A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia.
Which of the following findings should the nurse identify as inconsistent with preeclampsia?
Deep tendon reflexes of +1.
3+ protein in the urine.
Blood pressure 148/98 mm Hg.
Pitting sacral edema.
The Correct Answer is A
Choice A rationale
Deep tendon reflexes of +1 are hypoactive reflexes, indicating decreased neurological excitability. In preeclampsia, central nervous system irritability is a key feature, often leading to hyperreflexia, which would be documented as +2, +3, or +4. Therefore, +1 reflexes are inconsistent with preeclampsia.
Choice B rationale
3+ protein in the urine indicates significant proteinuria, which is a hallmark sign of preeclampsia. The kidneys are affected in preeclampsia, leading to increased excretion of protein in the urine.
Choice C rationale
A blood pressure of 148/98 mm Hg is elevated and falls within the diagnostic criteria for preeclampsia, which is hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) that develops after 20 weeks of gestation along with proteinuria or other signs of end-organ damage.
Choice D rationale
Pitting sacral edema, or swelling in the sacral area that leaves a pit when pressed, is a common finding in preeclampsia due to fluid retention and increased capillary permeability.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A platelet count of 50,000/mm³ is critically low (normal range is 150,000-450,000/mm³) in a client with pre-eclampsia. Thrombocytopenia is a serious complication of pre-eclampsia and can significantly increase the risk of bleeding and hemorrhage. This finding requires immediate reporting and intervention.
Choice B rationale
A hemoglobin level of 11 grams/dL is within the lower end of the normal range for postpartum women (typically 12-15 g/dL) and is not an immediate concern in the context of pre-eclampsia, unless there is a rapid decline or other concerning symptoms.
Choice C rationale
A creatinine level of 0.3 mg/dL is below the normal range for non-pregnant adults (typically 0.6-1.2 mg/dL) and might be lower in pregnancy due to increased glomerular filtration rate. While kidney function should be monitored in pre-eclampsia, this specific value is not immediately alarming.
Choice D rationale
A fasting blood glucose of 65 mg/dL is within the normal range (typically 70-100 mg/dL) and is not a typical finding that requires immediate reporting in pre-eclampsia, although gestational diabetes can sometimes coexist.
Correct Answer is B
Explanation
Choice A rationale
Reducing fluid intake will not alleviate breast engorgement and may even be detrimental to milk production and overall maternal hydration. Engorgement is caused by increased blood flow and milk production in the breasts, not excess fluid intake.
Choice B rationale
Frequent breastfeeding, ideally every 1-2 hours, helps to remove milk from the breasts, which relieves pressure and engorgement. Regular emptying of the breasts signals the body to regulate milk production and prevents the buildup of milk that causes discomfort and can lead to complications like mastitis.
Choice C rationale
Avoiding the use of a breast pump when breasts are engorged can worsen the condition. A breast pump can be used to express milk and relieve pressure if the infant is not feeding effectively or frequently enough. Complete milk removal is key to reducing engorgement.
Choice D rationale
Skipping feedings will exacerbate breast engorgement as milk will continue to accumulate in the breasts, increasing pressure, pain, and the risk of complications. Regular milk removal is essential for managing engorgement and establishing a healthy breastfeeding pattern.
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