A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?
Maternal blood pressure of 128/88.
Fetal heart rate baseline of 115 bpm.
Maternal heart rate of 128 bpm.
Maternal respiratory rate of 18 breaths per minute.
The Correct Answer is C
Choice A rationale
A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms
of preeclampsia appear.
Choice B rationale
A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.
Choice C rationale
A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.
Choice D rationale
A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.
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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.
Choice B rationale
While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.
Choice C rationale
Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.
Choice D rationale
This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.
Correct Answer is A
Explanation
Choice A rationale
Uterine atony is a common complication following polyhydramnios because the excessive amniotic fluid can lead to uterine overdistension, which in turn can cause poor uterine
muscle tone and increased risk of postpartum hemorrhage.
Choice B rationale
Thrombophlebitis is an inflammation of a vein with clot formation, but it is not directly associated with polyhydramnios.
Choice C rationale
Postpartum preeclampsia is high blood pressure and signs of organ damage after delivery, but there is no direct link between polyhydramnios and this condition.
Choice D rationale
Retained placental fragments can lead to postpartum hemorrhage but are not specifically associated with polyhydramnios.