Karl Joseph V.

Doria

BSN-2B

Mrs. M. is a 27-y/o gravida 3, para 2, who was admitted at term at 6:30 p.m. She stated that
she had been having contractions at 7 to 10 minute intervals since 4 p.m. They lasted 30 seconds.
She also stated that she had been having "a lot of false labor" and hoped that this was "the real
thing". Her membranes were intact. Mrs. M.'s temperature, pulse and respirations were normal
and her blood pressure was 124/80. The fetal heart tones were 134 and regular. The nurse
midwife examined Mrs. M. and found that the baby's head was at +1 station, and the cervix was
4 cm. dilated and 80 percent effaced. She reported her findings to the doctor and he ordered
Demerol 50 mg. with Phenergan 25 mg. to be given intravenously when needed.

1.       What type of labor is Mrs. M experiencing? (TRUE OR FALSE LABOR) Give reasons
for your answer based on the assessment data of the patient.

 False, Mrs. M baby's head was at +1 station, and the cervix was 4 cm. dilated and 80
percent effaced. No accurate pieces of information show that the patient is in true labor
based on the 3 phases

2.      As Mrs. M. was getting into bed, her membranes ruptured. What 2 interventions will you
do as a student nurse caring for Mrs. M? Give the rationale for your interventions?

 First intervention is notifying the physician and checking the fetal heart tone

Rationale: The rationale for that is to inform immediately the physician so that
they will give advice or intervention as soon as possible and after notifying the
physician check for the fetal heart tone if it is in normal rate and sound.
  Second intervention is to lie the client on the bed so that the fetus is not impinging on the
cord and position the client Trendelenburg position.

Rationale:  The rationale for that is to avoid the fetus choking in the umbilical
cord and placing the client in the Trendelenburg position to prevent the umbilical
cord to come out and expose to the environment because has a big effect on the
fetus.

3.      After her membranes ruptured, her contractions began coming every 4 minutes and lasted
45 to 55 seconds. They were moderately strong. Upon internal examination it revealed a
cervical dilatation of 7 cm. Based from the assessment data of the patient, what phase of the
1st stage of labor is the patient? Explain your answer by enumerating the signs and
symptoms that the patient presented.

 The phase of the 1 stage of labor of the patient is Active because active phase signs and
st

symptoms are cervical dilatation range from 4-7 cms which is one positive sign and also
contractions lasted to 45 to 55 seconds which also a sign and lastly the patient also feel it
as moderately strong.

4.      Why is it important for Mrs. M. to relax during her contractions? How can you help her to
relax?

 Staying relaxed means the muscles are loose, which makes it simpler to breathe in a more
rhythmic manner. This provides more oxygen to the mother and her baby. Relaxing
during early labor will help the mother's body manufacture more oxytocin, which will aid
in the progress of her labor. In order to help the patient to relax I will provide a quiet
environment to her room so that no destruction or noise will make her uncomfortable.

5.      Do you think Mrs. M. should be given the medication ordered by the doctor? What safety
measures should be taken at the time the medication is given? What observations should be
made after it is given? Why? 

 For me the medication ordered by her doctor is not appropriate for the condition of Mrs.
M on that time because first the Demerol 50 mg is to help relieve moderate to severe pain
 but Mrs. M is not in moderate to severe pain it may also be used before and during
surgery or other procedures but Mrs. M was not in surgery. Phenergan 25 mg may have
also an effect on the baby of Mrs. M. This medication will be given if the benefits of it
will outweigh the risk of taking the medications.     

6.      A vaginal exam revealed that Mrs. M. is complete and +2. What is the interpretation of
this? What should be the nursing interventions at this time? Explain the rationale behind
your interventions

 The interpretation of this was the patient may be at the transitional phase. The nursing
intervention at this time was to monitor contraction, maternal vital signs, and fetal heart
rate every 30 minutes -1 hour and also prepare necessary supplies and equipment and
administer routine perineal shaving.

7.      How would you know that Mrs. M. has entered the transition phase?

 If a slight slowing rate of cervical dilatation when 9cm reached and 10cm dilatation an
irresistible urge to push begins to occur to Mrs. M and also if the cervix was full dilated
and full effacement. The contractions also have a duration of 60-70 seconds and with the
interval of 2-3 minutes and feel of intense discomfort

8.      What are the interventions a nurse can do during the transition phase? Give 2
interventions.

 The first intervention I will do is to instruct the client on the proper breathing or the pant
blow breathing technique

 The second intervention I will do was to monitor maternal vital signs and fetal heart rate
every 30 minutes to 1 hour