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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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to

ectopic pregnancy.

Choice B rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.

Choice C rationale

Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside

the uterus.

Choice D rationale

Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing

localized pain.

Correct Answer is C

Explanation

Choice A rationale

Placenta formation begins shortly after implantation, but it continues to develop throughout the first trimester and into the early second trimester, making it less precise to attribute the

first 8 weeks solely to this process.

Choice B rationale

Fertilization occurs within the first week after ovulation, marking the beginning of pregnancy, but it is a singular event that happens prior to the developmental processes vulnerable to teratogens.

Choice C rationale

Organogenesis is the critical period during which the major organs and structures of the fetus form, typically occurring between the third and eighth weeks of gestation. This is the

time when the fetus is most susceptible to the effects of teratogens, which can cause congenital anomalies.

Choice D rationale

Implantation occurs approximately 6-10 days after fertilization, embedding the blastocyst into the uterine lining. While crucial, it is not the primary period when teratogenic effects are

most significant, as this happens during organogenesis.

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