A nurse is collecting data during an admission assessment of a client who is pregnant with twins.

The client has a healthy 5-year-old child that was delivered at 38 weeks, and tells the nurse that she does not have any history of abortion or fetal demise.

The nurse would document the GTPAL for this client as:

Choice A rationale

Methergine (methylergonovine) is an oxytocic medication that causes vasoconstriction and increases blood pressure. It is contraindicated in clients with hypertension. Therefore, assessing the client's blood pressure before administration is crucial to ensure safety. Normal adult blood pressure is typically less than 120/80 mmHg.

Choice B rationale

Assessing uterine tone is important in managing postpartum hemorrhage, as a boggy uterus contributes to bleeding. However, before administering a medication that affects blood pressure, the blood pressure itself is the priority assessment due to the contraindications of Methergine in hypertensive clients.

Choice C rationale

Deep tendon reflexes are assessed in the postpartum period, particularly for clients with preeclampsia who are at risk for magnesium sulfate toxicity. While important, it is not the priority assessment before administering Methergine, which has a direct impact on blood pressure.

Choice D rationale

Assessing the amount of lochia is essential for monitoring postpartum bleeding. However, before administering Methergine, which can significantly increase blood pressure, ensuring the client does not have a contraindication related to hypertension is the most critical immediate assessment. .

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.