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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
Correct Answer is C
Explanation
Choice A rationale
Decreased deep tendon reflexes are not typically associated with preeclampsia. In fact, hyperreflexia or increased deep tendon reflexes might be observed due to central nervous
system irritability in preeclampsia.
Choice B rationale
Uterine contractions are related to labor and not a specific indicator of preeclampsia. While they might occur simultaneously, they are not diagnostic of preeclampsia.
Choice C rationale
Proteinuria, the presence of excess protein in the urine, is a key diagnostic criterion for preeclampsia. It indicates kidney involvement and is used along with elevated blood pressure to diagnose this condition.
Choice D rationale
Increased blood glucose levels are associated with gestational diabetes rather than preeclampsia. Elevated blood pressure and proteinuria are the hallmarks of preeclampsia.