Physiological Integrity Q 24
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
A. Impaired gas exchange related to hyperventilation
B. Alteration in placental perfusion related to maternal position
C. Impaired physical mobility related to fetal-monitoring equipment
D. Potential fluid volume deficit related to decreased fluid intake
Correct Answer: D. Potential fluid volume deficit related to decreased fluid intake
Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted. Helps promote hydration and may provide some calories for energy production.
Option A: Impaired gas exchange related to hyperventilation would be indicated during the transition phase. Assess FHR changes during a contraction, noting decelerations and accelerations. Detects severity of hypoxia and possible cause. The fetus is vulnerable to potential injury during labor, owing to situations that reduce oxygen levels, such as cord prolapse, prolonged head compression, or uteroplacental insufficiency.
Option B: Instead of Impaired physical mobility, Risk for ineffective coping would be more appropriate at this stage of labor. Reinforce breathing and relaxation techniques during contractions. Minimizes anxiety and provides a distraction, which may block the perception of pain impulses within the cerebral cortex.
Option C: Fluid volume deficit is not correct in relation to the stem. Monitor intake & output. Note urine specific gravity. Encourage the client to empty the bladder at least once every 1 1/2–2 hr. Intake and output should be approximately equal, depending on degree of hydration. Concentration of urine increases as urine output decreases and may warn of dehydration. Fetal descent may be impaired if the bladder is distended.