A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia.
Which of the following findings should the nurse identify as inconsistent with preeclampsia?
Deep tendon reflexes of +1.
3+ protein in the urine.
Blood pressure 148/98 mm Hg.
Pitting sacral edema.
The Correct Answer is A
Choice A rationale
Deep tendon reflexes of +1 are hypoactive reflexes, indicating decreased neurological excitability. In preeclampsia, central nervous system irritability is a key feature, often leading to hyperreflexia, which would be documented as +2, +3, or +4. Therefore, +1 reflexes are inconsistent with preeclampsia.
Choice B rationale
3+ protein in the urine indicates significant proteinuria, which is a hallmark sign of preeclampsia. The kidneys are affected in preeclampsia, leading to increased excretion of protein in the urine.
Choice C rationale
A blood pressure of 148/98 mm Hg is elevated and falls within the diagnostic criteria for preeclampsia, which is hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) that develops after 20 weeks of gestation along with proteinuria or other signs of end-organ damage.
Choice D rationale
Pitting sacral edema, or swelling in the sacral area that leaves a pit when pressed, is a common finding in preeclampsia due to fluid retention and increased capillary permeability.
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Correct Answer is B
Explanation
Choice A rationale
Edema, particularly peripheral edema, is a common clinical sign of preeclampsia. It results from fluid shifts due to increased vascular permeability and decreased plasma protein levels associated with the disease process.
Choice B rationale
Glycosuria, the presence of glucose in the urine, is not typically a symptom of preeclampsia. It is more commonly associated with gestational diabetes, a separate condition of pregnancy characterized by impaired glucose tolerance.
Choice C rationale
Proteinuria, the presence of significant amounts of protein in the urine (typically ≥300 mg in a 24-hour urine collection), is a hallmark sign of preeclampsia. It reflects glomerular endothelial damage and increased permeability.
Choice D rationale
Hypertension, defined as a blood pressure of ≥140/90 mmHg on two separate occasions at least 4 hours apart after 20 weeks of gestation, is a key diagnostic criterion for preeclampsia. It results from systemic vasoconstriction.
Correct Answer is A
Explanation
Choice A rationale
Walking and increasing fluid intake can often alleviate the discomfort associated with Braxton Hicks contractions. Movement can sometimes cause the uterus to relax, and adequate hydration helps maintain uterine irritability within normal physiological limits. Dehydration can sometimes exacerbate uterine contractions, so ensuring sufficient fluid intake is a prudent measure.
Choice B rationale
Timing contractions is more relevant when assessing for true labor. Braxton Hicks contractions are irregular and do not follow a consistent pattern of increasing frequency, duration, and intensity. Instructing the client to time them for 30 minutes may cause unnecessary anxiety and is not the primary intervention for discomfort relief.
Choice C rationale
Aspirin is not recommended during pregnancy, especially in the third trimester, due to potential risks to both the mother and the fetus, such as increased bleeding tendencies. Furthermore, aspirin would not address the physiological cause of Braxton Hicks contractions.
Choice D rationale
Going to the hospital is not indicated for irregular, non-painful Braxton Hicks contractions, especially at 36 weeks' gestation. Hospital visits are reserved for signs of true labor, such as regular, increasing contractions, rupture of membranes, or significant bleeding.
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