Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?
Baseline BP 140/85, current BP 129/80
Baseline BP 110/70, current BP 145/85
Baseline BP 120/80, current BP 126/85
Baseline BP 110/60, current BP 120/63
The Correct Answer is B
Choice A rationale
This is incorrect because a decrease in BP from the baseline is not a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 140/85 mm Hg indicates pre-existing hypertension, which may or may not worsen during pregnancy. A current BP of 129/80 mm Hg indicates an improvement in the BP control, but not a risk for pregnancy-induced hypertension.
Choice B rationale
This is correct because an increase in BP from the baseline by 30 mm Hg systolic or 15 mm Hg diastolic is a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 110/70 mm Hg indicates a normal BP before pregnancy. A current BP of 145/85 mm Hg indicates a significant elevation in the BP, which could lead to complications such as preeclampsia, eclampsia, or placental abruption.
Choice C rationale
This is incorrect because a slight increase in BP from the baseline is not a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 120/80 mm Hg indicates a normal BP before pregnancy. A current BP of 126/85 mm Hg indicates a minor elevation in the BP, which is within the normal range and does not pose a risk for pregnancy-induced hypertension.
Choice D rationale
This is incorrect because a slight increase in BP from the baseline is not a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 110/60 mm Hg indicates a normal BP before pregnancy. A current BP of 120/63 mm Hg indicates a minor elevation in the systolic BP, but a decrease in the diastolic BP, which is within the normal range and does not pose a risk for pregnancy-induced hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This is correct because blood pressure 80/56 mm Hg is the nurse's priority finding. It indicates hypotension, which is a common and serious complication of epidural analgesia. Hypotension can compromise the maternal and fetal perfusion and oxygenation, leading to fetal distress and acidosis. The nurse should immediately administer oxygen, fluids, and vasopressors as prescribed, and monitor the fetal heart rate and variability.
Choice B rationale
This is incorrect because temperature 38.2°C (100.8°F) is not the nurse's priority finding. It indicates a fever, which could be a sign of infection or dehydration. The nurse should assess the client for other signs of infection, such as chills, malaise, or foul-smelling discharge, and administer antipyretics and antibiotics as prescribed. The nurse should also ensure adequate hydration and cooling measures for the client.
Choice C rationale
This is incorrect because the client reports weakness of the lower extremities is not the nurse's priority finding. It indicates a side effect of epidural analgesia, which blocks the nerve impulses from the lower spinal segments. The nurse should assess the client's motor and sensory function, and adjust the epidural infusion rate as prescribed. The nurse should also assist the client with positioning and mobility, and prevent pressure ulcers and nerve injuries.
Choice D rationale
This is incorrect because the client reports profuse itching is not the nurse's priority finding. It indicates a side effect of opioid epidural analgesia, which stimulates the histamine receptors in the skin. The nurse should assess the client's skin condition, and administer antihistamines as prescribed. The nurse should also provide comfort measures, such as cool compresses, lotion, or massage, for the client.
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen via face mask is a secondary intervention for late decelerations, which indicate fetal hypoxia. Oxygen may improve the fetal oxygenation, but it does not address the underlying cause of the late decelerations, which is uteroplacental insufficiency.
Choice B rationale
Increasing the infusion rate of the IV fluid is another secondary intervention for late decelerations. IV fluid may increase the maternal blood volume and cardiac output, but it does not improve the placental blood flow, which is the main problem in late decelerations.
Choice C rationale
Elevating the client's legs is not an appropriate intervention for late decelerations. Elevating the legs may reduce the venous return and lower the blood pressure, which can worsen the uteroplacental insufficiency and the fetal hypoxia.
Choice D rationale
Positioning the client on her side is the priority nursing action for late decelerations. This position reduces the pressure of the gravid uterus on the inferior vena cava and the aorta, which improves the maternal and fetal circulation and oxygenation.
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