The laboring 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 a natural, unmedicated birth.
Her contractions are every 3 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? 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome
2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent
3. Coping: Family, Compromised, related to labor process
4. Knowledge, Deficient, related to lack of information about normal labor process and comfort measures
Question 2
The nurse is listening to the fetal heart tones of a client at 37 weeks' gestation while the client is in a supine position. The client states, I'm getting lightheaded and dizzy. What is the nurse's best action?
1. Assist the client to sit up.
2. Remind the client that she needs to lie still to hear the baby.
3. Help the client turn onto her left side.
4. Check the client's blood pressure.
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