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
Explanation
A. “Rise slowly when getting out of bed.": Furosemide is a loop diuretic that can cause orthostatic hypotension due to fluid loss. Teaching the client to rise slowly helps prevent dizziness and falls associated with sudden position changes.
B. "Eat foods that are high in sodium.": Sodium intake should be limited in clients with heart failure, as high sodium can worsen fluid retention and counteract the effects of diuretics like furosemide.
C. “Taking furosemide can cause you to be overhydrated.": Furosemide increases urine output and poses a risk of dehydration, not overhydration. Monitoring fluid balance is essential during treatment.
D. "Taking furosemide can cause your potassium levels to be high.": Furosemide can lead to hypokalemia (low potassium), not hyperkalemia. Clients may need potassium supplementation or dietary adjustments to prevent electrolyte imbalance.
Correct Answer is C
Explanation
A. Insert an indwelling urinary catheter: Monitoring urine output is essential for assessing renal perfusion and fluid status. However, it should be done only after hemodynamic stability is established and internal bleeding is ruled out, as catheterization can pose risks if pelvic fractures are present.
B. Administer packed RBCs: Blood transfusion is necessary if the client is actively bleeding or hemodynamically unstable. However, access must first be secured to safely administer the transfusion, making IV insertion a priority.
C. Place a large-bore IV catheter in an upper extremity: Establishing IV access is the first step in stabilizing a trauma patient. It allows for rapid fluid resuscitation, administration of medications, and drawing of lab specimens necessary for further assessment.
D. Obtain a specimen for ABG analysis: Evaluating gas exchange and acid-base balance is important in trauma care, but it is not immediately life-saving. It should follow stabilization efforts like fluid resuscitation and hemorrhage control.
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