Question

Chapter 8—Intrapartum assessment and interventions

As the nurse, you admit Margarite Sanchez to the labor and delivery unit. She arrived in the triage unit at midnight in early labor. She presented with uterine contractions that were 5 minutes apart for 3 hours. The patient is a 28-year-old G3 P1011 Hispanic woman. She is at 39 weeks’ gestation. José, her husband, has accompanied her to the unit. Two years ago, she had a normal spontaneous vaginal delivery after an 18-hour labor for a baby girl, Sonya, who weighed 7 lb, 3 oz. Margarite’s cervix is now 4 cm/80%/0 station, and the fetal position is left occiput anterior.

Prenatal Labs:

• Blood type O+
• RPR NR
• GBS negative
• Hgb 11.7
• Hct 4
• Hepatitis negative

Vital signs:

• Blood pressure 110/60
• pulse 84 bpm
• respiratory rate 18
• temperature 98.6°F (37°C)

Margarite received regular prenatal care, beginning at 10 weeks of gestation. She gained 22 lb during pregnancy, and her current weight is 164 lb. She is 5 ft, 4 in. tall. She has no prior medical complications and has experienced a normal pregnancy. Her first pregnancy ended in miscarriage at 8 weeks’ gestation. She has no allergies to food or medication. She does not have a birth plan and says, “I just hope for a normal delivery and a healthy baby.”

1. Detail the aspects of your initial assessment.

Electronic fetal monitoring reveals an FHR pattern that is normal, category I, with an FHR baseline in the 140s, with moderate variability. Margarite is uncomfortable with the contractions and rates her pain at 5. She requests ambulation, because she feels more comfortable walking.

At 1:20 a.m., she has a spontaneous rupture of membranes (SROM), releasing a large amount of clear amniotic fluid. FHR baseline is in the 130s, with moderate variability, and accelerations and contractions are every 3 minutes and feel moderate when palpitated. Her sterile vaginal examination (SVE) reveals that her cervix is 5 cm/90%/0 station. She is very uncomfortable with the contractions but does not want pain medication at this time. José appears anxious and at a loss as to how to help his wife.

2. What are your immediate priorities in nursing care for Margarite and José Sanchez?
3. Discuss the rationale for the priorities.

4. What teaching would you include?

5. Discuss nursing diagnosis, expected outcome, and interventions related to managing Margarite’s labor pain.

6. What are appropriate nonpharmacological interventions for managing Margarite’s labor pain?

At 2 a.m., Margarite is increasingly uncomfortable with contractions and cries out that she can no longer take the pain. Her cervical examination reveals that her cervix is 6 cm/100%/0 station. She requests pain medication and is given a dose of Nubain at 2:15 a.m. for pain relief in active labor. José asks how much longer the labor will be and when the baby will be born.

7. Provide details of what you include in your ongoing assessment.

8. What are your current priorities in nursing care for Margarite Sanchez?
9. Discuss the rationale for your priorities.

10. State (3) nursing diagnosis, expected outcome, and interventions related to this problem.

Answer 1

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