Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?
a. Length of second-stage labor is 2 hours.
b. Client has received an epidural for pain control during the labor process.
c. Client is using breathing techniques during contractions to maximize pain relief.
d. Client is receiving parenteral fluids during the course of labor to maintain hydration.
ANS: B
A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.
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