A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

Plan to measure the blood pressure in four hours as prescribed.

Repeat the client's blood pressure measurement in fifteen minutes.

Obtain an automatic blood pressure machine for hourly readings.

Reassess the blood pressure if the client reports other symptoms.

Answer and Explanation

The Correct Answer is B

A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.

B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.

C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.

D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone

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Correct Answer is C

Explanation

A: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.

B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.

C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.

D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.

A. Compress the tissue around the ankles. B. Observe plantar flexion and dorsiflexion. C. Palpate the volume of the pedal pulses. D. Stroke the soles and note toe movement.

Correct Answer is C

Explanation

A. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.

B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.

C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.

D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.

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A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

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