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

A. Peanut butter and wheat bread contain high levels of phenylalanine, which should be avoided in clients with phenylketonuria.
B. A sliced apple and red grapes are low in phenylalanine and are safe choices for a client with phenylketonuria.
C. Chocolate, cookies, and milk contain phenylalanine, making them unsuitable for the client.
D. Eggs and cheese are high in phenylalanine and should be restricted in the diet.

A. Perform a vaginal exam. B. Monitor fetal heart rate with an internal fetal monitor. C. Frequently assess maternal heart rate. D. Initiate bed rest with bathroom privileges.

Correct Answer is ["C","D","E"]

Explanation

The correct answers are C, D, E.

Choice A reason:

Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.

Choice B reason:

Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.

Choice C reason:

Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.

Choice D reason:

Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.

Choice E reason:

Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.

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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 providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has placenta previa. Which of the following interventions should the nurse implement for this client? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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