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 A
Explanation
Choice A reason: The NST has no known contraindications, as it is a non-invasive and safe test that does not stimulate uterine contractions or cause fetal distress. It is the most widely used method of antepartum fetal surveillance.
Choice B reason: The NST is not slightly more expensive than the CST, as it requires less time and equipment. The NST usually takes 20 to 40 minutes, while the CST may take up to 2 hours. The NST only needs a fetal monitor, while the CST also needs an intravenous line and oxytocin infusion.
Choice C reason: The NST does not have fewer false-positive results than the CST, as it has a higher rate of nonreactive results that may indicate fetal compromise when there is none. A nonreactive NST is one that does not show at least two accelerations of the fetal heart rate of 15 beats per minute or more lasting 15 seconds or more in a 20-minute period.
Choice D reason: The NST is not more sensitive in detecting fetal compromise than the CST, as it has a lower predictive value for fetal well-being. A reactive NST is one that shows at least two accelerations of the fetal heart rate of 15 beats per minute or more lasting 15 seconds or more in a 20-minute period. However, a reactive NST does not rule out the possibility of fetal hypoxia or acidosis.
Correct Answer is C
Explanation
Choice A reason: The order in which the information is presented is not the most important factor, as it does not affect the client's motivation or ability to learn. The order of the information should be logical and sequential, but it can vary depending on the client's needs, preferences, and learning style. The nurse should assess the client's prior knowledge and tailor the teaching accordingly.
Choice B reason: The extent to which the pregnancy was planned is not the most important factor, as it does not determine the client's interest or willingness to learn. The pregnancy may be planned or unplanned, but the client may still have questions, concerns, or goals related to the pregnancy. The nurse should respect the client's feelings and emotions and provide support and guidance.
Choice C reason: The client's readiness to learn is the most important factor, as it influences the client's engagement and retention of the information. The client's readiness to learn depends on the client's perception of the relevance, importance, and benefits of the information, as well as the client's physical, psychological, and social readiness. The nurse should assess the client's readiness to learn and use appropriate strategies to enhance it, such as setting realistic and specific objectives, providing positive feedback, and involving the client in the learning process.
Choice D reason: The client's educational background is not the most important factor, as it does not reflect the client's learning needs or capabilities. The client's educational background may vary, but the client may still have similar or different learning needs depending on the pregnancy situation. The nurse should not assume the client's level of understanding or knowledge based on the client's educational background, but rather use simple and clear language, avoid medical jargon, and check for comprehension.
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