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 B
Explanation
A. 2+ deep-tendon reflexes: This is a normal reflex response and indicates that magnesium levels are not excessively high. Diminished or absent reflexes would be a more concerning sign of toxicity.
B. Respiratory rate 10/min: A respiratory rate below 12/min suggests respiratory depression, which is a serious adverse effect of magnesium sulfate toxicity. This is the priority finding requiring immediate intervention.
C. Urinary output 35 mL/hr: This is slightly above the minimum expected output of 30 mL/hr. While renal function must be monitored to prevent magnesium accumulation, this rate is adequate for now.
D. Pedal edema: Edema is common in preeclampsia and is not an urgent concern compared to signs of magnesium toxicity such as respiratory depression.
Correct Answer is C
Explanation
A. A client who consumes all the food from their meal tray: Eating a full meal is generally positive and does not require immediate reporting unless related to specific dietary restrictions or concerns.
B. A client who requests assistance to use the bedside commode: Requesting help to use the commode is expected and can be managed by the assistive personnel without urgent nurse notification.
C. A client who has a prescription for compression stockings and did not receive them: Compression stockings prevent deep vein thrombosis and promote circulation. Not receiving them as prescribed is a safety concern that requires prompt nurse awareness and intervention.
D. A client who requests to sit in the bedside chair while watching TV: This is a normal, non-urgent request that the assistive personnel can usually handle without needing to notify the nurse immediately.
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