Nokea
A nurse is monitoring a laboring person's vital signs during the first stage of labor. Which vital sign change is most likely to indicate the need for further evaluation?
Correct Answer: B
Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby.
A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions.
C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high.
D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.