Health Promotion and Maintenance Q 43
A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
A. Alteration in coping related to pain
B. Potential for injury related to precipitate delivery
C. Alteration in elimination related to anesthesia
D. Potential for fluid volume deficit related to NPO status
Correct Answer: A. Alteration in coping related to pain
Transition is the time during labor when the client loses concentration due to intense contractions. Assess nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent. Cervical dilation should be approximately 1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with a fetal descent. Choice and timing of medication is affected by the degree of dilation and contractile pattern.
Option B: Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. Monitor uterine activity manually and/or electronically, noting frequency, duration, and intensity of contraction. The uterus is susceptible to possible rupture if a hypertonic contractile pattern develops spontaneously or in response to oxytocin administration. Placental separation and hemorrhage can also occur if contraction persists.
Option C: Encourage periodic attempts to void, at least every 1–2 hr. Pressure of the presenting part on the bladder often reduces sensation and interferes with complete emptying. Regional anesthesia (especially in conjunction with IV fluid infusion and use of Stadol) also may contribute to voiding difficulties/bladder distension.
Option D: Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature). Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability, and loss of consciousness.