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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale

While remaining on clear liquids until the vomiting subsides may seem like a reasonable approach, it may not be the best course of action for a pregnant woman who has been vomiting for 24 hours. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus.

Choice B rationale

Taking nothing by mouth until there is no more nausea is not advisable in this situation. Nausea can persist even after vomiting has stopped, and it’s important for the woman to stay hydrated and nourished.

Choice C rationale

The best course of action in this situation is for the woman to come to the clinic to be seen by a healthcare provider. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus. In addition, the healthcare provider can assess the woman’s condition and provide appropriate treatment.

Choice D rationale

Making an appointment at the clinic if a fever occurs is not the best advice in this situation. While it’s important to seek medical attention if a fever develops, the woman should not wait for this to happen before seeking help. Prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus, and should be addressed promptly.

A. Insert a straight urinary catheter to drain the bladder. B. Scan the bladder for urinary retention. C. Test the fluid with a nitrazine strip. D. Palpate the suprapubic area for fetal head position.

Correct Answer is C

Explanation

Choice A rationale

Inserting a straight urinary catheter to drain the bladder is not the appropriate technique to evaluate fluid leakage in a pregnant woman. This procedure is invasive and can potentially introduce bacteria into the urinary tract, leading to infection.

Choice B rationale

Scanning the bladder for urinary retention is not the appropriate technique to evaluate fluid leakage in a pregnant woman. While ultrasound can be used to assess the amount of fluid in the bladder, it does not provide information about the nature of the fluid leakage.

Choice C rationale

Testing the fluid with a nitrazine strip is the appropriate technique to evaluate fluid leakage in a pregnant woman. Amniotic fluid has a higher pH than normal vaginal secretions and urine, and will turn a nitrazine strip blue. This test can help determine whether the fluid leakage is amniotic fluid, which could indicate rupture of membranes.

Choice D rationale

Palpating the suprapubic area for fetal head position is not the appropriate technique to evaluate fluid leakage in a pregnant woman. While this can provide information about the position of the fetus, it does not provide information about the nature of the fluid leakage.

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What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

Correct Answer is C

Explanation

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

Correct Answer is C

Explanation

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

A postpartum client who is formula-feeding her new baby inquires about when she should expect her menstruation to resume.What should the nurse inform the client?

The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?