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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: The stump should fall off in 10 to 14 days.
Choice A rationale: Cleanse the area around the cord with baby oil each day. This is incorrect because cleansing with baby oil is not recommended. Instead, the nurse should advise the client to clean the area with water and a mild soap if necessary
Choice B rationale: Do not immerse the newborn's abdomen in water until the cord is dry. This is incorrect because sponge baths are recommended until the umbilical cord falls off, and immersion in water is not strictly prohibited
Choice C rationale: The stump should fall off in 10 to 14 days. This is correct because the umbilical cord stump typically falls off within 10 to 14 days after birth
Choice D rationale: Protect the cord by covering it with the newborn's diaper. This is incorrect because the diaper should be folded down below the umbilical cord to keep it dry and exposed to air
In conclusion, the nurse should reinforce that the umbilical cord stump should fall off within 10 to 14 days after birth. It is essential to provide accurate information and instructions for proper cord care to prevent infection and promote healing
Correct Answer is A
Explanation
Choice A rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
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