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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Risk for injury related to seizures is an important nursing diagnosis for this client. The client is at risk of seizures due to the severe preeclampsia and the high blood pressure. Seizures can cause injury to the client and the fetus, as well as complications such as aspiration, cerebral hemorrhage, and coma. The nurse should monitor the client's neurological status, administer anticonvulsants as prescribed, and protect the client from injury during a seizure.

Choice B rationale
Impaired gas exchange related to pulmonary edema is an important nursing diagnosis for this client. The client is at risk of pulmonary edema due to the fluid overload and the high blood pressure. Pulmonary edema can impair the gas exchange and oxygen delivery to the client and the fetus, as well as cause respiratory distress, heart failure, and death. The nurse should monitor the client's respiratory status, administer oxygen as prescribed, and restrict the fluid intake.

Choice C rationale
Deficient fluid volume related to diuresis is not an important nursing diagnosis for this client. The client is not at risk of deficient fluid volume, but rather fluid overload. Diuresis is the increased production and excretion of urine, which can cause fluid loss and dehydration. The client does not have any signs of diuresis, such as increased urine output, decreased specific gravity, or weight loss.

Choice D rationale
Ineffective tissue perfusion related to placental abruption is not an important nursing diagnosis for this client. The client is not at risk of placental abruption, but rather uteroplacental insufficiency. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause bleeding, pain, and fetal distress. The client does not have any signs of placental abruption, such as vaginal bleeding, abdominal tenderness, or fetal heart rate abnormalities.

A. Unstageable B. Stage 2 C. Deep tissue injury D. Stage 1

Correct Answer is A

Explanation

Choice A:

This is the correct choice. An unstageable pressure ulcer is a wound that has full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. The blackened area in the center of the wound suggests the presence of eschar.

Choice B:

A stage 2 pressure ulcer involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This does not match the description of the wound.

Choice C:

Deep tissue injury is a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. This does not match the description of the wound.

Choice D:

A stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The skin may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. This does not match the description of the wound.

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Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center. How would you document this wound?

Correct Answer is A

Explanation

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