The Nurse Is Assessing a Pregnant Client Who Is at 29

The nurse is assessing a pregnant client who is at 29 weeks gestation.The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex.Which assessment findings led the nurse to document this finding?

A) There was no response when the area directly above the knee was struck with the percussion hammer.
B) The nurse noted an extension of the leg when the percussion hammer touched the area above the knee.
C) The client complained of pain when the foot was dorsiflexed.
D) The client's foot tapped against the nurse's hand when it was dorsiflexed.