A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

Choice A rationale:

Decreasing fiber intake is not a recommended action for urinary incontinence. Fiber intake is related to bowel health and does not directly affect urinary incontinence.

Choice B rationale:

Avoiding Kegel exercises is not recommended for urinary incontinence. Kegel exercises are beneficial for strengthening the pelvic floor muscles, which can help improve urinary continence.

Choice C rationale:

Restricting fluid intake to 1 liter per day is not advisable for urinary incontinence. Adequate hydration is essential for overall health, and limiting fluid intake can lead to dehydration and other health issues.

Choice D rationale:

Reducing intake of caffeinated and carbonated beverages is a helpful recommendation for a client experiencing urinary incontinence. Caffeine and carbonation can irritate the bladder and worsen incontinence symptoms.

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.