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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B","dropdown-group-3":"A","dropdown-group-4":"C"}
Explanation
- HEENT – Dry mouth; Amitriptyline has strong anticholinergic effects, which inhibit salivary gland secretion, commonly resulting in dry mouth. This side effect can affect oral comfort, dental health, and appetite.
- Cardiovascular – Tachycardia: Tricyclic antidepressants like amitriptyline can cause tachycardia due to their anticholinergic properties and direct effects on cardiac conduction. These drugs inhibit vagal tone, which increases heart rate, and can also affect the sodium channels in cardiac tissue.
- Genitourinary – Urinary retention: Amitriptyline’s anticholinergic activity relaxes the detrusor muscle and contracts the internal urethral sphincter, impairing normal bladder emptying. This can lead to difficulty initiating urination and incomplete bladder emptying, particularly in older adults.
- Gastrointestinal – Constipation: By inhibiting parasympathetic activity in the GI tract, amitriptyline slows peristalsis, leading to constipation. This side effect is common and can become severe without dietary adjustments or the use of stool softeners.
Correct Answer is C
Explanation
A. Systemic lupus erythematosus: SLE primarily affects connective tissue and organs through inflammation but rarely impacts the neuromuscular coordination needed for swallowing. It does not significantly raise aspiration risk during enteral feeding.
B. Increased gastric motility: Increased gastric motility helps clear stomach contents more quickly, decreasing the chance of regurgitation and aspiration. It is not typically considered a risk factor for aspiration.
C. Parkinson's disease: Parkinson’s disease impairs muscle coordination, including muscles used for swallowing. This dysphagia increases the risk of aspiration, especially with liquid feedings via a nasogastric tube.
D. Celiac disease: Celiac disease affects the small intestine’s ability to absorb nutrients but does not interfere with the swallowing reflex. It does not increase the risk of aspiration with tube feedings.
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