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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Warm the irrigation solution: While warming may enhance comfort, it does not impact the color of urine or address post-procedure bleeding. It is not a necessary intervention in this situation.
B. Perform the Credé's maneuver: This technique, which involves manual pressure over the bladder, is used for clients with neurogenic bladder or urinary retention. It is not appropriate during continuous bladder irrigation.
C. Replace the indwelling urinary catheter: Catheter replacement would only be considered if there was a complete blockage that couldn't be cleared, severe kinking, or signs of infection, none of which are indicated here. Replacing the catheter unnecessarily increases the risk of trauma and infection.
D. Maintain the irrigation solution rate: Pink-tinged urine is expected within the first few hours following TURP as a result of minor bleeding. Continuing irrigation at the current rate helps prevent clot formation and maintains catheter patency.

A. A client who consumes all the food from their meal tray. B. A client who requests assistance to use the bedside commode. C. A client who has a prescription for compression stockings and did not receive them. D. A client who requests to sit in the bedside chair while watching TV.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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