After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?
Place the client in the Trendelenburg position.
Remove the client's legs from the stirrups.
Instruct the client to take deep breaths.
Place a wedge under the client's hip.
The Correct Answer is D
A. Place the client in the Trendelenburg position: While this position may increase venous return, it does not address the underlying cause in a pregnant client, which is usually aortocaval compression by the uterus. Simply tilting the table may be less effective than proper lateral displacement.
B. Remove the client's legs from the stirrups: Removing the legs may relieve some discomfort but does not correct the maternal hypotension caused by pressure on the inferior vena cava. Additional interventions are needed to improve circulation.
C. Instruct the client to take deep breaths: Deep breathing may help with anxiety or mild shortness of breath but does not resolve the hemodynamic compromise caused by supine hypotensive syndrome.
D. Place a wedge under the client's hip: Placing a wedge under the right or left hip tilts the uterus off the inferior vena cava, improving venous return, cardiac output, and blood pressure. This is the priority action to relieve dizziness, pallor, and diaphoresis in a pregnant client at 26 weeks’ gestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.
B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.
C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.
D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.
Correct Answer is D
Explanation
A. "You should not worry about the growth tables. They are only averages for children.": Growth charts are standardized tools used to compare a child’s development with expected norms. Dismissing the concern overlooks an important clinical sign and fails to address the parent’s valid question.
B. "Haven't you been feeding according to recommended daily allowances for children?": This response places blame on the parent and does not acknowledge the child’s medical condition. It may also create unnecessary guilt rather than offering supportive education.
C. "Does your child seem mentally slower than his peers also?": Asking about developmental delay in this way is inappropriate and insensitive. It shifts the focus to cognitive ability rather than addressing the physical growth concern directly tied to the child’s condition.
D. "The smaller size is probably due to the heart disease.": Children with congenital heart defects often experience poor growth because of increased metabolic demands and reduced energy available for growth. This response gives the parent a clear, accurate explanation while validating the concern.
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