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
Risk for injury related to seizures is an important nursing diagnosis for this client. The client is at risk of seizures due to the severe preeclampsia and the high blood pressure. Seizures can cause injury to the client and the fetus, as well as complications such as aspiration, cerebral hemorrhage, and coma. The nurse should monitor the client's neurological status, administer anticonvulsants as prescribed, and protect the client from injury during a seizure.
Choice B rationale
Impaired gas exchange related to pulmonary edema is an important nursing diagnosis for this client. The client is at risk of pulmonary edema due to the fluid overload and the high blood pressure. Pulmonary edema can impair the gas exchange and oxygen delivery to the client and the fetus, as well as cause respiratory distress, heart failure, and death. The nurse should monitor the client's respiratory status, administer oxygen as prescribed, and restrict the fluid intake.
Choice C rationale
Deficient fluid volume related to diuresis is not an important nursing diagnosis for this client. The client is not at risk of deficient fluid volume, but rather fluid overload. Diuresis is the increased production and excretion of urine, which can cause fluid loss and dehydration. The client does not have any signs of diuresis, such as increased urine output, decreased specific gravity, or weight loss.
Choice D rationale
Ineffective tissue perfusion related to placental abruption is not an important nursing diagnosis for this client. The client is not at risk of placental abruption, but rather uteroplacental insufficiency. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause bleeding, pain, and fetal distress. The client does not have any signs of placental abruption, such as vaginal bleeding, abdominal tenderness, or fetal heart rate abnormalities.
Correct Answer is D
Explanation
Choice A rationale
This is incorrect because respirations 16/min are within the normal range and do not indicate magnesium toxicity. The nurse should monitor the client's respiratory rate and report any signs of respiratory depression, such as less than 12/min.
Choice B rationale
This is incorrect because fetal heart rate 158/min is within the normal range and does not indicate fetal distress. The nurse should monitor the fetal heart rate and report any signs of bradycardia, tachycardia, or decreased variability.
Choice C rationale
This is incorrect because headache for 30 min is a common symptom of pre-eclampsia and does not indicate magnesium toxicity. The nurse should administer analgesics as prescribed and report any signs of increased intracranial pressure, such as blurred vision, confusion, or seizures.
Choice D rationale
This is correct because urinary output 40 mL in 2 hr is below the expected amount and indicates renal impairment. The nurse should report this finding to the provider and monitor the client's fluid intake and output, serum creatinine, and blood urea nitrogen levels. The nurse should also assess the client for signs of fluid overload, such as edema, crackles, or dyspnea.
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