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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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 client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

Correct answer: A

Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.

3. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

Correct answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.

4. A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

Correct answer: C

Rationale: A decrease in respiratory rate from 24 to 16 indicates that magnesium sulfate is effectively reducing central nervous system irritability, a desired therapeutic effect. This decrease in respiratory rate signifies that the drug has reached a therapeutic level to control symptoms of severe pregnancy-induced hypertension. Choices A, B, and D are incorrect because 4+ reflexes, urinary output, and body temperature are not direct indicators of achieving a therapeutic level of magnesium sulfate for controlling PIH symptoms.

5. What maternal behavior is typically observed when a new mother first receives her infant?

Correct answer: B

Rationale: When a new mother first receives her infant, a typical maternal behavior is to use her arms and hands to receive the infant and then trace the infant's profile with her fingertips. This action is a gentle way of bonding with the newborn and aids in recognizing the infant's features. Choices A, C, and D are incorrect as they do not accurately describe the common behavior of tracing the infant's profile, which is a significant part of the initial interaction between a mother and her newborn.

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