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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

Explanation

Choice A rationale

The supine position is not recommended for breastfeeding because it can lead to issues with latching and milk flow, making it uncomfortable and potentially unsafe.

Choice B rationale

The cradle position is a common and effective breastfeeding position where the baby's head rests in the crook of the mother's arm, allowing for close contact and support.

Choice C rationale

Upright with chin support is not a standard breastfeeding position and may not provide the necessary support or alignment for effective breastfeeding.

Choice D rationale

Over-the-shoulder is also not a recommended breastfeeding position as it is impractical and does not facilitate proper latching or feeding.

Correct Answer is B

Explanation

Choice A rationale

Copious vernix is typically found on preterm newborns, not those born post-term.

Choice B rationale

Dry, cracked skin is a common finding in post-term newborns due to prolonged exposure to amniotic fluid.

Choice C rationale

Decreased subcutaneous fat is more likely in preterm newborns, while post-term newborns might lose some fat due to nutrient depletion.

Choice D rationale

Scant scalp hair is more common in preterm infants, whereas post-term infants usually have more developed hair. .

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