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    HESI RN EXIT 1 PROCTORED EXAM

    When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

    Explanation & Rationale

    A. Assessing DTRs when the client has ankle edema is important, but it is not the most critical time. Ankle edema can be a common occurrence in pregnancy due to increased fluid volume and changes in blood flow. B. Elevated blood pressure in a pregnant client can be a sign of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Assessing DTRs can help in detecting hyperreflexia, which is a sign of preeclampsia. Therefore, it is most important to assess DTRs when there is an elevated blood pressure. C. While assessing DTRs during admission to labor and delivery is a standard procedure to monitor the client's neurological status, it is not as critical as assessing them when there is an elevated blood pressure. D. Assessing DTRs within the first trimester of pregnancy is not typically a priority unless there are specific clinical indications or concerns. Elevated blood pressure is a more immediate concern that requires prompt assessment of DTRs

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