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?
A.
Blood pressure 160/115
B.
Anasarca
C.
Proteinuria 3+
D.
Deep tendon reflexes
The Correct answer and Explanation is:
In this scenario, the nurse is tasked with identifying which finding is inconsistent with preeclampsia in an adolescent client who is 38 weeks pregnant. The options presented are:
A. Blood pressure 160/115
B. Anasarca
C. Proteinuria 3+
D. Deep tendon reflexes
Correct Answer: D. Deep tendon reflexes
Explanation:
Preeclampsia is a pregnancy-related hypertensive disorder characterized by the onset of hypertension and proteinuria after 20 weeks of gestation. It can lead to serious complications if not managed properly. The main features of preeclampsia include:
- Hypertension: A blood pressure reading of 160/115 mmHg is consistent with severe hypertension associated with preeclampsia. Normal blood pressure in a pregnant woman should generally be below 140/90 mmHg, and the reading indicates that the client is experiencing a hypertensive crisis.
- Anasarca: This term refers to generalized edema or swelling due to fluid accumulation in the body. It is a significant finding in severe preeclampsia, as the condition can lead to fluid retention and increased vascular permeability.
- Proteinuria: A level of 3+ proteinuria indicates a significant amount of protein in the urine, which is a hallmark of preeclampsia. This finding suggests impaired kidney function, which is often seen in women with this condition.
- Deep Tendon Reflexes: While deep tendon reflexes can be affected in preeclampsia, especially in severe cases leading to hyperreflexia, the presence of normal reflexes does not rule out preeclampsia. In fact, hyperreflexia can be a sign of worsening condition or progression towards eclampsia (seizures). Thus, normal deep tendon reflexes are inconsistent with the severity typically expected in preeclampsia.
In summary, while options A, B, and C are characteristic findings in preeclampsia, option D (normal deep tendon reflexes) does not correlate with the expected clinical picture, making it the correct answer.