Health Promotion and Maintenance
22. During a routine ultrasound examination, a client, who is 33 weeks pregnant, states that she feels that her heart is pounding. She also reports feeling "hot and sweaty." Which intervention by a nurse is the most appropriate?
. Get the client a cool washcloth for her forehead.
. Administer nasal oxygen at 12 L/min.
. Place the client in Trendelenburg position.
. Assist her to a left lateral position.
Test-Taking Tip
Think about the underlying reason for this client's symptoms. Focus on the options that relate to positioning, and eliminate the option that is used for shock.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Hemodynamics
Health Promotion and Maintenance
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Answer 1 is incorrect because the client's symptoms are related to vena cava syndrome and are a result of low blood pressure. Assisting her to her side will likely resolve the problem. Answer 2 is incorrect because nasal oxygen is not needed and the flow rate is far too high for a nasal cannula. Assisting the mother to a lateral Sims' position will improve her blood pressure and reduce her symptoms. Answer 3 is incorrect because this position is indicated for a client in shock. This client should be positioned on her side to alleviate symptoms. Answer 4 is correct because changing to a left lateral position helps to alleviate vena cava compression from the gravid uterus, and will reduce her discomfort.