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 A
Explanation
Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.
Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.
Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.
Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.
Correct Answer is C
Explanation
Choice a reason:
Placing the client in the Trendelenburg position, which involves lying on the back with the feet higher than the head, is not indicated for the symptoms presented. This position is typically used to treat hypotension or improve venous return to the heart, not for respiratory depression or absent deep-tendon reflexes, which are signs of magnesium sulfate toxicity.
Choice b reason:
Assessing maternal blood glucose is important in the overall care of a preeclamptic patient, especially if there is a concern for gestational diabetes. However, it is not the immediate action required when a patient exhibits signs of magnesium sulfate toxicity, such as a respiratory rate of 10/min and absent deep-tendon reflexes.
Choice c reason:
Discontinuing the medication infusion is the correct action. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Immediate cessation of the drug is necessary to prevent further complications, such as respiratory depression or cardiac arrest. After stopping the infusion, the nurse should monitor the patient closely and prepare to administer calcium gluconate, the antidote for magnesium sulfate toxicity, if ordered by the physician.
Choice d reason:
Preparing for an emergency cesarean birth may be necessary if the fetus is in distress or if there are other obstetric indications. However, the information provided does not indicate fetal distress or an immediate need for delivery. The priority is addressing the signs of magnesium sulfate toxicity in the mother.
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