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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Nursing Elites

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. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

3. At 20 weeks gestation, a client is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Correct answer: C

Rationale: The primary reason for an ultrasound at 20 weeks gestation is to assess fetal growth, gestational age, and anatomical development. This evaluation helps ensure the fetus is developing appropriately and can detect any potential issues that may require intervention. Choices A, B, and D are incorrect because at 20 weeks, the primary focus of the ultrasound is not to determine the sex of the fetus, detect chromosomal abnormalities, or assess the lecithin-sphingomyelin ratio. While these factors may be evaluated in pregnancy, they are not the primary reasons for an ultrasound at 20 weeks gestation.

4. The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

Correct answer: B

Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.

5. The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

Correct answer: B

Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.

Similar Questions

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The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition?
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

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