Author Question: A laboring patient of Chinese descent has been very quiet during labor, and has made no noise during ... (Read 31 times)

luminitza · **on:** Jun 27, 2018

A laboring patient of Chinese descent has been very quiet during labor, and has made no noise during contractions during the past 4 hours. The nurse understands that this indicates that the client:

1. Believes pain should be endured and not expressed.
2. Is not in the active phase of labor yet.
3. Will not need pain medication during her hospitalization.
4. Has been abused by her husband, and is afraid to verbalize fear.

Question 2

The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100 effaced.

The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Encourage the husband to remain in the room.
2. Keep the client on bed rest at this time.
3. Apply an internal fetal scalp electrode.
4. Obtain a clean-catch urine specimen.

bob · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1
Rationale 1: The belief that pain should be endured and not expressed is a common traditional Chinese belief.
Rationale 2: In this case, the nurse must assess for the progression of labor in other ways.
Rationale 3: The nurse cannot make the assumption that no pain relief medication will be needed either during the labor and birth or the postpartum period.
Rationale 4: This patient's silence does not necessarily indicate domestic abuse.

Answer to Question 2

2
Explanation: 2. Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse.