COLLEGE OF HEALTH SCIENCES
DEPARTMENT OF NURSING
ASSESSMENT
Subjective Data:
• increased risk of
cesarean section
• shoulder dystocia with a
vaginal delivery as well as
an increased risk of
postpartum bleeding
• prolonged labor or failure
of progress
Objective Data:
• Abnormal fetal positions.
• Small pelvis
• Abnormally shaped
pelvis.
ACTIVITY 2 NURSING CARE PLAN MAKING
NURSING NURSING NURSING
PLANNING RATIONALE EVALUATION
DIAGNOSIS ANALYSIS INTERVENTIONS
Short term:
Risk for fetal injury Independent After 2 hours of
related to Cephalopelvic Cephalopelvic Within 2 hours of nursing
Disproportion as nursing •Establish rapport and -Reduces anxiety, interventions the
disproportion occurs
evidenced by prolonged interventions, the develop a trusting promotes relaxation patient was able to :
labor and fetal distress when there is patient will relationship with the and sense of control,
exhibit client and family assisting client and -Improve the labour
mismatch between the appropriate family to cope and the baby as
size of the fetal head coping positively with successfully
mechanisms in the situation. delivered within 12
and size of the order to hours after mother
maternal pelvis, cooperate to •Demonstrate and -To foster self- was fully dilated and
improve labor so encourage the client to esteem and effaced.
resulting in prolonged that the baby is perform special continued
labor and fetal delivered within breathing and participation in labour
12 hours. visualization techniques process.
distress. When the
baby becomes stuck in -Client/fetal response
The patient will to treatment and
the birth canal oxygen be able to make •Monitor fetal heart rate -Detects abnormal actions performed
informed every 15 minutes along responses, such as
deprivation creates a
decisions with uterine contractions exaggerated
risk of brain injury or regarding variability,
treatment bradycardia, and
even death if the options. tachycardia,
situation is not quickly which may be
caused by stress,
overcome. If left hypoxia, acidosis,
unattended, the or sepsis.
consequence is
obstructed labor
 Long term:
After 24 hours of
causing excessive and After 24 hours of • Monitor fetal descent -Descent that is less nursing
nursing in relation to the ischial than 1 cm/hr for a interventions :
traumatic contractions, interventions, the spine primipara, or less
putting the fetus at maternal patient than 2 cm/hr for a -The fetal patient
will deliver the multipara, may maintained a
greater risk for injury. baby indicate CPD or normal range of
Thus, medical successfully malposition. heart rate and
without any signs showed no
attention should be of complications. decelerations or
required and treatment Fetal patient will distress
display a fetal • Inform the client and -To ensure adequate throughout the
with antibiotics may be heart rate within family about the understanding of labour process.
needed to prevent or normal limits, progress and events and
and will show no procedures that will be procedures.
treat ascending distress and no undergone
late
infection and will
decelerations
protect fetus as well. noted. •Inform the patient and -To assist the
family for the best reduction of anxiety
When an accurate
method of delivery and provides data
diagnosis of CPD has necessary to make
informed decisions.
been made, surgical
intervention follows
immediately and the -A full bladder may
safest type of delivery •Encourage the client to inhibit uterine activity
void every 2 hours and interfere with
for mother and baby is the fetal descent.
through a cesarean
section.

 
 Dependent
-Labor that is
•Administer prescribed induced by oxytocin
oxytocin to induce and starts progresses
augment labor faster and stimulates
contractions.

-To monitor
•Administer analgesic if processes and
prescribed by the outcomes of pain
physician to relieve pain management.

-Prevents/treats
•Educate the client and ascending infection
family for the and will protect fetus
administration of the as well.
prescribed medication

Collaborative
-Immediate cesarean
•Refer for childbirth birth is indicated for
counselling with regards fetal distress due to
to the associated CPD. Once labor is
benefits and risks of a diagnosed, if delivery
cesarean section has not occurred
delivery within 12 hr, and
amniotomy and
oxytocin have been
used appropriately,
then a cesarean
delivery is
recommended.
Submitted by: De Balucos, Kyzell S. Submitted to: Ms. Villaflor, Lou
Doroon, Millette B.
Dela Peña, Reeka Izabel
Dibdib, Kristian James E.
Demaisip, Hilary Gwyneth