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?
Blood pressure 160/115
Anasarca
Proteinuria 3+
Deep tendon reflexes
The Correct Answer is D
a. This is a sign of severe preeclampsia.
b. This is a sign of severe preeclampsia.
c. This is a sign of severe preeclampsia.
d. Deep tendon reflexes are not affected by preeclampsia, which is a hypertensive disorder of pregnancy characterized by high blood pressure, proteinuria, and edema.
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Related Questions
Correct Answer is C
Explanation
a. This is a test for renal function, not fetal lung maturity.
b. This is a test for glucose control, not fetal lung maturity.
c. An L/S ratio of 2:1 or greater indicates that the fetal lungs have reached maturity.
d. This is a test of fetal well-being and does not indicate fetal lung maturity. This ratio indicates that the fetal lungs have enough surfactant to prevent alveolar collapse and respiratory distress syndrome.

Correct Answer is D
Explanation
a. A negative rubella titer indicates that the client is not immune to rubella.
b. Rubella vaccine is contraindicated during pregnancy.
c. A negative rubella titer does not indicate whether the client is currently experiencing a rubella infection.
d. A negative rubella titer means that the client does not have antibodies against the rubella virus, which can cause congenital defects in the fetus if the mother gets infected during pregnancy. Therefore, the client should receive the rubella vaccine after delivery, when it is safe to do so.
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