QUESTION: "A 20-year-old obese primigravida at 40 weeks' gestation is admitted to the birthing center in the first stage of labor with contractions lasting 50 seconds and occurring every 3 to 4 minutes. The client's cervix is dilated 5 cm and is 75% effaced. When assessing the client's emotional status, which of the following would the nurse anticipate the client to exhibit?"
CHOICES
( O ) a.) Seriousness.
( X ) b.) Fear.
( X ) c.) Excitement.
( X ) d.) Panic.
RATIONALE: Typically, as labor progresses, the client becomes serious and ready to get down to work. Thus, the nurse would expect the client to be exhibiting seriousness. Seriousness, not fear, is more common during this phase of labor. Early in the first stage of labor (1 to 4 cm) when complications are absent and contractions are still not very strong, the client usually is not very uncomfortable. She is usually excited that the delivery day has finally arrived, and she can expect to be happy and eager. As the transition phase approaches, the client is likely to become irritable, tired, and sometimes panicky or fearful. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
