NCLEX^® QUESTION OF THE WEEK

Question of the Day – June 17, 2022

June 17, 2022

The nurse is assisting with evaluating the deep tendon reflexes of a pregnant client who is receiving magnesium sulfate intravenously. The nurse exposes the woman’s lower leg, places one hand under the woman’s knee to raise it slightly off the bed, and uses the percussion hammer to strike the patellar tendon just below the patella. The nurse identifies the response as 4 +. How should the nurse document this response?

Show Answer Answer

Correct! The answer is number 3

Rationale:

Answer: 3

Rationale: The normal response is extension and forward thrusting of the foot. A 1 + response indicates a diminished response, 2 + indicates a normal response, 3 + indicates an increased or brisker-than-average response, and 4 + indicates a very brisk or hyperactive response.

Additional Info

Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Maternity: Antepartum
Health Problem: Maternity: Gestational Hypertension/Preeclampsia and Eclampsia

Practice Question Sourced From: Saunders Q & A Review for the NCLEX-PN® Examination, 5th Edition