A pregnant client in the transition phase of labor is taking shallow breaths at more than twice the normal adult breathing rate.
She comments that she is feeling light-headed, dizzy, and states that her fingers are tingling.
What should the nurse do?
Administer oxygen via a mask or nasal cannula.
Tell her to breathe at a normal rate.
Notify the physician.
Instruct the patient to breathe into her cupped hands.
The Correct Answer is A
Rationale for Choice A:
Administering oxygen via a mask or nasal cannula is the most appropriate nursing intervention in this situation. Here's a detailed explanation:
- Addresses Hypoxia: The client's symptoms of lightheadedness, dizziness, and tingling fingers strongly suggest hyperventilation, which can lead to hypoxemia (low blood oxygen levels). Administering oxygen directly increases the concentration of oxygen in the client's bloodstream, rapidly addressing the hypoxia and its associated symptoms.
- Promotes Calmness: Oxygen therapy can also have a calming effect, which can help to slow the client's breathing rate and further improve oxygenation. This is crucial during the transition phase of labor, as anxiety and stress can exacerbate hyperventilation.
- Supports Fetal Oxygenation: Ensuring adequate maternal oxygenation is essential for fetal well-being. By providing oxygen to the mother, the nurse is also indirectly supporting the oxygen supply to the fetus.
Rationale for Choice B:
Telling the client to breathe at a normal rate is not an effective intervention for hyperventilation. It's often challenging for a client experiencing hyperventilation to control their breathing rate on command. This approach can also increase anxiety, potentially worsening the hyperventilation.
Rationale for Choice C:
While notifying the physician is important to keep them informed of the client's status, it's not the immediate priority in this situation. The nurse can independently initiate oxygen therapy to address the client's hypoxia and improve her condition. The physician can then be consulted for further guidance or interventions if needed.
Rationale for Choice D:
Instructing the client to breathe into her cupped hands is a technique that can sometimes help to slow breathing and increase carbon dioxide levels. However, it's not as effective as administering oxygen in addressing the underlying hypoxia and may not provide sufficient relief for the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Fetal heart rate of 90 beats per minute is a sign of fetal bradycardia, which is a serious and potentially life-threatening condition. It indicates that the fetus is not getting enough oxygen, and it can lead to fetal distress, brain damage, or even death.
Oxytocin can cause uterine hyperstimulation, which can reduce blood flow to the placenta and cause fetal bradycardia. Therefore, if the nurse observes a fetal heart rate of 90 beats per minute, it is essential to discontinue the oxytocin infusion immediately and notify the healthcare provider.
Choice B rationale:
Increased urinary output is not a direct contraindication to oxytocin administration. In fact, oxytocin can sometimes cause a decrease in urinary output due to its antidiuretic effects.
While a significant increase in urinary output could be a sign of fluid overload, it would not necessarily indicate that the oxytocin infusion needs to be discontinued. The nurse would need to assess the patient's overall fluid status and other clinical indicators to make this determination.
Choice C rationale:
Three contractions occurring within a 10-minute period is considered a normal contraction pattern during labor. It is not a sign of uterine hyperstimulation or fetal distress.
In fact, the goal of oxytocin administration is to achieve regular contractions that are occurring every 2-3 minutes and lasting 40-60 seconds. Therefore, this finding would not indicate that the oxytocin infusion needs to be discontinued.
Choice D rationale:
Adequate resting tone of the uterus palpated between contractions is a normal finding during labor. It indicates that the uterus is contracting effectively and is not at risk for uterine atony (lack of muscle tone).
This finding would not be a reason to discontinue the oxytocin infusion.
Correct Answer is C
Explanation
The correct answer is C. Only one copy of the variant gene is needed for expression of the disease.
Choice A rationale:
Huntington's disease (HD) is not typically diagnosed in childhood. While symptoms can sometimes manifest in adolescence or early adulthood, the average age of onset is between 30 and 50 years old.
Early-onset HD, which occurs before the age of 20, is much rarer and accounts for only about 5-10% of cases.
It's crucial to convey accurate information about the typical age of onset to avoid unnecessary anxiety and unwarranted testing in children.
Choice B rationale:
The statement "If you are a carrier, there is a 25% chance your child will inherit the gene" is not entirely accurate for autosomal dominant disorders like HD.
If a parent has HD, each child has a 50% chance of inheriting the mutated gene, not 25%. This is because the parent with HD has one mutated copy of the gene and one normal copy.
During conception, each child randomly receives one copy of the gene from each parent. Therefore, there's a 50% chance the child will receive the mutated copy and a 50% chance they'll receive the normal copy.
Choice D rationale:
Referral to a genetic counselor is essential for all individuals with a family history of HD, regardless of their carrier status.
Genetic counselors can provide comprehensive information about HD, including: Inheritance patterns
Risk assessment
Testing options
Reproductive options
Support resources
Psychosocial counseling
They can assist individuals in making informed decisions about testing, family planning, and management of the condition.
Choice C is the correct answer because:
HD is indeed an autosomal dominant disorder, meaning that only one copy of the mutated gene is needed for an individual to develop the disease.
This contrasts with autosomal recessive disorders, which require two copies of the mutated gene (one from each parent) for the disease to manifest.
Understanding the pattern of inheritance is crucial for accurate risk assessment and genetic counseling.
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