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 {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The complication that poses the greatest risk for the client is hemorrhage as evidenced by their amount of lochia.
Rationale for correct answers
Postpartum hemorrhage (PPH) is a major concern when excessive lochia and a boggy uterus are present. The nurse’s assessment reveals a boggy fundus, which firmed with massage but then softened again, indicating uterine atony, a leading cause of PPH. Additionally, the saturation of the perineal pad with lochia rubra and small clots suggests ongoing bleeding that requires close monitoring.
Rationale for incorrect Response 1 options
- Infection: No fever (≥38°C or 100.4°F) or foul-smelling lochia, which would indicate postpartum endometritis.
- Thrombophlebitis: No calf pain, swelling, or localized tenderness suggesting deep vein thrombosis.
- Mastitis: Breasts are soft, warm, and tender but without redness or localized pain, making mastitis unlikely.
Rationale for incorrect Response 2 options
- Breast tenderness: Expected due to milk production, not indicative of infection or complications.
- Calf pain: No evidence of thrombophlebitis or deep vein thrombosis.
- Fever: Temperature is normal at 37.2°C, ruling out systemic infection.
Correct Answer is B
Explanation
Choice A rationale
Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.
Choice B rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.
Choice C rationale
Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.
Choice D rationale
Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.
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