Level: Advanced
Difficulty: Hard
Subtopic: Newborn safety
NCLEX: A 38-week newborn on the mother-baby unit is being evaluated for newborn care on the postpartum unit. The nurse r…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 38-week newborn on the mother-baby unit is being evaluated for newborn care on the postpartum unit. The nurse reviews this trend: blood pressure increased from 128/78 to 162/102 mm Hg with headache and visual spots. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Wait for a critical value or sentinel event before taking any nursing action.
D. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Wait for a critical value or sentinel event before taking any nursing action.
D. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale
Correct answer: D. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.