A nurse is caring for a 37-year-old G3P2 client who is at 14 weeks of gestation.
The client asks, "why are you taking my blood pressure? It's always been normal.”. Which of the following responses should the nurse make?
"Because blood pressure often increases early in the second trimester of pregnancy.”.
"You are at an increased risk for high blood pressure since you've had several pregnancies.”.
"Your age is a risk factor for developing high blood pressure during pregnancy.”.
"No need to worry about that, let's talk about how you're feeling.”.
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Postpartum blues are characterized by labile mood, tearfulness, anxiety, and irritability that typically peak around the third to fifth postpartum day and resolve within two weeks. These feelings are often attributed to hormonal shifts, psychological adjustments, and fatigue experienced after childbirth. The woman's statement of feeling "let down" and crying for no reason, occurring on the fourth postpartum day, aligns with the typical presentation of postpartum blues.
Choice B rationale
Postpartum depression (PPD) involves more intense and persistent symptoms than postpartum blues, including depressed mood, loss of interest or pleasure, changes in appetite and sleep, fatigue, feelings of worthlessness or guilt, and difficulty concentrating. These symptoms typically last longer than two weeks and interfere with daily functioning. The woman's statement alone does not provide enough information to diagnose PPD.
Choice C rationale
Postpartum delirium is a rare but serious psychiatric emergency characterized by rapid onset of confusion, disorientation, hallucinations, delusions, and agitation. It typically occurs within the first few days postpartum. The woman's description of her feelings does not suggest the presence of delirium.
Choice D rationale
Attachment difficulty refers to challenges in forming a secure emotional bond between the mother and her infant. While the woman expresses loving her son, her emotional state of feeling "let down" and crying is not a direct indicator of attachment difficulties, which manifest as a lack of engagement or negative interactions with the baby.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. Symptoms can include unilateral abdominal pain, light to heavy vaginal bleeding, and a positive pregnancy test. An ectopic pregnancy is a serious condition requiring prompt medical attention.
Choice B rationale
Molar pregnancy, also known as gestational trophoblastic disease, is characterized by abnormal growth of trophoblasts, the cells that normally develop into the placenta. It can present with symptoms such as vaginal bleeding (ranging from spotting to heavy bleeding), pelvic pain or pressure, and a uterus that may be larger than expected for the gestational age. The absence of a fetal heartbeat and elevated hCG levels are also characteristic.
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