The nurse is assessing a client with a third-trimester pregnancy in the obstetrical office. Which of the following findings would require immediate intervention by the nurse?
1. Weight gain of one pound in a week
2. Pulse of 92 beats per minute
3. Respiratory rate of 24 per minute
4. Blood pressure of 142/92
4. Blood pressure of 142/92
Rationale:
A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.
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