A nurse is caring for a 37-year-old G4P3 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?
You are at an increased risk for high blood pressure since you've had several pregnancies.
Because blood pressure often increases early in the second trimester of pregnancy.
No need to worry about that, let's talk about how you're feeling.
Your age is a risk factor for developing high blood pressure during pregnancy.
The Correct Answer is A
Choice A rationale
Multiparity, specifically being a gravida 4, is a recognized risk factor for developing hypertensive disorders during pregnancy. Each subsequent pregnancy can place additional strain on the maternal cardiovascular system. Although the client has had normal blood pressure in the past, the physiological demands of a fourth pregnancy increase the statistical likelihood of developing gestational hypertension or preeclampsia compared to a primigravida, necessitating frequent and consistent monitoring of baseline values.
Choice B rationale
This statement is physiologically incorrect and would provide the client with inaccurate medical information. In a healthy pregnancy, systemic vascular resistance typically decreases during the second trimester due to the effects of progesterone on smooth muscle. This hormonal shift usually causes the maternal blood pressure to slightly decrease or remain stable rather than increase. An increase in blood pressure during this specific gestational period is often an early clinical indicator of underlying pathology.
Choice C rationale
Using a dismissive tone or telling a client not to worry is non-therapeutic and blocks effective communication. It ignores the client's valid question about her clinical care and misses an opportunity for health education. Nurses must provide evidence-based rationales for interventions like blood pressure monitoring to foster a collaborative relationship. Dismissing concerns can lead to decreased client compliance and may cause the client to withhold important symptomatic information during future prenatal visits.
Choice D rationale
While advanced maternal age, typically defined as 35 years or older, is a risk factor for various pregnancy complications, the client is 37, which is only slightly above that threshold. While relevant, her obstetric history of being G4P3 is often a more immediate focus for discussing systemic changes. Monitoring blood pressure is a universal standard of care for all pregnant women regardless of age, as hypertensive disorders can emerge unexpectedly in any demographic group.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Notifying the provider is a necessary step when a client's condition changes, but it is not the immediate priority for an unresponsive patient. In an emergency situation, the nurse must first mobilize a team capable of performing advanced life support and stabilization. Delaying the emergency call to contact a single physician can lead to a loss of critical time during a potential cardiac or respiratory arrest. The provider will be notified once the life-saving team is en route.
Choice B rationale
Assessing vaginal bleeding is important in the context of intrauterine fetal demise because of the risk of disseminated intravascular coagulation. However, when a client becomes unresponsive, the clinical focus must immediately shift from specialty-specific assessments to basic life support and emergency response. Airway, breathing, and circulation take precedence over assessing for hemorrhage. Once the emergency team arrives and the client is stabilized, a thorough assessment of vaginal bleeding and coagulopathy can be performed.
Choice C rationale
When a client becomes unresponsive, the first action in a hospital setting is to activate the emergency response system. This ensures that specialized personnel and equipment, such as a crash cart and airway management experts, arrive quickly. Since the client is unresponsive, there is an immediate threat to life. Rapid intervention is crucial to address potential causes such as pulmonary embolism, amniotic fluid embolism, or severe hypovolemia. Activating the team is the most effective way to initiate resuscitation.
Choice D rationale
Obtaining a set of vital signs provides helpful diagnostic data, but the nurse can determine unresponsiveness and the need for immediate help through a quick physical check. Taking the time to cycle a blood pressure cuff or count a heart rate manually before calling for help can delay life-saving interventions. In a crisis, the priority is to get help to the bedside immediately. Vital signs will be monitored continuously by the rapid response team as part of their assessment.
Correct Answer is C
Explanation
Choice A rationale
Toxoplasma gondii is a protozoan parasite typically transmitted through undercooked meat or infected cat feces. While it poses significant risks to the fetus during pregnancy, such as congenital toxoplasmosis, it is not a primary causative agent of pelvic inflammatory disease. The pathogenesis of PID involves ascending vaginal or cervical bacteria, whereas T. gondii typically involves systemic infection through ingestion of oocysts rather than ascending reproductive tract colonization.
Choice B rationale
Group B Streptococcus is a common inhabitant of the lower gastrointestinal and female reproductive tracts, often monitored closely during pregnancy to prevent neonatal sepsis. Although it can cause various maternal infections like urinary tract infections or chorioamnionitis, it is not considered a primary or common driver of pelvic inflammatory disease. PID is predominantly associated with sexually transmitted pathogens that disrupt the mucosal barrier of the cervix to infect the upper tract.
Choice C rationale
Neisseria gonorrhoeae is a gram-negative diplococcus and a leading cause of pelvic inflammatory disease. It infects the columnar epithelium of the cervix, subsequently ascending to the uterus, fallopian tubes, and ovaries. This triggers a robust inflammatory response characterized by leukocyte infiltration and tissue damage. If left untreated, the resulting scarring and adhesions can lead to chronic pelvic pain, ectopic pregnancy, or infertility due to permanent tubal occlusion and damage.
Choice D rationale
Treponema pallidum is the spirochete responsible for syphilis, a systemic sexually transmitted infection. Syphilis progresses through primary, secondary, and tertiary stages, often presenting initially with a painless chancre. However, it does not typically cause the clinical syndrome of pelvic inflammatory disease, which involves the infection of the upper female genital tract. Its primary complications involve cardiovascular or neurological systems rather than the ascending pelvic inflammation seen with gonorrheal or chlamydial infections.
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