A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?
Administer propranolol IV to the client
Position the client on her side.
Ask the client to increase her daily calcium intake.
Use Leopold maneuvers to determine the fetal position.
The Correct Answer is B
A. Administer propranolol IV to the client: Propranolol is a beta-blocker used to treat hypertension and certain cardiac conditions. It is not indicated for sudden nausea during pregnancy and could be harmful if administered without cause.
B. Position the client on her side: At 36 weeks, the gravid uterus can compress the inferior vena cava when the client lies flat, reducing venous return and causing supine hypotensive syndrome, which often presents as nausea. Turning the client to her side relieves pressure and restores circulation.
C. Ask the client to increase her daily calcium intake: Calcium is important during pregnancy, especially for bone health, but increasing intake is not an acute intervention for nausea caused by positional blood flow issues.
D. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers assess fetal position but do not address the client’s immediate symptom of nausea, which may indicate compromised circulation from lying supine. Position change is the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “I should assess the client's skin integrity every 8 hours while in mechanical restraints.”: Skin integrity should be assessed much more frequently, typically every 1 to 2 hours, to prevent pressure injuries and ensure circulation is not impaired.
B. “I should expect the provider to evaluate the client within 4 hours of restraint application.”: Provider evaluation is required sooner, generally within 1 hour of restraint application, to ensure the necessity and appropriateness of restraints.
C. “I should ask the provider to write a prescription for mechanical restraints as needed.”: Restraints require a specific, time-limited provider order; PRN (as needed) orders are not appropriate because continuous assessment is necessary to determine ongoing need.
D. “I should visually monitor the client continuously when in mechanical restraints.”: Continuous visual monitoring is essential to ensure the client’s safety, prevent injury, and assess for any distress while restraints are in place.
Correct Answer is A,C,B,D
Explanation
A. Rolls from back to side typically occurs around 4 months of age, as the infant gains initial control of trunk and limbs. This is one of the earliest gross motor milestones.
B. Sits steadily unsupported generally develops by about 8 months, showing further improvement in core strength and postural control.
C. Rolls from back to abdomen follows around 5–6 months, demonstrating increased muscle coordination and control over the trunk and neck.
D. Changes from prone to sitting usually occurs between 9 to 10 months and indicates advanced coordination, enabling independent movement and transition between positions.
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