Leading of Contact form
Initial History and Assessment
At 0600 Jennie is taken to the Labor and Delivery triage place by her sister. The customer complains of any pounding frustration for the last half of the day unrelieved by simply acetaminophen (Tylenol), swollen hands and deal with for two days, and epigastric discomfort described as negative heartburn. Her sister tells the registered nurse, " We felt like that when I had toxemia during my motherhood. " Admission assessment by the nurse discloses: today's pounds 182 pounds, T 99. 1В° N, P seventy six, R twenty two, BP 138/88, 4+ pitting edema, and 3+ proteins in the urine. Heart rate is regular, and lung sounds are obvious. Deep tendons reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with one particular beat of ankle clonus.[pic][pic] The nurse is applicable the external fetal screen, which reveals a baseline fetal heart rate of 130, lack of variability, confident for accelerations, no decelerations, and no spasms. The nurse also performs a penile examination and finds the cervix is definitely 1 cm dilated and 50% effaced, with the embrionario head by a -2 station.
1 . In reviewing Jennie's history, the nurse is proper in ending that Jennie is in peril of developing a hypertensive disorder due to which in turn risk elements? [pic]A) Grow older (15), gustar pregnancy, good preeclampsia in previous pregnancy. [pic]B) Grow older (15), gravidity, familial history.
[pic]C) Age (15), good pounding headache, low socioeconomic status. [pic]D) Age (15), low socioeconomic status (SES), history of pedal edema.
installment payments on your To accurately assess this kind of client's state, what information from the prenatal record is most important for the nurse to obtain? [pic]A) Style and quantity of prenatal trips.
[pic]B) Prenatal blood pressure psychic readings.
[pic]C) Prepregnancy weight.
[pic]D) Jennie's Rh factor.
Examining Deep Tendon Reflexes
GOAL: To identify overstated reflexes (hyperreflexia) or diminished reflexes (hyporeflexia) You will need a reflex sludge hammer to finest assess the brachial as well as the patellar reflexes. Support your ex arm and instruct her to let that go limp while it will be held so the arm is totally relaxed and slightly flexed as you measure the brachial reflex. If you have problems identifying the proper tendon to tap, have woman bend and extend her arm until you are able to feel this moving through your thumb. Have her totally relax her arm after you identify the tendon. Place your thumb over the woman's tendon, as illustrated, to allow you to feel along with see the tendons response if the tendon is definitely tapped. Reach the thumb with the little end in the triangular response hammer. The standard response is slight flexion of the fore arm. [pic]
The patellar, or knee-jerk, response can be examined with the woman in two positions, seated or resting. When the woman is resting, allow her lower legs to dangle readily to flex the knees and stretch the muscles. If her patellar tendons is challenging to identify, include her contract and prolong her lower legs slightly until you palpate the tendon. Strike the tendon directly with the response hammer just beneath the patella. The patellar reflex is less reliable in the event the woman has received epidural analgesia, and top extremity reflexes should be evaluated. [pic]
If the woman is usually supine, the weight of her lower leg must be supported to bend the knee and extend the tendons. An accurate response requires which the limb become relaxed and the tendon partially stretched. Strike the partly stretched tendons just below the patella. Minor extension in the leg or maybe a brief twitch of the quadriceps muscle of the thigh is a expected response. [pic]
Intended for assessment of clonus, the girl lower leg ought to be supported, because illustrated, plus the foot well dorsiflexed to stretch the tendon. Contain the flexion. If perhaps no clonus is present, not any movement will probably be felt. When clonus (indicating hyperreflexia) is present, rapid stroking tapping motions of the ft . are present. [pic]
Deep Tendons Reflex Ranking Scale*
0 Reflex lack of
+1 Response present, hypoactive