Author Question: A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor ... (Read 62 times)

tiara099 · **on:** Jun 27, 2018

A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated.

Which nursing diagnoses might apply during the current stage of labor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome
2. Knowledge, Deficient, related to lack of information about pushing methods
3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent
4. Pain, Acute, related to perineal trauma
5. Coping: Family, Compromised, related to labor process

Question 2

A patient is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning.

A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the patient is in which phase of labor? 1. Active
2. Latent
3. Transition
4. Fourth

tranoy · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1, 3, 5
Explanation: 1. A Fear/Anxiety diagnosis would apply to the first stage of labor for a first-time labor client.
3. Contractions become more regular in frequency and duration, increasing discomfort and pain.
5. The woman and her boyfriend are about to undergo one of the most meaningful and stressful events in life together. Physical and psychologic resources, coping mechanisms, and support systems will all be challenged.

Answer to Question 2

3
Rationale 1: In the active phase, the woman dilates from 4 to 7 centimeters.
Rationale 2: The latent phase is the beginning of labor contractions.
Rationale 3: The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer together and more intense.
Rationale 4: There is no fourth phase. The fourth stage occurs after delivery of the placenta.