Which of the following interventions should the nurse prioritize for a patient in the early latent phase of labor with stable vital signs and mild contractions?

B) Encourage the patient to ambulate

A) Administer pain medication immediately

B) Encourage the patient to ambulate

C) Restrict fluid intake to prevent nausea

D) Prepare for an emergency cesarean section

During the early latent phase of labor, what is the most appropriate nursing action to support labor progression for the patient described?

C) Encourage ambulation and hydration

A) Encourage the patient to lie in bed and rest

B) Instruct the patient to avoid eating and drinking

C) Encourage ambulation and hydration

D) Administer analgesics to reduce pain

During the early stages of labor, which intervention is most appropriate to promote the progression of labor and comfort in the patient?

B) Offer the patient a birthing ball to sit on

A) Encourage the patient to lie on her back

B) Offer the patient a birthing ball to sit on

C) Restrict the patient from drinking fluids

D) Administer a sedative to reduce discomfort

What is the priority nursing action to support a patient in the early stages of labor with stable vital signs and a reassuring fetal heart rate pattern?

B) Encourage ambulation and position changes

A) Administer oxygen via face mask

B) Encourage ambulation and position changes

C) Start an intravenous line for potential hydration needs

D) Prepare for immediate cesarean section

What is the most appropriate non-pharmacological intervention the nurse should suggest to the patient experiencing active labor pain?

A) Encourage the patient to take a warm shower

B) Advise the patient to lie flat on her back to rest

C) Suggest the patient walk around the room

D) Recommend the patient drink a glass of cold water

A pregnant patient in the active phase of labor reports increased discomfort and frequent contractions. Which non-pharmacological intervention should the nurse prioritize to help manage the patient's pain?

C) Guide the patient in focused breathing techniques

A) Encourage the patient to ambulate

B) Offer the patient a warm shower

C) Guide the patient in focused breathing techniques

D) Administer intravenous fluids

What is the priority action for the nurse after the administration of an epidural in a laboring patient?

B) Monitor the patient's blood pressure closely

A) Encourage the patient to walk around

B) Monitor the patient's blood pressure closely

C) Increase the IV fluid rate without an order

D) Position the patient in a supine position

What is the primary reason for monitoring the patient's blood pressure closely after the administration of an epidural during labor?

B) To detect any potential drop in blood pressure, which can be a common side effect

A) To ensure the epidural is effective in managing pain

B) To detect any potential drop in blood pressure, which can be a common side effect

C) To assess for increased risk of infection following the procedure

D) To evaluate the fetal heart rate response to the epidural

What is a primary nursing intervention to prevent hypotension after epidural anesthesia is administered during labor?

C) Monitor the patient's blood pressure frequently

A) Encourage the patient to ambulate

B) Position the patient supine with legs elevated

C) Monitor the patient's blood pressure frequently

What is the primary reason for encouraging a laboring patient with an epidural to change positions periodically?

A) To enhance the effectiveness of the epidural analgesia

C) To prevent the epidural catheter from dislodging

D) To increase maternal comfort and decrease anxiety

labor and delivery - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal changes trigger labor, primarily through increased levels of oxytocin and prostaglandins, which stimulate uterine contractions, leading to cervical dilation and effacement.

• Secondary mechanism: Fetal engagement occurs as the baby moves into the pelvis, applying pressure on the cervix and enhancing the production of hormones that further intensify contractions.

• Key complication: Inefficient uterine contractions can lead to prolonged labor, increasing the risk of maternal and fetal distress and necessitating medical interventions such as augmentation or cesarean delivery.

Patient Profile

Demographics:

28-year-old female, teacher

History:

• Key past medical history: No significant past medical history

• Current medications: Prenatal vitamins

• Allergies: No known allergies

Current Presentation:

• Chief complaint: Onset of labor

• Key symptoms: Mild contractions occurring every 10 minutes, no rupture of membranes

• Vital signs: Blood Pressure 120/80 mmHg, Heart Rate 80 bpm, Respiratory Rate 18 breaths/min, Temperature 98.6°F, Oxygen Saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon the initial assessment in the labor and delivery unit, the patient, a 28-year-old female teacher, is found to be in the early latent phase of labor. The cervical examination reveals 2 cm dilation, 50% effacement, and the fetal station is at -2, indicating that the baby's head is still positioned above the pelvis. The fetal heart rate is reassuring at 140 bpm with moderate variability, and there are no decelerations noted, suggesting the fetus is tolerating labor well. The patient's contractions remain mild and are now occurring every 8 to 10 minutes, lasting approximately 30 to 45 seconds.

The patient's overall condition appears stable, and she reports manageable discomfort, rating her pain as 3 on a scale of 10. She is encouraged to ambulate around the unit to help progress labor, as movement can facilitate fetal descent and promote more effective contractions. The labor and delivery team discusses the importance of staying hydrated, and she is advised to drink clear fluids. As the patient continues through the early stages of labor, the nursing staff plans to monitor her progress closely, particularly watching for more regular contraction patterns and changes in cervical status. This approach will ensure timely identification of any potential progression or complications, allowing for appropriate interventions if necessary.

Section 2

As the labor progresses, the nursing team observes a change in the patient's contraction pattern. Approximately four hours after the initial assessment, the contractions have become more frequent, occurring every 5 to 6 minutes and lasting around 45 to 60 seconds. The patient reports increased discomfort, rating her pain at a 5 on a scale of 10. She continues to ambulate periodically, which appears to be aiding in the progression of labor. The nursing staff conducts a follow-up cervical examination, revealing that the cervix has dilated to 4 cm and is now 70% effaced, with the fetal station moving to -1. These findings indicate a positive progression in labor, as the baby is beginning to descend further into the pelvis.

The patient's vital signs remain stable, with a blood pressure of 118/76 mmHg, pulse of 82 bpm, and temperature of 98.6°F (37°C). The fetal heart rate continues to be reassuring, maintaining a rate of 140 bpm with moderate variability and no signs of decelerations. The patient is encouraged to continue drinking clear fluids to stay hydrated, and she is offered a birthing ball to sit on, which may help improve comfort and promote further descent of the fetus. The nursing staff remains vigilant, closely monitoring for any signs of complications such as abnormal fetal heart rate patterns or increased pain that might require additional interventions.

Overall, the patient is progressing well through the early stages of labor. The nursing team plans to continue monitoring the frequency and intensity of contractions, as well as any further cervical changes. They will provide support and guidance to ensure the patient's comfort and safety as she moves toward the active phase of labor. By maintaining a proactive approach, the staff aims to identify any potential complications early and respond promptly to support a healthy delivery process.

Section 3

As labor continues, the nursing team observes a change in the patient's status approximately two hours after the last cervical examination. The patient reports an increase in the intensity of her contractions, now rating her pain at a 7 on a scale of 10. Contractions have become more regular, occurring every 3 to 4 minutes and lasting 60 to 75 seconds. The patient experiences more discomfort while walking, so she opts to stay on the birthing ball, which still provides some relief. The nursing staff reassesses her and finds that the cervix is now dilated to 6 cm and is 80% effaced, with the fetal station moving to 0. This progression indicates that the patient has transitioned into the active phase of labor.

The patient's vital signs remain within normal ranges, with a blood pressure of 116/74 mmHg, pulse of 84 bpm, and temperature of 98.7°F (37.1°C). The fetal heart rate continues to show reassuring patterns, maintaining a baseline of 138 bpm with moderate variability and no decelerations. To address the increasing pain, the nursing team offers the patient various non-pharmacological pain relief methods, such as breathing techniques, visualization, and massage. The patient expresses interest in trying these methods before considering pharmacological options.

The nursing staff continues to provide close monitoring and support, ensuring the patient's comfort and safety. They educate her about the signs of transition to the next phase of labor and emphasize the importance of communicating any changes in her pain or sensations. The team remains vigilant for any potential complications, such as abnormal fetal heart rate patterns or signs of maternal distress. By maintaining open communication and a supportive environment, the team aims to facilitate a smooth transition through the active phase of labor, setting the stage for a successful delivery.

Section 4

As the labor progresses, approximately one hour after the last assessment, the nursing team notices that the patient's contractions have intensified further, now occurring every 2 to 3 minutes and lasting about 75 to 90 seconds. While the patient continues to utilize non-pharmacological pain relief methods, she reports that the pain has increased to an 8 out of 10. The team reassesses her cervical dilation and finds that she has progressed to 7 cm dilated and 90% effaced, with the fetal station now at +1. These findings suggest that the patient is advancing well through the active phase of labor.

The patient's vital signs remain stable, with a blood pressure of 118/76 mmHg, a pulse of 86 bpm, and a temperature of 98.8°F (37.1°C). The fetal heart rate continues to exhibit reassuring patterns, with a baseline of 136 bpm, moderate variability, and no decelerations. Based on the patient's increased pain level and the progression of labor, the nursing team discusses the option of initiating an epidural for pain management. The patient expresses interest in this option, and the anesthesiologist is called to the room to discuss the procedure and obtain informed consent.

While preparing for the epidural, the nursing staff continues to provide emotional support and reassurance, explaining each step of the process to the patient and her partner. They monitor the patient closely for any signs of distress or complications, such as hypotension, after the epidural is administered. By maintaining a calm and supportive environment, the nursing team helps ensure that the patient remains as comfortable as possible, facilitating a positive labor experience as she approaches the transition to the next stage of labor.

Section 5

As the epidural is administered successfully, the patient reports a significant decrease in pain, which is now at a manageable level of 3 out of 10. This relief allows her to relax and conserve energy for the upcoming stages of labor. The nursing team continues to monitor the patient's vital signs closely to detect any potential side effects from the epidural, such as hypotension. Fortunately, the patient's blood pressure remains stable at 110/74 mmHg, and her pulse is steady at 84 bpm. The fetal heart rate is also stable, maintaining a baseline of 134 bpm with moderate variability, indicating that the fetus is tolerating labor well.

With the patient more comfortable, the nursing staff encourages her to change positions periodically to promote optimal fetal positioning and progression of labor. They assist her in using a peanut ball between her legs while lying on her side, which can help facilitate cervical dilation and descent of the baby. Additionally, they continue to provide emotional support, encouraging the patient and her partner to focus on their breathing techniques and visualization exercises.

A short time later, during a routine assessment, the nurse notes that the patient now feels increased pressure in her pelvis, a sensation often described as the urge to push. The nurse performs a cervical check and finds that the patient is 9 cm dilated, 100% effaced, and the fetal station is at +2. These findings suggest that the patient is approaching the transition phase of labor. The nursing team prepares to notify the obstetrician and review the delivery plan, ensuring that all necessary equipment is ready for the impending birth. The patient is reassured that she is progressing well, and the team remains vigilant, monitoring both maternal and fetal status as they anticipate the delivery.