A nurse is assisting with the care of a client who is using paced breathing during the first stage of labor.
The client says she feels lightheaded and her fingers are tingling.
Which of the following actions should the nurse take?
Assist the client to breathe into a paper bag or cupped hand.
Instruct the client to maintain a breathing rate no less than twice the normal rate.
Have the client tuck her chin to her chest.
Administer oxygen via nasal cannula.
The Correct Answer is A
Choice A rationale:
The client is experiencing symptoms that suggest hyperventilation due to paced breathing, which can lead to respiratory alkalosis. Breathing into a paper bag or cupped hand allows the client to rebreathe carbon dioxide and helps correct the alkalosis by increasing the carbon dioxide levels in the blood. This is a common intervention for clients experiencing lightheadedness and tingling in the fingers due to hyperventilation.
Choice B rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate in this situation. It can worsen the client's symptoms and may lead to further hyperventilation. This choice does not address the underlying problem of respiratory alkalosis.
Choice C rationale:
Having the client tuck her chin to her chest is not the correct action for these symptoms. This maneuver is typically used to relieve supraventricular tachycardia (SVT) or vagal stimulation in situations of rapid heart rate. It is not relevant to the client's lightheadedness and tingling fingers.
Choice D rationale:
Administering oxygen via nasal cannula is not indicated in this case. The client's symptoms are not suggestive of hypoxemia, but rather, they are related to respiratory alkalosis. Providing oxygen could potentially worsen the condition by reducing carbon dioxide levels further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? The correct answer is choice D: "You will need an immunization following delivery.”.
Choice A rationale:
"You had the rubella infection as a child.”. This statement is incorrect. A negative rubella titer indicates that the client is not immune to rubella. Even if the client had the infection as a child, it does not guarantee immunity for life. Immunity can wane over time, and some individuals may not have developed sufficient immunity after a natural infection.
Choice B rationale:
"I will administer the rubella immunization to you today.”. This statement is not recommended. Rubella vaccination is a live attenuated vaccine, and it is generally contraindicated during pregnancy due to the theoretical risk of transmission to the fetus. Rubella vaccination is usually recommended postpartum if the woman is not immune. The nurse should not administer the vaccine during pregnancy.
Choice C rationale:
"You are immune to rubella.”. This statement is incorrect. A negative rubella titer clearly indicates that the client is not immune to rubella. It's crucial for healthcare providers to provide accurate information to the client and ensure that appropriate immunization is administered postpartum to protect both the mother and the newborn.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Blotting the perineal area dry after voiding is an important part of perineal care. Moisture can contribute to perineal infection, so it is essential to keep the area dry. This practice helps prevent the growth of bacteria and reduces the risk of infection.
Choice D rationale:
Cleaning the perineal area from front to back is crucial in reducing the risk of perineal infection. This method helps prevent the transfer of bacteria from the anal area to the perineum and vaginal area, reducing the risk of infection.
Choice E rationale:
Performing hand hygiene before and after voiding is an important aspect of perineal care and infection prevention. Proper hand hygiene helps prevent the transfer of bacteria from the hands to the perineal area and vice versa, reducing the risk of infection.
Choice B rationale:
Applying ice packs to the perineal area several times daily is not a recommended practice for reducing the risk of perineal infection. While ice packs can provide pain relief and reduce swelling, they should not be applied excessively, as prolonged exposure to cold can compromise blood flow and potentially increase the risk of tissue damage or infection.
Choice C rationale:
Sitting on an inflatable donut to protect the perineum is not a recommended practice for reducing the risk of perineal infection. Inflatable donuts can increase pressure on the perineal area, potentially causing discomfort and impairing blood flow. Proper hygiene and keeping the area clean and dry are more effective strategies for infection prevention. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.