Isabelle Hazel J.

Benemile

DR Rotation

Prof. Andrino

November 16, 2020

A 24-year-old woman, gravida1, para 0, has come to the birth setting because she thinks she is in labor. She tells you that she felt
the baby "drop" two days ago and that she has been having contractions for the past two hours. She reports that she has not had
any fluid leaking from her vagina and that she does not think her membranes have ruptured. She says, "My contractions are coming
every 15 minutes and they last for about 30 seconds. They don't change when I lie down or walk about. I think I saw some bloody
show, but I'm not sure. Do you think my labor has started?"

Guide Questions:
1. What signs of true labor that this woman has?
The signs of true labor that the woman has is the contraction and the bloody show. The contractions are regular and cannot be
relieved by activities such as walking or lying down. A bloody show or a “mucus plug” could mean a cervical change, which means
labor is close.

2. How can the nurse determine whether this is true labor?

The nurse can determine that this is a true labor by looking at the signs the woman is presenting. The woman has regular
contractions that cannot be relieved by activities and she has a bloody show that could mean a cervical change, which means labor is
close. Additionally, she also noted that she felt her baby “drop”. This is “lightening”, and it doesn't often happen until you’re truly in
labor. This is the time when the presenting (lowermost) part of the fetus descends into the maternal pelvis.
 3. How should the nurse answer the woman’s question about whether she is in labor?
The nurse can answer the woman by telling her that she is showing signs of labor but to confirm if her labor has truly begun, they
would need to further assess her and check for her cervical dilatation.

Assessment Nursing Outcome Criteria Nursing Rationale Evaluation Discharge

Diagnosis Intervention Planning
Objective: Deficient After 30 min - 1 Independent: Goals: Met. M - Encourage
-24 years old Knowledge hour of effective The client can the patient to
-G1P0 related to lack nursing - Assess client’s -This will guide in verbalize continuously
-Bloody show of intervention the baseline knowledge establishing understanding of take prescribed
exposure/recall client will and expectations learning needs and psychological medication.
Subjective: as evidenced by, verbalize during pregnancy. set priorities. and Taking note of
-Felt the baby “Do you think understanding of physiological the proper
“drop” two days ago psychological administration,
my labor has changes.
- "My contractions - Provide and - Active considering the
started?” As and physiological
are coming every 15 verbalized by discuss options for participation of the right time,
changes.
minutes and they the client. care during the client/couple is dosage and
last for about 30 labor process. important in the current status.
seconds. They don't Provide decision-making Take note that
change when I lie information about process. the patient is
down or walk about. birthing pregnant and
I think I saw some alternatives, if should not take.
bloody show, but
I'm not sure. Do you available and E - Advise the
think my labor has appropriate. client to have a
started?” As stress free,
verbalized by the - Provide -Prenatal education relaxing, and
patient. information about can facilitate calm
procedures the labor and environment.
(especially fetal delivery process, T - Advise the
monitor and assist the client in client to avoid
telemetry) and maintaining control stressful
normal progression during labor, help activities when
of labor. promote a positive performing
attitude, and may daily routines.
decrease reliance H – Advise the
on medication. client to adhere
strict prenatal
checkups
- Review -Provides O – Instruct the
appropriate activity guidelines for client patient to
levels and safety to make contact the
precautions, appropriate doctor or any
whether client informed choices; healthcare
remains in hospital allows client to provider, if
or returns home. engage in safe there are
diversional certain
activities to refocus circumstances
attention. that cannot be
handled. Also,
- Obtain informed - When procedures encouraged the
consent for involve client’s patient to
procedures, e.g., body, it is strictly follow
forceps necessary for client the prenatal
delivery, episiotom to have appropriate appointment
y. Explain information to schedule.
the procedures and make informed D - Encourage
the possible risks choices. the client to eat
associated with a healthy
labor and delivery. balanced diet
high in protein
with plenty of
- Educate the client - Unprepared vitamins and
about breathing couples need to minerals,
and relaxation learn coping especially
techniques mechanisms on calcium and
appropriate to each admission to help iron with folate
phase of labor; reduce stress as prescribed by
teach and review and anxiety. their OBGYNE
pushing positions Couples with prior Doctor
for stage II. preparation can S – Encourage
benefit from review the client,
and reinforcement. together with
family to pray
and build a
relationship
with God.
S – Encourage
the patient’s
family to
provide support
to the patient.
References:

36 Labor Stages, Induced and Augmented Labor Nursing Care Plans: https://nurseslabs.com/labor-stages-labor-induced-nursing-care-
plan/#a1

Pregnancy as a psychological event:

https://pubmed.ncbi.nlm.nih.gov/15462597/#:~:text=Psychological%20changes%20during%20pregnancy%3A%20Pregnancy,sleepin
ess%2C%20depressive%20reactions%20to%20excitement.