A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?
"Assist the client in slowing her hyperventilation and breathe into a paper bag."
"Administer oxygen via nasal cannula while encouraging her to pant."
"Have the client tuck her chin to her chest."
"Instruct the client to increase her respiratory rate to more than 42 breaths per minute."
The Correct Answer is A
Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.
Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.
Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.
Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Leukorrhea, which refers to an increase in vaginal discharge, is a common discomfort during pregnancy and is generally not a cause for concern.
Choice B: Painful and tender areas on the leg may be a sign of deep vein thrombosis (DVT), a potentially dangerous condition. During pregnancy, there is an increased risk of developing blood clots, and DVT can be a serious complication that requires immediate medical attention.
Choice C: Nausea and vomiting are common in early pregnancy and are usually associated with morning sickness. While it can be uncomfortable, it is generally not considered a dangerous symptom unless it leads to severe dehydration.
Choice D: Urinary frequency is a common discomfort during pregnancy, especially in the first and third trimesters. Although it can be bothersome, it is not typically a sign of immediate danger.
Correct Answer is C
Explanation
A. "This always happens by the end of the first trimester of pregnancy.": Quickening typically occurs later in pregnancy, not by the end of the first trimester.
B. "This will occur during the last trimester of pregnancy.": Quickening occurs much earlier than the last trimester.
C. "This usually happens between the fourth and fifth months of pregnancy.": Quickening, which is the first perception of fetal movements by the mother, generally occurs between 16 to 20 weeks of gestation.
D. "This will happen once the uterus begins to rise out of the pelvis.": Quickening does not directly correlate with the rising of the uterus out of the pelvis.
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