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 rationale:

This statement is incorrect. A nonstress test does not involve receiving medication through an

IV. It is a simple and non-invasive test that monitors the baby's heart rate in response to its movements.

Choice B rationale:

This is the correct choice. A nonstress test typically takes about 30 minutes to complete. During the test, the client will have a fetal heart rate monitor placed on her abdomen to measure the baby's heart rate while it is moving.

Choice C rationale:

This statement is incorrect. There is no requirement for the client to fast or restrict food and drink before a nonstress test. The client can eat and drink as usual before the procedure.

Choice D rationale:

This statement is incorrect. A nonstress test is not used to determine if the baby's lungs are mature. Instead, it assesses the baby's heart rate patterns in response to its own movements, which helps evaluate the baby's overall well-being in the third trimester of pregnancy.

A. Initiate continuous monitoring of the FHR. B. Administer a dose of betamethasone. C. Check the cervix for dilation every 8 hours. D. Request that the provider prescribe misoprostol PRN.

Correct Answer is A

Explanation

The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply

Choice A reason:

Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.

Choice B reason:

Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.

Choice C reason:

Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.

Choice D reason:

Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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