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
The normal sequence of postpartum vaginal discharge, known as lochia, follows this order:
D. Lochia rubra, lochia serosa, lochia alba.
Here's a quick breakdown:
-
Lochia rubra (Days 1–4): Bright red discharge with blood, mucus, and tissue.
-
Lochia serosa (Days 4–10): Pinkish or brownish discharge as bleeding slows.
-
Lochia alba (Days 10–6 weeks): Yellowish-white discharge as the body completes healing.
Correct Answer is B
Explanation
Choice A rationale:
Gender of the fetus. Amniocentesis is a medical procedure used to sample amniotic fluid surrounding the fetus in the womb. It is primarily performed to obtain information about the fetus's health and development. Determining the gender of the fetus is not a standard indication for amniocentesis.
Choice B rationale:
Weeks of gestation. This is the correct answer. Amniocentesis is often performed to determine the gestational age of the fetus. It helps healthcare providers confirm the number of weeks of gestation and ensure the fetus is at an appropriate developmental stage.
Choice C rationale:
Anatomic abnormalities. Amniocentesis can be used to detect certain chromosomal abnormalities and genetic disorders in the fetus, but it is not primarily performed to identify anatomic abnormalities.
Choice D rationale:
Maturity of lungs. Determining the maturity of the fetus's lungs is typically done using other methods, such as assessing lung function and surfactant levels. It is not the primary purpose of amniocentesis.
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.