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A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?

A.

Maternal blood pressure of 128/88.

B.

Fetal heart rate baseline of 115 bpm.

C.

Maternal heart rate of 128 bpm.

D.

Maternal respiratory rate of 18 breaths per minute.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.

Choice B rationale

The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.

Choice C rationale

Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.

Choice D rationale

While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.

Correct Answer is A

Explanation

Step 1 is: 12 mg ÷ 6 mg/ml.

Step 2 is: 12 ÷ 6 = 2 ml. Answer: 2 ml

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