What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?
Remind her to push three times with each contraction.
Assessing the strength of uterine contractions.
Re-evaluate the need for medication.
Assisting her to maintain control.
The Correct Answer is D
Choice A rationale
While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
Choice B rationale
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
Choice C rationale
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
Choice D rationale
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.
Choice B rationale
Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.
Choice C rationale
While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.
Choice D rationale
While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.
Correct Answer is B
Explanation
Choice A rationale
While hard, painful uterine afterpains can be uncomfortable for the patient, they are a normal part of the postpartum period and are not typically a priority complication following a severe postpartum hemorrhage16.
Choice B rationale
Disseminated intravascular coagulation (DIC) is a serious condition that can occur as a complication of severe postpartum hemorrhage. It involves an overactive clotting process leading to the formation of small blood clots that can block blood vessels and cause significant organ damage16.
Choice C rationale
Postpartum psychosis is a serious mental health disorder that can occur after childbirth. However, it is not directly related to postpartum hemorrhage and would not typically be the priority complication in this scenario16.
Choice D rationale
Placenta accreta is a condition where the placenta grows too deeply into the uterine wall. While it can cause severe bleeding after delivery, it would not typically be a priority complication to assess for following a severe postpartum hemorrhage16.
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