A nurse is assisting with the care of a client who is using pattern-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?

Instruct the client to maintain a breathing rate no less than twice the normal rate.

Administer oxygen via nasal cannula.

Assist the client to breathe into a paper bag.

Have the client tuck her chin to her chest.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Assist the client to breathe into a paper bag.

Choice A rationale:

Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.

Choice B rationale:

Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.

Choice C rationale:

Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.

Choice D rationale:

Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.

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Correct Answer is B

Explanation

Choice A rationale:

Hypotension is not an expected finding in a client with severe preeclampsia. In preeclampsia, the client typically experiences hypertension (high blood pressure) rather than hypotension (low blood pressure). Hypotension may be concerning as it could indicate inadequate perfusion to vital organs.

Choice B rationale:

Headache is an expected finding in a client with severe preeclampsia. Headaches are a common symptom of preeclampsia and are often described as persistent and severe. They can result from increased blood pressure and possibly cerebral oedema.

Choice C rationale:

Tachycardia is not an expected finding in a client with severe preeclampsia. Tachycardia refers to an abnormally fast heart rate, but in preeclampsia, bradycardia (abnormally slow heart rate) or a normal heart rate is more typical. Tachycardia could indicate other underlying issues.

Choice D rationale:

Polyuria is not an expected finding in a client with severe preeclampsia. Polyuria is characterized by excessive urination, and in preeclampsia, the opposite may occur due to decreased kidney perfusion, resulting in oliguria (reduced urine output).

A. Blood pressure. B. Cerebral manifestations. C. Fetal heart rate. D. Respiratory rate. E. Deep tendon reflexes. F. Gastrointestinal assessment findings.

Correct Answer is ["A","B","E"]

Explanation

The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.

Choice A rationale:

Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.

Choice B rationale:

Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.

Choice C rationale:

The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.

Choice D rationale:

The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.

Choice E rationale:

Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.

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A nurse is assisting with the care of a client who is using pattern-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?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?

Correct Answer is B

Explanation

Correct Answer is ["A","B","E"]

Explanation

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