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
Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as
current treatments pose risks without guaranteed efficacy.
Choice B rationale
Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by
transferring through contact with cat feces.
Choice C rationale
While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.
Choice D rationale
Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.
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. .