ATI PN Maternity
ATI PN Maternity ( 62 Questions)
A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?
Instruct the client to maintain a breathing rate no less than twice the normal rate. Rationale: Instructing the client to breathe at a rate no less than twice the normal rate may worsen the hyperventilation. This will further decrease the level of carbon dioxide in the blood, exacerbating the respiratory alkalosis and its associated symptoms. Therefore, this option is not appropriate and should be avoided.
The client's complaint of feeling lightheaded and experiencing tingling fingers indicates hyperventilation, which can occur with pattern-paced breathing during labor. Administering oxygen via nasal cannula helps to address the respiratory alkalosis that may result from excessive breathing. The additional oxygen can help correct the imbalanced levels of carbon dioxide and oxygen in the blood, alleviating the symptoms of lightheadedness and tingling.
Assist the client to breathe into a paper bag. Rationale: Breathing into a paper bag is a common intervention used to treat hyperventilation. However, it is not suitable for a pregnant woman in labor. It is essential for the mother to have an adequate intake of oxygen during labor to support both her and the baby's needs. Breathing into a paper bag would prevent her from getting enough oxygen and could potentially harm both her and the baby.
Have the client tuck her chin to her chest. Rationale: Tucking the client's chin to her chest is not a relevant action to address hyperventilation. This maneuver is commonly used during the second stage of labor to promote fetal descent and prevent cervical lacerations. However, it is not useful in managing the client's current symptoms of lightheadedness and tingling fingers resulting from hyperventilation.
Choice B rationale:
The client's complaint of feeling lightheaded and experiencing tingling fingers indicates hyperventilation, which can occur with pattern-paced breathing during labor. Administering oxygen via nasal cannula helps to address the respiratory alkalosis that may result from excessive breathing. The additional oxygen can help correct the imbalanced levels of carbon dioxide and oxygen in the blood, alleviating the symptoms of lightheadedness and tingling.
Choice A rationale:
Instruct the client to maintain a breathing rate no less than twice the normal rate. Rationale: Instructing the client to breathe at a rate no less than twice the normal rate may worsen hyperventilation. This will further decrease the level of carbon dioxide in the blood, exacerbating respiratory alkalosis and its associated symptoms. Therefore, this option is not appropriate and should be avoided.
Choice C rationale
Assist the client to breathe into a paper bag. Rationale: Breathing into a paper bag is a common intervention used to treat hyperventilation. However, it is not suitable for a pregnant woman in labor. It is essential for the mother to have an adequate intake of oxygen during labor to support both her and the baby's needs. Breathing into a paper bag would prevent her from getting enough oxygen and could potentially harm both her and the baby.
Choice D rationale
Have the client tuck her chin to her chest. Rationale: Tucking the client's chin to her chest is not a relevant action to address hyperventilation. This maneuver is commonly used during the second stage of labor to promote fetal descent and prevent cervical lacerations. However, it is not useful in managing the client's current symptoms of lightheadedness and tingling fingers resulting from hyperventilation.