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 B
Explanation
Choice A reason: A total placenta previa is when the placenta completely covers the internal os, blocking the baby's exit from the uterus.
Choice B reason: Placenta previa is a condition where the placenta implants in the lower uterine segment and may cover or be near the cervical internal os. When the placental edge just reaches the internal os but does not cover it, it is called a marginal previa.
Choice C reason: A complete placenta previa is when the placenta partially covers the internal os, reducing the space for the baby to pass through.
Choice D reason: "Partial placenta previa" refers to a situation where the placenta partially covers the internal cervical os — meaning some, but not all, of the opening is obstructed by placental tissue.
Correct Answer is D
Explanation
The correct answer is d. Amenorrhea.
Choice A: Chadwick’s sign is a non-specific, early sign of pregnancy that is typically characterized by a bluish discoloration of the cervix, vagina, and vulva. The Chadwick sign can typically be observed as early as six to eight weeks after conception, and commonly disappears shortly after birth. However, it’s not a definitive indication of pregnancy, and the absence of it on physical exam does not exclude a potential pregnancy.
Choice B: Hegar’s sign is a non-specific indication of pregnancy that is characterized by the compressibility and softening of the cervical isthmus (i.e., the portion of the cervix between the uterus and the vaginal portion of the cervix). It typically presents between the fourth and sixth week of pregnancy and may be present until the 12th week of pregnancy. However, the Hegar sign is not a definitive indication of pregnancy, and the absence of it does not exclude a potential pregnancy.
Choice C: A positive pregnancy test By 10 weeks, a home pregnancy test would almost certainly show a positive result if the woman is pregnant. This is because the hormone human chorionic gonadotropin (hCG), which is produced by the placenta after implantation of the embryo into the uterine wall, would be present in high enough levels to be detected by the test. However, a positive pregnancy test is not a presumptive sign of pregnancy, but rather a probable one.
Choice D: Amenorrhea, or the absence of menstrual periods, is often considered the most presumptive sign of pregnancy. This is because it’s one of the first noticeable signs of pregnancy for many women. By 10 weeks of gestation, the woman would likely have missed two menstrual periods if she usually has regular cycles. However, while amenorrhea is a common early sign of pregnancy, it can also be caused by various other conditions or factors such as stress, significant weight loss or gain, or certain medical conditions. Therefore, a missed period should be followed up with a pregnancy test to confirm pregnancy.
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