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
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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Related Questions
Correct Answer is D
Explanation
a. Spontaneous rupture of the membranes (SROM) may or may not occur during labor and is not a reliable sign.
b. Engagement of the presentation is the descent of the fetal head or breech into the pelvis and can occur before labor begins.
c. Irregular contractions can occur during false labor (Braxton Hicks contractions) and are not a reliable sign of true labor.
d. Cervical effacement is the thinning and shortening of the cervix that occurs during labor. It is a sign of true labor, along with cervical dilation and regular contractions.

Correct Answer is A
Explanation
a. In this case, the woman is pregnant for the fourth time, so her gravidity is 4.
She has one child born at 39 weeks, another child born at 40 weeks, and one child born at 36.2 weeks. The first two are considered term births, and the last one is considered a preterm birth. Therefore, her term is 1 and her preterm is 2. She has no abortions, so her abortion is 0. She has three living children, so her living children is 3. Hence, her GTPAL is 4-2-1-0-3.
b. This indicates 1 full-term pregnancy, 1 preterm pregnancy, and 3 living child.
c. This would indicate 1 full-term pregnancy, 2 preterm pregnancies, and 3 living children.
d. 4-3-0-0-3: This would indicate 3 full-term pregnancies and 3 living children.
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