Author Question: A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She ... (Read 70 times)

anshika · **on:** Jun 28, 2018

A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention?

a. Perform a vaginal exam to denote progress.
b. Reposition the client to a side lying position.
c. Instruct the client to breathe into her cupped hands.
d. Notify the physician about current findings.

Question 2

To relieve a mild postdural puncture headache, the nurse should encourage the intake of:

a. milk.
b. orange juice.
c. tea or coffee.
d. beef or chicken bouillon.

xoxo123 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
This client is exhibiting signs of hyperventilation associated with a rapid breathing pattern, which can occur during the labor process. The nurse should instruct the client to breathe into her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process. A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in labor progress. Repositioning the client may be an option but is not the priority intervention at this time. Notifying the physician is not appropriate at this time because the RN should attend to actions that are readily available to her based on her scope of practice and standard of care. The physician may have to be notified once the intervention has been performed.

Answer to Question 2

ANS: C
Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine.