CASE SIMULATION 115

INSTRUCTION: All questions apply to this case study. Your responses should be
brief and to the point. When asked to provide several answers, list them in order
of priority of significance. Do not assume information that is not provided. Please
print or write clearly. If your response is not legible, it will be marked as?, and
you will need to rewrite it.

Scenario
You are the charge nurse working in labor room and delivery at a local hospital.
D.H. comes to the unit having contractions and feeling somewhat uncomfortable.
You take her to the intake room to provide privacy, have her change into gown,
and asks her three initial questions to determine your next course of action, that
is, where to do a vaginal exam or to continue asking her more questions
1. What three initial questions will you ask?
 Is there any discharge from your vagina?
 What's the condition of your contractions? How far apart are
they? Lasting? Pain?
 What are the intervals of your contractions?

2. D. H. has contractions 2 to 3 minutes apart and lasting 45 seconds. It is her

third pregnancy (gravida 3, para 2002). Her bag of waters is intact at this
time. She states that her due date is 2 days way. You determine that it is
appropriate to ask for further information before vaginal exam is done.
What information do you need before vaginal exam?
 I'd like to know if her previous deliveries had any complications.
 I'd inquire about her due date as well as any allergies she might have.
 I'd also inquire about her birth plan and any medications she's taking.
3. What assessment should you make to gain further information from DH?
  I'd take a look at the baby's position. If the baby isn't in a good
position to monitor her amniotic fluid, the location should be such
that the shoulders come first.
 Monitor the mother's blood pressure and the temperature of the
other to prepare for a C section if the baby is in breech position.
 After that, look at the dilation, which is measured in centimeters and
ranges from 0 to 10. The pain and cervix effacement should then be
assessed.

4. Upon examination, D. H. is 80% effaced and 4cm, FHR is 150 beats/min, and
regular. She is admitted to a labor and delivery room. What nursing
measures should be done at this time?
 The D.H. is currently in active labor. She should be placed in bed by a
nurse, who should also respond to any questions she may have. On
the D.H.'s abdomen, place a contraction and a fetal monitor. Then, to
help her handle contractions, assist her with breathing and relaxation
techniques.

5. As part of your assessment, you review the fetal heart strip pictured below.
What will you do?
 Nothing, these are early decelerations caused by fetal head
compression.
 Continue to monitor them to make sure they're not late or variable
decelerations.

6. List the stages of labor. D.H. is in what stage of labor?

 In the first stage of labor, some steps include early labor, active
labor, and transition to the second stage. The baby is born in the
second stage. Afterbirth is the third stage, and recovery is the fourth.
The D.H. is in active labor because she is dilated 4 cm with
contractions 2-3 minutes apart that last 45 seconds.

7. D.H. states that she is feeling discomfort and asks you whether there is
alternative therapy available before taking medication. List at least four
alternative methods to assist D.H. with controlling her discomfort.
  I would advise her to relax by taking slow, deliberate breaths.
 Massage therapy is also beneficial to her, particularly on her back.
 I'd also apply cold or heat to any areas where she's uncomfortable.
 Lastly, use a pillow to shift her into a more comfortable position.

8. As you assess both the mother and the fetus during active labor, you will
look for abnormalities. Which of these are potential abnormalities during
labor? ( select all that apply)
a. Unusual bleeding
b. Brown or greenish amniotic fluid
c. Contraction that last 40 to 70 seconds
d. Sudden, sever pain
e. Increased maternal fatigue

CASE STUDY PROGRESS

Although D.H. Continues to use alternative therapies for discomforts, she asks for
pain medication and receives a dose of meperidine (Demerol). Three hours later,
D.H. is lying on her back, and during contractions you notice a few late
decelerations of the FHT. You stay with D. H. to monitor her and her fetus and
immediately call for someone to notify the PCP.

9. Put these actions in order of priority:

2 a. D/C the oxytocin infusion
1 b. Turn onto her left side and elevate legs
4c. Increase the rate of the maintenance of IV fluid
3 d. Administer oxygen at 8-10L/min by facemask
 10. Deceleration occur in an early, variable, or late pattern. What is the
significance of these patterns? State what the nurse should do for each
type.
 Decelerations are temporary drops in the fetal heart rate.
 Early decelerations are thought to be caused by fetal head
compression and are considered a benign finding. It's a common
occurrence that isn't caused for alarm.
 Cord compression is often indicated by variable decelerations. Turn
the patient's position and monitor. They usually happen during
transition phase of the first stage of labor and during the second
stage of labor.
 Because the fetus could be in distress, late decelerations are
considered more urgent.

11. As you monitor D. H., you observe for prolapse of the umbilical cord.
Describe what this is and what can happen to the fetus if this occurs.
 A prolapsed cord occurs when part of the umbilical cord lies below
the presenting part of the fetus.
 During delivery, the cord can become trapped against the baby's
body. Umbilical cord prolapse affects about one out of every 300
births.

12.What would be done if you noted prolapse?

 Call for help and notify the physician as soon as possible.
 Place the woman into Trendelenburg or a modified Sims position.
 Tell the woman what's happening and the plan.
 Closely monitor FHR.
 To avoid vasospasm, avoid handling the cord.
 By vaginal digital examination, manually lift the presenting part off
the cord.
 Encourage into a left lateral position, with the head down and a
pillow under the left hip or knee-chest. The cord from the presenting
part will be relieved of pressure.

CASE STUDY PROGRESS

The Decelerations stop, and the remainder of the labor is uneventful; D.H. has an
episiotomy to allow more room for the infant to emerge and delivers a male
infant.
13.What is involved in the immediate care of the new born?
 The baby should be dried and wrapped in warm blankets.
 Place the infant under the warming light
 Suction is used to clear the airway.
 At 1 and 5 minutes after birth, assess and record the Apgar score
(heart rate, color, respiratory effort, muscle tone, and reflexes).
 Maintain a clear airway.
 For identification, place the correct wrist and ankle identification
bands on the infant, as well as a matching wrist band on the mother.
Footprints might be taken.
 Placed the infant on the mother's abdomen or in her arms.

14.You asses the newborn, you observe for CNS depressant effects that might
result because the mother received an opioid during labor. Opioid
antagonist such as Naloxone ( Narcan) can promptly reverse the CNS
depressant effects in the newborn, but when is naloxone contraindicated
for infant? When Naloxone is contraindicated for infant?
 If the mother is known to be physically dependent on opioids.
 Acute abstinence syndrome can occur when narcotic effects are
suddenly and completely reversed.

15.D.H. has her episiotomy repaired and the placenta delivered. What are the
signs that the placenta has released from the uterine wall?
 The uterus is firmly contracted.
 The umbilical cord lengthens.
 There is a sudden release of blood from the vagina.

16. What assessments are important following delivery?

 Bleeding in the vagina
 Contraction of the uterus
 Fundal height
 Temperature and heart rate (pulse) should be taken every hour for
the first 24 hours after birth.
  Shortly after birth, blood pressure should be checked.

CASE STUDY OUTCOME

D.H. and her newborn baby boy are taken to the maternity unit where she begins
to breastfeed him.