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 A
Explanation
Choice A rationale
This is correct because a frank breech position is when the fetus's buttocks are presenting at the cervix and the legs are extended upward toward the head. The fetal heart tones would be located above the umbilicus at midline, as the nurse observed.
Choice B rationale
This is incorrect because a cephalic position is when the fetus's head is presenting at the cervix and the body is aligned with the maternal spine. The fetal heart tones would be located below the umbilicus, either on the right or left side, depending on the fetal position.
Choice C rationale
This is incorrect because a posterior position is when the fetus's back is facing the maternal spine and the occiput is toward the sacrum. The fetal heart tones would be located below the umbilicus, either on the right or left side, depending on the fetal position.
Choice D rationale
This is incorrect because a transverse position is when the fetus's spine is perpendicular to the maternal spine and the shoulder is presenting at the cervix. The fetal heart tones would be located in the upper quadrants, either on the right or left side, depending on the fetal position.
Correct Answer is D
Explanation
Choice A rationale
This is incorrect because monitoring vital signs every 5 min is not the priority action. The client's blood pressure is low, indicating hypotension, which is a common complication of epidural anesthesia. Hypotension can compromise the placental blood flow and fetal oxygenation, so the nurse should act quickly to correct it.
Choice B rationale
This is incorrect because elevating the client's legs is not the priority action. Elevating the legs can increase venous return and cardiac output, but it can also worsen the hypotension by pooling blood in the lower extremities. The nurse should lower the head of the bed and place the client in a lateral position to improve blood pressure and fetal perfusion.
Choice C rationale
This is incorrect because notifying the provider is not the priority action. The nurse should first implement interventions to correct the hypotension, such as placing the client in a lateral position, administering oxygen, and increasing IV fluids. The nurse should notify the provider after stabilizing the client's condition or if the interventions are ineffective.
Choice D rationale
This is correct because placing the client in a lateral position is the priority action. This helps to relieve the pressure of the gravid uterus on the inferior vena cava and improve venous return, cardiac output, and blood pressure. It also enhances placental blood flow and fetal oxygenation, which are vital for a successful labor and delivery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today