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 D

Explanation

A. A High-Fowler's with the arm on the operative side elevated on pillows: While elevating the arm is important, a high-Fowler's position may cause unnecessary strain on the surgical site and is not recommended for comfort and healing in the immediate postoperative period.

B. Semi-Fowler's with the arm on the operative side in a dependent position: Keeping the arm in a dependent position can increase the risk of swelling and lymphedema, which should be avoided after a mastectomy.

C. High-Fowler's with the arm on the operative side in a dependent position: The high-Fowler's position, combined with keeping the arm in a dependent position, would likely increase swelling and discomfort and is not recommended postoperatively.

D. Semi-Fowler's with the arm on the operative side elevated on pillows: The semi-Fowler's position is ideal for comfort and healing, and elevating the arm helps reduce the risk of lymphedema by encouraging proper drainage and circulation post-surgery. This is the most appropriate position to promote recovery.

A. Morning sickness. B. Hegar's sign. C. Amenorrhea. D. Breast tenderness.

Correct Answer is C

Explanation

A. Morning sickness: While morning sickness (nausea and vomiting) is a common symptom in early pregnancy, it is not the most reliable sign of pregnancy, as it can also occur with other conditions.

B. Hegar's sign: Hegar's sign, which is the softening of the lower uterine segment, is a probable sign of pregnancy but requires a clinical exam for confirmation. It is not as definitive as amenorrhea.

C. Amenorrhea: Amenorrhea, or the absence of menstruation, is one of the most reliable early signs of pregnancy. A missed period is often the first indication that a woman may be pregnant.

D. Breast tenderness: While breast tenderness can occur during pregnancy, it can also happen due to other factors such as hormonal changes, making it a less definitive sign of pregnancy compared to amenorrhea.

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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

How should the nurse plan to position a client who has just undergone a radical mastectomy?

Correct Answer is D

Explanation

A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant?

Correct Answer is C

Explanation

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