Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
59. A client, who is a 22-year-old primigravida, is at 38 weeks' gestation and 9 cm of dilation. Her contractions are 2 to 4 minutes apart and her uterus palpates soft between very firm contractions. She is very irritable and screaming in pain. A nurse should instruct this client to:
. Take deep breaths.
. Practice patterned breathing with deep cleansing breath.
. Hold her breath and bear down.
. Do shallow chest breathing.
Test-Taking Tip
Remember the stages and phases of labor and how the client would respond to latent, active, and transition phases of labor. Knowing what could be the client's expected response will guide appropriate coaching for breathing.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Non-pharmacological Comfort Interventions
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because deep breathing is the correct technique for the latent phase of the first stage of labor, when the client is trying to relax and allow labor to progress. Taking deep breaths in this phase of labor can lead to hyperventilation. Answer 2 is incorrect because patterned breathing is the correct technique for the active phase of the first stage of labor when the client is trying to relieve the pain of labor. Using patterned breathing in this phase of labor can lead to bearing down before complete dilation and hyperventilation. Answer 3 is incorrect because this client is not completely dilated and it is inappropriate to bear down with contractions. Pushing before being completely dilated can cause cervical lacerations and edema of the cervix. Answer 4 is correct because this client is in the transition phase of the first stage of labor. The proper breathing technique is shallow chest breathing, which prevents hyperventilation and bearing down before she is completely dilated.