Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

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.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is B

Explanation

Choice A rationale

The supine position is not recommended for breastfeeding because it can lead to issues with latching and milk flow, making it uncomfortable and potentially unsafe.

Choice B rationale

The cradle position is a common and effective breastfeeding position where the baby's head rests in the crook of the mother's arm, allowing for close contact and support.

Choice C rationale

Upright with chin support is not a standard breastfeeding position and may not provide the necessary support or alignment for effective breastfeeding.

Choice D rationale

Over-the-shoulder is also not a recommended breastfeeding position as it is impractical and does not facilitate proper latching or feeding.

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. .

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.