A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?
Assist the client to void every 3 hr.
Monitor contractions every 30 min.
Place the client into a lithotomy position.
Encourage the client to use a pant-blow breathing pattern.
The Correct Answer is D
Choice D rationale:
During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.
Choice A rationale:
Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.
Choice B rationale:
Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.
Choice C rationale:
Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tamoxifen is not used to treat Non-Hodgkin's lymphoma. Tamoxifen is a selective estrogen
receptor modulator (SERM) and is primarily used in breast cancer treatment. It functions by
binding to estrogen receptors, blocking estrogen's effects, and inhibiting the growth of
hormone-sensitive breast cancer cells.
Choice B rationale:
Tamoxifen is not used to treat endometriosis. Endometriosis is a condition in which tissue
similar to the lining of the uterus grows outside the uterus, and it is typically managed with
hormonal therapies, pain medications, or surgical interventions, but not tamoxifen.
Choice C rationale:
This is the correct choice. Tamoxifen is widely used in the treatment of breast cancer,
especially in cases of estrogen receptor-positive breast cancer. It helps prevent cancer
recurrence and is often prescribed for both early-stage and advanced breast cancer patients.
Choice D rationale:
Tamoxifen is not used to treat polycystic ovary syndrome (PCOS). PCOS is a hormonal
disorder characterized by enlarged ovaries with small cysts, and it is typically managed with
lifestyle changes, hormonal contraceptives, and medications to regulate menstrual cycles and
manage symptoms like hirsutism and acne.
Correct Answer is B
Explanation
Choice A rationale:
Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.
Choice B rationale:
This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.
Choice C rationale:
Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.
Choice D rationale:
Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.
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