An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting "Please give me something for the pain. I can't take the pain.” What is the priority nursing diagnosis?
Ineffective coping related to inadequate preparation for labor
Pain related to uterine contractions
Risk for injury related to lack of prenatal care
Knowledge deficit related to the birth experience
The Correct Answer is A
A. Ineffective coping related to inadequate preparation for labor: This addresses the client’s inability to manage labor effectively due to a lack of childbirth preparation, as evidenced by her emotional distress.
B. Pain related to uterine contractions: While pain is present, addressing ineffective coping takes precedence because it impacts how the client handles labor and her perception of pain.
C. Risk for injury related to lack of prenatal care: This is important but not immediately relevant to her current emotional state and pain management needs.
D. Knowledge deficit related to the birth experience: While true, the immediate priority is the client's emotional and coping response.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Help the client to the bathroom to empty the bladder: It is unsafe to ambulate a client in active labor who feels the urge to push; crowning must first be ruled out.
B. Assist the client to a comfortable position: Comfort is important, but immediate assessment for crowning takes priority to prepare for delivery.
C. Assess the perineum for signs of crowning: While this is an important assessment, the immediate action to take when the client feels the urge to push is to instruct her to pant to prevent premature pushing.
D. Have the client pant during the next few contractions: Panting helps the patient avoid pushing before full dilation is achieved, reducing the risk of complications such as cervical lacerations or fetal distress. This technique helps manage the urge to push until the cervix is fully dilated.
Correct Answer is D
Explanation
A. Changing positions in bed: This may indicate discomfort but not necessarily pain.
B. Frequently asking for ice chips: Suggests thirst or distraction, not pain.
C. Taking deep breaths: Often part of coping strategies, not a direct indicator of unrelieved pain.
D. Facial grimacing: A non-verbal cue strongly associated with pain or discomfort.
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