QUESTION: "A 19-year-old primigravida at 38 weeks' gestation, in active labor for the past 8 hours, is admitted to the hospital accompanied by her mother. On admission, the client's cervix is 5 cm dilated, her blood pressure is 120/84 mm Hg, and she is breathing rapidly, complaining of feeling dizzy and lightheaded. The nurse determines that the client is most likely experiencing effects of which of the following?"
CHOICES
( X ) a.) Rapid cervical dilation.
( X ) b.) Elevated blood pressure.
( O ) c.) Hyperventilation.
( X ) d.) Excitement about labor.
RATIONALE: When a client is hyperventilating during labor, she is eliminating more carbon dioxide than usual. As a result, she becomes lightheaded or dizzy. Being lightheaded or dizzy is not correlated with rapid cervical dilation. The client's complaints are not related to an elevated blood pressure. Being lightheaded or dizzy is not correlated to excitement about the labor process. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
