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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A: While relaxation can be helpful during a pelvic examination, it is not the most comprehensive response to address the client's concerns.

Choice B: A pelvic examination is not always required for prescribing birth control pills. In many cases, a healthcare provider can prescribe oral contraceptives based on the client's medical history and other factors without a pelvic exam.

Choice C: This response encourages the client to express her specific concerns and fears related to the examination, allowing the nurse to address them directly and provide appropriate support and reassurance.

Choice D: Although offering support during the exam is important, it does not address the client's nervousness and concerns about the examination itself.

A. Temperature 38.2°C (100.8°F) B. The client reports reduced sensation of the lower extremities. C. The client reports generalized itching. D. Blood pressure 80/52 mm Hg

Correct Answer is D

Explanation

A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Correct Answer is D

Explanation

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