A nurse is caring for a 37-year-old gravida para 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?

Choice A rationale

While addressing the client's feelings is important, dismissing the need for blood pressure monitoring is not appropriate nursing practice during pregnancy. Routine blood pressure checks are essential for detecting potential complications.

Choice B rationale

While blood pressure can increase in the second trimester due to physiological changes like increased blood volume, it doesn't invariably increase early in the second trimester, and this statement might cause unnecessary alarm if the client's blood pressure is currently normal.

Choice C rationale

Advanced maternal age (typically over 35) is a risk factor for gestational hypertension, but stating this directly without knowing the client's baseline blood pressure or other risk factors might be alarming and isn't the primary reason for routine monitoring at every prenatal visit.

Choice D rationale

Routine blood pressure monitoring is a standard component of prenatal care for all pregnant clients, regardless of their past medical history or perceived risk. This allows for the early detection of gestational hypertension or preeclampsia, which can develop even in women with previously normal blood pressure. Early detection and management are crucial for maternal and fetal well-being.

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.