Assignment
Case Study: Intrapartum Assessment and Interventions
Scenario I: As the nurse, you received report from the triage nurse and take Margarite Sanchez to the labor and delivery unit. She arrived in the triage unit at midnight in early labor. She states "uterine contractions that were 5 minutes apart for 3 hours".
Patient is a 28-year-old G3 P1 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 (NSVD) after an 18-hour labor for a baby girl, Sonya, who weighed 7 lbs., 3 oz. Margarite's cervix is now 4 cm/80%/0 station and fetal position is left occiput anterior.
Prenatal Labs
Blood type O+
RPR NR
GBS negative
Hgb:40
Hct: 13
Hepatitis negative
Vital signs: Blood pressure 110/60; pulse 84 bpm; respiratory rate 18; temperature 98.6oF (37oC).
Began prenatal care at 10 weeks of gestation and received regular prenatal care. She gained 22 pounds during pregnancy, and her current weight is 164 lbs. She is 5 feet, 4 inches 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 states, "I just hope for a normal delivery and a healthy baby."
i. Detail the aspects of your assessment when admitted to labor and delivery from triage.
Scenario II: At 0100 EFM reveals an FHR pattern that is normal, category I, with an FHR baseline of 140s moderate variability with accelerations to 160s ? 20 seconds. She is uncomfortable with contractions and rates her pain at 5. She requests ambulation because she feels more comfortable with walking. At 0120 she has a spontaneous rupture of membrane (SROM) for a large amount of clear amniotic fluid. FHR is baseline 130s with moderate variability, and accelerations and contractions are every 3 minutes and feel moderate to palpation. Her sterile vaginal exam (SVE) after SROM reveals her cervix is 5 cm/90/0 station. She is very uncomfortable with contractions but does not want pain medication currently. José appears anxious and at a loss for how to help his wife.
i. What are your immediate priorities in nursing care for Margarite and José Sanchez? Discuss the rationale for the priorities.
ii. What teaching would you include for both?
iii. What is the nursing diagnosis, expected outcome, and interventions related to managing her labor pain?
iv. What are appropriate nonpharmacological interventions to manage her labor pain?
Scenario III: At 2 a.m., Margarite is increasingly uncomfortable with contractions and cries out that she can no longer take the pain. Her cervical exam is 6/100/0. She requests pain medication and is given a dose of Dilaudid (Hydromorphone) at 0215 for pain relief in active labor. José asks how much longer the labor will be and when the baby will be born.
i. Detail the aspects of your ongoing assessment.
ii. What are your current priorities in nursing care? Discuss the rationale for the priorities.
iii. State the nursing diagnosis, expected outcome, and interventions related to scenario III.
Scenario IV: At 0410, Margarite is very uncomfortable with contractions and cries out that she feels more pressure. She vomits a small amount of bile-colored fluid and is perspiring and breathing hard with contractions. Her cervical exam is 8/90/0. She is requesting pain medication for pain relief in transition.
i. What would be your appropriate interventions for scenario IV?
Scenario V: At 0630, Margarite reports an urge to bear down and push with contractions, is very uncomfortable with contractions, and cries out that she feels more pressure. Her SVE reveals she is 10 cm/100% and +1 station. She has a strong urge to push with contractions that are every 2 minutes and strong to palpation. The fetal heart rate (FHR) is 130 with moderate variability, and the FHR drops to 90 bpm for 40 seconds with pushing efforts.
i. What are your immediate priorities in nursing care for Margarite Sanchez? Discuss the rationale for the priorities.
ii. What is going on with the FHT, what does it mean?
iii. State the nursing diagnosis, expected outcome, and interventions related to managing her from scenario V.
Scenario VI: Margarite continues to bear down, using open glottis pushing with contractions, and the fetal head is descending with contractions. The fetal heart rate is 130 with moderate variability and the FHR drops to 90 bpm for 40 seconds with pushing efforts. At 7:30 a.m., Margarite is increasingly unfocused with contractions and states, "I can't push . . . call my doctor to get the baby out!" José is at her side, holding her hand and encouraging her pushing efforts.
i. What are your immediate priorities in nursing care in scenario VI? Discuss the rationale for the priorities.
Scenario VII: At 0815, Margarite continues to bear down with contractions and the fetal head is descending with contractions. The FHR is 130 with moderate variability and the FHR drops to 90 bpm for 40 seconds with pushing efforts. Margarite is focused with contractions. The fetal head is starting to crown with pushing efforts.
i. What are your immediate priorities in nursing care for Margarite Sanchez in scenario VII?