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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While Type 1 diabetes is a significant health concern, it is not the most prevalent form of diabetes. Type 2 diabetes is more common, affecting a larger proportion of the population.
Choice B rationale
Type 2 diabetes often remains undiagnosed because its symptoms can be subtle and develop slowly. People with Type 2 diabetes may not recognize these symptoms as signs of high blood sugar, leading to a delay in diagnosis and treatment.
Choice C rationale
Type 1 diabetes cannot transition to Type 2 diabetes. These are distinct conditions with different underlying causes. Type 1 diabetes is an autoimmune condition, while Type 2 diabetes is primarily associated with lifestyle factors and genetic predisposition.
Choice D rationale
Gestational diabetes mellitus (GDM) does not imply that the woman will require insulin treatment until 6 weeks postpartum. While some women with GDM may require insulin during pregnancy, this is not always the case. Furthermore, GDM usually resolves after delivery.
Correct Answer is A
Explanation
Choice A rationale
Late decelerations in the Fetal Heart Rate (FHR) are a type of FHR pattern observed during labor, indicating a potential compromise of fetal well-being. They often begin just after a contraction, with their lowest point occurring after the peak of the contraction. These decelerations are associated with maternal and fetal conditions. Changing the client’s position can help alleviate the pressure on the fetus and improve blood flow, potentially reducing the occurrence of late decelerations. Therefore, the first action the nurse should take when noting late decelerations in the FHR is to change the client’s position.
Choice B rationale
Applying a fetal scalp electrode is a method used to monitor the FHR more accurately. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice C rationale
Administering oxygen can help increase the oxygen supply to the fetus. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice D rationale
Increasing the rate of the IV infusion can help improve uteroplacental perfusion. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
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