A nurse in a provider’s office is caring for a client who is pregnant.
Which of the following assessment findings should the nurse report to the provider? (Select all that apply)
Temperature 36.6°C (97.9°F)
Pulse rate 88/min
Respiratory rate 20/min
Blood Pressure 179/99 mm Hg .
Correct Answer : D
A blood pressure of 179/99 mm Hg in a pregnant client is a cause for concern and should be reported to the provider. This could be a sign of preeclampsia, a serious condition that can occur during pregnancy characterized by high blood pressure and damage to other organ systems, most often the liver and kidneys. The other vital signs (temperature, pulse rate, and respiratory rate) are within normal ranges for a pregnant woman.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Fetal head compression is associated with early decelerations, not late. Early decelerations are a normal finding during labor as the fetal head is compressed during contractions, leading to a vagal response that temporarily decreases the heart rate.
Choice B reason:
Umbilical cord compression leads to variable decelerations, not late. Variable decelerations can occur at any time during the contraction cycle and are caused by compression of the umbilical cord, which can restrict blood flow to the fetus.
The correct answer is C. Uteroplacental insufficiency.
Late decelerations are indicative of uteroplacental insufficiency, which is a condition where the placenta is not delivering enough oxygen and nutrients to the fetus.
Choice D reason:
Maternal bradycardia, which is a slower than normal heart rate in the mother, does not cause late decelerations in the fetus. Instead, maternal bradycardia can be a separate concern and does not directly affect the fetal heart rate pattern observed on the monitor.
Correct Answer is D
Explanation
Choice A rationale
Estrogen is a hormone that plays a crucial role in pregnancy. It helps develop the placenta and triggers increased blood volume and flow throughout pregnancy. However, it is not the primary hormone responsible for maintaining pregnancy.
Choice B rationale
Oxytocin is a hormone that plays a key role in labor and breastfeeding. It causes contractions during labor and helps eject milk during breastfeeding. However, it is not the primary hormone responsible for maintaining pregnancy.
Choice C rationale
Human chorionic gonadotropin (hCG) is a hormone produced during pregnancy. It is made almost exclusively in the placenta and its main function is to maintain the corpus luteum in the ovary and stimulate it to produce progesterone. However, hCG itself is not the primary hormone responsible for maintaining pregnancy.
Choice D rationale
Progesterone is the primary hormone responsible for maintaining pregnancy. It prevents the uterine muscles from contracting prematurely, which could lead to a miscarriage or preterm birth.
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