Flauta, Jazmin M.

BSN 2D

Course Title: NCM 107: Care of Mother, Child and Adolescent (Well Clients

CASE STUDY #3: LABOR AND DELIVERY SITUATION:

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
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. Do you think Mrs. M. is in false labor? Give reasons for your answer.
- No, because according to her statement that she had been having contractions at
7 to 10 minute intervals since 4 p.m. and they lasted 30 seconds. Her labor is
regular and has been predicted during hours of labor. She also stated that she had
been having "a lot of false labor" and hoped that this was "the real thing". She
was aware of how they felt since the real labor differs from the false labor in that it
lasts much longer and is more painful.
2. As Mrs. M. was getting into bed, her membranes ruptured. What is the first thing that
you would do after this occurs? Why?
- Check if the baby is okay by checking its assessing the fetal heart rate to detect changes
associated with prolapse of umbilical cord.
3. After her membranes ruptured, her contractions began coming every 4 minutes and
lasted 45 to 55 seconds. They were moderately strong. Why is it important for Mrs. M.
to relax during her contractions? How can you help her to relax?
- It is important for her relax so that she can still control herself and she needs to
conserve her energy. The nurse can help her to change positions, provide comfort, pain
relief measures as needed, provide emotional support, and encouragement
4. When 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? What observations would you
report to the doctor?
a. During first stage of labor
b. Pt would be a risk fall after giving the meds; bed at lowest position
c. FHR for signs of late decelerations; urinary retention is anticipated
d. Seizures, respiratory depression, cardiac arrest
5. How would you know that Mrs. M. has entered the transition phase?
- The contractions would pick up and become stronger and last up 60-90 seconds. May
feel strong pressure in the back or rectum. Feeling warmer and sweaty, nausea and
vomiting. Often during this phase, she starts to feel the pressure of the baby's head
coming down, sometimes accompanied by an urge to push.
 6. A vaginal exam revealed that Mrs. M. is complete and +2. What should be the nursing
interventions at this time?
 Use breathing techniques
 Maternal blood pressure
 Prepare the mother to start pushing and getting everything set up for the baby
The doctor gave her a pudendal block and did a midline episiotomy. At 8:05 p.m. Mrs. M. gave
birth to a 7 lbs., 5 oz. (3.317 gm.) boy in the L.O.A. position. The nurse put medicine in the
baby's eyes and placed an identifying bracelet on his right wrist and ankle. A matching bracelet
was placed on the mother's wrist. The baby was shown to his mother and then taken to the
newborn nursery. At 8:08 p.m. the placenta was expelled.

7. Why is the medicine put in the baby's eyes?

- to protect babies from getting bacterial eye infections that can occur during birth
8. Why is it important to put identification on the baby in the delivery room?
- So that incidents like baby switching will be avoided and to give identity to the baby.
9. What care should Mrs. M. receive before she is transferred to the recovery room.
Why?
- To ensure that she is healthy and stable, it is important to take her vital signs. She
should be stitched up before handing over her baby. She needs to be cleaned up after
giving birth as well.