervous system, deepening respiratory depression and potentially leading to respiratory arrest, cardiac arrhythmias, and loss of consciousness. The nurse must recognize the signs of toxicity and act to reverse the effects of magnesium, not to administer more of the medication, which would be a critical medical error.
Correct answer: B. Option A: Increasing the magnesium sulfate infusion rate would exacerbate the client's current signs of magnesium toxicity, which include absent deep tendon reflexes (DTRs) and respiratory depression. Magnesium acts as a central nervous system depressant, and an increased dose would further suppress neurological and respiratory function, leading to a critical and potentially fatal outcome such as respiratory arrest. The nurse's priority in this situation is to reverse the magnesium effects, not intensify them, to ensure client safety and prevent further complications.
Option B: Absent deep tendon reflexes and a respiratory rate of 10 breaths per minute are classic signs of severe magnesium toxicity, indicating a dangerously high serum magnesium level that is depressing the central nervous system. Stopping the magnesium sulfate infusion immediately halts further administration of the toxic agent, while administering calcium gluconate acts as a direct antagonist to magnesium, rapidly reversing its neuromuscular and respiratory depressant effects. This intervention is critical and life-saving, directly addressing the underlying overdose and preventing progression to respiratory arrest or cardiac complications.
Option C: Repositioning the client and rechecking in 30 minutes would delay critical intervention for a life-threatening condition. Absent DTRs and a respiratory rate of 10 are clear indications of magnesium toxicity requiring immediate action, not observation. Magnesium toxicity can rapidly progress to severe respiratory depression and cardiac arrest, making a "wait and see" approach extremely dangerous and negligent. The nurse's responsibility is to intervene promptly to mitigate harm and stabilize the client.
Option D: Administering an additional bolus of magnesium sulfate would drastically worsen the client's condition, as it would increase the already toxic serum magnesium levels. This action would further depress the central nervous system, deepening respiratory depression and potentially leading to respiratory arrest, cardiac arrhythmias, and loss of consciousness. The nurse must recognize the signs of toxicity and act to reverse the effects of magnesium, not to administer more of the medication, which would be a critical medical error.
4. A client at 34 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which finding requires the nurse to stop the infusion?
A. Respiratory rate of 10 with absent patellar reflexesCorrect. Absent deep tendon reflexes with respiratory depression indicates magnesium toxicity; stop the infusion and give calcium gluconate.
B. Urine output of 45 mL/hrThis output is above the 30 mL/hr minimum and is acceptable.
C. Blood pressure of 148/92This pressure is elevated but expected during treatment and does not indicate toxicity.
D. Reported warmth and flushingWarmth and flushing are common, expected effects of magnesium infusion.
Correct answer: A. Magnesium toxicity presents as loss of reflexes, then respiratory depression, then cardiac arrest. Stop the drug and give calcium gluconate.
5. Which complaint from a client with preeclampsia at 34 weeks is most concerning?
A. Mild ankle swelling at the end of the dayDependent ankle edema is common in late pregnancy and is not a severe feature.
B. A persistent headache with visual spotsCorrect. Headache with visual disturbance reflects cerebral irritability and warns of an impending eclamptic seizure.
C. Occasional heartburn after mealsHeartburn is a common discomfort of pregnancy caused by reflux.
D. Twelve fetal movements in two hoursTwelve movements in two hours is a reassuring fetal count.
Correct answer: B. Headache, visual changes and epigastric pain are severe features of preeclampsia that precede seizure and must be reported at once.
6. Which medication must be immediately available at the bedside of a client receiving magnesium sulfate?
A. NaloxoneNaloxone reverses opioids, not magnesium.
B. Calcium gluconateCorrect. Calcium gluconate is the antidote for magnesium sulfate toxicity.
C. Protamine sulfateProtamine sulfate reverses heparin.
D. Vitamin KVitamin K reverses warfarin.
Correct answer: B. Calcium gluconate is kept at the bedside during any magnesium sulfate infusion as the reversal agent.
7. Which environment is most appropriate for a client with severe preeclampsia?
A. A bright room with frequent visitorsBright light and activity increase cerebral irritability and seizure risk.
B. A quiet, dim room with limited stimulation and seizure precautionsCorrect. Reducing stimulation lowers seizure risk, and seizure precautions remain in place until the client is stable after delivery.
C. Hallway ambulation every hourFrequent ambulation raises blood pressure and offers no benefit during severe disease.
D. A shared room with the television onNoise and additional stimulation increase the risk of an eclamptic seizure.
Correct answer: B. Minimize stimulation and maintain seizure precautions in severe preeclampsia until after delivery.
8. A client with preeclampsia has platelets of 92,000, elevated AST and evidence of hemolysis. The nurse recognizes these findings as:
A. Gestational diabetesGestational diabetes is defined by glucose intolerance, not hemolysis or thrombocytopenia.
B. HELLP syndromeCorrect. Hemolysis, elevated liver enzymes and low platelets define HELLP, a severe variant of preeclampsia.
C. Placenta previaPlacenta previa presents with painless bright red bleeding, not these laboratory changes.
D. Hyperemesis gravidarumHyperemesis gravidarum causes intractable vomiting with dehydration and weight loss.
Correct answer: B. HELLP syndrome — hemolysis, elevated liver enzymes, low platelets — signals severe preeclampsia and prompt delivery planning.
9. A nurse caring for a laboring client at 39 weeks gestation observes recurrent late decelerations on the electronic fetal monitor strip. After changing the client's position to a lateral side-lying position, which action should the nurse take next?
A. Administer oxygen at 8 to 10 L/min via a non-rebreather face mask.Administering high-flow oxygen via a non-rebreather mask improves maternal oxygen saturation and enhances oxygen delivery across the placenta, directly addressing uteroplacental insufficiency causing late decelerations.
B. Increase the infusion rate of the intravenous oxytocin maintenance line.Increasing oxytocin is dangerous because oxytocin stimulates uterine contractions, worsening uterine tachysystole and exacerbating uteroplacental insufficiency and fetal hypoxia.
C. Perform a vaginal examination to check for umbilical cord prolapse.Checking for umbilical cord prolapse is the primary intervention for variable decelerations caused by cord compression, whereas late decelerations are caused by uteroplacental insufficiency.
D. Prepare the client for an immediate stat amniotomy.Amniotomy does not resolve uteroplacental insufficiency and could exacerbate fetal distress if variable decelerations from umbilical cord compression occur following rupture of membranes.
Correct answer: A. Late decelerations indicate uteroplacental insufficiency. Priority intrauterine resuscitation interventions include turning the client onto her side, discontinuing oxytocin, administering high-flow oxygen via non-rebreather mask, increasing IV fluids, and notifying the provider.
10. A nurse is caring for a newborn at 36 hours of life who is placed under intense phototherapy lights for pathological jaundice. Which nursing intervention is essential to ensure safety during this procedure?
A. Place opaque eye protective shields over the infant's eyes and cover the genitalia with a small diaper.Covering the eyes prevents retinal damage from intense phototherapy light, and shielding the genitals protects sensitive tissues from radiation and thermal exposure.
B. Apply a generous layer of moisturising lanolin lotion to the infant's entire body surface.Ointments or lotions must not be applied during phototherapy because they can absorb heat and cause severe superficial burns on the infant's delicate skin.
C. Restrict oral fluid intake between phototherapy sessions to prevent excessive fluid accumulation.Dehydration is a risk during phototherapy due to insensible fluid loss; fluid intake should be maintained or increased, never restricted.
D. Turn off the phototherapy lights continuously throughout the night so the newborn can sleep undisturbed.Phototherapy lights should remain on continuously except during feedings, parental bonding, and brief diagnostic procedures to maximize therapeutic efficacy.
Correct answer: A. Phototherapy converts unconjugated bilirubin into a water-soluble form for excretion. Eye shields prevent retinal damage, and minimal clothing with genital coverage maximizes exposed skin surface while protecting sensitive germ cells. Ointments should be avoided to prevent thermal skin injury.