What should the nurse do first if a pregnant woman at 32 weeks of gestation complains of feeling dizzy and light-headed while her fundal height is being measured and her skin is pale and moist?
Raise the woman's legs.
Have the woman breathe into a paper bag.
Turn the woman on her side.
Assess the woman's blood pressure and pulse.
The Correct Answer is C
Choice A reason: Raising the woman's legs is not the best initial response, as it may worsen the dizziness and light-headedness. This is because raising the legs can increase the blood flow to the lower extremities and decrease the blood flow to the brain, which can cause hypotension (low blood pressure) and hypoxia (low oxygen) in the woman and the fetus.
Choice B reason: Having the woman breathe into a paper bag is not the best initial response, as it may not address the underlying cause of the dizziness and light-headedness. This technique is usually used for hyperventilation (rapid breathing), which can cause respiratory alkalosis (high blood pH) and reduce the carbon dioxide levels in the blood. However, the woman may not be hyperventilating, but rather experiencing supine hypotensive syndrome (low blood pressure when lying on the back) due to the pressure of the uterus on the inferior vena cava (a large vein that returns blood to the heart)².
Choice C reason: Turning the woman on her side is the best initial response, as it can relieve the dizziness and light-headedness by improving the blood flow to the brain and the fetus. This is because turning the woman on her side can reduce the pressure of the uterus on the inferior vena cava and increase the cardiac output (the amount of blood pumped by the heart) and the blood pressure. The left lateral position is preferred, as it can also optimize the placental perfusion (the blood flow to the placenta) and the fetal oxygenation.
Choice D reason: Assessing the woman's blood pressure and pulse is an important response, but not the first one. After turning the woman on her side, the nurse should monitor the vital signs and the fetal heart rate to evaluate the condition of the woman and the fetus. The nurse should also check for other signs and symptoms of supine hypotensive syndrome, such as nausea, sweating, and visual disturbances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because providing the patient with handouts is not enough to ensure effective communication. The handouts may not be in the patient's preferred language or may use unfamiliar words or concepts. The nurse should also use other methods, such as interpreters, translators, or visual aids, to convey information to the patient.
Choice B reason: This is incorrect because speaking quickly and efficiently may hinder the patient's comprehension and increase the risk of misunderstanding. The nurse should speak slowly and clearly, using simple and common words, and allow time for the patient to ask questions or clarify information.
Choice C reason: This is correct because assessing whether the patient understands the discussion is essential for effective communication and patient education. The nurse should use techniques such as teach-back, ask-me-3, or show-me to verify the patient's understanding and address any gaps or misconceptions.
Choice D reason: This is incorrect because using maternity jargon may confuse the patient and create barriers to communication. The nurse should avoid using medical terms, abbreviations, or slang that the patient may not be familiar with. The nurse should explain any necessary terms in plain language and use examples or analogies to illustrate them.
Correct Answer is C
Explanation
Choice A reason: The order in which the information is presented is not the most important factor, as it does not affect the client's motivation or ability to learn. The order of the information should be logical and sequential, but it can vary depending on the client's needs, preferences, and learning style. The nurse should assess the client's prior knowledge and tailor the teaching accordingly.
Choice B reason: The extent to which the pregnancy was planned is not the most important factor, as it does not determine the client's interest or willingness to learn. The pregnancy may be planned or unplanned, but the client may still have questions, concerns, or goals related to the pregnancy. The nurse should respect the client's feelings and emotions and provide support and guidance.
Choice C reason: The client's readiness to learn is the most important factor, as it influences the client's engagement and retention of the information. The client's readiness to learn depends on the client's perception of the relevance, importance, and benefits of the information, as well as the client's physical, psychological, and social readiness. The nurse should assess the client's readiness to learn and use appropriate strategies to enhance it, such as setting realistic and specific objectives, providing positive feedback, and involving the client in the learning process.
Choice D reason: The client's educational background is not the most important factor, as it does not reflect the client's learning needs or capabilities. The client's educational background may vary, but the client may still have similar or different learning needs depending on the pregnancy situation. The nurse should not assume the client's level of understanding or knowledge based on the client's educational background, but rather use simple and clear language, avoid medical jargon, and check for comprehension.
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