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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Related Questions
Correct Answer is D
Explanation
Choice A rationale
The umbilical cord typically contains two arteries and one vein, not one artery and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice B rationale
The umbilical cord typically contains two arteries and one vein, not two veins and one artery. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice C rationale
The umbilical cord typically contains two arteries and one vein, not two arteries and two veins. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice D rationale
The umbilical cord typically contains two arteries and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Correct Answer is A
Explanation
Choice A rationale
Preeclampsia is a condition that can occur during pregnancy, characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. If a patient is experiencing preeclampsia, the nurse should initiate seizure precautions, as seizures can occur in severe cases. The nurse should also monitor the patient’s neurological status and liver function studies, as these can be affected by preeclampsia.
Choice B rationale
Hypertension, or high blood pressure, can occur during pregnancy, but the actions listed do not fully address the condition. While bed rest was once commonly recommended for high blood pressure during pregnancy, research has not shown it to be effective. Monitoring blood pressure and heart rate is important, but other interventions, such as medication, may also be necessary.
Choice C rationale
Gestational diabetes is a condition characterized by high blood sugar that develops during pregnancy. Insulin may be administered to help control blood glucose levels. The nurse should monitor blood glucose levels and fetal heart rate, as gestational diabetes can affect both the mother and the baby. However, the condition the patient is most likely experiencing, given the gestational age and symptoms, is preeclampsia.
Choice D rationale
Preterm labor refers to labor that begins before the 37th week of pregnancy. Tocolytics may be administered to slow or stop contractions. The nurse should monitor the contraction pattern and cervical dilation to assess for progression of labor. However, the condition the patient is most likely experiencing, given the gestational age and symptoms, is preeclampsia.
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