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. The fetus is in distress: Fetal distress often presents as decelerations or an abnormal baseline heart rate, not accelerations.
B. The mother is in severe pain: Maternal pain does not cause fetal heart accelerations.
C. Uteroplacental insufficiency: This condition is associated with late decelerations, not accelerations.
D. A well-oxygenated fetus: FHR accelerations indicate adequate oxygenation and a reactive, healthy fetal status.
Correct Answer is C
Explanation
A. Caput succedaneum: This swelling crosses suture lines and involves edema caused by birth trauma.
B. Molding: This refers to the shaping of the fetal head to pass through the birth canal and does not involve swelling.
C. Cephalohematoma: A localized collection of blood between the skull and periosteum, which does not cross suture lines, is characteristic of cephalohematoma.
D. Nevus flammeus: This is a flat, red birthmark (port-wine stain) and is unrelated to swelling or trauma.
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