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 C
Explanation
Choice A rationale
While it’s true that phytonadione, also known as vitamin K, plays a role in the immune system, this is not the primary reason it is given to newborns. Therefore, this statement does not show an understanding of why the medication is being given.
Choice B rationale
Phytonadione does not aid an immature liver. It is necessary for the synthesis of certain proteins required for blood clotting. However, it does not directly aid the liver’s function.
Choice C rationale
This is the correct statement. Phytonadione is given to newborns to prevent hemorrhagic disorders, specifically vitamin K deficiency bleeding (VKDB). Newborns are at risk for VKDB because their gut does not yet have the bacteria necessary to produce vitamin K5.
Choice D rationale
While it’s true that vitamin K is obtained from dietary intake, newborns do not receive phytonadione to compensate for insufficient dietary intake. They receive it to prevent VKDB, a bleeding disorder caused by vitamin K deficiency.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that AFP results can sometimes be false readings, it’s not the most appropriate advice for the nurse to give in this situation. Simply reassuring the client without suggesting further investigation could potentially overlook a serious condition.
Choice B rationale
Discussing options for intrauterine surgical correction of congenital defects at this stage is premature. The elevated AFP level alone does not confirm the presence of congenital defects, and suggesting surgical intervention may cause unnecessary anxiety.
Choice C rationale
Informing the client that a repeat AFP test should be conducted is a reasonable suggestion. However, it’s not the most appropriate next step in this case. A repeat test would provide more information, but it wouldn’t give definitive results about the cause of the elevated AFP level.
Choice D rationale
Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.