A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping.

Which of the following instructions should the nurse include in the plan of care?

Lie on your left side with your top leg forward.

Soak in a bathtub of hot water each night.

Obtain a prescription for pramipexole.

Use a transcutaneous electrical nerve stimulator.

Answer and Explanation

The Correct Answer is A

Explanation

A .Lie on your left side with your top leg forward

During pregnancy, it is generally recommended for pregnant individuals to sleep on their left side. This position promotes optimal blood flow and circulation to the uterus and placenta, which is beneficial for both the mother and the baby. Placing the top leg forward can help maintain a comfortable and supported position.

Soaking in a bathtub of hot water each night in (option B) is not recommended during pregnancy, as excessive heat from hot baths or saunas can potentially harm the developing fetus. Pregnant individuals should avoid prolonged exposure to hot temperatures.

Obtaining a prescription for pramipexole in (option C) is not a standard intervention for addressing trouble sleeping during pregnancy. Pramipexole is a medication used for the treatment of Parkinson's disease and restless legs syndrome, and its use during pregnancy should be evaluated on a case-by-case basis under the guidance of a healthcare provider.

Using a transcutaneous electrical nerve stimulator (TENS) in (option D) is not typically indicated for sleep difficulties during pregnancy. TENS units are commonly used for pain management, and their use for sleep problems during pregnancy is not a standard recommendation.

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Correct Answer is C

Explanation

Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.

Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.

While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.

While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.

A. A client who is postoperative and reports intermittent nausea B. A client whose blood pressure is 160/90 mm Hg and reports a headache C. A client who is scheduled for surgery in 2 hr D. A client who is postoperative and has a Jackson-Pratt drain

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.

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A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping.

Which of the following instructions should the nurse include in the plan of care?