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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action for a client with blood glucose levels ranging from 180 mg/dL to 250 mg/dL following meals. In this scenario, the client's blood glucose levels are already elevated, and increasing carbohydrates may further exacerbate hyperglycemia. It's important to focus on blood glucose control rather than increasing carbohydrate intake.

Choice B rationale:

Scheduling a 2-hour oral glucose tolerance test is not the immediate action required in this case. While this test can help diagnose gestational diabetes, the client's elevated post-meal blood glucose levels are already a concern. The primary concern is addressing and managing these high levels before proceeding with additional testing.

Choice C rationale:

Anticipating an order for insulin administration is the correct action. When a client with gestational diabetes has blood glucose levels consistently above the target range, despite dietary modifications, insulin administration may be necessary to achieve glycemic control. This is a key intervention to prevent complications for both the mother and the baby.

Choice D rationale:

Obtaining an HbA1c is not typically done during pregnancy to assess glucose control, as it reflects the average blood glucose levels over the past 2-3 months. In this case, more immediate monitoring and intervention are required to address the high post-meal blood glucose levels. Now, let's move on to the final question.

A. A client who is scheduled for discharge in 2 hr following a laparoscopic tubal ligation. B. A client who experienced a cesarean birth 4 hr ago and reports pain. C. A client who has preeclampsia and a BP of 138/90 mm Hg. D. A client who experienced a vaginal birth 24 hr ago and reports no bleeding.

Correct Answer is B

Explanation

Choice A rationale:

The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.

Choice B rationale:

A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.

Choice C rationale:

A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.

Choice D rationale:

A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results from a client who is at 28 weeks of gestation and has gestational diabetes.The nurse notes that blood glucose levels taken 1 hr following a meal range from 180 mg/dL to 250 mg/dL over the past week.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is receiving report about assigned clients at the start of his shift.Which of the following clients should the nurse plan to attend to first?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

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A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth.Which of the following information should the nurse include in the teaching? (Select all that apply.).

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform?

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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?