QUESTION: "Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at -1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which of the following actions would be most appropriate?"
CHOICES
( X ) a.) Have the client take several whiffs of oxygen through a nasal cannula.
( O ) b.) Give the client a paper bag and have her breathe into it.
( X ) c.) Tell the client to breathe quickly and then hold her breath.
( X ) d.) Encourage the client to inhale with as much force as possible.
RATIONALE: Hyperventilation results in excess carbon dioxide being eliminated from the body. Hence, rebreathing into a paper bag or cupping the hands is beneficial. This increases the carbon dioxide intake during respiration. Although taking whiffs of oxygen via nasal cannula may increase oxygen intake with breathing, it will not replace the lost carbon dioxide, the major problem with hyperventilation. Having the client hold her breath has no effect on minimizing the excess carbon dioxide being eliminated. However, doing so can lead to increased intracranial pressure. Breathing with forceful inspirations will not resolve the hyperventilation nor will it replace the carbon dioxide deficiency. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
