Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
7. During the active phase of labor, a client, who is a gravida 2, para 0, begins to complain of dizziness, tingling in her fingers, and numbness in her lips. The most appropriate nursing intervention for this client would be to:
. Have her breathe into a paper bag.
. Help her assume a left lateral position in bed.
. Instruct her in shallow chest breathing.
. Notify the physician immediately.
Test-Taking Tip
When calling the physician is one of the options, consider why you are calling the physician and what assessment information you need before calling. If you cannot identify why you would call the physician and what you want him/her to do about the situation, eliminate the option.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because this client is hyperventilating, resulting in a reduction of carbon dioxide in her blood and causing her symptoms. Having her breathe into a paper bag will increase the carbon dioxide in her blood and alleviate the symptoms. Answer 2 is incorrect because helping her to assume a left lateral position in bed will not increase carbon dioxide in her blood. Answer 3 is incorrect because shallow chest breathing is a form of hyperventilation and will not reverse the imbalance between the oxygen and carbon dioxide levels in the lungs. This imbalance delivers less oxygen to the brain, the heart, and the rest of the body. Answer 4 is incorrect because this situation can be resolved using nursing interventions that do not require calling the physician.