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The nurse is caring for a primagravida 1 para 0 client without complications who is near the end of the first stage of labor. Which nursing diagnosis is most appropriate at this time?

Explanation

• Adequate intake of fluids and nourishment is needed to maintain hydration and energy during the early stage of labor.  Traditionally fluids were restricted during labor to only ice chips due to the risk for aspiration should a maternal client require anesthesia; however, that practice has been challenged due the predominance of regional anesthesia for cesarean section.

• Regardless of unit policy, the nurse should recognize that clients have inadequate intake of fluids during the first stage of labor due to delayed gastric emptying and decrease PO intake. The nurse should allow the intake of clear fluids as tolerated or according to facility policy.

• For an uncomplicated labor, placental perfusion would not be hindered by the client who may reposition ad lib.

• Primagravida indicates this is the client's first pregnancy, so anxiety related to a previous delivery is not appropriate.

• Anxiety related to frequent vaginal examinations would not be appropriate for a client near the end of pregnancy.

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