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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?

A.

Decreased deep tendon reflexes.

B.

Uterine contractions.

C.

Proteinuria.

D.

Increased blood glucose level.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale

Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.

Choice B rationale

Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.

Choice C rationale

Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.

Choice D rationale

Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .

Correct Answer is ["A","B","C","D","G"]

Explanation

Choice A: Respiratory assessment

  • The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.

Choice B: Hemoglobin

  • The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.

Choice C: Serum glucose

  • The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.

Choice D: Heart rate

  • The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.

Choice G: Hematocrit

  • The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2

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