Question

Desiree, a 28-year-old G2P1, is admitted to the labor and birth unit. Her birth plan indicates that she is planning natural childbirth without pharmacological interventions. She has attended childbirth education classes. Desiree is considered low risk based on her personal and family health history and physical examination. Her pregnancy has progressed without complications. She is approximately 38 weeks pregnant. Vaginal assessment reveals cervical dilation at 10 cm, 100% effaced, and +1 station. Position of the fetus is LOA. The external fetal monitor indicates a reassuring fetal heart rate at 130 beats per minute. Maternal status is stable. (Learning Objectives 1, 5, and 8)

A. Based on the vaginal assessment, what is the stage of labor and what are the appropriate nursing interventions for this stage of labor?

B. Explain how the nurse determined that the external fetal monitor would be appropriate for Desiree. What factors would necessitate a change to internal fetal monitoring during labor?

C. Desiree says, “I’m not sure I can cope with the pain much longer.” How would you respond, considering her birth plan, stage of labor, and assessment data?

Answer 1

( A) Mrs Desiree is in first stage of labour with third phase - transition.The nursing interventions of the first stages are as follow:
• Asking about the client’s expectations of the birthing
process
• Providing information about labor, birth, pain-
management options, and relaxation techniques
• Presenting information about fetal monitoring equipment
and the procedures needed
• Monitoring FHR and identifying patterns that need
further intervention
• Monitoring the mother’s vital signs to obtain a baseline
for later comparison
• Reassuring the client that her labor progress will be
monitored closely and nursing care will focus on ensur-
ing fetal and maternal well-being throughout
As the woman progresses through the first stage of
labor, nursing interventions include:
• Encouraging the woman’s partner to participate
• Keeping the woman and her partner up to date on the
progress of the labor
• Orienting the woman and her partner to the labor and
birth unit and explaining all of the birthing procedures
• Providing clear fluids (e.g., ice chips) as needed or
requested
• Maintaining the woman’s parenteral fluid intake at the
prescribed rate if she has an IV
• Initiating or encouraging comfort measures, such as
back rubs, cool cloths to the forehead, frequent position
changes, ambulation, showers, slow dancing, leaning
over a birth ball, side-lying, or counterpressure on lower
back (Teaching Guidelines 14-1)
• Encouraging the partner’s involvement with breathing
techniques
• Assisting the woman and her partner to focus on breath-
ing techniques
• Informing the woman that the discomfort will be inter-
mittent and of limited duration; urging her to rest
between contractions to preserve her strength; and
encouraging her to use distracting activities to lessen
the focus of uterine contractions
• Changing bed linens and gown as needed
• Keeping perineal area clean and dry
• Supporting the woman’s decisions about pain
management
• Monitoring maternal vital signs frequently and report-
ing any abnormal values
• Ensuring that the woman takes deep cleansing breaths
before and after each contraction to enhance gas ex-
change and oxygen to the fetus
• Educating the woman and her partner about the need for
rest and helping them plan strategies to conserve strengthursing Interventions
Nursing interventions during the admission process should
include:
• Asking about the client’s expectations of the birthing
process
• Providing information about labor, birth, pain-
management options, and relaxation techniques
• Presenting information about fetal monitoring equipment
and the procedures needed
• Monitoring FHR and identifying patterns that need
further intervention
• Monitoring the mother’s vital signs to obtain a baseline
for later comparison
• Reassuring the client that her labor progress will be
monitored closely and nursing care will focus on ensur-
ing fetal and maternal well-being throughout
As the woman progresses through the first stage of
labor, nursing interventions include:
• Encouraging the woman’s partner to participate
• Keeping the woman and her partner up to date on the
progress of the labor
• Orienting the woman and her partner to the labor and
birth unit and explaining all of the birthing procedures
• Providing clear fluids (e.g., ice chips) as needed or
requested
• Maintaining the woman’s parenteral fluid intake at the
prescribed rate if she has an IV
• Initiating or encouraging comfort measures, such as
back rubs, cool cloths to the forehead, frequent position
changes, ambulation, showers, slow dancing, leaning
over a birth ball, side-lying, or counterpressure on lower
back (Teaching Guidelines 14-1)
• Encouraging the partner’s involvement with breathing
techniques
• Assisting the woman and her partner to focus on breath-
ing techniques
• Informing the woman that the discomfort will be inter-
mittent and of limited duration; urging her to rest
between contractions to preserve her strength; and
encouraging her to use distracting activities to lessen
the focus of uterine contractions
• Changing bed linens and gown as needed
• Keeping perineal area clean and dry
• Supporting the woman’s decisions about pain
management
• Monitoring maternal vital signs frequently and report-
ing any abnormal values
• Ensuring that the woman takes deep cleansing breaths
before and after each contraction to enhance gas ex-
change and oxygen to the fetus
• Educating the woman and her partner about the need for
rest and helping them plan strategies to conserve strength.

( B ) The progression of the labour is taking place properly with no complication of fetal heart rate the nurse will go for external monitor ing only but sometimes if the abnormal fetal heart rate ,poor progress in late labour may determine for internal fetal monitoring.

( C) The response of the nurse would be assuring Desiree to push as the head of the baby is about to deliver and she would be entering into second phase immediately and some breathing exercises would surely help her to cope up the pain and would have successful safe confinement.