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.

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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Correct Answer is A

Explanation

Choice A rationale

A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to prevent hypoxia and other complications.

Choice B rationale

Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.

Choice C rationale

Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.

Choice D rationale

A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate life-threatening condition. .

Correct Answer is ["2"]

Explanation

Step 1 is: 12 mg ÷ 6 mg/ml.

Step 2 is: 12 ÷ 6 = 2 ml. Answer: 2 ml

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 2 hr postpartum and received spinal anesthesia for a cesarean birth.Which of the following findings requires immediate intervention by the nurse?

Correct Answer is A

Explanation

A nurse is preparing to administer betamethasone 12mg IM to a client at 32 weeks gestation at risk for preterm delivery. Betamethasone is available as 6mg/ml. How many ml will the nurse prepare for injection? (Use a leading zero, if it applies. Do not use a trailing zero)

Correct Answer is ["2"]

Explanation

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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?