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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

Hydralazine is an antihypertensive medication used to manage hypertension, not preterm labor. Administering hydralazine would be inappropriate for a client in preterm labor unless she also has hypertension.

Choice B rationale

Preparing the client for immediate delivery based solely on a lecithin-to-sphingomyelin (L/S) ratio of 1: is premature. An L/S ratio of 2: or greater is generally indicative of fetal lung maturity. A ratio of 1: suggests lung immaturity, and interventions to promote lung maturity are indicated.

Choice C rationale

Infusing a bolus of IV fluids might be considered for hydration in preterm labor, but it does not directly address the issue of fetal lung immaturity indicated by the low L/S ratio. While hydration can help manage preterm contractions in some cases, it is not the primary intervention to improve fetal lung maturity.

Choice D rationale

Administering betamethasone, a corticosteroid, is the appropriate action for a client in preterm labor with a low L/S ratio (1:). Betamethasone crosses the placenta and stimulates the production of surfactant in the fetal lungs, accelerating lung maturity and reducing the risk of respiratory distress syndrome in the preterm infant. The typical dose is 12 mg IM, given in two doses 24 hours apart. .

A. Encouraging the woman to assume a hands-and-knees position. B. Providing a comfortable environment with dim lighting. C. Administering oxytocin. D. Preparing the woman for an amniotomy.

Correct Answer is C

Explanation

Choice A rationale

Encouraging a hands-and-knees position may help rotate a malpositioned fetus or relieve back pain, but it does not directly address hypotonic uterine dysfunction, which is characterized by weak, ineffective contractions. While it can improve maternal comfort and potentially aid in fetal descent if malpositioning is a contributing factor to slow labor progress, it will not augment the strength or frequency of contractions necessary for cervical dilation.

Choice B rationale

Providing a comfortable environment with dim lighting can promote relaxation and potentially enhance the progress of labor in cases of hypertonic uterine dysfunction (uncoordinated, painful contractions). However, in hypotonic dysfunction, the issue is a lack of adequate uterine muscle activity. While comfort measures are always important, they do not directly stimulate stronger contractions.

Choice C rationale

Administering oxytocin is the primary medical intervention for hypotonic uterine dysfunction. Oxytocin is a synthetic hormone that stimulates uterine smooth muscle to contract more frequently and with greater intensity. This augmentation of uterine activity aims to establish an effective labor pattern, leading to cervical dilation and fetal descent when fetopelvic disproportion has been ruled out.

Choice D rationale

Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, the question states the membranes have already ruptured. Amniotomy can sometimes stimulate contractions by releasing prostaglandins, but it is not the first-line intervention for established hypotonic dysfunction after membrane rupture, and oxytocin is generally more effective in this situation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in preterm labor with a current LUS ratio of 1:1. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.Which intervention would the nurse expect to include in the plan of care for this client?

Correct Answer is C

Explanation

At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:

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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?