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 D
Explanation
A. "The test will be performed if your baby's heartbeat is heard."
Incorrect: Amniocentesis is not typically performed based on whether the baby's heartbeat is heard. It is done for specific diagnostic purposes, such as genetic testing or assessing certain fetal conditions.
B. "This test will determine if your baby's lungs are mature."
Incorrect: Amniocentesis does not determine fetal lung maturity. The test involves the extraction of a small amount of amniotic fluid to analyze fetal chromosomes and identify genetic conditions.
C. "After the test, you will be given Rh immune globulin since you are Rh positive."
Incorrect: Rh immune globulin (Rhogam) is given to Rhnegative pregnant women to prevent Rh sensitization, which occurs when an Rhnegative mother is exposed to
Rhpositive fetal blood. Rhogam is not directly related to amniocentesis.
D. "This test requires the presence of an adequate volume of amniotic fluid."
Correct: Amniocentesis requires a sufficient amount of amniotic fluid around the fetus for safe and accurate testing. If there is not enough amniotic fluid, the procedure may be postponed or canceled.
Correct Answer is C
Explanation
Choice A: Posterior neck flexion is not an expected change during pregnancy.
Choice B: Increased abdominal muscle tone is not an expected change during pregnancy. In fact, the abdominal muscles tend to stretch and may become less toned as the uterus expands.
Choice C: During pregnancy, the woman's center of gravity shifts due to the growing uterus, leading to an increased arch in the lower back known as lordosis. This change helps to maintain balance and reduce the strain on the back. The other options are not expected physiologic changes during pregnancy.
Choice D: Decreased mobility of pelvic joints is not an expected change during pregnancy. Some joint laxity may occur due to hormonal changes, but decreased mobility is not typical.
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