The laboring primiparous client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on having a natural, unmedicated birth.
Her contractions are every three minutes, and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now during contractions she is writhing on the bed, and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? A. Health seeking behaviors related to increased pain level
B. Acute pain related to contractions and the birth process
C. Compromised family coping related to birth process
D. Deficient knowledge related to lack of information about relaxation
Question 2
The primigravida client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that.
What is the best response by the nurse? I stimulated the top of the baby's head to: A. Wake him up a little.
B. Try to get his heart rate to accelerate.
C. Calm the baby down before birth.
D. Find out if he is in distress.
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