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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Report any increase in the white blood cell count: An elevated WBC may indicate infection, but this is a late finding and does not directly prevent recurrence. Reporting lab changes is important but not the most immediate or effective intervention

B. Change the surgical dressing when soiled: Keeping the surgical site clean and dry is the most critical step in preventing wound infection, particularly in clients with a history of MRSA. A soiled dressing promotes bacterial growth and increases the risk of reinfection, making timely dressing changes essential.

C. Wear a face mask while performing wound care: A face mask protects against droplet spread but MRSA is primarily transmitted by direct contact. While masks may reduce overall infection risk, they are less critical than maintaining strict wound and dressing hygiene.

D. Instruct the family to adhere to contact precautions: Family education is important in preventing MRSA transmission, but in the immediate postoperative period, the nurse’s priority is direct wound care. Preventing contamination at the surgical site takes precedence.

A. Sugar cookies. B. Pizza. C. Tacos. D. Chocolate milkshake.

Correct Answer is A

Explanation

A. Sugar cookies: Sugar cookies are low in fat and not highly acidic, making them less likely to trigger reflux. This choice demonstrates understanding of dietary restrictions because it avoids common GERD triggers such as high-fat, spicy, or acidic foods.

B. Pizza: Pizza is high in fat, contains tomato sauce, and often includes spices—all of which can increase gastric acid secretion and exacerbate reflux symptoms. This food is not an appropriate choice for a child with GERD.

C. Tacos: Tacos typically contain seasoned meat, spices, and fatty ingredients that are known to aggravate reflux. The combination of fat and spice makes them unsuitable for someone managing GERD symptoms.

D. Chocolate milkshake: Chocolate and high-fat dairy products can lower esophageal sphincter tone and delay gastric emptying, both of which contribute to worsening reflux. This makes it an inappropriate snack option.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?

Correct Answer is A

Explanation

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