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 C
Explanation
A.Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.
B.Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.
C.Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.
D.Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.
Correct Answer is ["C","D","E","F"]
Explanation
Case management can be beneficial in situations involving assault to help coordinate and provide ongoing support and resources for the client. This intervention is appropriate in this scenario.
Ensuring a safe and private environment is crucial to protect the client's confidentiality and provide a supportive atmosphere during this difficult time. This intervention is necessary. Since the client reports being assaulted and has sore genitals, it is important to consider the risk of sexually transmitted infections (STIs). Administering STI prophylaxis can help prevent potential infections.
The client may benefit from additional support services such as counseling or support groups. Providing resources for local support services can help the client access the necessary help and support they need.
Contacting children and youth services is not applicable in this scenario as the client is a full-time college student and not a child or youth.
While the client mentioned drinking, it is not explicitly stated that they have an alcohol addiction or problem. Therefore, providing resources for Alcoholics Anonymous may not be the most appropriate intervention at this time.
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