the lpnlvn instructs a laboring client to use accelerated blow breathing the client begins to complain of tingling fingers and dizziness what action s
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HESI RN

Maternity HESI Quizlet

1. 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?

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.

2. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the healthcare provider take?

Correct answer: C

Rationale: Placing the woman in a lateral position is the appropriate action to improve venous return and cardiac output, helping to stabilize the blood pressure. This position can alleviate pressure on the inferior vena cava, reducing the risk of hypotension associated with epidural anesthesia. Turning off the continuous epidural would not be the initial action as it may not be necessary and could lead to inadequate pain relief for the client. Notifying the healthcare provider or anesthesiologist immediately is premature and should be done after attempting non-invasive interventions. Continuing to assess the blood pressure every 5 minutes is important, but placing the woman in a lateral position should be the first intervention to address the hypotension.

3. A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?

Correct answer: A

Rationale: Post-liver transplant pregnancy is high-risk due to potential complications associated with immunosuppressive therapy and the transplanted organ's health. Providing information about the risks involved allows the client to make an informed decision regarding family planning.

4. A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?

Correct answer: C

Rationale: Numbness and inability to move fingers are concerning findings that suggest potential nerve damage or compartment syndrome due to increased pressure within the cast. This requires immediate notification of the healthcare provider to prevent further complications or permanent damage.

5. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

Similar Questions

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What maternal behavior is typically observed when a new mother first receives her infant?
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The healthcare provider is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention?

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