A nurse is caring for a client who is pregnant.
For each recent assessment finding. click to specify if the finding indicates the client’s condition has improved or has not changed. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
Deep tendon patellar reflex
Blood pressure
Edema
Heart rate
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Rationale:
Deep tendon patellar reflex (DTR): The client’s reflexes decreased from 4+ on Day 1 to 2+ on Day 2. Hyperactive reflexes are a hallmark of preeclampsia with severe features, so the reduction indicates an improvement in neuromuscular excitability.
Blood pressure: While slightly decreased from 166/110 mm Hg (Day 1, 0930) to 152/90 mm Hg (Day 2, 0900), indicating partial improvement with antihypertensive therapy. However, the BP remains elevated above normal range requiring further management.
Heart rate: The heart rate changed from 84–90/min (Day 1–Day 2), which is stable and within normal limits, suggesting no acute cardiovascular compromise.
Edema: The client continues to have +3 pitting edema in bilateral lower extremities on both Day 1 and Day 2, showing no change in fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
. The nurse should check the medication label three times—when obtaining, preparing, and before administering.
B. Using two identifiers (e.g., name and date of birth) ensures correct patient identification per the Joint Commission National Patient Safety Goals.
C. Documentation should occur immediately after administration, not before, to avoid medication errors.
D. The accepted time frame is within 30 minutes of the scheduled time, not 3 hours.
Correct Answer is ["A","C","D","E"]
Explanation
Findings Requiring Immediate Follow-Up
Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, soft tissue injury, or early compartment syndrome. Edema can compromise circulation and should be assessed promptly.
Fingers slightly cool to touch: Cool fingers may indicate reduced perfusion to the extremity, which is concerning after trauma. Immediate assessment of capillary refill, color, and temperature is necessary.
Child verbalizes a pain level of 4/10: Pain in children, even moderate, requires attention because it can indicate significant underlying injury and may escalate. Pain assessment and management should be prioritized.
Child can move fingers and reports a mild "tingling" sensation: Tingling may indicate nerve involvement or early neurovascular compromise, even if movement is preserved. Timely evaluation is essential.
Findings Not Requiring Immediate Follow-Up
Radial pulse +2: A +2 radial pulse is normal and indicates adequate arterial flow, so it does not require immediate intervention.
Multiple areas of bruising noted on lower extremities in various stages of healing: In this scenario, the bruising is assumed to be from normal childhood activity or minor trauma. It does not automatically signify abuse and is not an urgent concern.
Heart rate 102/min: Slightly elevated heart rate may reflect pain or stress. It is within normal limits for a 9-year-old (70–120/min).
Respiratory rate 22/min: Within normal range for a 9-year-old (18–26/min) and not urgent.
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