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:
Elevating the client's legs can help increase venous return to the heart and may be beneficial in some cases of hypotension. However, it is not the first-line action for hypotension in a client with an epidural block during labor.
Choice B reason:
Notifying the provider is important, but it is not the immediate priority action. The provider should be informed after initial measures to stabilize the client's blood pressure have been taken.
Choice C reason:
Placing the client in a lateral position is the priority nursing action for hypotension during labor with an epidural block. This position helps improve uterine blood flow and can help increase blood pressure. It is a part of the initial management of hypotension in this situation.
Choice D reason:
Monitoring vital signs every 5 minutes is an important part of ongoing assessment but is not the immediate priority action. The nurse should first address the hypotension and then continue to monitor the client closely.
Correct Answer is D
Explanation
Choice a reason:
While ultrasound can be used for estimating fetal age, at 36 weeks of gestation, this is not the primary reason for performing an ultrasound before an amniocentesis. Fetal age is usually estimated earlier in the pregnancy to help with dating the pregnancy and determining the due date.
Choice b reason:
Determining if there is more than one fetus is typically established earlier in the pregnancy. By 36 weeks, the presence of multiples would already be known, so this would not be the primary reason for an ultrasound before an amniocentesis at this stage.
Choice c reason:
An ultrasound can be used as a screening tool for spina bifida, but it is not the main reason for an ultrasound before an amniocentesis at 36 weeks. Screening for spina bifida and other anomalies is usually done during the second trimester.
Choice d reason:
The primary reason for an ultrasound before an amniocentesis is to identify the location of the placenta and fetus. This information is crucial to ensure the safety of both the mother and the fetus during the procedure by avoiding injury to the placenta and ensuring the amniotic needle is inserted in a safe location.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today