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:
Increasing potassium intake is not specifically associated with relieving breast discomfort during menstruation. There is no established link between potassium intake and fibrocystic breast changes.
Choice B rationale:
Increasing fluid intake is generally beneficial for overall health, but it is not a specific recommendation for managing breast discomfort during menstruation. It may not have a direct impact on fibrocystic breast changes.
Choice C rationale:
Decreasing sodium intake before menstruation is a relevant instruction for managing breast discomfort associated with fibrocystic breast changes. High sodium intake can lead to water retention and breast swelling, exacerbating discomfort.
Choice D rationale:
Daily fiber intake is important for bowel health but is not directly related to managing breast discomfort during menstruation or fibrocystic breast changes.
Correct Answer is C
Explanation
Choice A rationale:
Raloxifene is not used to treat migraines. It is a selective estrogen receptor modulator (SERM) that primarily acts on bone tissues, estrogen receptors, and has anti-estrogenic effects in the breast, which may reduce the risk of breast cancer.
Choice B rationale:
Raloxifene is not used to treat hypertension (high blood pressure) It is primarily indicated for the prevention and treatment of osteoporosis in postmenopausal women.
Choice C rationale:
This is the correct choice. Raloxifene is indicated for the treatment and prevention of osteoporosis in postmenopausal women. It helps increase bone density and reduces the risk of fractures associated with osteoporosis.
Choice D rationale:
Raloxifene is not used to treat heart disease. While it may have some cardiovascular benefits due to its effects on cholesterol levels, it is not a primary medication for heart disease management.
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