A nurse is caring for an adolescent client who is gravida 1, 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 148/98 mm Hg
3+ protein in the urine
1+ pitting sacral edema
Deep tendon reflexes of +1
The Correct Answer is D
Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.
Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.
Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.
Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a Reason: Encourage the client to move to the left lateral position
Moving to the left lateral position is often recommended to improve circulation and prevent compression of the vena cava by the uterus in a pregnant client. However, in the case of a boggy fundus postpartum, this position is not the primary action to be taken.
Choice b Reason: Ask the client to rate her pain
While assessing pain is important in the postpartum period, it is not the immediate action required for a boggy fundus. A boggy fundus indicates that the uterus is not contracting properly, which can lead to excessive bleeding.
Choice c Reason: Assist the client to the bathroom to void
A boggy fundus that is displaced to the right often indicates a full bladder, which can prevent the uterus from contracting effectively. Assisting the client to the bathroom to void can help the uterus contract and reduce the risk of hemorrhage.
Choice d Reason: Encourage the client to perform Kegel exercises
Kegel exercises are beneficial for strengthening the pelvic floor muscles after childbirth. However, they are not the immediate action to take for a boggy fundus postpartum
Correct Answer is D
Explanation
Choice A reason:
Reducing exercise to 3 days a week may not be sufficient for managing gestational diabetes. Regular physical activity is an important part of diabetes management because it helps lower blood sugar levels and can improve insulin sensitivity. The American Diabetes Association recommends that pregnant women with gestational diabetes engage in at least 150 minutes of moderate-intensity aerobic activity per week. This can be distributed over at least three days per week, with no more than two consecutive days without exercise.
Choice B reason:
The statement that the client knows she is at increased risk of developing type 2 diabetes is accurate. Women with gestational diabetes have a higher risk of developing type 2 diabetes later in life. Therefore, they should be monitored for diabetes postpartum and in the years following the birth.
Choice C reason:
Taking glyburide, an oral hypoglycemic agent, is a common treatment for gestational diabetes when diet and exercise are not enough to control blood sugar levels. It is usually taken before breakfast to help control blood sugar levels throughout the day.
Choice D reason:
The statement about limiting carbohydrates to 50% of caloric intake indicates a need for further teaching. While it is important to monitor carbohydrate intake, there is no one-size-fits-all recommendation for the percentage of calories that should come from carbohydrates. Dietary needs can vary based on individual factors, and it is generally recommended to follow a balanced diet with carbohydrates coming from whole grains, fruits, vegetables, and legumes. The client should work with a dietitian to determine the appropriate amount of carbohydrates for her specific needs.
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