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 A
Explanation
Choice A rationale:
The rooting reflex is the newborn's natural response to touch around their mouth, particularly the cheek. When the cheek is touched, the infant will turn their head in that direction and open their mouth, initiating the sucking reflex. This reflex helps the newborn find the breast or bottle for feeding.
Choice B rationale:
The Moro reflex is not associated with the initiation of sucking. The Moro reflex is a startle reflex that involves extending and retracting the arms and legs when a newborn feels a sudden loss of support or experiences a loud noise.
Choice C rationale:
The stepping reflex is not related to the initiation of sucking. The stepping reflex is an automatic response that occurs when you hold a newborn upright with their feet touching a surface, causing them to make stepping movements.
Choice D rationale:
The Babinski reflex involves the extension and fanning out of the toes when the sole of the foot is stroked. It is not associated with the initiation of sucking.
Correct Answer is C
Explanation
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding is more suggestive of abruptio placentae rather than placenta previa. Placenta previa is characterized by painless vaginal bleeding, and the absence of pain is a key distinguishing factor in its diagnosis. Therefore, this finding does not align with the typical presentation of placenta previa.
Choice B rationale:
Severe abdominal pain with increasing fundal height is not consistent with the typical presentation of placenta previa. Placenta previa is generally associated with painless vaginal bleeding, and fundal height measurements are not typically used to diagnose placenta previa. This finding suggests a different condition, such as abruptio placentae, which involves painful bleeding with a rising fundal height.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus is more characteristic of preterm labor or other conditions, not placenta previa. Placenta previa is primarily associated with painless, bright red vaginal bleeding without contractions or pain. Therefore, this finding does not align with the typical presentation of placenta previa.
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