A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?
Administer propranolol IV to the client
Position the client on her side.
Ask the client to increase her daily calcium intake.
Use Leopold maneuvers to determine the fetal position.
The Correct Answer is B
A. Administer propranolol IV to the client: Propranolol is a beta-blocker used to treat hypertension and certain cardiac conditions. It is not indicated for sudden nausea during pregnancy and could be harmful if administered without cause.
B. Position the client on her side: At 36 weeks, the gravid uterus can compress the inferior vena cava when the client lies flat, reducing venous return and causing supine hypotensive syndrome, which often presents as nausea. Turning the client to her side relieves pressure and restores circulation.
C. Ask the client to increase her daily calcium intake: Calcium is important during pregnancy, especially for bone health, but increasing intake is not an acute intervention for nausea caused by positional blood flow issues.
D. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers assess fetal position but do not address the client’s immediate symptom of nausea, which may indicate compromised circulation from lying supine. Position change is the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Wear a dosimeter film badge to measure exposure: The dosimeter badge tracks cumulative radiation exposure to ensure the nurse stays within safe limits. It is essential personal protective equipment when caring for clients undergoing internal radiation therapy.
B. Place a caution sign on the client’s door: A radiation warning sign alerts staff and visitors about the presence of a radioactive source, ensuring they follow safety protocols to minimize unnecessary exposure.
C. Discard bed linens from the client's room at the end of each day: Linens are not contaminated by a sealed implant, as the radiation source is enclosed and does not leak into the environment. Linens should be handled per routine procedure unless visibly soiled.
D. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should be instructed to stay at least 6 feet (approximately 183 cm) away and limit visits to 30 minutes. The 2-foot distance is insufficient to ensure safety from radiation exposure.
E. Don a lead apron when providing care: A lead apron helps shield the nurse from radiation exposure when close contact is necessary. It is a standard precaution when interacting with clients who have a sealed radiation source.
Correct Answer is D
Explanation
A. Seizure: While seizures may occur in severe cases of hypernatremia, they are more typically associated with hyponatremia, where cerebral edema is more prominent due to water shifts into brain cells.
B. Elevated hematocrit: An elevated hematocrit may be seen with dehydration, which can accompany hypernatremia, but it is not a direct or reliable indicator of sodium imbalance itself.
C. Bradypnea: Respiratory changes like bradypnea are not characteristic of hypernatremia. This condition primarily affects the neurological system, not the respiratory system.
D. Personality change: Hypernatremia causes cellular dehydration, particularly in brain cells, leading to neurological symptoms such as confusion, agitation, irritability, and personality changes.
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