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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 A

Explanation

Choice A rationale

Uteroplacental insufficiency leads to late decelerations, which are characterized by a gradual decrease in fetal heart rate after the peak of a contraction. This indicates compromised blood flow between the uterus and placenta, affecting the fetus.

Choice B rationale

Umbilical cord compression usually causes variable decelerations, not late decelerations.

Choice C rationale

Maternal bradycardia does not cause changes in fetal heart rate patterns like late decelerations.

Choice D rationale

Fetal head compression causes early decelerations, which coincide with contractions, not late decelerations.

Correct Answer is C

Explanation

Choice A rationale

Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.

Choice B rationale

While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.

Choice C rationale

Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.

Choice D rationale

This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.

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