During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time?

Question

A) Risk for fluid volume deficit
B) Anxiety related to stress of labor
C) Risk for ineffective breathing pattern related to breathing exercises
D) Powerlessness related to duration of labor

Answer 1

C
Feedback:
Hyperventilation occurs when the patient exhales more deeply than inhaling. As a result, extra carbon dioxide is blown off, and respiratory alkalosis results. This can occur during actual labor. The best way to manage hyperventilation is to prevent it by coaching the patient to end all breathing sessions with a long cleansing breath to help restore carbon dioxide balance. Difficulty using breathing techniques will not cause a risk for fluid volume deficit, anxiety related to stress of labor, or powerlessness related to duration of labor.