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:
Semen analysis is the initial test often performed in the evaluation of infertility. It's a non-invasive, cost-effective, and informative assessment of male fertility. Here's a detailed explanation of its significance:
Assessment of Sperm Quality:
Measures sperm count, motility (movement), and morphology (shape).
Abnormalities in any of these parameters can significantly impact the chances of conception.
Identification of Male Factor Infertility:
Contributes to approximately 40% of infertility cases.
Early identification of male factor infertility guides treatment options and avoids unnecessary testing for the female partner.
Non-Invasive and Cost-Effective:
Simple procedure involving the collection of a semen sample.
Relatively inexpensive compared to other fertility tests.
Informative Results:
Provides valuable insights into sperm health and potential causes of infertility.
Guides further diagnostic evaluation and treatment strategies.
Rationale for other choices:
Choice B: Transvaginal ultrasound
Primarily evaluates female reproductive organs.
Assesses uterine structure, ovarian function, and potential abnormalities like fibroids or cysts.
Not typically the first test in infertility evaluation unless there's a specific female-factor concern.
Choice C: Hysterosalpingography (HSG)
Assesses the patency of the fallopian tubes.
Involves X-ray imaging after injecting contrast dye into the uterus.
Often performed after semen analysis if male factor infertility is not identified.
Choice D: Hysteroscopy
A more invasive procedure involving direct visualization of the inside of the uterus.
Used to diagnose and treat uterine abnormalities such as polyps or fibroids.
Not typically a first-line test in infertility evaluation.
Correct Answer is C
Explanation
The correct answer is C. The test results are normal.
Choice A rationale:
A biophysical profile (BPP) score of 8 does not necessarily indicate a need for immediate cesarean delivery.
Cesarean delivery is typically reserved for cases where there is a clear and urgent risk to the health of the mother or fetus, such as severe fetal distress or placental abruption.
A score of 8, while not the highest possible score, is still within the normal range and does not, by itself, constitute a reason for immediate surgical intervention.
Choice B rationale:
Additional tests may be considered in certain cases, such as when the BPP score is borderline or when there are other risk factors present.
However, a score of 8 is generally considered reassuring and does not typically warrant further testing.
It's essential to evaluate the BPP score in the context of the overall clinical picture, including the gestational age, maternal health, and fetal history.
Choice D rationale:
While an obstetric specialist may review the BPP results and discuss delivery options with the patient, this is not typically done within a week for a score of 8.
A score of 8 indicates reassuring fetal well-being, and there is usually no need for such urgent consultation or decision-making.
The timing of delivery discussions would depend on the overall clinical situation and the patient's individual preferences.
Choice C rationale:
A BPP score of 8 is considered normal.
It suggests that the fetus is well-oxygenated and has normal heart rate, breathing movements, muscle tone, and amniotic fluid levels.
This score does not raise immediate concerns about fetal well-being and does not typically require any immediate interventions.
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