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. Promoting delivery of the placenta: The placenta is delivered after the infant, making this a lower priority.
B. Preventing the perineum from tearing: While important, protecting the infant during birth takes precedence.
C. Cutting the umbilical cord: Cutting the cord occurs after delivery and is not the immediate priority.
D. Supporting the infant during the birth: The safety of the infant during rapid delivery is the top priority.
Correct Answer is B
Explanation
A. “We have a neonatal unit here equipped to handle emergencies.” While reassuring, it does not address the client’s emotions and may seem dismissive.
B. “You must be feeling very scared.” Acknowledges and validates the client’s emotions, fostering therapeutic communication.
C. “You are far enough along that your baby will be just fine.” Provides false reassurance without specific evidence, which is not appropriate.
D. “Everyone worries about their baby while they are in labor.” Generalizes the client’s feelings and may minimize their concerns.
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