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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Free Nursing Study Resources

Correct Answer is ["A","D","F"]

Explanation

Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.

B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.

D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.

E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.

F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.

A. Apply warm blankets B. Administer an antipyretic C. Place ice packs around the client's head D. Check the temperature of the humidified oxygen attached to the ventilator E. Instill warm fluids in the nasogastric tube F. Microwave a pack of gauze and distribute across the body G. Administer intravenous fluids with a rapid infuser H. Use a fluid warmer for intravenous fluids

Correct Answer is ["A","D","E","G","H"]

Explanation

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: Warm IV fluids given rapidly restore circulating volume in trauma clients and also help increase core body temperature, addressing both shock and hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

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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

Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Correct Answer is ["A","D","F"]

Explanation

Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Correct Answer is ["A","D","E","G","H"]

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Which finding should the nurse recognize as a potential complication in a client with hypertension?

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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?

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