A Gravida 1, Para 0 patient, 40 weeks pregnant, is laboring in bed, flat on her back, in the supine position.
She becomes pale, her skin becomes clammy, and she states she feels dizzy.
What is the first action by the nurse?
Apply oxygen 10 liters by simple face mask.
Notify her medical provider.
Administer 250 ml Lactated Ringer's IV fluid bolus.
Turn the patient to her side.
The Correct Answer is D
Choice A rationale
Applying oxygen is a supportive measure for fetal or maternal hypoxemia, but it does not address the underlying cause of the supine hypotension syndrome, which is compression of the vena cava. Oxygen (10 L/min by simple face mask) may be administered after or concurrently with positional change if symptoms persist, but restoring blood flow by repositioning is the essential first step. Simply administering oxygen will not relieve the mechanical obstruction.
Choice B rationale
While the medical provider should be notified of the patient's deteriorating condition, the immediate priority is to correct the cause of the supine hypotension syndrome and stabilize the patient. The patient's pale, clammy, and dizzy symptoms indicate immediate circulatory compromise due to aortocaval compression. Turning the patient is a rapid, non-invasive intervention that should precede making a phone call to the provider.
Choice C rationale
Administering an IV fluid bolus of 250 mL of Lactated Ringer's is appropriate for true hypovolemia or shock. However, in this case, the hypotension is caused by a mechanical obstruction (aortocaval compression) from the heavy gravid uterus pressing on the vena cava, reducing venous return and cardiac output. The first action must be to alleviate the compression by changing the maternal position, which is faster and addresses the root problem.
Choice D rationale
The patient's symptoms (pallor, clamminess, dizziness) while lying flat on her back are classic signs of supine hypotension syndrome, also known as aortocaval compression. The heavy uterus compresses the inferior vena cava, decreasing venous return to the heart, which drastically reduces cardiac output and maternal blood pressure. The immediate and most effective intervention is to turn the patient to her left side (or right side) to displace the uterus and relieve the compression, rapidly restoring blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The normal baseline fetal heart rate (FHR) range for a term fetus is defined as 110 to 160 beats/min over a 10-minute segment, excluding periodic or episodic changes. A rate of 135 beats/min falls within this established normal range, indicating an appropriate balance between the fetal sympathetic and parasympathetic nervous systems.
Choice B rationale
Fetal bradycardia is defined as a baseline FHR of less than 110 beats/min for a duration of 10 minutes or longer. A rate of 135 beats/min is significantly higher than this definition and thus does not meet the criteria for bradycardia.
Choice C rationale
Fetal tachycardia is defined as a baseline FHR of greater than 160 beats/min for a duration of 10 minutes or longer. A rate of 135 beats/min is below this threshold and does not meet the criteria for fetal tachycardia.
Choice D rationale
Fetal hypoxia, a state of inadequate oxygen supply at the tissue level, is typically manifested by non-reassuring FHR patterns, such as late decelerations, absent or minimal variability, or sustained bradycardia. A normal baseline rate of 135 beats/min does not suggest hypoxia.
Correct Answer is B
Explanation
Choice A rationale
A weight gain of 5 pounds per month, especially in the second and third trimesters, often exceeds the recommended rate for a woman with a normal BMI, which is typically about one pound per week (approximately 4-5 pounds per month) during this period. Excessive weight gain can increase the risk of gestational hypertension, preeclampsia, and macrosomia, potentially complicating both delivery and postpartum recovery for the mother and fetus. The total recommended weight gain is usually 25 to 35 pounds.
Choice B rationale
The recommendation for total weight gain during pregnancy for a woman who has a normal pre-pregnancy body mass index (BMI of 18.5 to 24.9) is 25 to 35 pounds (11.5 to 16 kg). This weight gain is necessary to support the growth of the fetus, placenta, amniotic fluid, increased maternal blood volume, breast tissue, and uterine size. Achieving this range is associated with the best outcomes for both the mother and the newborn, reducing risks like preterm birth.
Choice C rationale
A weight gain of 40 pounds (18 kg) is at the higher end of or exceeds the recommended range for a woman with a normal BMI, suggesting it is not the minimum healthy gain. Furthermore, the rate of gain should be slow in the first trimester (2 to 4 pounds total) and then accelerate to about one pound per week in the second and third trimesters, making one pound per month much too slow after the first trimester.
Choice D rationale
Maternal obesity (BMI ≥ 30) is strongly associated with numerous adverse pregnancy outcomes, including an increased risk of miscarriage (pregnancy loss), stillbirth, gestational diabetes, preeclampsia, and a higher chance of needing a cesarean delivery. Obese women are typically advised to gain less weight, generally 11 to 20 pounds (5 to 9 kg) during the entire pregnancy, and should be monitored closely due to the elevated risks.
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