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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Massaging the client's back: Activates larger nerve fibers, blocking pain signals to the brain, which aligns with the gate control theory.
B. Administering prescribed analgesic medication: Provides pharmacological pain relief but does not align with gate control theory principles.
C. Turning the client onto her left side: May improve comfort and circulation but does not directly engage the gate control mechanism.
D. Encouraging the client to rest between contractions: Helpful for overall labor management but unrelated to gate control theory.
Correct Answer is D
Explanation
A. Obtaining consents: Necessary for procedures and interventions during labor and delivery.
B. Intravenous infusion: Often started for hydration and medication access.
C. Determining the fetal presentation: Important to plan the delivery approach.
D. DNA blood testing to identify the newborn's father: This is not a routine procedure during labor and delivery.
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