A nurse is caring for a 37-year-old gravida para 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?
"No need to worry about that, let's talk about how you're feeling.”.
"Because blood pressure often increases early in the second trimester of pregnancy.”.
"Your age is a risk factor for developing high blood pressure during pregnancy.”.
"We take blood pressure on all pregnant clients as part of routine care.”.
The Correct Answer is D
Choice A rationale
While addressing the client's feelings is important, dismissing the need for blood pressure monitoring is not appropriate nursing practice during pregnancy. Routine blood pressure checks are essential for detecting potential complications.
Choice B rationale
While blood pressure can increase in the second trimester due to physiological changes like increased blood volume, it doesn't invariably increase early in the second trimester, and this statement might cause unnecessary alarm if the client's blood pressure is currently normal.
Choice C rationale
Advanced maternal age (typically over 35) is a risk factor for gestational hypertension, but stating this directly without knowing the client's baseline blood pressure or other risk factors might be alarming and isn't the primary reason for routine monitoring at every prenatal visit.
Choice D rationale
Routine blood pressure monitoring is a standard component of prenatal care for all pregnant clients, regardless of their past medical history or perceived risk. This allows for the early detection of gestational hypertension or preeclampsia, which can develop even in women with previously normal blood pressure. Early detection and management are crucial for maternal and fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cocaine is a stimulant that typically causes fetal tachycardia (an elevated fetal heart rate) due to its sympathomimetic effects, increasing maternal and subsequently fetal heart rate and blood pressure. It does not usually lead to fetal bradycardia.
Choice B rationale
Prolonged umbilical cord compression can lead to fetal bradycardia because it restricts oxygenated blood flow to the fetus. The baroreceptors in the fetus respond to decreased oxygen by slowing the heart rate in an attempt to conserve oxygen and maintain perfusion to vital organs.
Choice C rationale
Fetal anemia, a decrease in red blood cell count, can lead to fetal tachycardia as the heart attempts to compensate for reduced oxygen-carrying capacity by increasing cardiac output. Bradycardia is not a typical initial response to fetal anemia.
Choice D rationale
Terbutaline is a tocolytic medication used to relax the smooth muscle of the uterus and prevent preterm labor. Its side effects often include maternal and fetal tachycardia due to its beta-adrenergic agonist activity.
Correct Answer is D
Explanation
Choice A rationale
While addressing the client's feelings is important, dismissing the need for blood pressure monitoring is not appropriate nursing practice during pregnancy. Routine blood pressure checks are essential for detecting potential complications.
Choice B rationale
While blood pressure can increase in the second trimester due to physiological changes like increased blood volume, it doesn't invariably increase early in the second trimester, and this statement might cause unnecessary alarm if the client's blood pressure is currently normal.
Choice C rationale
Advanced maternal age (typically over 35) is a risk factor for gestational hypertension, but stating this directly without knowing the client's baseline blood pressure or other risk factors might be alarming and isn't the primary reason for routine monitoring at every prenatal visit.
Choice D rationale
Routine blood pressure monitoring is a standard component of prenatal care for all pregnant clients, regardless of their past medical history or perceived risk. This allows for the early detection of gestational hypertension or preeclampsia, which can develop even in women with previously normal blood pressure. Early detection and management are crucial for maternal and fetal well-being.
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