Question

Chapter 1 Obstetrical Cases 9 % CASE #3 SUZANNE NETHERS S Learning Objectives 1. Interpret the data given and determine which phase of the first stage of labor the client is experiencing 2. Discuss the appropriate psychological and physiological characteristics of all phases of the first stage of labor. 3. Analyze available data and determine actual or potential nursing diagnoses and/or collaborative problems appropriate to the first stage of labor. 4. Identify appropriate nursing interventions relative to each phase of the first stage of labor. ynthia 0800 Suzanne Nethers is an excited and talkative 24-year-old (GIP) kindergarten teacher mar. ried to Jeff, a 26-year-old computer analyst. She is admitted to the labor and delivery suite with signs of bloody show and contractions occurring every 16 minutes and lasting 20-30 seconds. Jeff reports to the nurse that she is doing really well with her breathing and that they are excited about having a natural childbirth. During the assessment the nurse finds the current preg- nancy, family, and medical history are normal; BP 128/64, P. 90, R. 24. FHT are 140, strong and regular. Membranes are intact. A vaginal check reveals Suzanne to be 2 cm. dilated, 50% effaced, and at 0 station. Focus Questions 1. In what stage and phase of labor is Suzanne? 2. What would the nurse need to assess? 3. What data would prompt the nurse to call the physician or nurse midwife (list warning signs)?

Answer 1

1. Suzane is in latent phase of first stage of labor as cervical dilation is 2cm and regular contractions are there.

2. A nurse should assess by using partograph

• vital signs of mother: pulse, blood pressure, temperature
• Urine testing for sugar protein and ketones should be done
• Assess for fluid balance by noting urine output and assessing patient’s tongue
• Abdominal examination should be done to assess length, frequency and strength of contractions. Descent of presenting part should be assessed by pelvic grip.
  vaginal examination should be done to check dilation of cervix, position , station of the fetus, color of the liquor, degree of moulding of head
• contunuous monitoring of fetal heart rate should be done
• In addition , nurse need to assess for fetal distress from fetal heart rate and colour of meconium.

3. Nurse should report whenever she notices following warning signs

• rupture of membranes
• fetal distress in form of feral tachycardia or fetal bradycardia, meconium stained liquor
• bleeding before baby is born may be because of placental abruption
• strong headache, blurred or double vision, sudden, steady severe pain at the top of the belly, just below the high point between the ribs, overactive reflexes, high blood pressure And protein in the urine as these are signs of preeclampsia.