Question

10 Unfolding Case Studies: Experiencing the Realities of Clinical Nursing Practice 4. What nursing diagnoses or collaborative problems and interventions are appropriate this stage of labor? w 1400 Suzanne's contractions are 4 minutes apart, last 45-60 seconds, and are of moderate inten sity, Vaginal assessment is 6 cm. dilated, +2 station, 100% effaced. Suzanne is more serious and focused on each contraction, feels helpless and apprehensive, and wants to get this over with." She asks, "Can I have something to take the edge off this pain?" Jeff is supportive and atten tive. She has been ambulating with Jeff in the hallway but now wants to lie down. As she gets into bed, her membranes spontaneously rupture and atinge of green is noted in the fluid color. There is increasing bloody show Focus Questions 1. What stage and phase of labor is she in? 2. What nursing diagnoses and interventions are appropriate now? 3. What collaborative problems are possible considering this data? 1900 Suzanne's contractions are 2-3 minutes apart, last 70-80 seconds, and are of very strong intensity. She shows frustration, loss of control, has nausea, and vomits small amounts. She tells her husband, "Get away, do not touch me!" As the nurse enters the room, she asks for a bedpan and says she feels like she has to have a bowel movement. She screams, "I have to push!"

Answer 1

1. Suzane in active phase of 1st stage of labour

Beacuse after start of True labour pain to 5cm dilation of cervix is latent phase

6 to 10cm dilation of cervix and start descent of fetal head in active phase of labour

2. Nurse Check presantion of baby by per vaginal examination

If Head present in lower end and feel vertex of baby so it normal cephalic presentation

If in this condition normal presantion of baby wait and watch for fully dilation of cervix and descent of fetus record

When cervix fully dilated and fetal head see support for delivery and give to birth a baby

If malpresation of baby or cervix not dilate after that or fetus head not desent required gynaecologist in a hospital

3. In this condition these problems are possible

1st protracted active phase

Do augmentation of labour by oxytocin