The nurse is assessing a woman in early labor.
While positioning her for a vaginal exam, she complains of dizziness and nausea and appears pale.
Her blood pressure has dropped slightly.
What is the appropriate initial nursing action?
Call the healthcare provider.
Elevate the head of the bed.
Encourage deep breathing.
Turn her to her side.
The Correct Answer is D
Choice A rationale
Calling the healthcare provider delays immediate intervention needed to alleviate the client's symptoms of dizziness and nausea due to supine hypotensive syndrome. Quick repositioning is crucial to improve venous return and alleviate the symptoms.
Choice B rationale
Elevating the head of the bed will not relieve the pressure on the inferior vena cava caused by the supine position. This intervention does not address the underlying cause of the client's symptoms.
Choice C rationale
Encouraging deep breathing is unlikely to resolve the symptoms of supine hypotensive syndrome, which is caused by the compression of the vena cava by the gravid uterus when lying supine. This intervention does not address the physiological cause.
Choice D rationale
Turning her to her side relieves the pressure on the inferior vena cava, improving venous return and increasing blood pressure. This is the correct initial action to address the symptoms of supine hypotensive syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The fetal heartbeat can be heard with a Doppler at the fourth week of gestation is incorrect. At this early stage, the embryonic heart has only just begun to form, and its activity cannot be detected by Doppler.
Choice B rationale
The fetal heartbeat can be heard with a Doppler at the sixth week of gestation is incorrect. Although the heart begins to beat around this time, it is usually too faint to be detected by Doppler.
Choice C rationale
The fetal heartbeat can be heard with a Doppler at the seventh week of gestation is incorrect. It remains challenging to detect the fetal heartbeat this early with standard Doppler equipment.
Choice D rationale
The fetal heartbeat can be heard with a Doppler at the twelfth week of gestation is correct. By the end of the first trimester, the fetal heart is sufficiently developed and strong enough to be detected using Doppler ultrasound, allowing healthcare providers to monitor fetal well-being.
Correct Answer is C
Explanation
Choice A rationale
Fetal nutrition and excretion are carried out by the placenta. This statement is correct. The placenta provides essential nutrients to the fetus and removes waste products from fetal blood.
Choice B rationale
Fetal respirations are carried out by the placenta. This statement is correct. The placenta facilitates gas exchange, providing oxygen to the fetus and removing carbon dioxide.
Choice C rationale
The placenta filters harmful substances from maternal blood. This statement is incorrect. While the placenta provides some barrier function, it does not filter all harmful substances from maternal blood, and certain drugs and toxins can cross the placental barrier and affect the fetus.
Choice D rationale
The placenta receives maternal blood from the uterine arteries. This statement is correct. Maternal blood flows to the placenta via the uterine arteries, supplying oxygen and nutrients to the fetal side of the placenta.
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