Difficulty: Medium
Average Score: 91%
Simulated
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?
Correct answer
B
Rationale
The correct answer is B. Deep tendon reflexes of 1+ are inconsistent with preeclampsia. In preeclampsia, deep tendon reflexes are typically hyperactive (3+ or 4+). This is due to the central nervous system irritability caused by hypertension. Therefore, a reflex of 1+ suggests normal reflexes, which is not expected in preeclampsia. Other choices A, C, and D are consistent with preeclampsia. Proteinuria (choice A) is a hallmark sign of preeclampsia. Elevated blood pressure (choice C) is a common finding in preeclampsia. Pitting edema (choice D) is also commonly observed in preeclampsia due to fluid retention.