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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. It is not effective in treating allergic reactions like urticaria caused by antibiotics.
B. Diphenhydramine: Diphenhydramine is an antihistamine used to treat allergic reactions, including urticaria. It blocks histamine release, reducing itching, redness, and swelling associated with allergic responses.
C. Hydralazine: Hydralazine is an antihypertensive medication used to treat severe high blood pressure. It has no role in managing allergic reactions and would not address the urticaria symptoms.
D. Protamine: Protamine is used to reverse the effects of heparin in cases of overdose or bleeding. It does not counteract allergic responses and is not indicated for urticaria.

A. Palpate the pulse distal to the cast. B. Place an ice pack over the cast. C. Teach the client to keep the cast clean and dry. D. Position the tasted extremity on a pillow.

Correct Answer is A

Explanation

A. Palpate the pulse distal to the cast: Assessing circulation is the priority after cast application to detect signs of compartment syndrome or impaired perfusion. A diminished or absent distal pulse may indicate an emergency requiring immediate intervention.
B. Place an ice pack over the cast: Applying ice can reduce swelling and discomfort in the first 24 to 48 hours, but it is a supportive measure. It should be done after confirming that circulation is intact.
C. Teach the client to keep the cast clean and dry: Client education is important for long-term cast care, but it is not an immediate priority following application. Circulatory checks take precedence to prevent complications.
D. Position the casted extremity on a pillow: Elevation helps minimize swelling and promote venous return, but it should be done after confirming that blood flow is adequate and not compromised by the cast.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urticaria following administration of an antibiotic. Which of the following medications should the nurse prepare to administer?

Correct Answer is B

Explanation

A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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