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 B

Explanation

Choice A reason: Recommending the use of support stockings to enhance venous return is not a priority intervention for the nurse, as this does not address the underlying cause of the peripheral edema, which is fluid overload due to inadequate dialysis. This is a distractor choice.

Choice B reason: Ensuring the client receives frequent small meals containing complete proteins is a priority intervention for the nurse, as this can help improve the client's nutritional status and increase their serum albumin level, which can reduce fluid leakage into the interstitial spaces and decrease edema. Therefore, this is the correct choice.

Choice C reason: Evaluating patency of the AV graft for resumption of hemodialysis is not a priority intervention for the nurse, as this is not feasible at this point since the AV graft is no longer available to use. This is another distractor choice.

Choice D reason: Instructing the client to continue to follow the prescribed rigid fluid restriction amounts is not a priority intervention for the nurse, as this does not address the root problem of inadequate dialysis and low serum albumin level, which are contributing to fluid overload and edema. This is another distractor choice.

A. Apply the client's positive airway pressure device. B. Elevate the head of the bed to a 45 degree angle. C. Remove dentures or other oral appliances. D. Lift and lock the side rails in place.

Correct Answer is A

Explanation

Choice A reason: applying the client's positive airway pressure device can help prevent or reduce episodes of apnea and hypopnea during sleep by keeping the airway open and delivering oxygen. The nurse should ensure that the device fits properly and that the client knows how to use it.

Choice B reason: elevating the head of the bed to a 45 degree angle is not as effective as using a positive airway pressure device for a client with OSA. Elevating the head of the bed may help reduce snoring and improve breathing, but it may not prevent airway collapse or oxygen desaturation.

Choice C reason: removing dentures or other oral appliances is not as important as applying a positive airway pressure device for a client with OSA. Removing dentures or other oral appliances may help prevent choking or aspiration, but it may not prevent airway collapse or oxygen desaturation.

Choice D reason: lifting and locking the side rails in place is not as important as applying a positive airway pressure device for a client with OSA. Lifting and locking the side rails in place may help prevent falls or injuries, but it may not prevent airway collapse or oxygen desaturation.

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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

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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