A 38-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks gestation.Assessment findings include: blood pressure 140/90 mm Hg; pulse, 80 beats/min; respiratory rate, 16 breaths/min.
The nurse suspects preeclampsia.
What additional finding would the nurse assess for?
Decreased deep tendon reflexes.
Uterine contractions.
Proteinuria.
Increased blood glucose level.
The Correct Answer is C
Choice A rationale
Decreased deep tendon reflexes are not typically associated with preeclampsia. In fact, hyperreflexia or increased deep tendon reflexes might be observed due to central nervous system irritability in preeclampsia.
Choice B rationale
Uterine contractions are related to labor and not a specific indicator of preeclampsia. While they might occur simultaneously, they are not diagnostic of preeclampsia.
Choice C rationale
Proteinuria, the presence of excess protein in the urine, is a key diagnostic criterion for preeclampsia. It indicates kidney involvement and is used along with elevated blood pressure to diagnose this condition.
Choice D rationale
Increased blood glucose levels are associated with gestational diabetes rather than preeclampsia. Elevated blood pressure and proteinuria are the hallmarks of preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Irregular menses are not a direct risk factor for cervical cancer. While they can indicate hormonal imbalances, they are not strongly linked to cervical cancer risk.
Choice B rationale
Menopausal status and hormone replacement therapy (HRT) are more closely linked to breast cancer risks rather than cervical cancer. Cervical cancer is primarily associated with HPV infection.
Choice C rationale
Multiple sexual partners increase the risk of HPV infection, which is the primary cause of cervical cancer. HPV is a sexually transmitted infection that significantly raises the likelihood of developing cervical cancer.
Choice D rationale
A family history of breast cancer is more relevant to breast cancer risk rather than cervical cancer. Cervical cancer risk is more closely linked to HPV infection and sexual behavior.
Correct Answer is B
Explanation
Choice A rationale
Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the head is turned and the opposite arm bending at the elbow, resembling a fencing position.
Choice B rationale
Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.
Choice C rationale
Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe moving upward or toward the top surface of the foot and the other toes fanning out.
Choice D rationale
Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object placed at the base of the toes. .
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