Question

A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is \(8 \mathrm{~cm}\) dilated withcomplete 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

Short answer

Answer: B. Potential for injury related to precipitate delivery.

Step-by-step solution

1. Analyze option A - Alteration in coping related to pain

Considering the woman is in labor and has significant cervical dilation, it is reasonable that she may experience pain. However, the priority nursing diagnosis should focus on the most critical aspect for the patient's safety and well-being.

2. Analyze option B - Potential for injury related to precipitate delivery

Precipitate delivery refers to rapid labor and delivery, which can increase the risk of injury for both the mother and baby. With the client's cervix being 8 cm dilated, it indicates that she is in the active stage of labor and close to delivery. This factor makes option B a strong contender for the priority nursing diagnosis.

3. Analyze option C - Alteration in elimination related to anesthesia

Anesthesia may impact a patient's elimination, but the question doesn't mention that the patient has received or is expected to receive anesthesia, so this option doesn't have strong evidence to be considered as a priority nursing diagnosis.

4. Analyze option D - Potential for fluid volume deficit related to NPO status

NPO (nothing by mouth) status refers to the restriction of oral intake. Although fluid volume deficit can be a concern during labor, the fact that the client's cervix is 8 cm dilated with complete effacement suggests that the primary concern should focus on a more imminent issue related to labor and delivery.

5. Determine the priority nursing diagnosis

Based on the analysis of each option, the priority nursing diagnosis at this time is: B. Potential for injury related to precipitate delivery. This is because the client is in the active stage of labor with significant cervical dilation, which indicates a higher risk for a rapid delivery and potential injury for both the mother and baby.

Key concepts

Cervical Dilation

Cervical dilation is a critical process during labor and delivery, signifying the opening of the cervix to prepare for the baby's passage through the birth canal. As labor progresses, the cervix dilates from a closed position to one that is fully open at 10 centimeters, allowing for delivery. Understanding cervical dilation is essential for healthcare professionals to determine the labor stage the patient is in and to make appropriate clinical decisions.

For instance, a cervix that is 8 cm dilated, as in the exercise presented, indicates that the patient is in the active labor stage and may soon transition to the second stage of labor, which involves pushing and delivering the baby. It is vital to closely monitor the mother's progress and any signs that may point to complications, such as precipitate labor. Appropriate interventions should be timely to promote mother and baby's health.

Prioritizing Patient Safety

Prioritizing patient safety is paramount in all healthcare settings, especially during labor and delivery. It involves a series of careful assessments and interventions to avoid potential harm. For a pregnant woman in labor, this means continuous monitoring of both the mother and the unborn child's well-being, preparing for any sudden changes in the condition, and being ready to act swiftly to prevent injury.

Strategies to ensure patient safety include identifying high-risk factors, such as signs of precipitate delivery or other complications, and having emergency equipment and trained personnel readily available. The application of evidence-based practices and protocols, along with clear communication among the healthcare team, is also crucial in creating a safe delivery environment. By focusing on patient safety, healthcare providers aim to minimize risks and ensure a positive outcome for mother and baby.

Precipitate Delivery

Precipitate delivery is a term that describes an unusually rapid labor and birth, typically lasting fewer than three hours from the onset of contractions to delivery. While quick delivery might seem advantageous, it can be fraught with complications for both the mother and the newborn, such as trauma or fetal distress.

Healthcare professionals must recognize the signs of precipitate delivery and prepare for immediate action to manage potential risks effectively. The signs can include sudden intense contractions, rapid cervical dilation, and the mother's urge to push sooner than expected. Effectively managing precipitate delivery requires a skilled and responsive team effort to ensure a safe and controlled birthing process. Quick and efficient delivery room preparation and resources to stabilize the mother and newborn post-delivery are also vital considerations in care planning.