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 B
Explanation
Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.
While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.
The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.
The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.
Correct Answer is A
Explanation
A case manager is a member of the interprofessional team who specializes in coordinating and facilitating access to healthcare services and resources for individuals and families. They can assist the client in identifying and accessing financial assistance programs or resources that can help with the cost of baby formula.
Case managers have knowledge of community resources and can provide guidance and support in navigating the system to meet the client's needs. While a nutritionist may provide guidance on infant nutrition, they may not have direct access to financial assistance programs or resources. The primary care provider and pediatric nurse practitioner may be involved in the client's care but may not have the specific expertise in addressing financial concerns.
Therefore, referring the client to a case manager is the most appropriate action in this situation.
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