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Difficulty: EasyAnte/Intra/Postpartum and Newborn Care

A client at 34 weeks of gestation lies flat on her back during a prenatal ultrasound examination. She suddenly reports feeling lightheaded and nauseous, and the nurse observes that her skin is pale and clammy. What is the most appropriate initial nursing action?

  1. Turn the client onto her left side.Answer
  2. B
    Elevate the client's legs while keeping her flat on the examination table.
  3. C
    Instruct the unlicensed assistive personnel to immediately obtain the client's blood pressure.
  4. D
    Initiate a rapid sequence of deep breathing exercises to increase oxygenation.

Answer

Turn the client onto her left side.
The correct action relieves vena cava compression caused by the weight of the pregnant uterus. Shifting the client to a lateral position immediately restores venous return, cardiac output, and adequate blood pressure, rapidly resolving the symptoms of supine hypotensive syndrome.

Step-by-Step Solution

1
Identify the client's symptoms and position.
The client is experiencing lightheadedness, nausea, and pallor while lying supine.
These are classic signs of supine hypotensive syndrome.
2
Determine the underlying physiological cause.
The gravid uterus is compressing the inferior vena cava, decreasing venous return to the heart.
Recognizing the mechanical cause dictates the correct intervention.
3
Select the most direct and effective intervention.
Lateral positioning is chosen as the immediate action.
Shifting the uterus off the major blood vessels immediately restores normal hemodynamics.

Key Concept

Supine hypotensive syndrome and lateral positioning
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Topics

Ante/Intra/Postpartum and Newborn Care

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