Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?
Baseline BP 140/85, current BP 129/80
Baseline BP 110/70, current BP 145/85
Baseline BP 120/80, current BP 126/85
Baseline BP 110/60, current BP 120/63
The Correct Answer is B
Choice A rationale
This is incorrect because a decrease in BP from the baseline is not a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 140/85 mm Hg indicates pre-existing hypertension, which may or may not worsen during pregnancy. A current BP of 129/80 mm Hg indicates an improvement in the BP control, but not a risk for pregnancy-induced hypertension.
Choice B rationale
This is correct because an increase in BP from the baseline by 30 mm Hg systolic or 15 mm Hg diastolic is a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 110/70 mm Hg indicates a normal BP before pregnancy. A current BP of 145/85 mm Hg indicates a significant elevation in the BP, which could lead to complications such as preeclampsia, eclampsia, or placental abruption.
Choice C rationale
This is incorrect because a slight increase in BP from the baseline is not a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 120/80 mm Hg indicates a normal BP before pregnancy. A current BP of 126/85 mm Hg indicates a minor elevation in the BP, which is within the normal range and does not pose a risk for pregnancy-induced hypertension.
Choice D rationale
This is incorrect because a slight increase in BP from the baseline is not a sign of pregnancy-induced hypertension. A normal BP during pregnancy is less than 140/90 mm Hg. A baseline BP of 110/60 mm Hg indicates a normal BP before pregnancy. A current BP of 120/63 mm Hg indicates a minor elevation in the systolic BP, but a decrease in the diastolic BP, which is within the normal range and does not pose a risk for pregnancy-induced hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This is incorrect because the right upper quadrant is not the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the same side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Choice B rationale
This is incorrect because the left upper quadrant is not the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the opposite side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Choice C rationale
This is incorrect because the left lower quadrant is not the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the opposite side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Choice D rationale
This is correct because the right lower quadrant is the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the same side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Correct Answer is B
Explanation
Choice A rationale
Vaginal discharge is not a finding that indicates preeclampsia. Vaginal discharge is a normal occurrence during pregnancy, as the cervix and vaginal walls soften and produce more mucus. Vaginal discharge can also indicate infections, such as yeast or bacterial vaginosis, which are not related to preeclampsia.
Choice B rationale
Elevated blood pressure is a finding that indicates preeclampsia. Preeclampsia is a condition that causes high blood pressure and proteinuria in pregnant women after 20 weeks of gestation. Preeclampsia can lead to serious complications, such as eclampsia, HELLP syndrome, and placental abruption, which can endanger the mother and the fetus. The nurse should monitor the client's blood pressure and report any readings above 140/90 mm Hg.
Choice C rationale
Joint pain is not a finding that indicates preeclampsia. Joint pain is a common complaint during pregnancy, as the hormones and weight gain cause changes in the joints and ligaments. Joint pain can also indicate other conditions, such as arthritis, gout, or lupus, which are not related to preeclampsia.
Choice D rationale
Increased urine output is not a finding that indicates preeclampsia. Increased urine output is a normal occurrence during pregnancy, as the growing uterus puts pressure on the bladder and the kidneys filter more blood. Increased urine output can also indicate diabetes, urinary tract infection, or diuretic use, which are not related to preeclampsia.
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