After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?
Place the client in the Trendelenburg position.
Remove the client's legs from the stirrups.
Instruct the client to take deep breaths.
Place a wedge under the client's hip.
The Correct Answer is D
A. Place the client in the Trendelenburg position: While this position may increase venous return, it does not address the underlying cause in a pregnant client, which is usually aortocaval compression by the uterus. Simply tilting the table may be less effective than proper lateral displacement.
B. Remove the client's legs from the stirrups: Removing the legs may relieve some discomfort but does not correct the maternal hypotension caused by pressure on the inferior vena cava. Additional interventions are needed to improve circulation.
C. Instruct the client to take deep breaths: Deep breathing may help with anxiety or mild shortness of breath but does not resolve the hemodynamic compromise caused by supine hypotensive syndrome.
D. Place a wedge under the client's hip: Placing a wedge under the right or left hip tilts the uterus off the inferior vena cava, improving venous return, cardiac output, and blood pressure. This is the priority action to relieve dizziness, pallor, and diaphoresis in a pregnant client at 26 weeks’ gestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["18"]
Explanation
Calculation:
- Convert the client's weight from pounds (lb) to kilograms (kg).
The client's weight is 220 lb.
Client weight (kg) = 220lb/2.2lb/kg
= 100kg.
- Calculate the total heparin dose to be administered per hour (units/hr).
The ordered rate is 18 units/kg/hour.
Total dose rate (units/hr) = 18units/kg/hour×100kg
= 1800units/hr.
- Determine the concentration of the available solution (units/mL).
Available solution is 25,000units in 250mL.
Concentration (units/mL) = 25,000units/250mL
= 100units/mL.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Totaldoserate(units/hr)/Concentration(units/mL)
= 1800units/hr/100units/mL
= 18mL/hr.
Correct Answer is C
Explanation
A. Assess for spinal scoliosis: While scoliosis can affect posture and mobility, it is less likely to immediately impact the client’s safety in performing daily activities at home.
B. Compare shoulder symmetry: Shoulder asymmetry may indicate musculoskeletal issues but is not the most critical factor in evaluating fall risk or functional independence.
C. Observe gait while walking: Gait assessment provides direct information about balance, coordination, and mobility, which are key indicators of fall risk and home safety. Observing how the client walks helps the nurse plan interventions to prevent injury.
D. Palpate for joint nodules: Detecting nodules can identify conditions such as osteoarthritis, but the presence of nodules alone does not provide immediate insight into functional mobility or home safety.
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