Clinical Judgment Practice Exam (138 Questions & Answers) with Rationale

1. When it is most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)? A. Within the first trimester of pregnancy. B. If the client has an elevated blood pressure. C. When the client has ankle edema. D. During admission to labor and delivery. - Correct answer if the client has an elevated blood pressure. 2. Rationale: 3. A systolic greater than 140 mm Hg or a diastolic greater than 90 mm Hg is a sign of preeclampsia. Deep tendon reflexes (DTRs) greater than 2+ are also a sign of preeclampsia as is proteinuria greater than or equal to 1+ on dipstick measurement. Preeclampsia usually occurs after the 20th week of pregnancy. 4. When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. She received butorphanol 2 mg IVP during labor. B. The