A client is in active labor. The nurse determines that the fetus's position is occiput posterior. Which nursing diagnosis will apply to this woman's care if the occiput posterior position becomes persistent?
1. Acute pain
2. Risk for injury
3. Impaired gas exchange
4. Fluid volume deficit
1
Rationale:
1. Acute pain is the diagnosis that will apply to this client. Back pain is experienced during persistent occiput posterior position because the fetal occiput compresses the sacral nerves.
2. Risk for injury would be an appropriate diagnosis if the labor were to start progressing quickly or precipitously.
3. Impaired gas exchange occurs when there is an interruption in umbilical blood, often secondary to compression of the cord.
4. Fluid volume deficit would be an appropriate diagnosis if there were risk of excessive bleeding.
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