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 ["A","B","D"]

Explanation

Choice A rationale:

The nurse should ask the client if they are taking over-the-counter medications because ibuprofen is also available over-the-counter. It is important to know if the client is already taking ibuprofen or any other non-prescription pain relievers to avoid potential drug interactions or overdosing.

Choice B rationale:

The nurse should inquire about the client's history of gastric problems because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation and bleeding. If the client has a history of gastric ulcers or other gastric issues, the nurse may need to consider an alternative pain relief option.

Choice C rationale:

The question about contraception is not directly related to administering ibuprofen for postpartum cramping. It is essential to provide adequate pain relief, but the method of contraception the client plans to use is not relevant to the administration of the medication.

Choice D rationale:

This question is pertinent because NSAIDs like ibuprofen can cause fluid retention and potentially worsen hypertension.

Choice E rationale:

The presence of cataracts is not relevant to the administration of ibuprofen for postpartum cramping. Cataracts are a concern with eye health and are not associated with taking this pain medication.

A. Prepare the equipment necessary to initiate an amnioinfusion. B. Administer oxygen at 10 L/min via a nonrebreather face mask. C. Discontinue the infusion of oxytocin. D. Place the client in a left lateral position.

Correct Answer is D

Explanation

Choice A reason:

Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

Choice B reason:

Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.

Choice C reason:

Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.

Choice D reason:

This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

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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 caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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