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?
"No need to worry about that, let's talk about how you're feeling.”.
"Because blood pressure often increases early in the second trimester of pregnancy.”.
"Your age is a risk factor for developing high blood pressure during pregnancy.”.
"We take blood pressure on all pregnant clients as part of routine care.”.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While assessing cervical dilation is important for understanding the progress of labor, it is not the priority intervention in the case of umbilical cord prolapse. The immediate danger is fetal oxygen deprivation due to compression of the prolapsed cord. Delaying intervention to perform a cervical exam could worsen fetal hypoxia.
Choice B rationale
Increasing the rate of intravenous fluids might be indicated to support maternal blood pressure and placental perfusion, but it does not directly address the immediate problem of cord compression. The priority is to relieve pressure on the umbilical cord to restore fetal oxygen supply.
Choice C rationale
Administering oxygen to the mother is a helpful supportive measure to increase the oxygen available to the fetus. However, it does not directly relieve the compression on the umbilical cord, which is the immediate life-threatening situation for the fetus.
Choice D rationale
Repositioning the mother to a knee-chest position (or Trendelenburg) uses gravity to help relieve pressure on the prolapsed umbilical cord by moving the presenting part of the fetus away from the pelvis. This is the priority nursing intervention as it directly aims to improve fetal oxygenation by reducing cord compression until the fetus can be delivered. .
Correct Answer is D
Explanation
Choice A rationale
Methylergonovine is an oxytocic medication that stimulates smooth muscle contraction of the uterus. While it can cause vasoconstriction and potentially lead to an increase in blood pressure, this is a potential side effect, not the intended therapeutic effect indicating the medication's effectiveness in the postpartum period. The primary goal is uterine contraction to control postpartum bleeding.
Choice B rationale
Breast pain is related to engorgement and milk production, not directly influenced by methylergonovine's action on the uterus. The medication's effectiveness is assessed by its impact on uterine tone and bleeding, not breast comfort. Therefore, the absence of breast pain does not indicate that the methylergonovine has been effective.
Choice C rationale
Methylergonovine is given to decrease postpartum bleeding by promoting uterine contraction, which helps to compress the blood vessels at the placental site. An increase in lochia (postpartum vaginal discharge) would suggest that the medication is not effective in achieving its intended therapeutic outcome of reducing hemorrhage.
Choice D rationale
Methylergonovine's primary therapeutic effect in the postpartum period is to stimulate uterine smooth muscle contraction, leading to a firm fundus. A firm fundus indicates that the uterus is contracting effectively, which helps to compress blood vessels at the placental site and control postpartum bleeding. This is the desired outcome of methylergonovine administration.
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