Question

Scenario: 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.

1. What are your immediate priorities in nursing care for Margarite Sanchez? Discuss the rationale for the priorities.

2. What does the FHR indicate?

3. State the nursing diagnosis, expected outcome, and interventions related to managing her labor pain.

Scenario: 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.

1. What are your immediate priorities in nursing care for Margarite Sanchez? Discuss the rationale for the

priorities.

Scenario: 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.

1. What are your immediate priorities in nursing care for Margarite Sanchez?

Answer 1

1. Since her sve shows signs of labor . It is time to push the baby as soon as possible. So the nursinf interventions would be:

• Inform patient on progress of her labor.
• Assist patient with pant-blow breathing.
• Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or depending on the doctor’s order. Contraction monitoring is also continued.
• When perineal bulging is noticeable, prepare for delivery. Check room temperature (25-28⁰C and free of air drafts). The nurse should also notify staff and prepare necessary supplies and equipment, including resuscitation machine. Lastly, perform handwashing and double gloving.

2. FHR indicates the fetal heart rate of the baby .Fetal distress or what doctors prefer to call "nonreassuring fetal status"occurs when your baby's oxygen supply is compromised in utero, usually during labor but occasionally in the third trimester of pregnancy. Oxygen deprivation can result in decreased fetal heart rate and can be serious for the baby.So since fhr is low , it needs to be taken seriously.

3. Comfort measaures to relax the mother would be:

• Asking the mother to relax
• Distracting her mind away from the pain so that she isnt very stressed
• Would pray with her , if that comforts her.
• Would show her good breathing techniques
• Therapeutic touch and massage

1.

Here are nursing care tips for this stage:

1. Instruct patient on quality pushing. The abdominal muscles must aid the involuntary uterine contractions to deliver the baby out.
2. Provide a quiet environment for the patient to concentrate on bearing down.
3. Provide positive feedback as the patient pushes.
4. Repeat doctor’s instructions. At this phase, the patient barely hears the conversation around the room because all her energy and thoughts are being directed toward giving birth.
5. Take note of the time of delivery and proceed to initiate essential newborn care. Delayed cord clamping is recommended.
6. Assist in restrictive episiotomy for patients who had vaginal births.