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.
The Correct Answer is B
Choice B is correct because assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.
Choice A is incorrect because ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.
Choice C is incorrect because assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.
Choice D is incorrect because assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.
Choice B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.
Choice C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.
Choice D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.
Correct Answer is A
Explanation
Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.
Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.
Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.
Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.
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