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 C
Explanation
The correct answer is choice c. Negative.
Choice A rationale:
“Satisfactory” is not a standard term used to describe the results of a contraction stress test (CST). The terms typically used are “negative,” “positive,” “equivocal,” or “unsatisfactory.”
Choice B rationale:
“Unsatisfactory” is used when the test cannot be interpreted due to inadequate contractions or other technical issues. In this case, the client is experiencing contractions every three minutes, and the fetal heart rate (FHR) is being monitored effectively.
Choice C rationale:
A “Negative” CST indicates that there are no late decelerations of the FHR during contractions, suggesting that the fetus is not experiencing significant distress and is likely tolerating the contractions well.
Choice D rationale:
A “Positive” CST would indicate the presence of late decelerations of the FHR with at least 50% of contractions, suggesting fetal hypoxia and compromised placental function. Since there are no decelerations in this scenario, this choice is incorrect.
Correct Answer is C
Explanation
Choice A rationale:
Effleurage is a gentle massage technique often used in labor to promote relaxation and reduce discomfort. It involves using light, stroking movements over the abdomen or back. While effleurage can be soothing for some women, it may not be as effective for specifically addressing the intense back pain associated with back labor. It is more focused on general relaxation than on targeted pain relief in the sacral region.
Choice B rationale:
Pant-blow (breaths and puffs) breathing techniques are commonly taught in childbirth classes as a way to manage labor pain. They involve using specific patterns of breathing to help control contractions and minimize discomfort. While these techniques can be helpful for some women, they may not be as effective for back labor pain as they are primarily focused on managing the sensations of contractions in the abdomen and uterus. They don't directly address the sacral pain that characterizes back labor.
Choice C rationale:
Counterpressure against the sacrum is a specific technique that can be very effective for relieving back labor pain. It involves applying firm, steady pressure to the lower back, specifically the sacral area, using the hands, a fist, or a tennis ball. This pressure can help to counteract the intense sensations of pain and pressure in the lower back, providing significant relief. The mechanism behind this relief is likely related to:
Gate-control theory: Counterpressure may stimulate other nerve pathways, which can block or reduce pain signals from reaching the brain.
Counteracting pressure: The pressure applied to the sacrum may help to counteract the internal pressure of the baby's head against the sacrum, which can be a major source of back labor pain.
Muscle relaxation: Firm pressure can help to relax tense muscles in the lower back, which can contribute to pain.
Choice D rationale:
Conscious relaxation or guided imagery are techniques that can promote overall relaxation and reduce anxiety during labor. They involve using mental exercises to focus the mind on calming images or sensations. While these techniques can be helpful for some women, they may not be as effective for specifically targeting back labor pain as they are more general relaxation methods that don't directly address the sacral pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.