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 D
Explanation
A. Maternal fever: Fever is associated with fetal tachycardia, not variable decelerations.
B. Fetal head compression: This causes early decelerations, not variable decelerations.
C. Polyhydramnios: Excess amniotic fluid can cause complications but does not directly cause variable decelerations.
D. Umbilical cord compression: Variable decelerations are due to compression of the umbilical cord, which affects fetal oxygenation.
Correct Answer is A
Explanation
A. Assure the client that the score is within the expected range: A score of 8–10 on a biophysical profile indicates fetal well-being, requiring no intervention.
B. Offer the client orange juice and repeat the assessment in 1 hour: This is unnecessary since the score indicates no concern.
C. Administer oxygen and notify the provider: There is no indication of fetal distress.
D. Assist the client into a side-lying position: A position change is not needed as there is no evidence of compromise.
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