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
Assessing vital signs is important in evaluating a postpartum hemorrhage, but it is not the immediate priority. Significant blood loss can occur before changes in vital signs become apparent due to compensatory mechanisms in the body. Addressing the source of bleeding is the initial critical step.
Choice B rationale
Calling the primary health care provider is a necessary step, but it should occur after the nurse has taken immediate action to address the likely cause of the excessive bleeding. Direct intervention to control the hemorrhage takes precedence over notification.
Choice C rationale
Massaging the fundus is the highest priority because uterine atony, a soft and boggy uterus that does not contract effectively, is the most common cause of early postpartum hemorrhage. Stimulating uterine contraction by massage can help to compress the blood vessels at the placental site and reduce bleeding.
Choice D rationale
Initiating an intravenous (IV) infusion of Ringer's lactate solution is important for volume replacement if bleeding is significant, but it is not the immediate first action. Addressing the uterine atony through fundal massage should be done first to try and control the bleeding.
Correct Answer is A
Explanation
Choice A rationale
True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.
Choice B rationale
The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.
Choice C rationale
Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.
Choice D rationale
A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.
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