What is the best nursing intervention for a pregnant woman in her third trimester who complains of feeling faint, dizzy, and agitated while her vital signs are being assessed?
Have the patient stand up and retake her blood pressure.
Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms.
Have the patient sit down and hold her arm in a dependent position.
Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
The Correct Answer is D
Choice A reason: This is not a good intervention, as it may worsen the symptoms of faintness, dizziness, and agitation. Standing up can cause a sudden drop in blood pressure (orthostatic hypotension), which can reduce the blood flow to the brain and the fetus. This can cause lightheadedness, blurred vision, and loss of consciousness in the woman, as well as fetal distress or hypoxia.
Choice B reason: This is not a good intervention, as it may also worsen the symptoms of faintness, dizziness, and agitation. Lying supine can cause compression of the inferior vena cava (a large vein that returns blood to the heart) by the gravid uterus, which can reduce the cardiac output (the amount of blood pumped by the heart) and the blood pressure. This can cause nausea, sweating, and visual disturbances in the woman, as well as fetal distress or hypoxia.
Choice C reason: This is not a good intervention, as it may not improve the symptoms of faintness, dizziness, and agitation. Sitting down and holding the arm in a dependent position can lower the blood pressure in the arm, but not in the rest of the body. This can cause inaccurate readings of the blood pressure and delay the detection of hypotension or hypertension. This can also cause discomfort and pain in the arm due to impaired circulation.
Choice D reason: This is the best intervention, as it can relieve the symptoms of faintness, dizziness, and agitation by improving the blood flow to the brain and the fetus. Turning to the left side can reduce the pressure of the uterus on the inferior vena cava and increase the cardiac output and the blood pressure. This can also optimize the placental perfusion (the blood flow to the placenta) and the fetal oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Magnesium sulfate does not improve patellar reflexes and increase respiratory efficiency. In fact, it may cause hyporeflexia and respiratory depression as adverse effects. These are signs of magnesium toxicity and require immediate intervention.
Choice B reason: Magnesium sulfate does not prevent a boggy uterus and lessen lochial flow. A boggy uterus is a sign of uterine atony, which can lead to postpartum hemorrhage. Lochia is the normal vaginal discharge after childbirth. Magnesium sulfate has no effect on these conditions.
Choice C reason: Magnesium sulfate does not shorten the duration of labor. It may actually prolong labor by relaxing the uterine muscles and inhibiting contractions. Magnesium sulfate is not used to induce or augment labor.
Choice D reason: Magnesium sulfate is used to prevent and treat convulsions in women with preeclampsia and eclampsia. Convulsions are a life-threatening complication of severe hypertension during pregnancy. Magnesium sulfate acts as a central nervous system depressant and anticonvulsant. It reduces the risk of seizures and lowers blood pressure.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Normal weight women should gain 11.5 to 16 kg during pregnancy, according to the Institute of Medicine (IOM) guidelines. This is based on the body mass index (BMI) of 18.5 to 24.9 before pregnancy.
Choice B reason: Underweight women should gain 12.5 to 18 kg during pregnancy, according to the IOM guidelines. This is based on the BMI of less than 18.5 before pregnancy. Underweight women are at risk of having low birth weight infants, so they need to gain more weight to support fetal growth and development.
Choice C reason: Adolescents are encouraged to strive for weight gains at the upper end of the recommended scale, according to the IOM guidelines. This is because adolescents are still growing themselves and need extra nutrients and calories to meet their own needs and those of the fetus.
Choice D reason: In twin gestations, the weight gain recommended for a single fetus pregnancy should not be simply doubled. The IOM guidelines suggest that women with twin gestations should gain 16.5 to 24.5 kg if they have a normal weight before pregnancy, 14 to 22.5 kg if they are overweight, and 11 to 19 kg if they are obese.
Choice E reason: Obese women should gain at least 7 to 11.5 kg during pregnancy, according to the IOM guidelines. This is based on the BMI of 30 or more before pregnancy. Obese women are at risk of having complications such as gestational diabetes, preeclampsia, and cesarean delivery, so they need to limit their weight gain to avoid further complications.
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