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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?

Blood pressure 160/115

Anasarca

Proteinuria 3+

Deep tendon reflexes

Answer and Explanation

The Correct Answer is D

a. This is a sign of severe preeclampsia.

b. This is a sign of severe preeclampsia.

c. This is a sign of severe preeclampsia.

d. Deep tendon reflexes are not affected by preeclampsia, which is a hypertensive disorder of pregnancy characterized by high blood pressure, proteinuria, and edema.

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Correct Answer is A

Explanation

a. Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy that occurs around the time of implantation of the fertilized egg.
b. A positive pregnancy test is a probable sign of pregnancy that can occur as early as 7-10 days after conception.
c. Chadwick's sign, or the bluish discoloration of the cervix and vagina, is a probable sign of pregnancy that typically occurs around 6-8 weeks of gestation.
d. Hegar's sign, or the softening of the lower uterine segment, is a probable sign of pregnancy that typically occurs around 6-12 weeks of gestation.

A. Preparing the woman for vaginal birth B. Covering the cord in sterile gauze soaked in saline C. c Placing the patient on knee-chest position D. Preparing the woman for a cesarean birth E. Preparing the woman for a cesarean birth

Correct Answer is C

Explanation

a. This is not the correct intervention for a prolapsed umbilical cord.

b. This is not the correct intervention for a prolapsed umbilical cord.

c. This is the correct intervention for a prolapsed umbilical cord as it helps relieve pressure on the cord and improve fetal oxygenation.
d. This may be necessary if other interventions are not successful, but it is not the initial priority.

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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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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?