Difficulty: Medium
Average Score: 84%
Simulated
A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
Correct answer
D
Rationale
Assessing deep tendon reflexes and clonus detects CNS irritability, critical for identifying severe preeclampsia and eclampsia risk.