A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit.

Exhibits

For each potential client finding, click to specify if the finding is expected or unexpected.

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.

Choice A rationale

Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.

Choice B rationale

Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.

Choice C rationale

Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.

Choice D rationale

Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .