When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

When the client has ankle edema.

If the client has an elevated blood pressure.

During admission to labor and delivery.

Within the first trimester of pregnancy.

Answer and Explanation

The Correct Answer is B

Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.

Choice B reason: This is the correct answer because if the client has an elevated blood pressure, it is important for the nurse to assess for other signs of preeclampsia or eclampsia, such as proteinuria, headache, blurred vision, epigastric pain, and hyperreflexia or increased DTRs. These conditions can cause seizures and other complications that can endanger the mother and fetus.

Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.

Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.

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Correct Answer is C

Explanation

Choice A reason: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.

Choice B reason: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.

Choice C reason: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.

Choice D reason: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.

A. Determine the need for urinary catheterization B. Titrate oxygen to prescribed parameters. C. Receive a postoperative client and conduct the assessment. D. Evaluate and update plans of care for clients.

Correct Answer is B

Explanation

Choice A reason: Determining the need for urinary catheterization is not a task that the nurse should assign to the PN, as this requires clinical judgment and critical thinking, which are beyond the scope of practice of the PN. This is a distractor choice.

Choice B reason: Titrating oxygen to prescribed parameters is a task that the nurse can assign to the PN, as this involves following orders and protocols, which are within the scope of practice of the PN. Therefore, this is the correct choice.

Choice C reason: Receiving a postoperative client and conducting the assessment is not a task that the nurse should assign to the PN, as this requires initial assessment and data collection, which are the responsibility of the registered nurse. This is another distractor choice.

Choice D reason: Evaluating and updating plans of care for clients is not a task that the nurse should assign to the PN, as this requires nursing diagnosis and outcome identification, which are part of the nursing process that only the registered nurse can perform. This is another distractor choice.

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When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

Correct Answer is B

Explanation

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When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

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