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Initial History and Assessment
At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad heartburn. Her sister tells the nurse, "I felt like that when I had toxemia during my pregnancy." Admission assessment by the nurse reveals: today's weight 182 pounds, T 99.1° F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the urine. Heart rate is regular, and lung sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus.[pic][pic] The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station.
1. In reviewing Jennie's history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder due to which risk factors? [pic]A) Age (15), molar pregnancy, history of preeclampsia in previous pregnancy. [pic]B) Age (15), gravidity, familial history.
[pic]C) Age (15), history of pounding headache, low socioeconomic status. [pic]D) Age (15), low socioeconomic status (SES), history of pedal edema.
2. To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain? [pic]A) Pattern and number of prenatal visits.
[pic]B) Prenatal blood pressure readings.
[pic]C) Prepregnancy weight.
[pic]D) Jennie's Rh factor.
Assessing Deep Tendon Reflexes
PURPOSE: To identify exaggerated reflexes (hyperreflexia) or diminished reflexes (hyporeflexia) You will need a reflex hammer to best assess both the brachial and the patellar reflexes. Support the woman's arm and instruct her to let it go limp while it is being held so that the arm is totally relaxed and slightly flexed as you assess the brachial reflex. If you have difficulty identifying the correct tendon to tap, have the woman flex and extend her arm until you can feel it moving beneath your thumb. Have her fully relax her arm after you identify the tendon. Place your thumb over the woman's tendon, as illustrated, to allow you to feel as well as see the tendon response when the tendon is tapped. Strike the thumb with the small end of the triangular reflex hammer. The normal response is slight flexion of the forearm. [pic]
The patellar, or knee-jerk, reflex can be assessed with the woman in two positions, sitting or lying. When the woman is sitting, allow her lower legs to dangle freely to flex the knee and stretch the tendons. If her patellar tendon is difficult to identify, have her flex and extend her lower legs slightly until you palpate the tendon. Strike the tendon directly with the reflex hammer just below the patella. The patellar reflex is less reliable if the woman has had epidural analgesia, and upper extremity reflexes should be assessed. [pic]
When the woman is supine, the weight of her leg must be supported to flex the knee and stretch the tendons. An accurate response requires that the limb be relaxed and the tendon partially stretched. Strike the partially stretched tendons just below the patella. Slight extension of the leg or a brief twitch of the quadriceps muscle of the thigh is the expected response. [pic]
For assessment of clonus, the woman's lower leg should be supported, as illustrated, and the foot well dorsiflexed to stretch the tendon. Hold the flexion. If no clonus is present, no movement will be felt. When clonus (indicating hyperreflexia) is present, rapid rhythmic tapping motions of the foot are present. [pic]
Deep Tendon Reflex Rating Scale*
0 Reflex absent
+1 Reflex present, hypoactive
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