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 C
Explanation
Choice A rationale
A 10% to 15% increase in blood volume during pregnancy is too low compared to the average physiological changes that occur.
Choice B rationale
A 20% to 30% increase in blood volume is also below the expected range of increase during pregnancy.
Choice C rationale
Blood volume typically increases by 40% to 50% during pregnancy. This significant increase supports the demands of the growing fetus and placenta and prepares the mother's body for the blood loss that occurs during delivery.
Choice D rationale
A 65% to 75% increase is an overestimate. Such an extensive increase would be abnormal and is not typical in healthy pregnancies.
Correct Answer is A
Explanation
Choice A rationale
Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.
Choice B rationale
Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.
Choice C rationale
Respirations are within normal range (17/min) and do not require immediate intervention.
Choice D rationale
Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.