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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months is incorrect. This schedule delays the immune response and leaves the infant unprotected during the critical early period when the risk of transmission is highest.

Choice B rationale

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth is the correct approach. This combination provides immediate passive immunity through the immune globulin and active immunity through the vaccine, significantly reducing the risk of hepatitis B transmission from mother to child.

Choice C rationale

Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is incorrect. Monthly administration alone is insufficient without the initial dose of immune globulin, especially since the infant may remain at risk until the negative test result.

Choice D rationale

Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days is incorrect. The delay in the first vaccine dose reduces its efficacy, and the immune globulin schedule does not align with established guidelines for preventing hepatitis B transmission.

A. I will limit exercising to low-impact aerobics. B. I will swim in the pool because this is considered a safe exercise for me. C. I will walk around the indoor track. D. I only go to the spa to sit in the sauna in the morning.

Correct Answer is D

Explanation

Choice A rationale

Limiting exercise to low-impact aerobics is safe and suitable for pregnant women.

Choice B rationale

Swimming is considered a safe and beneficial exercise during pregnancy.

Choice C rationale

Walking is a recommended form of exercise for pregnant women.

Choice D rationale

Sitting in a sauna is not advised during pregnancy due to risks of overheating and dehydration. .

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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?

Nursing Test Bank

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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?