Author Question: The client who is 35 weeks pregnant tells the nurse she had some contractions last night but they ... (Read 63 times)

faduma · **on:** Jul 22, 2018

The client who is 35 weeks pregnant tells the nurse she had some contractions last night but they went away when she got up and walked around. The nurse correctly responds by saying:

1. Those were probably Braxton-Hicks contractions, sometimes called false labor.
2. You should have gone to the Labor and Delivery unit when the contractions started.
3. If that happens again, you should lie down on your left side and drink something with sugar.
4. If you had contractions last night, it probably indicates it will soon be time to deliver.

Question 2

The nurse discovers that the client suddenly has become short of breath. Which of the following assessment findings would increase the nurse's suspicion of a spontaneous pneumothorax of the left lung? Standard Text: Select all that apply.

1. Diminished breath sounds in the bases bilaterally, with rhonchi in the left lower lobe
2. Trachea is at midline.
3. Subcutaneous emphysema palpable on the left side of the chest
4. Absent breath sounds on the left side of the chest
5. Tachycardia and tachypnea

Sammyo · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1
Rationale: Braxton-Hicks contractions, often called false labor, do not affect the cervix, and pose no harm to the client. They are often relieved by walking, while normal labor will advance with activity. There is no need for the client to do anything with Braxton-Hicks contractions.

Answer to Question 2

3,4,5
Rationale: When the lung deflates due to a pneumothorax, the nurse will hear no breath sounds over the involved site. If air leaks from the lungs into the subcutaneous space, a crackling sensation will be feltcalled subcutaneous emphysemausually in the upper chest on the involved side. Heart rate can increase or decrease, respiratory rate increases, and the client reports suddenly feeling short of breath. A large pneumothorax can cause the trachea to shift to the side of the collapse, as chest organs suddenly have room to shift toward the empty space left by the pneumothorax. Breath sounds are not diminished, they are absent, as air is no longer entering the lobe or lobes of the lungs that are no longer functioning.