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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 ["B","E","F"]

Explanation

Choice A rationale:

The statement suggests supplementing with formula due to the baby’s weight loss. However, a 5% weight loss in the first few days is normal for breastfed infants, and formula

supplementation is not necessary unless recommended by a healthcare provider. Early breastfeeding should be encouraged to increase milk supply and support newborn weight gain.

Choice B rationale:

This statement correctly indicates that newborns should feed 8 to 12 times per day and on demand to ensure adequate nutrition and promote milk production. Frequent breastfeeding

helps establish and maintain milk supply.

Choice C rationale:

Using plastic-lined breast pads can retain moisture and increase the risk of infection or irritation. Sore nipples can be managed with lanolin creams, air-drying, and proper latching

techniques during breastfeeding.

Choice D rationale:

Drinking more whole milk is a common misconception and does not directly increase a mother's milk supply. Milk production is influenced by frequent breastfeeding, proper hydration,

and balanced nutrition, not by specific types of foods or drinks.

Choice E rationale:

Newborn stools transition from dark greenish meconium to yellow, seedy stools within the first few days of life as breastfeeding becomes established. This indicates effective feeding

and milk intake.

Choice F rationale:

It is normal for a breastfeeding mother’s breasts to feel full, warm, and slightly tender as her milk comes in. This indicates that the milk supply is increasing and the body is responding

to the newborn’s feeding needs.

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. .

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