The nurse notes the pregnant client's blood pressure has dropped from 122/70 taken during her second month of pregnancy to 118/64 during her fifth month of pregnancy. Which of the following actions by the nurse is most appropriate?
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.
2
Rationale 1: This small drop in blood pressure is expected and the nurse does not need to assess the client for signs of hemorrhage.
Rationale 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.
Rationale 3: The healthcare provider does not need to be consulted because this is a normal finding.
Rationale 4: The client does not need to return to have her blood pressure checked on the following day.
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