A nurse is caring for an adolescent client who is gravida 1, 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 148/98 mm Hg
3+ protein in the urine
1+ pitting sacral edema
Deep tendon reflexes of +1
The Correct Answer is D
Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.
Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.
Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.
Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Telling a client that a pelvic exam is required for birth control pills is not accurate. Current medical guidelines indicate that a pelvic exam is not necessary to prescribe oral contraceptive medications, hormonal contraceptives can be safely prescribed based on medical history and blood pressure measurement without the need for a pelvic or breast examination.
Choice B reason:
While offering support is important, simply telling the client not to worry does not address her specific concerns or provide her with information about the process and her options.
Choice C reason:
Advising the client to relax does not acknowledge the validity of her feelings or provide her with any concrete information or support to help alleviate her anxiety.
Choice D reason:
Asking the client what part of the exam makes her most nervous is an open-ended question that invites dialogue. It allows the nurse to provide targeted information and reassurance, addressing the client's specific concerns and promoting a sense of control and participation in her own health care decisions.
Correct Answer is A
Explanation
Choice A reason: When a client in active labor presents with hypotension, as indicated by a blood pressure reading of 82/52 mm Hg, the priority nursing intervention is to assist the client to turn onto her side. This position helps to alleviate pressure on the inferior vena cava, which can be compressed by the gravid uterus, thereby improving venous return and increasing blood pressure. It also enhances uteroplacental perfusion, providing better oxygenation to the fetus.
Choice B reason: While preparation for a cesarean birth may be necessary if there are signs of fetal distress or if the hypotension does not resolve, it is not the first-line intervention for isolated hypotension without other indications.
Choice C reason: Preparing for an immediate vaginal delivery is not the priority action in response to hypotension. The focus should be on stabilizing the mother's blood pressure to ensure safe delivery, whether vaginal or cesarean.
Choice D reason: Assisting the client to an upright position is not advisable in the case of hypotension, as this can further decrease venous return to the heart and exacerbate the low blood pressure.
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