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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Iron-deficiency anemia is a common nutritional issue among pregnant teenagers. During pregnancy, the body needs more iron to support the growth and development of the fetus. Teenagers, who are still growing themselves, may already have lower iron stores. Therefore, it is crucial to include information about the importance of iron and how to get enough from the diet in a nutrition education program for pregnant teenagers.
Choice B rationale
While gestational diabetes is a concern during pregnancy, it is not the most crucial topic for a nutrition education program specifically for pregnant teenagers. Gestational diabetes is a condition that can develop during pregnancy in women who don’t already have diabetes. It’s not as common in teenagers as it is in older women.
Choice C rationale
High cholesterol is generally not a primary concern during pregnancy. In fact, it’s normal for cholesterol levels to rise during pregnancy. However, long-term high cholesterol can increase the risk of heart disease.
Choice D rationale
Excessive weight gain can be a concern during pregnancy, but it is not the most crucial topic for a nutrition education program for pregnant teenagers. It’s normal and healthy to gain weight during pregnancy, but the amount should be carefully monitored. Excessive weight gain can lead to complications such as gestational diabetes or high blood pressure.
Correct Answer is B
Explanation
Choice A rationale
Covering the lesion with a dressing is not the standard care for a pregnant client with active herpes lesions. Herpes can be transmitted to the baby during a vaginal birth, even if lesions are covered.
Choice B rationale
Preparing for a cesarean section is the correct action. A cesarean section is often recommended for women with active genital herpes lesions to prevent transmission of the virus to the baby during delivery.
Choice C rationale
Obtaining blood cultures is not typically necessary for a client with active herpes lesions. Herpes is a viral infection, and its presence is usually determined through a visual examination of lesions and sometimes a swab of the lesion, not through blood cultures.
Choice D rationale
Administering penicillin is not the correct action. Penicillin is an antibiotic, which is used to treat bacterial infections, not viral infections like herpes.
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