Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center.She is lying supine on a backboard, is awake, and denies any complaints.
Her blood pressure is 80/50 mmHg and her heart rate is 130 beats/minute.
Which action should the nurse implement first?

Infuse 1,000 mL normal saline using a large bore IV.

Obtain a blood sample for a complete blood count.

Tilt the backboard sideways to displace the uterus laterally.

Palpate the abdomen for contractions.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.

Choice B rationale

Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.

Choice C rationale

Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.

Choice D rationale

Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.

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Free Nursing Study Resources

Correct Answer is ["50"]

Explanation

Step 1 is (2 grams/hour ÷ 20 grams) × 500 mL.

Step 2 is (2 ÷ 20) × 500.

Step 3 is 0.1 × 500. The final calculated answer is 50 mL/hour.

A. Infuse 1,000 mL normal saline using a large bore IV. B. Obtain a blood sample for a complete blood count. C. Tilt the backboard sideways to displace the uterus laterally. D. Palpate the abdomen for contractions.

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

View Question and Answer

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["50"]

Explanation

Correct Answer is C

Explanation

In preparing a gravid client for a triple screen analysis, which action should the nurse take?

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