Chapter 15

Nursing Care of a Family During Labor and Birth

CD PATIENT SCENARIO

CARE STUDY: A WOMAN IN LABOR

Sally Hudson is a 28-year-old, G1P0, 41-weeks pregnant woman admitted to the

maternity service in labor.

CHIEF CONCERN:

"I'm in labor. Tell me what I’m supposed to do."

HISTORY OF CHIEF CONCERN:

Sally has been in labor for 8 hours; contractions have progressed from 30-minute

intervals to 3-minute intervals and from 10-second duration to 60-second duration. She

last ate 8 hours ago.

FAMILY PROFILE:

Separated from father of baby for 7 months. Sister is with her to be support person in

labor. Client works as French teacher at state university; is taking courses part time

toward her doctorate. Lives in one-bedroom condo by herself. Has supplies prepared for

infant.

HISTORY OF PAST ILLNESSES:

Chickenpox at 3 years. Dislocated knee at 14 years and again at 16 years. No major

illnesses; no hospitalizations.

HISTORY OF FAMILY ILLNESSES:

Grandmother has Alzheimer’s disease. A sister had rheumatic fever as a child.

GYNECOLOGICAL HISTORY:

Menarche at 11 years; duration of cycle: 32 days. Length of menstrual flow: 7 days. Was

treated for trichomoniasis x 2 last year. No other STDs.

OBSTETRICAL HISTORY:

No previous pregnancies. This pregnancy was not planned but is wanted. Had prenatal

care with private obstetrician since second month; was found to be anemic early in

pregnancy; this was treated with extra iron supplement. Attended preparation-for-labor

classes with sister as coach.

DAY HISTORY:

Nutritional: 24-hour recall nutritional history reveals adequate pregnancy diet. Took

prenatal vitamin and extra iron supplement.

Sleep: Sleep 6 hours per night. One afternoon nap.

Recreation: Has participated in aerobic class for pregnant women during pregnancy.

Had an exercise program of daily jogging before pregnancy.

REVIEW OF SYSTEMS:

Neuropsych: had febrile convulsions two times as preschooler; maintained on

phenobarbital until she was 6. No further difficulty.

PHYSICAL EXAMINATION:

General Appearance: Composed, well groomed young adult pregnant woman breathing

without apparent distress with contractions. Height: 5'5"; weight: 142. Temperature:

38°C; BP: 112/70.

HEENT: Normocephalic; Nose: profuse clear watery discharge present; mucous

membrane red and swollen. Throat: reddened; geographic tongue; coughing periodically.

Ears: Tympanic membrane slightly inflamed; good motility.

Chest: Breasts full and soft; no masses palpable. Lungs: rhonchi heard in all lobes.

Respiratory rate: 20 breaths per minute. Heart rate is at 62 beats per minute. No murmur.

Abdomen: Fundal height at 35 cm; fetus palpable in LOA position; linea nigra and striae

present. FHR = 150 beats per minute.

Pelvic Exam: Cervix 6 cm dilated; 100% effaced. Station +1.

Extremities: negative

Sally is diagnosed as having an upper respiratory infection; she is in active labor.

CARE STUDY QUESTIONS:

1. Based on Sally’s health history, the best nursing diagnosis for her would be

a. fear related to slow fetal heart rate by monitor.

b. anxiety related to lack of preparation for labor.

c. Health-seeking behaviors related to role in labor.

d. grief related to absence of baby’s father during labor.

Answer: c. Sally’s labor is progressing normally. She wants to learn more about what is

her role.

2. Sally asks what causes labor to begin. Which of the following would be your best

answer?

a. “A fetal ‘time clock’ that releases estrogen after 9 months.”

b. “Progesterone withdrawal caused by fetal/maternal factors.”

c. “Secretion of fetal pituitary hormone begins contractions.”

d. “Expulsion of the cervical mucous plug triggers oxytocin.”

Answer: b. The exact trigger that causes labor to begin is unknown, but it is thought to

be a combination of fetal and maternal factors that leads to progesterone withdrawal.

3. A cervix is said to be “ripe” for labor if

a. it feels “butter-soft” to touch.

b. the color is that of a ripe peach.

c. vaginal secretions have a fruity odor.

d. the cervix is hard as kernels of corn.

Answer: a. A ripe cervix feels considerably softer than it did during pregnancy.
4. How easily a fetus is born depends a great deal on the position of the fetal head in the

woman’s pelvis. The narrowest anteroposterior diameter of the fetal skull is

a. occipitofrontal.

b. suboccipitobregmatic.

c. occipitomental.

d. subfrontal bregmatic.

Answer: b. The suboccipitobregmatic diameter is only 9.5 cm where the occipitofrontal

is 12 cm and the occipitomental is 13.5 cms.

5 Sally is told that her fetus has a bad attitude. This means

a. it shows “fisting” on a sonogram.

b. the baby is resisting being born.

c. it is presenting in a “fetal position.”

d. the fetal head is not well flexed.

Answer: d. A fetus with the head flexed is in a good attitude for passage through the

birth canal.

6. Sally’s fetus is not engaged. If it were, this would mean the fetal head is

a. held rampart straight rather than flexed.

b. at the level of the ischial tuberosities.

c. at the level of the maternal ischial spines.

d. “floating” and comfortable in the uterus.

Answer: c. Engagement means the fetal head has settled into the inlet of the pelvis. This

happens about 2 weeks prebirth in a primipara or at the beginning of labor in multiparas.

7. Sally’s fetus is in a ROA position. This means the

a. fetal head faces left and backward.

b. fetus is positioned to be born breech first.

c. shoulders of the fetus point to the right.

d. fetal nose points to the right and forward.

Answer: a. The back of the head (occiput) points to the right anterior pelvis.

8. A fetus follows a series of steps through the birth canal. These cardinal movements

are

a. flexion, right position, descent, left position, expulsion, natural birth.

b. descent, flexion, interior rotation, extension, exterior rotation, expulsion.

c. circling, settling, engagement, turning, flexion, continuation, birth.

d. flexion, extension, internal rotation, flexion, external rotation, expulsion.

Answer: b. The fetus descends, flexes the head, rotates and extends, rotates back to the

original position, and then is expulsed or born.

9. Uterine contractions follow a pattern of

a. increment, relaxation, dissolution, wait period.

b. relaxation, acme, decrement, resolution.

c. increment, acme, decrement, relaxation.

d. acme, resolution, relaxation, increment.

Answer: c. A typical contraction rises in intensity (increment), reaches a peak (acme)

and then lessens (decrement). Next follows a period of relaxation before the next

contraction.

10. A cervix effaces during labor. This means the cervix

a. turns inside out as the baby is born.

b. shortens in length and then becomes thinner.

c. hardens to support the fetal head.

d. bleeds profusely as endocervix cells rupture.

Answer: b. Effacement means the cervix thins and shortens, an action that allows it to

dilate.

11. The cervix also dilates or widens. Full dilatation is

a. 10 cm.

b. 7 cm.

c. 14 cm.

d. 20 cm.

Answer: a. A fully dilated cervix is 10 cm in diameter.

12. Sally’s physician asks you to assist with Leopold’s maneuvers. This means

a. she needs you to help deliver the baby.

b. the placenta is about to be delivered.

c. the fetus needs to be turned in utero.

d. she wants to determine the fetal position.

Answer: d. Leopold’s movements discern fetal presentation and position through

abdominal palpation.

13. Sally has a fetal monitor attached to measure fetal heart rate. Which is a normal fetal

heart rate response to a contraction?

a. FHR decreases with beginning of the contraction; it rises again at the end.

b. FHR shows little or no variability with uterine contractions.

c. FHR increases with beginning of the contraction and slows afterward.

d. FHR increases at the acme of the contraction and then falls abruptly.

Answer: a. As the contraction puts pressure on the fetal head, the FHR slows. As the

contraction ends, the FHR rises back to baseline.

14. Sally has an episiotomy just prior to birth of her infant. The purpose of an episiotomy

is to

a. allow the infant to take respirations before birth.

b. encourage perineal blood flow to prevent clotting.

c. make the mother more comfortable postpartally.

d. prevent or lessen perineal tearing of the mother.

Answer: d. Episiotomy incisions can prevent perineal tearing. Compared to no

episiotomy, they are more painful for the mother postpartally.

15. Sally wants to walk while in labor. You would advocate for this under which

circumstances?

a. The fetal heart rate is less than usual.

b. She is having some vaginal bleeding.

c. The fetal membranes are still intact.

d. She has a clear watery vaginal discharge.

Answer: c. As a rule, women can ambulate in labor until membranes rupture. After that

point there is increased danger of umbilical cord prolapse.

16. You detect variable decelerations on Sally’s fetal monitor. Variable decelerations

suggest

a. a healthy fetus.

b. cord compression.

c. contractions are too short.

d. the fetus has a heart defect.

Answer: b. If the fetal head presses against the umbilical cord, variable decelerations

(lowered FHR separate from contractions) occurs.

17. How often would you ask Sally to void during labor?

a. The less times, the better to keep pressure on the uterus.

b. Every 2 to 4 hours to keep her bladder almost empty.

c. Every ½ to 1 hour to prevent urine incontinence.

d. Not more than every 8 hours as she is not drinking any fluid.
Answer: b. Keeping the bladder empty is important to best allow descent of the fetal

head.

18. Sally has her membranes artificially ruptured. Following this procedure it would be

most important to assess

a. maternal blood pressure.

b. maternal pulse rate.

c. Sally’s temperature.

d. fetal heart rate.

Answer: d. There is a danger of cord prolapse following rupture of the membranes. This

is best detected by recording a fetal heart rate.

19. Sally’s physician wants to use a lithotomy position for Sally’s baby’s birth. Which of

the following statements is true of the lithotomy position?

a. This position does not supply a good view of the perineum.

b. This position makes cutting for an episiotomy more difficult.

c. Lithotomy position can increase the risk of thrombophlebitis.

d. Lithotomy position encourages cord prolapse or compression.

Answer: c. Because of the sharp bend of the leg, a lithotomy position can lead to

maternal thrombophlebitis. It is the best position to allow a view of the perineum and for

an episiotomy.
20. Sally’s physician wants you to record the time of her baby’s birth. You would record

this as what point?

a. When the baby’s total body is born

b. When the head presents at the perineum

c. When the infant takes his or her first breath

d. When the head or the breech is born

Answer: a. A baby is considered born when the total baby is born.