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":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Rationale for Essential Actions:
- Monitor for elevated temperature: Epidural anesthesia can increase the risk of maternal fever due to decreased peripheral heat loss. Monitoring temperature helps detect infection or epidural-related hyperthermia early.
- Assess for urinary retention:Epidural anesthesia can impair bladder sensation and motor control, making urinary retention common. Ongoing bladder assessments are crucial to prevent bladder distention and associated labor complications.
- Encourage the client to turn from side to side: Repositioning promotes fetal descent and optimal uteroplacental perfusion, and helps prevent supine hypotension by avoiding vena cava compression in laboring women.
Rationale for Contraindicated Actions:
- Assist the client with ambulation: Epidural anesthesia impairs lower extremity motor function and balance, posing a high fall risk. Bedrest is required after epidural placement unless sensation and motor function are fully restored and evaluated.
- Inform the client to expect drowsiness: Drowsiness is not a typical or expected effect of epidural anesthesia. Sedation may indicate systemic effects or complications and should not be presented as expected.
Correct Answer is D
Explanation
A. Instruct the client to flex the right knee every 30 min: Flexing the knee can increase the risk of bleeding or hematoma formation at the femoral access site and is generally avoided immediately after the procedure.
B. Elevate the head of the client's bed to 45°: Elevating the head more than 30 degrees can put pressure on the femoral site and increase bleeding risk; typically, the head of the bed is kept flat or slightly elevated.
C. Change the client’s dressing 4 hr following the procedure: The initial dressing is usually kept intact for at least 24 hours unless it becomes saturated, as frequent dressing changes can disrupt the site and increase infection risk.
D. Assess the client’s peripheral pulses every 15 min: Frequent monitoring of peripheral pulses is critical to detect early signs of impaired circulation or complications such as arterial occlusion or hematoma at the catheter insertion site.
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