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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.

Choice B reason:

Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.

Choice C reason:

Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.

Choice D reason:

Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.

A. Multiparity. B. Endometriosis. C. Under 40 years of age. D. Use of contraceptive medications.

Correct Answer is B

Explanation

Choice A rationale:

Multiparity, or having given birth to multiple children, is associated with a decreased risk of ovarian cancer, not an increased risk. The protective effect may be due to the repeated ovulatory cycles that occur during pregnancy.

Choice B rationale:

Endometriosis is a condition where endometrial tissue grows outside the uterus. It is associated with an increased risk of ovarian cancer. The exact link is not fully understood, but it is believed that the inflammatory and hormonal changes in endometriosis may contribute to cancer development.

Choice C rationale:

Being under 40 years of age does not increase the risk of ovarian cancer. Advanced age is a known risk factor for ovarian cancer, with the highest incidence occurring in women over 60.

Choice D rationale:

Use of contraceptive medications, particularly oral contraceptives, has been shown to reduce the risk of ovarian cancer. These medications suppress ovulation and decrease the exposure of the ovaries to potential carcinogens.

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A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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