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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While non-pharmacologic methods can promote relaxation and coping, they may not guarantee full alertness at all times.
The intensity of labor pain can vary significantly, and even non-pharmacologic methods may not completely prevent fatigue or exhaustion.
Factors such as prolonged labor, anxiety, or discomfort can still impact alertness.
Choice C rationale:
Non-pharmacologic methods often provide significant pain relief, but they may not achieve the same degree of pain control as pharmacologic options like epidural analgesia.
The level of pain relief experienced with non-pharmacologic methods can depend on individual factors, preferences, and the specific techniques used.
Choice D rationale:
While relaxation and reduced anxiety can sometimes contribute to a more efficient labor, there's no guarantee that nonpharmacologic methods will consistently lead to a more rapid labor.
The duration of labor is influenced by various factors, including the strength and frequency of contractions, the position of the fetus, and the mother's overall health and preparedness.
Choice B rationale:
Non-pharmacologic pain management techniques do not involve medications or interventions that could potentially have adverse effects on the fetus.
This makes them a safe and desirable option for many pregnant women who are concerned about the potential risks of pharmacologic pain relief.
Common non-pharmacologic techniques include:
Relaxation techniques (deep breathing, guided imagery, meditation)
Hydrotherapy (immersion in water, showers, hot or cold compresses)
Positioning and movement (walking, rocking, changing positions frequently)
Massage and touch therapy
Acupuncture and acupressure
Transcutaneous electrical nerve stimulation (TENS)
Biofeedback
Hypnosis
Continuous labor support (from a doula, partner, or other support person)
Correct Answer is A
Explanation
Choice A rationale:
Joining a support group can be beneficial. I can provide some recommendations.
Support groups offer a safe and supportive environment where couples can share their experiences, feelings, and coping strategies with others who understand what they are going through. This can be incredibly helpful in reducing isolation, normalizing their emotions, and promoting a sense of hope. Support groups can also provide valuable information and resources about infertility, treatment options, and coping strategies. Additionally, they can help couples develop a sense of community and belonging, which can be especially important during a challenging time.
I can provide some recommendations for support groups in your area. This demonstrates the nurse's willingness to help the couple find the resources they need and underscores the value of support groups in managing infertility.
Choice B rationale:
Share your situation with friends and family so they can provide support.
While sharing with friends and family can be helpful for some couples, it's important to recognize that not everyone may be able to provide the kind of support that is needed. Some friends and family members may not understand the challenges of infertility or may offer unsolicited advice, which can be hurtful. Additionally, couples may not feel comfortable sharing such personal information with their loved ones. It's important to respect the couple's privacy and preferences in this regard.
Choice C rationale:
Start adoption proceedings immediately as it can be challenging to adopt an infant.
This response is not appropriate as it does not address the couple's immediate concern, which is how to maintain their emotional balance while dealing with infertility. It also assumes that the couple is interested in adoption, which may not be the case. While adoption can be a wonderful option for some families, it's a major decision that requires careful consideration and should not be rushed into.
Choice D rationale:
Speak only with other friends who are dealing with infertility as they can provide the most help.
While connecting with others who are experiencing infertility can be helpful, it's important not to isolate oneself from other sources of support. Friends and family who are not dealing with infertility can still offer valuable support, understanding, and companionship. It's important to have a variety of supportive relationships in one's life.
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