Name: Glory Mi Shanley Carumba Date: 09-24-2021

Section: BSN2A Score:

Assignments, Chapter 15, Nursing Care of a Family During Labor and

Birth

Written Assignments

1. Make a list of nursing diagnoses and expected outcomes for the following families
who are in labor:

∙ A woman is in the second stage of labor and is having a difficult labor. Her birth
attendant states that the fetus is in the breech presentation and prepares her
for a cesarean birth. (5pts)

NURSING DIAGNOSES EXPECTED OUTCOMES

Acute Pain related to Tissue dilation
Anxiety related to actual threat of maternal 
and fetal well-being
 Client will verbalize reduction of pain.
 Client will use appropriate techniques to
maintain control.
 Client will rest between contractions.
Patient discusses feelings about cesarean
birth.
 Patient appears relaxed and comfortable.
 Patient verbalizes fears for the safety of
herself and infant.

Risk for Infection related to Invasive  Patient is free from infection

procedures
 Patient achieves timely wound healing
without complications.
Risk for Impaired Fetal Gas Exchange related to  Patient displays optimal FHR.
Altered blood flow to placenta or through
 Patient manifests normal variability on
umbilical cord
monitor strip.
  Patient reduces frequency of late or
prolonged variable decelerations.

Risk for Maternal Injury related to Traumatized  Patient is free of injury.

tissue

Risk For Fluid Volume Deficit related to Active  Client will be free of thirst.
loss
 Client will maintain vital signs within
normal limit, adequate urine output, moist
mucous membranes.

Risk for fetal injury related to breach position  Fetus will be free of preventable trauma or
of the fetus. other complications.

Impaired Skin Integrity related to cesarean  Client will relax perineal musculature
surgery procedure. during bearing-down efforts.
 Client will be free of preventable
lacerations.

Risk For Fatigue related to Presence of pain.  Client will effectively participate in
bearing-down activities
 Client will relax/rest between efforts.

∙ An 8-month pregnant woman who is visiting her parents in another city visits
the emergency department with signs of labor. The woman is admitted to the
maternity ward to be delivered by a resident of the hospital. The woman states
that she is not ready to be a mother yet and does not want to go through an
unplanned labor. When the nurse checks on her, she is crying uncontrollably
and states that she wants to be moved back to her hometown where she has a
birth plan in place. (5pts)

NURSING DIAGNOSES EXPECTED OUTCOMES

Anxiety related to Situational crisis as evidence  Patient will verbalize understanding of
by Increasing tension and crying.
Risk for Injury related to Delivery of preterm 
infant
Acute Pain related to uterine contractions
Deficient Knowledge related to unplanned 
labor
Anxiety related to Situational crisis as evidence 
by Increasing tension and crying.
Risk for Injury related to Delivery of preterm 
individual situation and possible outcomes
 Patient will report anxiety is reduced
and/or manageable
 Patient will appear relaxed; with maternal
vital signs within normal limits.
Patient will maintain pregnancy at least to
the point of fetal maturity.
 Fetus will be delivered safely, free from
trauma and complications
 Patient will report discomfort is minimized
or controlled.
 Patient will use relaxation techniques,
effectively.
 Patient will appear relaxed and will rest
appropriately.
Patient will verbalize awareness of
implications and possible outcomes of
preterm labor.
 Patient will identify signs and symptoms
requiring evaluation and intervention.
 Patient will demonstrate understanding of
home therapy and/or self-care needs.
Patient will verbalize understanding of
individual situation and possible outcomes
 Patient will report anxiety is reduced
and/or manageable
 Patient will appear relaxed; with maternal
vital signs within normal limits.
Patient will maintain pregnancy at least to
infant
Acute Pain related to uterine contractions
Deficient Knowledge related to unplanned 
labor
Anxiety related to Situational crisis as evidence 
by Increasing tension and crying.
the point of fetal maturity.
 Fetus will be delivered safely, free from
trauma and complications
 Patient will report discomfort is minimized
or controlled.
 Patient will use relaxation techniques,
effectively.
 Patient will appear relaxed and will rest
appropriately.
Patient will verbalize awareness of
implications and possible outcomes of
preterm labor.
 Patient will identify signs and symptoms
requiring evaluation and intervention.
 Patient will demonstrate understanding of
home therapy and/or self-care needs.
Patient will verbalize understanding of
individual situation and possible outcomes
 Patient will report anxiety is reduced
and/or manageable
 Patient will appear relaxed; with maternal
vital signs within normal limits.
 2. Use the Internet to research the stages of labor. Devise a nursing care plan that
reflects the appropriate care for a woman who is in each stage of labor. You
may refer to this websites: (20pts)

https://www.babycenter.com/pregnancy/your-body/stages-of-labor_177

https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/stages-of-
labor/art-20046545

https://www.webmd.com/baby/guide/pregnancy-stages-labor#1

First Stage of Labor

Nursing Diagnosis Nursing Intervention
Risk For Ineffective Coping related to > Establish rapport and accept behavior
Personal Vulnerability without judgment. Make verbal contract
about expected behaviors of client and
nurse.

> Reinforcing breathing and relaxation

techniques during contractions.

> Note age of client and presence of

partner/support person(s).

> Stay with/provide companion for a

client who is alone.

Second Stage of Labor

Nursing Diagnosis Nursing Intervention
Risk For Impaired Fetal Gas Exchange > Position client in lateral recumbent or
related to Prolonged labor upright position, or turn side to side as
indicated.

> Assess client’s breathing pattern. Note

reports of tingling sensation of face or
hands, dizziness, or carpopedal spasms.

> Determine fetal station, presentation,

and position. If fetus is in occiput
posterior position, place client on her
side.

> Monitor periodic changes in FHR for

severe, moderate, or prolonged
 decelerations. Note presence of variable
or late decelerations.

Third Stage of Labor

Nursing Diagnosis Nursing Intervention
Risk For Fluid Volume Deficit related to > Instruct the client to push with
Retained placental fragments contractions; help direct her attention
toward bearing down.

> Inspect maternal and fetal surfaces of

placenta. Note size, cord insertion,
intactness, vascular changes associated
with aging, and calcification (which
possibly contributes to abruption).

> Obtain and record information related

to inspection of uterus and placenta for
retained placental fragments.

> Record time and mechanism of

placental separation; i.e., Duncan’s
mechanism (placenta separates from the
inside to outer margins) versus Schulze’s
mechanism (placenta separates from
outer margins inward).

> Assist as needed with manual removal

of placenta under general anesthesia and
sterile conditions.

3. A 3. 5-year-old adolescent arrives on the birthing unit after being brought to the
emergency department by EMS. The initial assessment reveals she has been in labor
for approximately 12 hours and is at 0 station; contractions are approximately 4 to 5
minutes apart and 30 to 45 seconds in duration. Complicating the situation is the
known facts that her family did not know she was pregnant and she had no prenatal
care. The parents are with her and demanding things be done their way.

A. What are some various concerns and issues the nurse should be alert for?(5pts)

The various concerns and issues that the nurse should be alert for is the
patient’s condition and the one is her moral issues towards her parents.
Since she haven’t done any prenatal care, it is possible that she might
caught some potential issues and complication. Here, the nurse must check
the patient's immunization status, then determine whether she is anemic
and also check the respiratory rate. On the other hand, the nurse must also
be alert that her parents should not conduct any unfavorable actions.

B. What might the nurse do to protect her patient while also respecting the parents’
wishes? (5pts)

It is not uncommon for providers to become involved in conflicts with

patients and their parents. For this situation, in order to protect the patient,
the nurse must provide privacy safeguard to the adolescent mother.
Keeping the decisions between the patient and the health care team, since
she has the rights as a patient inside the hospital. The nurse will then
explain the situation and condition of the patient to the parents. The parents
must be aware about the serious consequences if they demand things to be
done their way. After it, the nurse may forward on developing a therapeutic
relationship between the patient and her parents. Pull them aside and invite
them to talk about the matter and tell you everything they're worried about.

C. What are some nursing diagnoses related to this case? (5pts)

 > Fatigue related to anxiety as evidenced by guilt about difficulty maintaining

responsibilities

> Risk for impaired parenting

> Risk for infection related to compromised immune system

 > Insufficient breast milk production

> Risk for delayed development

 > Risk for sudden infant death

> Risk for disturbed maternal-fetal dyad