Nursing diagnoses for a client experiencing a hypertonic labor ...

[audragclark]

Nursing diagnoses for a client experiencing a hypertonic labor pattern may include which of the following? (Select all that apply.)
 
  a. Risk for infection (maternal or fetal) related to prolonged latent labor process
  b. Chronic pain (maternal) related to uterine irritability and prolonged labor
  c. Deficient knowledge of the labor process and variations related to inexperience and unfamiliarity with intervention options
  d. Excess maternal energy related to a prolonged labor process
  e. Impaired gas exchange (fetoplacental) related to hyperstimulation of the uterus with oxytocin augmentation
  f. Anxiety related to unfamiliar experiences, surroundings, and unexpected medical interventions

Question 2

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In eva-luating the woman's behavior with her infant, the nurse realizes that:
 
  a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits.
  b. The woman is inexperienced in caring for newborns.
  c. The woman needs a referral to a social worker for further evaluation of her pa-renting behaviors once she goes home with the newborn.
  d. Extra time needs to be planned for assisting the woman in bonding with her newborn.

[diesoon]

Answer to Question 1

A, C, E, F
Nursing diagnoses for a client experiencing a hypertonic labor pattern may include: Risk for infection (maternal or fetal) related to prolonged latent labor process; Acute maternal pain (not chronic pain) related to uterine irritability and prolonged labor; Deficient knowledge of the labor process and variations related to inexperience and unfamiliarity with intervention options; Maternal fatigue (not excess energy) related to a prolonged labor process; Impaired gas exchange (fetoplacental) related to hyperstimulation of the uterus with oxytocin augmentation; and Anxiety related to unfamiliar experiences, surroundings, and unexpected medical interventions.

Answer to Question 2

A

Feedback
A The nurse may observe a Vietnamese woman who gives minimal care to her in-fant and refuses to cuddle or interact with her infant. The apparent lack of inter-est in the newborn is this cultural group's attempt to ward off evil spirits and actually reflects an intense love and concern for the infant.
B Cultural beliefs are important determinates of parenting behaviors. The woman's lack of interest is a Vietnamese cultural behavior.
C Cultural beliefs are important determinates of parenting behaviors. The woman's lack of interest is a Vietnamese cultural behavior. The lack of infant interaction is not a form of infant neglect but rather a demonstration of love and concern for the infant.
D The nurse may observe the woman and may be concerned by the apparent lack of interest in the newborn when, in fact, this is a cultural display of love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices.

[audragclark]

TYSM

[sailorcrescent]

Gracias!