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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?

A.

"Because blood pressure often increases early in the second trimester of pregnancy.”.

B.

"You are at an increased risk for high blood pressure since you've had several pregnancies.”.

C.

"Your age is a risk factor for developing high blood pressure during pregnancy.”.

D.

"No need to worry about that, let's talk about how you're feeling.”.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

  • White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
  • Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
  • Uterine findings: Expected—firm and midline uterus indicating effective involution.
  • Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
  • Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
  • Blood pressure: Expected—within normal postpartum range.

Correct Answer is B

Explanation

Choice A rationale

Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.

Choice B rationale

Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.

Choice C rationale

Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.

Choice D rationale

Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.

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