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 C
Explanation
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding is more suggestive of abruptio placentae rather than placenta previa. Placenta previa is characterized by painless vaginal bleeding, and the absence of pain is a key distinguishing factor in its diagnosis. Therefore, this finding does not align with the typical presentation of placenta previa.
Choice B rationale:
Severe abdominal pain with increasing fundal height is not consistent with the typical presentation of placenta previa. Placenta previa is generally associated with painless vaginal bleeding, and fundal height measurements are not typically used to diagnose placenta previa. This finding suggests a different condition, such as abruptio placentae, which involves painful bleeding with a rising fundal height.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus is more characteristic of preterm labor or other conditions, not placenta previa. Placenta previa is primarily associated with painless, bright red vaginal bleeding without contractions or pain. Therefore, this finding does not align with the typical presentation of placenta previa.
Correct Answer is D
Explanation
Choice A rationale:
Placing the newborn in a prone position is not recommended during phototherapy. The infant should be placed in a supine position to maximize the surface area exposed to the phototherapy lights.
Choice B rationale:
Applying lotion to the newborn's skin can interfere with phototherapy. It's important to keep the baby's skin free from lotions or ointments to ensure the effectiveness of the treatment.
Choice C rationale:
Monitoring the newborn's blood glucose level hourly is not a standard practice during phototherapy. The primary concern during phototherapy is monitoring the infant's bilirubin levels and ensuring proper eye protection.
Choice D rationale:
Monitoring the baby's temperature while on phototherapy is essential. Phototherapy can lead to heat loss, so maintaining the baby's temperature within the normal range is crucial to prevent complications. This choice is the correct answer.
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