Question 66 pts
Tomato juice
,Question 67 pts
,Question 68 pts
, Question 69 pts
The nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e.,
reflex present, hypoactive). On the basis of this finding, what should the nurse do?
Co
orrrec
ct! Document the findings
Contact the primary health care provider
Ask the client to walk for 5 minutes, then recheck the reflexes
Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the
reflexes
Rationale: The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present,
hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes
should be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes (3+ to 4+)
suggest preeclampsia and must be reported to the primary health care provider. It is not
necessary to contact the primary health care provider, because the finding is normal. Likewise,
rechecking the client’s reflexes after ambulation and performing active and passive ROM
exercises incorrect and unnecessary actions.
Test-Taking Strategy: Focus on the subject, deep tendon relfexes. Use the process of
elimination. Eliminate the options that are comparable or alike in that they involve the
rechecking of reflexes. To select from the remaining options, note that the finding is normal,
which will direct you to the correct option.
Review: scale rating of deep tendon reflexes
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Mobility
HESI Concepts: Assessment, Mobility
Question 70 pts
Administration of oxytocin
Tomato juice
,Question 67 pts
,Question 68 pts
, Question 69 pts
The nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e.,
reflex present, hypoactive). On the basis of this finding, what should the nurse do?
Co
orrrec
ct! Document the findings
Contact the primary health care provider
Ask the client to walk for 5 minutes, then recheck the reflexes
Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the
reflexes
Rationale: The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present,
hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes
should be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes (3+ to 4+)
suggest preeclampsia and must be reported to the primary health care provider. It is not
necessary to contact the primary health care provider, because the finding is normal. Likewise,
rechecking the client’s reflexes after ambulation and performing active and passive ROM
exercises incorrect and unnecessary actions.
Test-Taking Strategy: Focus on the subject, deep tendon relfexes. Use the process of
elimination. Eliminate the options that are comparable or alike in that they involve the
rechecking of reflexes. To select from the remaining options, note that the finding is normal,
which will direct you to the correct option.
Review: scale rating of deep tendon reflexes
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Mobility
HESI Concepts: Assessment, Mobility
Question 70 pts
Administration of oxytocin
