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 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.
Correct Answer is C
Explanation
Choice A rationale
Lie on back when counting kicks is incorrect. It is recommended to lie on the side, preferably the left side, as lying on the back can compress major blood vessels and affect circulation to the fetus.
Choice B rationale
You can begin counting fetal movements at 8 weeks gestation is incorrect. Fetal movements are typically felt by the mother starting around 18-20 weeks of gestation, not as early as 8 weeks.
Choice C rationale
Call healthcare provider if at least 3 movements are not felt over an hour. This is an important guideline as decreased fetal movements can indicate potential issues and should be reported to the healthcare provider for further evaluation.
Choice D rationale
Count movements at the same time each day is a good practice but it is not the most critical instruction. While consistency is beneficial, the immediate action for decreased movements is more urgent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.