Question

Labor and delivery  Scenario

At 0830 hrs. - Leanne arrived by car to your unit, with her husband George and her mother Catherine. She states the membranes ruptured at 0800 hrs and is feeling uncomfortable

With contractions that started at 0500 hrs.

She is G1 P0 A0, Her LMP was April 2nd 2019. The Ultrasound and dates confirmed her.

EDD to be January 9th; making her 40+1 today.

Leanne last ate at 1800 hrs the night before and has been drinking clear fluids this morning.

Her blood group is A positive.

She is a healthy woman and has had a healthy pregnancy; taking vitamins only. Leanne plans to breastfeed.

Leanne has no allergies and has not been in contact with communicable diseases or had any recent hospitalization. GBS, HBsAG, HSV negative.

Leanne is having regular q 2-3 minute (3-4/10min) contractions that are strong on palpation with the uterus relaxing between. Her pad reveals clear amniotic fluid with scant mucous show.

Leanne states the baby has been moving; that she feels supported the way she is managing her labor even though the pain is intense. She describes her pain as a "6" on the pain scale.

She has been admitted directly to a birthing room.

0845 hrs - you perform a physical assessment -- Leopold's Maneuvers reveal a vertex

Presentation; Fundal Height 37cm; longitudinal lie, position LOA and the EFW 3600 gms. The FHR was 144 bpm .

The vaginal exam revealed a fully effaced cervix, 8cm dilated, station +1.

BP 110/70 Pulse 100 bpm and Respirations 24 Temperature 37.4C Urine Nil for protein and ketones.

After 2hrs she have regular q 2-3 minute (4-5/10min) contractions that are strong on palpation with the uterus relaxing between , with vaginal examination cervix, was 9cm dilated.

Vital signs are BP 115/75, p. 92 Respirations 24 Temperature 37C.

Questions:

-Develop nursing care plan ? (3)

Answer 1

- Administer onelgence as inducted Aryani Ruk for inpasted gas exchange it allered oxygen supply I slood flow Desired outcome: Peters will display fetal heart rate in normal lirits & Jetus will be fece of adresse effects of hypoxia during lebon Nisg Interventions: Assess FIR during contractions and Note & recond Color, amount & odor of annistic flued a time of membrane rupture • Monitor uterine activity manually electronically • Monitor fetel descent by vaginal exami place client in leveral recumbent position: or turn client from side to side Administer oxygen if required If lefe on persistent decelerations, transfer cs sto Level 2/3 hospital CamScanner

I Nursing care flow Acupe pain est pressure on adjacent orgens, r g o Stimulation of both parasympathetic a sympathole nerve enelings or tissue dilation Desired out come! - client will use techniques to contend pain/ ..- client will report relief in discomfort Ng Interventions -- Assess degree of dissimfort through verbal & non verbal cues - Assess neture of refined show, cervical deletion ; effacement fetel station & descent - Time & record the frequeny, intensity & duration of erine Entrections - Provide information about available anelgesics, usual response 1 side effects & duration of analgesic effect - Assess Bl a fulse every 1-2 min after Regional injection . for first is mens Monitor FHR - Encourage patent in conversation. - Encourage client to void q 1-2 kr Assist the client with back massage / Kepositioning ferred core mouth care, breathing / relaxation technique Scanned with CamScanner