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    RN Comprehensive Predictor Proctored Exam (National U CA San Diego)

    The nurse is continuing to care for the client. Exhibits A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

    Explanation & Rationale

    Rationale: • Deep tendon patellar reflex: The reflex response decreased from 4+ to 2+, demonstrating a reduction in hyperreflexia. This improvement indicates effective magnesium sulfate therapy, showing decreased neuromuscular irritability and a lower risk of progression to eclampsia. • Blood pressure: The blood pressure declined from 166/110 mm Hg to 152/90 mm Hg, reflecting effective antihypertensive therapy and improved vascular tone. This moderate reduction suggests that labetalol and magnesium sulfate are successfully controlling severe preeclampsia symptoms. • Heart rate: The heart rate remained within normal parameters (72–90/min) across both days, showing stable cardiac function without significant deviation. This consistency indicates no notable change in hemodynamic status related to treatment. • Edema: The client continues to exhibit +3 pitting edema in both lower extremities, reflecting persistent fluid retention and endothelial dysfunction. This ongoing finding suggests that intravascular fluid shifts typical of preeclampsia have not yet resolved.

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