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
2
Explanation: 2. The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor.
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A client is brought to the emergency department with a diagnosis of possible cerebral vascular accident (CVA) and is being typed and crossmatched for fresh frozen plasma (FFP). Which is the best nursing understanding for this action?
A) Best treatment for embolus causing stroke B) The stroke is still evolving. C) Client is experiencing a hemorrhagic stroke. D) The client is experiencing hypervolemia.
A nurse overhears other staff discussing a family who lost their business in a fire. "That family agrees on nothing. It is totally dysfunctional
" Which of the following questions by the nurse would facilitate increased understanding of the family's situation? A) "What roles do the family members take on?" B) "Are they ever able to resolve their disagreements?" C) "Families who disagree are a challenge to therapists." D) "You seem very critical of the family. I guess you feel unable to help them."
When androgens are given to children, it is important to monitor:
1. x-ray films of the hand and wrist to evaluate epiphyses. 2. CBC for anemia. 3. urinalysis for ketones. 4. weight for wasting.
A disaster occurs when a hazard interacts with human vulnerability.
Answer the following statement(s) true (T) or false (F)