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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?

A.

Assist the client to breathe into a paper bag or cupped hand.

B.

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

C.

Have the client tuck her chin to her chest.

D.

Administer oxygen via nasal cannula.

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Quickening occurs between the first and second months of pregnancy. This statement is incorrect. Quickening is the term used to describe the first sensations of fetal movement, which usually occur between the 18th and 20th weeks of pregnancy. During the first and second months of pregnancy, the fetus is too small for the mother to feel any movement. This choice is inaccurate.

Choice B rationale:

Quickening occurs between the fourth and fifth months of pregnancy. This is the correct choice. Quickening typically occurs between the 18th and 20th weeks of pregnancy. It marks an important milestone in pregnancy when the mother can start feeling the baby's movements. This is a key point to include in teaching.

Choice C rationale:

Quickening starts soon after implantation. This statement is inaccurate. Quickening does not occur immediately after implantation. Implantation typically occurs around 6-10 days after fertilization. Quickening happens much later in pregnancy, as previously mentioned, between the fourth and fifth months.

Choice D rationale:

Quickening starts during the last weeks of pregnancy. This statement is also incorrect. Quickening is a term used to describe the first movements of the fetus, and it occurs during the second trimester of pregnancy, not during the last weeks. This choice is not accurate.

Correct Answer is B

Explanation

To calculate the estimated date of delivery (EDD) using Naegele’s rule, the nurse would:

  1. Add one year to the year of the last menstrual period (LMP).
  2. Subtract three months from the month of the LMP.
  3. Add seven days to the day of the LMP.

Given the first day of the client’s last menstrual period was April 4, 2023:

  1. Adding one year: April 4, 2024
  2. Subtracting three months: January 4, 2024
  3. Adding seven days: January 11, 2024

So, the nurse should tell the client that her estimated date of delivery (EDD) isJanuary 11, 2024.

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