The nurse is assessing a woman in early labor.
While positioning her for a vaginal exam, she complains of dizziness and nausea and appears pale.
Her blood pressure has dropped slightly.
What is the appropriate initial nursing action?
Call the healthcare provider.
Elevate the head of the bed.
Encourage deep breathing.
Turn her to her side.
The Correct Answer is D
Choice A rationale
Calling the healthcare provider delays immediate intervention needed to alleviate the client's symptoms of dizziness and nausea due to supine hypotensive syndrome. Quick repositioning is crucial to improve venous return and alleviate the symptoms.
Choice B rationale
Elevating the head of the bed will not relieve the pressure on the inferior vena cava caused by the supine position. This intervention does not address the underlying cause of the client's symptoms.
Choice C rationale
Encouraging deep breathing is unlikely to resolve the symptoms of supine hypotensive syndrome, which is caused by the compression of the vena cava by the gravid uterus when lying supine. This intervention does not address the physiological cause.
Choice D rationale
Turning her to her side relieves the pressure on the inferior vena cava, improving venous return and increasing blood pressure. This is the correct initial action to address the symptoms of supine hypotensive syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
The correct answer is:
A. Administer azithromycin 1 g PO one time. Anticipated.
B. Administer ibuprofen 600 mg PO twice a day PRN pain. Nonessential.
C. Notify all sexual partners within the prior 30 days of the need for STI screening. Anticipated.
D. Administer ceftriaxone 250 mg IM now. Anticipated.
E. Notify the appropriate public health agency of the positive diagnostic test results. Anticipated.
F. Administer acyclovir 400 mg PO three times per day. Nonessential. .
Correct Answer is A
Explanation
Choice A rationale
At 9 weeks gestation, the primary purpose of an ultrasound is to confirm the presence of a fetal heartbeat, which indicates a viable pregnancy.
Choice B rationale
Chromosomal defects are typically assessed using different tests, such as chorionic villus sampling or amniocentesis, rather than an ultrasound at this early stage.
Choice C rationale
Fetal lung maturity cannot be assessed at 9 weeks gestation because the lungs are not yet developed. This assessment is usually done later in pregnancy if preterm delivery is anticipated.
Choice D rationale
The position of the fetus in utero is not a concern at this early stage of pregnancy. Fetal positioning becomes relevant later in pregnancy, closer to delivery.
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