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.
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Correct Answer is B
Explanation
Choice A rationale
Precipitous labor is a rapid labor that typically lasts less than 3 hours. While it can result in trauma and complications, it does not inherently increase the risk for an operative delivery,
which is more often related to other factors like fetal distress or failure to progress.
Choice B rationale
Postpartum hemorrhage (PPH) is a significant concern with precipitous labor due to the rapid and forceful contractions that can cause uterine atony, leading to increased bleeding
after birth.
Choice C rationale
In a precipitous labor, the rapid delivery can cause vaginal lacerations, not a decreased risk. The swift passage of the baby through the birth canal increases the risk of tears and
trauma.
Choice D rationale
Neonatal sepsis is related to infections acquired during delivery but is not specifically linked to the speed of labor. The primary concern in precipitous labor is maternal trauma and
hemorrhage, not infection.
Correct Answer is C
Explanation
Choice A rationale
Irregular menses are not a direct risk factor for cervical cancer. While they can indicate hormonal imbalances, they are not strongly linked to cervical cancer risk.
Choice B rationale
Menopausal status and hormone replacement therapy (HRT) are more closely linked to breast cancer risks rather than cervical cancer. Cervical cancer is primarily associated with HPV infection.
Choice C rationale
Multiple sexual partners increase the risk of HPV infection, which is the primary cause of cervical cancer. HPV is a sexually transmitted infection that significantly raises the likelihood of developing cervical cancer.
Choice D rationale
A family history of breast cancer is more relevant to breast cancer risk rather than cervical cancer. Cervical cancer risk is more closely linked to HPV infection and sexual behavior.