A nurse is caring for a 37-year-old G3P2 client who is at 14 weeks of gestation.
The client asks, "why are you taking my blood pressure? It's always been normal.”. Which of the following responses should the nurse make?
"Because blood pressure often increases early in the second trimester of pregnancy.”.
"You are at an increased risk for high blood pressure since you've had several pregnancies.”.
"Your age is a risk factor for developing high blood pressure during pregnancy.”.
"No need to worry about that, let's talk about how you're feeling.”.
The Correct Answer is C
Choice A rationale
While blood pressure can increase during the second trimester due to changes in the maternal cardiovascular system, it doesn't typically increase *early* in the second trimester. Physiologic changes usually lead to a slight decrease in blood pressure during the first and early second trimester before gradually returning to pre-pregnancy levels or potentially increasing later.
Choice B rationale
While multiparous women can develop gestational hypertension or preeclampsia, having had "several pregnancies" in the past does not inherently increase the risk of high blood pressure at 14 weeks gestation in the current pregnancy, especially if previous pregnancies were normotensive. Risk factors like age, pre-existing conditions, and family history are more significant.
Choice C rationale
Advanced maternal age, generally considered 35 years or older, is a known risk factor for developing gestational hypertension and preeclampsia during pregnancy. Physiological changes associated with aging can affect vascular function and increase susceptibility to hypertensive disorders.
Choice D rationale
While addressing the client's feelings is important for therapeutic communication, it avoids answering her direct question about why her blood pressure is being taken. The nurse has a responsibility to provide accurate information regarding routine assessments during pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Immediately postpartum, the fundus is typically palpable. It gradually descends into the pelvic cavity over the following days.
Choice B rationale
By 6 to 12 hours postpartum, the fundus is usually located at the level of the umbilicus or slightly below it. It descends approximately one fingerbreadth (1 cm) per day.
Choice C rationale
In the immediate postpartum period, within the first few hours after delivery, the nurse should expect to find the fundus at the level of the umbilicus. This indicates that the uterus is contracting to control bleeding at the placental site.
Choice D rationale
Immediately after delivery, the fundus is typically higher than the symphysis pubis. It descends into the abdomen as the uterus contracts and the placental site begins to heal. .
Correct Answer is C
Explanation
Choice A rationale
Increasing ambulation is generally encouraged in the postpartum period to prevent complications like thrombophlebitis, but it does not address the potential cause of foul-smelling lochia. Foul odor is a key indicator of infection, and ambulation will not resolve an existing infection.
Choice B rationale
Increasing oral fluids is important for hydration in the postpartum period, but it will not directly address a foul-smelling odor in the lochia. While adequate hydration supports overall healing, it does not treat an infection. A foul odor strongly suggests a localized infectious process in the uterus.
Choice C rationale
Lochia that is red (rubra) is normal in the first few days postpartum. However, a foul-smelling odor is an abnormal finding and a significant indicator of a potential uterine infection, also known as endometritis or puerperal infection. Further assessment and intervention are required to identify and treat the infection.
Choice D rationale
Normal lochia progresses from rubra (red) to serosa (pinkish-brown) to alba (yellowish-white) over several weeks postpartum. Normal lochia should have a fleshy, not foul, odor. A foul smell is an abnormal finding that suggests an infectious process within the uterus and requires prompt attention.
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