The laboring primiparous patient 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 patient's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this patient? 1. Health-seeking Behaviors related to increased pain level
2. Acute Pain related to contractions and the birth process
3. Compromised Family Coping related to birth process
4. Deficient Knowledge related to lack of information about relaxation
2
Rationale 1: The patient is not asking questions; therefore, this diagnosis does not fit.
Rationale 2: The patient is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor.
Rationale 3: There is no evidence regarding the family's coping, only the patient's coping with the pain.
Rationale 4: The patient used breathing and relaxation techniques earlier in labor, demonstrating a knowledge of these techniques.
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