Author Question: The nurse notes the pregnant client's blood pressure has dropped from 122/70 mmHg taken during her ... (Read 142 times)

D2AR0N · **on:** Jun 25, 2018

The nurse notes the pregnant client's blood pressure has dropped from 122/70 mmHg taken during her second month of pregnancy to 118/64 mmHg during her fifth month of pregnancy. Which action by the nurse is most appropriate based on this data?

1. Assess for signs of hemorrhage.
2. Document the blood pressure as a normal finding.
3. Consult the healthcare provider.
4. Tell the client to come in the next day so the nurse can recheck her blood pressure.

Question 2

The nurse is assessing a young adult client and notes the presence of bilateral earlobe creases. Which actions by the nurse are appropriate based on this data? Select all that apply.

1. Refer the client to a plastic surgeon.
2. Document this finding as normal.
3. Document the finding and notify the healthcare provider.
4. Ask the client about any history of injuries to his ears.
5. Assess the client's risk factors for coronary artery disease.

tsternbergh47 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2
During pregnancy, there is a substantial increase in cardiac workload secondary to the increase in blood volume. Despite this, the systolic and diastolic blood pressures may decrease during the first half of pregnancy. This is secondary to the peripheral vasodilatation. During the second half of the pregnancy, the blood pressure will return to previous pre-pregnancy levels. This small drop in blood pressure is expected and the nurse does not need to assess the client for signs of hemorrhage. The healthcare provider does not need to be consulted because this is a normal finding. The client does not need to return to have her blood pressure checked on the following day.

Answer to Question 2

Correct Answer: 3, 4, 5
This is an abnormal finding and the client should be carefully monitored for the development of coronary artery disease. The nurse should document the finding, request information from the client regarding any injuries to the ears, and notify the healthcare provider about the presence of the bilateral earlobe creases. The nurse should assess the client for any other clinical manifestations and risk factors associated with coronary artery disease. At this point, the client does not need to be referred to a plastic surgeon.