What is the best nursing intervention for a pregnant woman in her third trimester who complains of feeling faint, dizzy, and agitated while her vital signs are being assessed?
Have the patient stand up and retake her blood pressure.
Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms.
Have the patient sit down and hold her arm in a dependent position.
Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
The Correct Answer is D
Choice A reason: This is not a good intervention, as it may worsen the symptoms of faintness, dizziness, and agitation. Standing up can cause a sudden drop in blood pressure (orthostatic hypotension), which can reduce the blood flow to the brain and the fetus. This can cause lightheadedness, blurred vision, and loss of consciousness in the woman, as well as fetal distress or hypoxia.
Choice B reason: This is not a good intervention, as it may also worsen the symptoms of faintness, dizziness, and agitation. Lying supine can cause compression of the inferior vena cava (a large vein that returns blood to the heart) by the gravid uterus, which can reduce the cardiac output (the amount of blood pumped by the heart) and the blood pressure. This can cause nausea, sweating, and visual disturbances in the woman, as well as fetal distress or hypoxia.
Choice C reason: This is not a good intervention, as it may not improve the symptoms of faintness, dizziness, and agitation. Sitting down and holding the arm in a dependent position can lower the blood pressure in the arm, but not in the rest of the body. This can cause inaccurate readings of the blood pressure and delay the detection of hypotension or hypertension. This can also cause discomfort and pain in the arm due to impaired circulation.
Choice D reason: This is the best intervention, as it can relieve the symptoms of faintness, dizziness, and agitation by improving the blood flow to the brain and the fetus. Turning to the left side can reduce the pressure of the uterus on the inferior vena cava and increase the cardiac output and the blood pressure. This can also optimize the placental perfusion (the blood flow to the placenta) and the fetal oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the main reason, as the use of contraceptives for an extended time does not necessarily affect the fertility of a woman. Most contraceptives are reversible and do not cause permanent damage to the reproductive system. However, some contraceptives may take longer to wear off than others, and some may have side effects that can interfere with ovulation or implantation.
Choice B reason: This is the main reason, as the aging process can affect the ovaries and the quality and quantity of the eggs. As a woman ages, her ovarian reserve (the number of eggs in the ovaries) declines, and the eggs become more prone to chromosomal abnormalities. This can reduce the chances of conception and increase the risk of miscarriage or birth defects.
Choice C reason: This is not the main reason, as prepregnancy medical attention is not a prerequisite for achieving pregnancy. However, prepregnancy medical attention can be beneficial for a woman who is older than 35 years, as it can help identify and manage any existing or potential health problems that may affect the pregnancy, such as diabetes, hypertension, or thyroid disorders.
Choice D reason: This is not the main reason, as personal risk behaviors are not specific to a woman who is older than 35 years. Personal risk behaviors are factors that can negatively affect the fertility of any woman, regardless of age. Some examples of personal risk behaviors are smoking, drinking, using drugs, having multiple sexual partners, or having sexually transmitted infections.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Limiting time spent wearing a wet bathing suit is a good preventive measure, as it can reduce the moisture and warmth that can promote the growth of bacteria and fungi in the genital area. The nurse should advise the 15-year old to change into dry clothes as soon as possible after swimming or bathing.
Choice B reason: Not douching is a good preventive measure, as it can preserve the natural balance of the vaginal flora and pH. The nurse should explain to the 15-year old that douching can wash away the protective mucus and lactobacilli that prevent infections, and it can also introduce harmful substances or microorganisms into the vagina.
Choice C reason: Wearing nylon undergarments is not a good preventive measure, as it can trap heat and moisture in the genital area and create a favorable environment for infections. The nurse should recommend the 15-year old to wear cotton or breathable fabrics that can absorb sweat and allow air circulation.
Choice D reason: Using floral scented bath salts is not a good preventive measure, as it can irritate the genital mucosa and alter the vaginal pH. The nurse should caution the 15-year old to avoid using any products that contain perfumes, dyes, or chemicals in the genital area, as they can cause allergic reactions or infections.
Choice E reason: Decreasing sugar intake is a good preventive measure, as it can lower the risk of yeast infections. The nurse should educate the 15-year old that sugar can feed the growth of Candida albicans, which is a common cause of vaginal candidiasis. The nurse should also encourage the 15-year old to eat a balanced diet that includes probiotics, such as yogurt, to maintain a healthy vaginal flora.
Choice F reason: Avoiding tight-fitting jeans is a good preventive measure, as it can prevent friction and pressure on the genital area. The nurse should suggest the 15-year old to wear loose or comfortable clothing that can reduce the risk of skin irritation or injury, which can lead to infections.
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