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?
3+ protein in the urine.
Deep tendon reflexes of 1+.
Blood pressure 148/98 mm Hg.
1+ pitting sacral edema.
None
None
The Correct Answer is B
Choice A Reason:
The presence of 3+ protein in the urine is consistent with preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, indicating kidney involvement and damage. High levels of protein in the urine are a common finding in patients with preeclampsia.
Choice B Reason:
Deep tendon reflexes of 1+ are inconsistent with preeclampsia. Preeclampsia often causes hyperreflexia, which means increased reflex responses. Typically, patients with preeclampsia exhibit brisk reflexes (3+ or 4+), which can be a sign of central nervous system irritability and an increased risk of seizures.
Choice C Reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. Preeclampsia is characterized by high blood pressure, defined as systolic blood pressure of 140 mm Hg or higher, or diastolic blood pressure of 90 mm Hg or higher, measured on two occasions at least four hours apart.
Choice D Reason:
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the lower extremities and sacral area, is a common symptom of preeclampsia due to increased capillary permeability and fluid retention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Allowing the grandmother to push the baby to the room in a wheeled bassinet is not advisable. Hospitals have strict protocols to prevent infant abduction, and only authorized personnel should transport newborns. This ensures the safety and security of the infant.
Choice B Reason:
Requiring photo identification from the grandmother before allowing her to take the infant is not a standard practice. While identification is crucial, it is typically the responsibility of the hospital staff to transport the newborn to ensure proper security measures are followed.
Choice C Reason:
Having the mother call and the nurse taking the baby to the room is the most appropriate response. This ensures that the newborn is transported safely by authorized personnel, adhering to hospital protocols designed to prevent infant abduction and ensure the baby’s safety.
Choice D Reason:
Allowing the grandmother to carry the grandchild to the room is not recommended. Similar to choice A, this does not align with hospital security protocols. Only authorized personnel should handle the transportation of newborns within the hospital to maintain safety and security.
Correct Answer is A
Explanation
Choice A reason:
Dyspnea: Dyspnea, or difficulty breathing, is a serious adverse effect that should be reported immediately. Terbutaline can cause pulmonary edema, a condition where fluid accumulates in the lungs, leading to severe breathing difficulties. This side effect is critical and requires prompt medical attention to prevent further complications.
Choice B reason:
Headaches: While headaches are a common side effect of terbutaline, they are generally not considered severe enough to require immediate reporting unless they are persistent or unusually intense. Headaches can be managed with over-the-counter pain relief and do not typically indicate a serious problem.
Choice C reason:
Nervousness: Nervousness is another common side effect of terbutaline. It is usually mild and does not require immediate medical intervention. However, if the nervousness is severe or accompanied by other symptoms, it should be discussed with a healthcare provider.
Choice D reason:
Tremors: Tremors are a known side effect of terbutaline and are usually not severe. They occur due to the medication’s action on the nervous system. While they can be bothersome, they are not typically dangerous and do not require urgent reporting unless they are severe or persistent.
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