A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.
Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

The client's heart rate increases by 10/min.

The client's diastolic blood pressure increases by 10 mm Hg.

The client reports heart palpitations.

The client's systolic blood pressure decreases by 25 mm Hg.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

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Correct Answer is A

Explanation

A. Correct. Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.
B. Incorrect. The hepatitis B immunization is safe during pregnancy and can be administered if indicated, regardless of breastfeeding status.
C. Incorrect. Rubella immunization is not recommended during pregnancy due to potential risks to the fetus. It should be given prior to pregnancy or after delivery.
D. Incorrect. Varicella immunization is also not recommended during pregnancy due to potential risks. It should be administered before pregnancy or after delivery if needed.

A. "I will get oxytocin during this test.” B. "During this test, I must not eat or drink anything.” C. "This test will tell me if my baby has a genetic problem.” D. "During this test, I will push a button if my baby moves.”

Correct Answer is D

Explanation

Choice A rationale:

Oxytocin is not typically administered during a nonstress test. Oxytocin is a hormone that induces or augments labor contractions; it is not used in nonstress testing, which monitors fetal heart rate and movement. The administration of oxytocin during nonstress testing would not be appropriate or necessary.

Choice B rationale:

Fasting is not required for a nonstress test. Nonstress testing involves attaching electronic fetal monitors to the mother's abdomen to measure the baby's heart rate and movement. It does not require the patient to abstain from eating or drinking. Imposing unnecessary restrictions on the client's diet could cause discomfort and anxiety, which is not conducive to an accurate assessment.

Choice C rationale:

Nonstress testing is used to evaluate the baby's heart rate response to its own movements. It does not diagnose genetic problems. Genetic testing, such as amniocentesis or chorionic villus sampling, is a different type of test used to detect genetic abnormalities in the fetus. Therefore, this statement does not reflect an understanding of the purpose of nonstress testing.

Choice D rationale:

This is the correct answer. Nonstress testing involves monitoring the baby's heart rate and movement. During the test, the mother pushes a button when she feels the baby move. This allows the healthcare provider to correlate fetal movements with changes in the baby's heart rate. An understanding of this process indicates that the client comprehends the purpose and procedure of the nonstress test.

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A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Nursing Test Bank

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A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.
Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?