A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.
Which of the following actions should the nurse take?
Provide the client with a glass of orange juice.
Instruct the client to take a brisk walk.
Position the client on their left side.
Check the client's temperature.
The Correct Answer is C
Explanation
C. Position the client on their left side
The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.
Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.
Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.
Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.
Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.
Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A nasal cannula is a device used to deliver supplemental oxygen to a client. It consists of two prongs that are inserted into the client's nostrils and connected to an oxygen source. The nasal cannula is commonly used for low-flow oxygen delivery at a rate of 1 to 2 liters per minute (L/min).
The other options mentioned are not necessary supplies for the client upon discharge:
B- Petroleum jelly is not directly related to oxygen therapy and is not a required supply for the client. It is a common topical ointment used for various purposes such as moisturizing the skin or protecting the lips, but it is not specifically needed for oxygen administration.
C- An oxygen mask is an alternative device for oxygen delivery but is not typically used at a flow rate of 1 to 2 L/min. Oxygen masks are usually employed for higher flow rates or in specific clinical situations that require a different oxygen delivery method.
D- A reservoir bag is a component of some oxygen delivery systems, such as a non-rebreather mask or a bag-valve-mask device. However, at a flow rate of 1 to 2 L/min, a reservoir bag is not typically used. It is more commonly utilized in situations where higher oxygen concentrations or higher flow rates are required.
Correct Answer is D
Explanation
Furosemide works by promoting diuresis, which helps to reduce fluid volume overload in heart failure. Increased urinary output indicates that the medication is effectively removing excess fluid from the body. This can help alleviate symptoms such as edema and fluid retention commonly associated with heart failure. Therefore, an increased urinary output is a positive response to furosemide therapy in this context.
Decreased BUN (blood urea nitrogen) levels and weight loss are also expected outcomes of diuretic therapy, further indicating the effectiveness of the medication. However, a decreased hemoglobin level is not directly related to the efficacy of furosemide and might be indicative of other factors such as anemia or bleeding, requiring further assessment and intervention.
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