The clinic nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
Listen to the fetal heart rate.
Assess the client’s recent food and fluid intake.
Check the client’s blood pressure and pulse.
Turn the client to a lateral position.
The Correct Answer is D
Choice A rationale
Evaluating the fetal heart rate does not address maternal symptoms of supine hypotensive syndrome. Moving the client first corrects the underlying issue. Fetal evaluation can follow once maternal circulation improves, ensuring both are assessed.
Choice B rationale
Checking recent food and fluid intake does not immediately address the likely cause of supine hypotensive syndrome. Correcting maternal positioning is urgent to improve venous return and prevent adverse effects, then other assessments can follow.
Choice C rationale
Measuring blood pressure and pulse can confirm hypotension but does not address its cause. Immediate repositioning to lateral position alleviates the compression on the inferior vena cava, improving blood flow before measuring vitals.
Choice D rationale
Turning to a lateral position relieves the vena cava from compression by the gravid uterus, reducing symptoms of supine hypotensive syndrome. This action improves venous return, stabilizing maternal hemodynamics and alleviating dizziness and pallor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fasting for 8 hours before the AFP test is not required. This misinformation might cause unnecessary patient anxiety. Understanding test protocols helps in providing accurate and reassuring patient education, reducing pre-test stress.
Choice B rationale
AFP test is a screening tool to identify potential anomalies such as neural tube defects or chromosomal abnormalities. It does not provide a definitive diagnosis but indicates if further diagnostic testing is warranted for confirming anomalies.
Choice C rationale
Absence of chronic illnesses does not guarantee normal AFP test results. This statement is misleading, as AFP levels can be affected by a variety of factors, including gestational age and fetal conditions, requiring comprehensive analysis.
Choice D rationale
Bed rest is not necessary after an AFP test. This misinformation may cause unnecessary concern or inconvenience for the patient. Proper understanding of post-test care helps in providing correct patient instructions and alleviating fears.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Linea nigra, a dark line on the abdomen, appears due to increased melanocyte-stimulating hormone during pregnancy.
Choice B rationale
Eczema is not specifically associated with pregnancy and can occur independently of it.
Choice C rationale
Striae gravidarum, or stretch marks, are due to skin stretching and increased cortisone during pregnancy.
Choice D rationale
Psoriasis is not commonly related to pregnancy changes and occurs regardless of pregnancy.
Choice E rationale
Chloasma, also known as the mask of pregnancy, is due to increased pigmentation from hormonal changes.
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