A nurse in a provider’s office is caring for a client who is pregnant.
Which of the following assessment findings should the nurse report to the provider? (Select all that apply)
Temperature 36.6°C (97.9°F)
Pulse rate 88/min
Respiratory rate 20/min
Blood Pressure 179/99 mm Hg .
Correct Answer : D
A blood pressure of 179/99 mm Hg in a pregnant client is a cause for concern and should be reported to the provider. This could be a sign of preeclampsia, a serious condition that can occur during pregnancy characterized by high blood pressure and damage to other organ systems, most often the liver and kidneys. The other vital signs (temperature, pulse rate, and respiratory rate) are within normal ranges for a pregnant woman.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The priority finding for a nurse caring for a client receiving opioid epidural analgesia during labor would be a blood pressure of 80/56 mm Hg. This could indicate hypotension, a known side effect of epidural analgesia. Hypotension can lead to decreased perfusion to vital organs, including the placenta, potentially compromising the fetus. Immediate interventions might include positioning the patient on her side, increasing the rate of IV fluids, and notifying the healthcare provider.
Correct Answer is []
Explanation
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
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