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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.
Choice B rationale
Starting a pad count is a useful way to quantify the amount of lochia, but it does not address the immediate issue of the displaced fundus and potential bladder distention. It would be a subsequent step to monitor the bleeding after addressing the fundal position.
Choice C rationale
While fundal massage is appropriate for a soft or boggy uterus, the assessment indicates the fundus is already firm. Massaging a firm uterus is not the priority and will not address the displacement caused by a likely full bladder.
Choice D rationale
Notifying the healthcare provider is necessary if the fundus remains displaced and elevated after the client voids, as this could indicate other complications. However, the initial action should be to address the most likely cause, which is bladder distention.
Correct Answer is B
Explanation
Choice A rationale
Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.
Choice B rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.
Choice C rationale
Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.
Choice D rationale
Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.
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