What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
Avoid alcohol, caffeine, and smoking.
Eliminate between meal snacks
Practice relaxation techniques when the nausea first begins
Increase intake of fluids to 3 quarts daily
The Correct Answer is C
A. Avoid alcohol, caffeine, and smoking: This is generally good advice during pregnancy to promote a healthy environment for the developing fetus, but it may not specifically address nausea.
B. Eliminate between meal snacks: While this might be suggested for some individuals, keeping something light on the stomach, like crackers, can sometimes help alleviate nausea.
C. Practice relaxation techniques when the nausea first begins: Relaxation techniques, such as deep breathing or meditation, can be beneficial in managing nausea, especially if stress or anxiety contributes to the symptoms.
D. Increase intake of fluids to 3 quarts daily: Staying hydrated is important during pregnancy, but drinking too much fluid at once might not necessarily alleviate nausea and could potentially make it worse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Encourage voiding:A boggy uterus that is displaced above and to the right of the umbilicus often indicates that the bladder may be distended, which can push the uterus out of its normal position and prevent it from contracting properly. Encouraging the client to void can help to reduce bladder distension and allow the uterus to return to its normal position and firm up.
Notify healthcare provider:While this may ultimately be necessary if the problem persists or other complications are noted, the immediate action should be to address the most common cause of uterine displacement, which is bladder distension.
Inspect the perineal pad:
Checking the perineal pad can give clues about the amount of lochia (postpartum vaginal discharge). However, in this scenario, the priority lies in addressing the potential uterine atony.
Monitor vital signs:
While it's important to monitor vital signs, especially in postpartum clients, the priority here is recognizing and managing the potential uterine atony.
Correct Answer is B
Explanation
A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.
B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.
C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.
D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.
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