A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole, for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

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.