1:
(see full question)
A nurse notices that a client in the first stage of labor seems
agitated. When the nurse asks why she's upset, she begins to cry
and says, "I guess I'm a little worried. The last time I gave birth, I
was in labor for 32 hours." Based on this information, the nurse
should include which nursing diagnosis in the client's care plan?
You selected: Fear related to a potentially difficult childbirth
Correct
Explanation: A client's ability to cope during labor and childbirth may be
hampered by fear of a painful or difficult childbirth, fear of loss of
control or self-esteem during childbirth, or fear of fetal death. A
previous negative experience may increase these fears.
Therefore, fear related to a potentially difficult childbirth is the
most appropriate nursing diagnosis. The client's anxiety stems
from her past history of a long labor, not from being in the facility;
therefore a diagnosis of anxiety related to the facility environment
isn't warranted. There is no evidence of compromised family
coping related to hospitalization. Although acute pain related to
labor contractions may be a problem, the information provided by
the client doesn't support this diagnosis. (less)
Question 2:
(see full question)
What would be the priority when caring for a primigravid client
whose cervix is dilated at 8 cm when the fetus is at 1+ station and
the client has had no analgesia or anesthesia?
You selected: offering encouragement and support
Correct
Explanation: The client is in the transition phase of the first stage of labor.
During this phase, the client needs encouragement and support
because this is a difficult and painful time, when contractions are
especially strong. Usually, the client finds it difficult to maintain
self-control. Everything else seems secondary to her as she
progresses into the second stage of labor. Although ice chips may
be given, typically the client does not desire sips of water. Labor
is hard work. Generally, the client is perspiring and does not
desire additional warmth. Frequent perineal cleansing is not
necessary unless there is excessive amniotic fluid leaking. (less)
Question 3:
(see full question)
A primary care provider has prescribed nalbuphine hydrochloride
10 mg intravenously for a client in active labor. The pharmacy
supplies a vial labeled as 50 mg in a 5-mL vial. How many
milliliters should the nurse administer? Record your answer using