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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
The pattern of contractions can be a sign of true labor when they are regular, frequent, and increase in intensity and duration over time. In true labor, contractions do not subside with rest or hydration and become progressively more organized. However, contractions alone can be misleading, as Braxton Hicks contractions may also present a pattern but do not lead to cervical changes.
Choice b reason:
The station of the presenting part refers to the position of the baby's head (or presenting part) in relation to the ischial spines of the mother's pelvis. While the station can indicate how far labor has progressed, it is not a definitive sign of true labor. The station changes as labor progresses, but it can also be affected by other factors such as the baby's position.
Choice c reason:
Rupture of the membranes, commonly known as water breaking, can occur before or during labor. While it is a sign that labor may be imminent, it does not confirm true labor. Some women may experience premature rupture of membranes without contractions or cervical changes.
Choice d reason:
Changes in the cervix, including effacement (thinning) and dilation (opening), are the most reliable signs of true labor. Effacement is measured in percentages, and dilation is measured in centimeters. The cervix must be 100% effaced and dilated to 10 centimeters for childbirth to occur. These changes are a direct result of true labor contractions and indicate that the body is preparing for delivery.
Correct Answer is A
Explanation
Choice a reason:
Panting can help control the urge to push and is often recommended during the crowning stage to prevent tearing and to allow the perineum to stretch gradually. It can also help manage the pain and provide the baby with a gentle descent.
Choice b reason:
Slow-paced breathing is generally advised during the earlier stages of labor to help manage contractions and maintain relaxation. However, during the crowning stage, slow-paced breathing might not be effective in controlling the strong urge to push.
Choice c reason:
Telling the client to go ahead and push without proper guidance could lead to rapid delivery, which increases the risk of perineal tearing. The nurse should instruct the client on when and how to push effectively, often during a contraction, with controlled effort.
Choice d reason:
Taking a deep, cleansing breath can be calming and help the client focus, but it does not directly address the immediate need to control the pushing during crowning. Controlled breathing techniques specific to the delivery stage are more appropriate.
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