The nurse is listening to the fetal heart tones of a client at 37 weeks' gestation while the client is in a supine position. The client states, "I'm getting lightheaded and dizzy." The best action by the nurse is to:
1. Assist the client to sit up.
2. Remind the client that you need to hear the baby.
3. Help the client turn onto her side.
4. Check the client's blood pressure.
3
Rationale:
1. The client is experiencing supine hypotension syndrome. The fetus is compressing the vena cava, which decreases blood flow to the left atrium, resulting in low blood pressure, dizziness, lightheadedness, pallor, and clamminess. Turn the client to her side to get the weight of the fetus off the vena cava.
2. This would not improve the situation, and is not therapeutic. The client is experiencing supine hypotension syndrome. The fetus is compressing the vena cava, which decreases blood flow to the left atrium, resulting in low blood pressure, dizziness, lightheadedness, pallor, and clamminess. Turn the client to her side to get the weight of the fetus off the vena cava.
3. The client is experiencing supine hypotension syndrome. The fetus is compressing the vena cava, which decreases blood flow to the left atrium, resulting in low blood pressure, dizziness, lightheadedness, pallor, and clamminess. Turn the client to her side to get the weight of the fetus off the vena cava, and she will feel better.
4. When a client in the third trimester is in a supine position, the vena cava becomes compressed by the fetus, causing supine hypotension syndrome. We know that the client is hypotensive because she is lying supine at the end of pregnancy. This compression of the vena cava decreases blood flow to the left atrium, resulting in low blood pressure, dizziness, lightheadedness, pallor, and clamminess. Turn the client to her side to get the weight of the fetus off the vena cava.
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