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 B
Explanation
Choice A reason:
This choice is incorrect because the hepatitis B vaccine is recommended to be given within 24 hours of birth, but there is no recommendation for hepatitis B immune globulin (HBIG) to be given every 12 hours for 3 days. The HBIG is typically given as a single dose.
Choice B reason:
This is the correct choice. Newborns whose mothers are positive for the hepatitis B surface antigen should receive both HBIG and the first dose of the hepatitis B vaccine within 12 hours of birth. The HBIG provides immediate protection against hepatitis B infection, and the vaccine begins the process of building long-term immunity.
Choice C reason:
This choice is incorrect because delaying the administration of HBIG and the hepatitis B vaccine until 1 week after birth would leave the newborn vulnerable to hepatitis B infection. The recommended schedule is to administer these within 12 hours of birth.
Choice D reason:
This choice is incorrect because the hepatitis B vaccine is not given monthly. The typical schedule for the hepatitis B vaccine is the first dose at birth, the second dose at 1-2 months of age, and the third dose at 6 months of age. Additionally, the vaccine is not administered based on the newborn's hepatitis B surface antigen status.
Correct Answer is C
Explanation
Choice A reason:
Elevating the client's legs can help increase venous return to the heart and may be beneficial in some cases of hypotension. However, it is not the first-line action for hypotension in a client with an epidural block during labor.
Choice B reason:
Notifying the provider is important, but it is not the immediate priority action. The provider should be informed after initial measures to stabilize the client's blood pressure have been taken.
Choice C reason:
Placing the client in a lateral position is the priority nursing action for hypotension during labor with an epidural block. This position helps improve uterine blood flow and can help increase blood pressure. It is a part of the initial management of hypotension in this situation.
Choice D reason:
Monitoring vital signs every 5 minutes is an important part of ongoing assessment but is not the immediate priority action. The nurse should first address the hypotension and then continue to monitor the client closely.
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