A pregnant client is anticipating a vaginal birth without complications. During the course of her labor, complications arise and the fetus has to be delivered via cesarean section
The client is visibly upset and wants to know why this has happened to her because she did everything right during her pregnancy. Which priority nursing diagnosis would apply?
a. Risk for injury
b. Pain
c. Impaired skin integrity
d. Anxiety
ANS: D
Although risk for injury, pain, and impaired skin integrity apply as nursing diagnoses, the client situation is such that she was anticipating a vaginal birth. Thus, she is more likely to be experiencing anxiety related to the change in birth plan so the nurse should respond to that as the priority need.
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