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?
3+ protein in the urine.
Deep tendon reflexes of 1+.
Blood pressure 148/98 mm Hg.
1+ pitting sacral edema.
None
None
The Correct Answer is B
Choice A Reason:
The presence of 3+ protein in the urine is consistent with preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, indicating kidney involvement and damage. High levels of protein in the urine are a common finding in patients with preeclampsia.
Choice B Reason:
Deep tendon reflexes of 1+ are inconsistent with preeclampsia. Preeclampsia often causes hyperreflexia, which means increased reflex responses. Typically, patients with preeclampsia exhibit brisk reflexes (3+ or 4+), which can be a sign of central nervous system irritability and an increased risk of seizures.
Choice C Reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. Preeclampsia is characterized by high blood pressure, defined as systolic blood pressure of 140 mm Hg or higher, or diastolic blood pressure of 90 mm Hg or higher, measured on two occasions at least four hours apart.
Choice D Reason:
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the lower extremities and sacral area, is a common symptom of preeclampsia due to increased capillary permeability and fluid retention.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Cocaine use: Cocaine use during pregnancy is a significant risk factor for placental abruption. Cocaine causes vasoconstriction, which can reduce blood flow to the placenta and lead to its premature separation from the uterine wall. However, it is not the most common risk factor.
Choice B reason:
Blunt force trauma: Trauma to the abdomen, such as from a car accident or a fall, can cause placental abruption. This type of trauma can lead to the separation of the placenta from the uterine wall, resulting in bleeding and potential complications for both the mother and the fetus.
Choice C reason:
Hypertension: Hypertension, or high blood pressure, is the most common risk factor for placental abruption. Chronic hypertension or pregnancy-induced hypertension (preeclampsia) can damage the blood vessels in the placenta, leading to its premature separation. This condition can significantly increase the risk of placental abruption and is a critical factor to monitor in pregnant women.
Choice D reason:
Cigarette smoking: Smoking during pregnancy is another risk factor for placental abruption. Nicotine and other harmful substances in cigarettes can affect placental blood flow and increase the risk of abruption. However, like cocaine use, it is not the most common risk factor.
Correct Answer is ["C","D"]
Explanation
Choice A reason:
“Small for gestational age” (SGA) refers to babies who are smaller than the typical weight for their gestational age, usually below the 10th percentile. An 8-pound 15-ounce baby born at 35 weeks is not considered SGA because this weight is above the average for that gestational age
Choice B reason:
“Term” refers to babies born between 37 and 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered term.
Choice C reason:
“Preterm” refers to babies born before 37 weeks of gestation. A baby born at 35 weeks falls into this category and is specifically classified as a “late preterm” infant3. Late preterm infants are those born between 34 and 36 weeks of gestation. These babies may require additional medical support compared to full-term infants but generally have better outcomes than those born earlier.
Choice D reason:
“Average for gestational age” (AGA) refers to babies whose weight is within the normal range for their gestational age, typically between the 10th and 90th percentiles. An 8-pound 15-ounce baby born at 35 weeks is considered AGA because this weight is within the expected range for that gestational age.
Choice E reason:
“Post term” refers to babies born after 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered post term.
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