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 B
Explanation
a. This is not the correct choice because the woman has signs of magnesium toxicity, such as low urine output, high blood pressure, and increased DTR. Continuing the infusion could worsen her condition and put her and the fetus at risk.
b. This is the correct choice because the woman needs to be treated for magnesium toxicity, which is a serious complication of preeclampsia. Stopping the infusion will prevent further accumulation of magnesium in her body and allow her to excrete the excess.
c. This is not the correct choice because it will delay the treatment of magnesium toxicity, which is a medical emergency. The woman's vital signs and symptoms are enough to indicate that she has a high level of magnesium and needs immediate intervention.
d. This is not the correct choice because it will not address the underlying cause of magnesium toxicity, which is the infusion. Oxygen may help with some symptoms, such as respiratory depression, but it will not reverse the effects of magnesium on the nervous system and blood vessels.
Correct Answer is D
Explanation
a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.
c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.
d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.
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