During her prenatal exam at 26-weeks gestation, a client expresses feeling faint while lying supine on the examination table.
Which action should the practical nurse (PN) implement?
Elevate the head of the examination table.
Assist the client to a lateral position.
Place the examination table in Trendelenburg.
Step out of the room to notify the healthcare provider (HCP).
The Correct Answer is B
Choice A rationale
Elevating the head of the examination table would not effectively alleviate supine hypotensive syndrome. This condition occurs due to compression of the vena cava by the gravid uterus, reducing venous return to the heart. While elevating the head might provide some comfort, it does not directly address the underlying circulatory compromise.
Choice B rationale
Assisting the client to a lateral position, particularly the left lateral position, is the most effective intervention. This maneuver displaces the gravid uterus off the inferior vena cava, increasing venous return to the heart, thereby improving cardiac output and uteroplacental perfusion, which alleviates symptoms of faintness and dizziness.
Choice C rationale
Placing the examination table in Trendelenburg position involves lowering the head and raising the foot of the bed. This position would further exacerbate vena caval compression in a pregnant client, potentially worsening supine hypotensive syndrome and increasing the risk of aspiration, making it an contraindicated intervention.
Choice D rationale
Stepping out of the room to notify the healthcare provider (HCP) before addressing the immediate physiological distress is inappropriate. The PN should first implement immediate interventions to stabilize the client's condition, such as repositioning, and then promptly inform the HCP about the event and the interventions performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Using blunt scissors to do cut-outs typically requires fine motor skills and hand-eye coordination that are characteristic of older preschool-aged children, generally around 3 to 4 years old. A two-year-old is still developing these complex manipulative skills, making this behavior not typical for their developmental stage.
Choice B rationale
Riding a tricycle generally emerges as a developmental milestone for children between 3 to 4 years of age. This activity demands advanced gross motor coordination, balance, and bilateral pedaling skills that are usually beyond the capabilities of an average two-year-old, who is still mastering walking and running.
Choice C rationale
Sustained attention to a picture book for 15 minutes is a cognitive ability that develops with age, typically seen in older preschool or school-aged children. A two-year-old's attention span is much shorter, usually limited to a few minutes, reflecting their ongoing neurological maturation and cognitive development.
Choice D rationale
Taking toys away from another child is a common and normal behavior observed in toddlers. This is characteristic of their egocentric stage of development, where they struggle with sharing and understanding others' perspectives, often leading to possessive actions as they explore their environment and assert their will.
Correct Answer is A
Explanation
Choice A rationale
Rho immune globulin (RhoGAM) is administered to Rh-negative mothers who have given birth to an Rh-positive baby. This injection prevents the mother's immune system from developing antibodies against Rh-positive red blood cells, which could otherwise harm future Rh-positive fetuses in subsequent pregnancies through hemolytic disease of the newborn.
Choice B rationale
If the mother is Rh positive and the baby is Rh negative, there is no risk of Rh incompatibility. The Rh-positive mother's immune system will not produce antibodies against the Rh-negative fetal red blood cells, as she already possesses the Rh antigen. Therefore, Rho immune globulin is not indicated in this scenario, as there is no sensitization risk.
Choice C rationale
When both the mother and the baby are Rh negative, there is no Rh incompatibility. Since neither the mother nor the baby has the Rh antigen, the mother's immune system will not be stimulated to produce anti-Rh antibodies. Consequently, Rho immune globulin administration is unnecessary in this situation, as no immune response will be triggered.
Choice D rationale
The Rh status of the father is relevant in determining the potential for Rh incompatibility, but it does not directly dictate the need for Rho immune globulin. The critical factor is the Rh status of the mother and the baby. If the mother is Rh positive, regardless of the father's Rh status, she will not produce Rh antibodies, and RhoGAM is not indicated.
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