Nokea
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
- A. Administer oxygen by face mask.
- B. Notify the healthcare provider of the client's symptoms.
- C. Have the client breathe into her cupped hands.
- D. Check the client's blood pressure and fetal heart rate.
Correct Answer: C
Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.
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A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Keep airway equipment at the bedside.
- B. Allow liberal family visitation.
- C. Monitor blood pressure, pulse, and respirations q4h.
- D. Assess temperature q1h.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?
- A. Decrease the oxytocin infusion rate
- B. Determine current cervical dilation
- C. Request placement of the epidural
- D. Give a bolus of intravenous fluids
Correct Answer: D
Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.
In which chromosome pattern is Duchenne disease inherited?
- A. Autosomal dominant
- B. Autosomal recessive
- C. X-linked recessive
- D. Mitochondrial
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy?
- A. Breastfeed exclusively at least every 3 to 4 hours.
- B. Condoms and contraceptive foam or gel.
- C. Rhythm method (natural family planning).
- D. Combined estrogen-progesterone oral contraceptives.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
- A. Encourage the mother to provide total care for her infant.
- B. Provide privacy so the mother can develop a relationship with the infant.
- C. Encourage the father to provide most of the infant's care during hospitalization.
- D. Meet the mother's physical needs and demonstrate warmth toward the infant.
Correct Answer: D
Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.