Question

Marvis is a 29-year-old G1P0 in labor at 40 weeks of gestation. She was admitted at 0200 with a history of contractions since 2200 the night before. On admission, she denied spontaneous rupture of membranes or vaginal bleeding. She felt good fetal movement. Her vital signs and the fetal heart rate were normal. Her contractions were every 6 minutes and lasting 30 seconds. Her cervical examination was 2 cm/70%/−2 vertex. It is now 0600 and she has been reexamined. Her cervical examination is now 3 cm/90%/−2 vertex. Her contractions are now every 4 to 5 minutes lasting 60 seconds. She states they are still mild. Marvis has stated that she wants a natural unmedicated birth.

Answer with complete statements

1. Marvis expresses disappointment in her progress. What can the nurse do to help her at this point in labor?

2. it is now 1000, and Marvis states the contractions have become much stronger. She now needs to use breathing techniques to cope with the contractions. She declines pain medication. Her cervical examination is now 5/100/0. What stage of labor is Marvis in at this time?

3. What nursing care is indicated at this phase of labor?

4. Marvis is now profusely perspiring and is shaky. She feels she cannot cope any longer. She pushes away her husband as he tries to rub her back. An increased amount of bloody show is present. She also reports a gush of fluid. Even without a cervical examination, what phase of labor is Marvis most likely in?

5. A cervical examination at 1300 confirms the transition phase as Marvis is 8/100/0 station with spontaneous rupture of membranes with clear fluid. What nursing care is indicated at this time?

6. Marvis managed to cope well through the transition by going into the shower. She now reports an urge to push. A cervical examination at 1600 reveals that Marvis is still 8/100/0. The fetal heart rate is normal, and maternal vital signs are normal. She is distraught at her lack of progress and states she cannot do it anymore. What nursing care is appropriate at this time?

7. Nursing assessment reveals an abdominal mass just above the symphysis pubis. What is a likely explanation, and what should be done?

Answer 1

1) Explain to them that the progress in this stage is slow because the average duration of a nullipara in latent state is 7.5 to 8.5 hrs.Touch and comfort also can be provided.

2)She is still in stage one phase now in Active stage (this is characterized by rapid dilatation of the cervix(4-6 cm)the discomfort and pain increases and contractions come every 3 to 4 minutes for 40 to 60 seconds,this stage lasts about 50 minutes but could be from 30 min to 3 hrs. . 3)*inform patient on the progress of her labor to lessen her anxiety and obtain her trust and cooperation *start monitoring progress of labor with the use of who partograph , two hour action line *encourage patient to be continually active to maximise the effect of utrine contractions *assist patient in assuming her position of comfort * monitor matternal vital signs and fetal heart rate every 2 hours *anticipate patients needs to promote comfort. *determine when patient last voided because a full bladder can hinder fast labor progress. * institute non pharmacological pain measures (eg. breathing exercises, distraction method,etc)   

5) now she is in transition phase , here are nursing responsiblities is * inform patient on progress of her labor *assist patient with pant -blow breathing * monitor maternal vital signs and fetal heart rate every 30 minutes -hour, or depending on the doctor's order. contraction monitoring is also continued. *when perineal bulging is noticeable, prepare for delivery. check room temperature (25-28 and free of air drafs). the nurse should also notify staff and prepare necessary supplies and equipment, including resuscitation machine. lastly , perform handwashing and double gloving