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

Re-evaluate the need for medication.

Assisting her to maintain control.

Assessing the strength of uterine contractions.

Remind her to push three times with each contraction.

Answer and Explanation

The Correct Answer is B

A. Re-evaluate the need for medication: While it's important to reassess the client's pain management preferences, the primary focus for an unmedicated delivery is to provide support and help the client cope with labor without the use of medications.
B. Assisting her to maintain control: The primary focus during the active phase of labor for an unmedicated delivery is helping the client maintain control over her body and manage the pain through non-pharmacological methods. This could include breathing techniques, relaxation, and positioning.
C. Assessing the strength of uterine contractions: While monitoring contractions is essential for assessing labor progress, the focus should be more on providing emotional support and ensuring the client is empowered to manage the pain without medication.
D. Remind her to push three times with each contraction: Pushing instructions are typically given in the second stage of labor, not the active phase. During the active phase, the client is usually focusing on coping with the contractions.

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Correct Answer is C

Explanation

A. Maternal apical heart rate: While monitoring the maternal heart rate is important, the primary concern in this scenario is the timing of the oxytocin infusion in relation to the onset of bleeding. The time of the infusion helps determine if there is a correlation with the excessive bleeding.

B. Maternal blood pressure: Blood pressure is important for assessing hemodynamic stability, especially in cases of hemorrhage, but the most important immediate information would be related to the timing of the oxytocin infusion, as this could help determine if it is a contributing factor to the bleeding.

C. Time oxytocin infusion completed: The timing of the oxytocin infusion is the most important piece of information to provide. If the bleeding began after the infusion, the healthcare provider can consider oxytocin as a potential cause of uterine atony or other complications.

D. Total amount of oxytocin infused: While the total amount of oxytocin administered is important, the timing of the infusion is more critical in understanding the connection between the oxytocin administration and the onset of bleeding.

A. Soft and not palpable. B. Above the umbilicus. C. At or below the umbilicus. D. To the left or right of the umbilicus.

Correct Answer is C

Explanation

A. Soft and not palpable: Immediately after delivery, the fundus should be firm and palpable. A soft, non-palpable fundus may indicate uterine atony, which is a serious condition that could lead to hemorrhage and requires immediate intervention.

B. Above the umbilicus: Immediately after delivery, the fundus is typically at or just below the umbilicus. If it is above the umbilicus, it could indicate uterine distension, a retained placenta, or excessive bleeding that needs to be addressed.

C. At or below the umbilicus: The fundus is expected to be firm and palpable at or just below the umbilicus immediately after delivery. This position reflects normal uterine contraction as the uterus begins to return to its pre-pregnancy size.

D. To the left or right of the umbilicus: The fundus should be midline after delivery. A deviation to the left or right may suggest a full bladder or uterine displacement, which can interfere with uterine contraction and increase the risk of bleeding.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused. When notifying the healthcare provider of the client's condition, which information is most important for the nurse to provide?

Correct Answer is C

Explanation

Which assessment finding should the nurse expect when palpating the fundus immediately after delivery?

Correct Answer is C

Explanation

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