A woman has returned to the clinic for her second prenatal visit. Her blood pressure is significantly higher than on her previous visit. What action should the nurse do first?
A.
Administer oxygen and inform the provider.
B.
Ask the woman to lie down on the table.
C.
Ensure that the blood pressure cuff is the appropriate size.
D.
Take the blood pressure again.
ANS: C
Taking and recording maternal vital signs is an important component of every prenatal visit. Because this blood pressure reading is significantly different, the nurse should first ensure that the correct-sized cuff is being used and that the situation (i.e., maternal position) is consistent with the last reading. There is no need for oxygen or to have the woman lie down, unless the nurse determines that the woman was lying down for her last blood pressure measurement. The nurse should not take the blood pressure again until those factors are verified.
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