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 A
Explanation
Choice A Reason:
The priority action is to assess the safety of both the client and the newborn. Asking the client if she has considered harming her newborn is crucial to determine if there is an immediate risk of harm. This question helps identify any potential danger and allows for immediate intervention if necessary. Ensuring the safety of the mother and baby is the top priority in managing postpartum depression.
Choice B Reason:
Anticipating a prescription for an antidepressant is important, but it is not the immediate priority. Medication can be part of the treatment plan for postpartum depression, but first, it is essential to assess the client’s safety and risk of harm to herself or her newborn.
Choice C Reason:
Reinforcing postpartum and newborn care discharge teaching is beneficial for the client’s overall understanding and management of her condition. However, it does not address the immediate concern of potential harm to the newborn or the severity of the client’s depressive symptoms
Choice D Reason:
Assisting the family to identify proper use of positive coping skills is a valuable long-term strategy for managing postpartum depression. However, the immediate priority is to assess the client’s safety and ensure there is no risk of harm to herself or her newborn.
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.
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