Name _______________________________________ Date _______________________
Patient Scenario, Chapter 15, Nursing Care of a Family During Labor and
Birth
A WOMAN IN LABOR
Sally Hudson is a 28-year-old, G1P0, 41 weeks pregnant woman admitted to your 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 5minute intervals and from 10-second duration to 60-second duration. She last ate or drank 8
hours ago.
FAMILY PROFILE:
She is separated from the father of baby for 7 months. Her close female friend is with her to be
support person in labor. The client works as French teacher at state university; she is taking
courses part-time toward her doctorate. She lives in one-bedroom condo by herself. She has
supplies prepared for infant.
HISTORY OF PAST ILLNESSES:
She had chickenpox at age 3 years. She had dislocated kneecap at age 14 years and again at
age 16 years. She had no major illnesses and no hospitalizations.
HISTORY OF FAMILY ILLNESSES:
Her grandmother has Alzheimer’s disease. A sister had rheumatic fever as a child.
GYNECOLOGIC HISTORY:
Menarche was at age 11 years; duration of cycle is 32 days. Length of menstrual flow is 7 days.
She was treated for trichomoniasis twice last year. She had no other STIs.
OBSTETRIC HISTORY:
She had no previous pregnancies. This pregnancy was not intended but is wanted. She had
prenatal care with private obstetrician since second month; she was found to be anemic early in
pregnancy and was treated with extra iron supplement. She attended preparation for labor
classes with friend as coach.
DAY HISTORY:
Nutrition: 24-hour recall nutritional history reveals adequate pregnancy diet; took prenatal
vitamin and extra iron supplement routinely; last ate toast and coffee 8 hours ago
Sleep: Sleeps 6 hours per night; one afternoon nap
Recreation: Has participated in aerobics class for pregnant women during pregnancy; had an
exercise program of daily jogging before pregnancy
REVIEW OF SYSTEMS:
Neuropsychologic: 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 appearing woman
breathing without apparent distress with contractions; height: 5 ft 5 in.; weight: 142 lb;
temperature: 38°C; BP: 112/70 mmHg
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/min; heart rate: 70 beats/min, no murmur
Abdomen: Fundal height at 35 cm; fetus palpable in ROA position; linea nigra and striae
present: FHR: 150 beats/min
Pelvic examination: Cervix 6 cm dilated; 100% effaced; station +1
Extremities: Negative
Sally is diagnosed as being in active labor and also has an upper respiratory infection.
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
2. An appropriate nursing plan for care of Sally during labor should include which of the
following?
a. Continue to give her iron supplements so her newborn is not born anemic.
b. Phone the father of her baby to come to the hospital to be her labor coach.
c. Encourage her to drink fluids so she doesn’t become dehydrated during labor.
d. Caution her not to blow her nose (she has a cold) to avoid FHR decelerations.
Answer C
3. Sally tells you that her prenatal instructor often referred to “ripe” cervix but did not explain
exactly what this meant. How should you describe this to Sally?
a. “This happens when your cervix feels soft to touch.”
b. “This happens when the cervical color is darker red than usual.”
c. “Your cervix is considered ‘ripe’ when you first feel labor pains.”
d. “Your cervix is described as ‘ripe’ when it becomes firm in preparation for labor.”
Answer A
5. Sally was told during an earlier assessment that her fetus has a bad attitude. This assessment
finding implies which of the following?
a. Her fetus’s position is difficult to visual by sonogram.
b. The baby appears large for gestational age.
c. Her fetus is presenting in a “fetal position.”
d. The fetal head is not well flexed forward.
Answer D
6. Sally’s fetus is declared to be engaged. How should the nurse respond to this assessment
finding?
a. Explain to Sally that the fetal head is held rampart straight rather than flexed.
b. Recognize that the fetal head is at the level of the ischial tuberosities.
c. Recognize that the fetal head is at the level of the maternal ischial spines.
d. Assure Sally that the fetal head is “floating” and comfortable in the uterus.
Answer C
7. Sally’s fetus is declared to be in an ROA position. The nurse should interpret this assessment
finding to mean which of the following?
a. The fetal nose faces left and backward.
b. The fetus is positioned to be born breech.
c. The shoulders of the fetus point to the right.
d. The fetal nose points to the right and forward.
Answer A
8. A fetus follows a series of linear steps through the birth canal. The nurse should expect to
observe the cardinal movements to occur in what sequence?
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
9. The maternity nurse is assessing the duration and course of Sally’s contractions. The nurse
should expect to observe what pattern?
a. Increment, relaxation, dissolution, wait period
b. Relaxation, acme, decrement, resolution
c. Increment, acme, decrement, relaxation
d. Acme, resolution, relaxation, increment
Answer C
10. Sally has 80% cervical effacement. What will the nurse document upon performing a vaginal
examination?
a. The cervix has transitioned from being concave to being convex.
b. The nurse may have difficulty palpating the thin cervix.
c. Upon performing a vaginal exam, the nurse will note that the cervix is hardened.
d. Scant cervical bleeding will be noted upon vaginal examination.
Answer B
11. The obstetrician has informed the care team that Sally is fully dilated. What is the diameter
of Sally’s cervix at this time?
a. 10 cm
b. 7 cm
c. 14 cm
d. 18 to 20 cm
Answer A
12. Sally’s obstetrician asks you to assist with Leopold’s maneuvers. What nursing action should
you consequently take?
a. Turn Sally on her side.
b. Prepare for the imminent delivery of the placenta.
c. Assist the obstetrician with turning the fetus in utero.
d. Assist the obstetrician in determining fetal position.
Answer D
13. Including QSEN competencies in care, such as informatics, helps to ensure that care is of
the highest quality possible. Sally has a fetal monitor attached to measure fetal heart rate.
Which of the following would the nurse interpret as a normal fetal heart rate response to a
contraction?
a. FHR decreases with beginning of the contraction and 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
14. You detect variable decelerations on Sally’s fetal monitor. You should choose interventions
that address what potential complication?
a. Imminent uterine rupture
b. Presence of cord prolapse
c. Possible meconium aspiration
d. The presence of a fetal heart defect
Answer B
15. Sally asks if she can use a birthing ball while in labor. Because her fetus is not yet engaged,
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
16. During your early interactions with Sally, you emphasize voiding during labor. You would
provide what instruction to Sally?
a. “In order to keep pressure on your uterus, don’t void too often.”
b. “You should void every ½ hour to 1 hour to prevent urine incontinence.”
c. “You should try to void every 2 to 4 hours to keep your bladder empty.”
d. “You won’t void more than every 6 hours because you’re not drinking much fluid.”
Answer C
17. Sally’s membranes rupture as her dilation reaches 8 cm. Following this, it would be most
important to perform what assessment?
a. Assess Sally’s blood pressure.
b. Assess maternal pulse rate.
c. Assess Sally’s temperature.
d. Assess the fetal heart rate.
Answer D
18. At 10-cm dilatation, Sally tells you she needs to use the bathroom to move her bowels. Your
best action would be to do which of the following?
a. Ask her to try and wait until her baby is born to maintain asepsis.
b. Ask her to begin pushing; she’s entering the second stage of labor.
c. Offer her a bedpan as it’s unsafe at this point to walk to the bathroom.
d. Assist her to the bathroom to protect the birthing bed.
Answer B
19. Sally’s obstetrician asks you to help with a vaginal exam. What nursing action should you
perform?
a. Warm a vaginal speculum so it’s no longer cold vaginally.
b. Provide a good light source so the cervix is easily visible.
c. Provide clean gloves and a water soluble based lubricant.
d. Assure Sally the exam will cause pressure but not pain.
Answer D
20. Sally’s obstetrician asks you to record the time of her baby’s birth and you record the time
0706. This time denotes what event?
a. The baby’s total body is born.
b. The head presents at the perineum.
c. The infant takes his or her first breath.
d. The head is fully visible.
Answer A
OPEN-ENDED QUESTIONS:
21. What if when Sally is admitted to a birthing room, she states she has read nothing about
labor so has no idea what to expect? What would you want to teach her early in labor? Midway
in labor? Why might a woman enter labor without having learned anything about it?
Answer: Early in labor, explanning and demonstrating breathing patterns and how thee can
reduce pain would be important. Midway through, review with her she will need to push with
contractions.
22. What if after applying an electronic monitor to record FHR, you enter Sally’s room and
discover she is lying on her back, seemingly frozen in that position? What would you urge her to
do?
I recommended lie on their sides, walk about, sit in chair.
FILL IN THE BLANK QUESTIONS:
23. The frequency of uterine contractions is measured from the __________ of one contraction
to the ________________ of the next.
Answer: begining, begining
24. If a fetus is breech and the sacrum points toward the right of a woman’s pelvis, this position
would be documented as ___________.
Answer RSAP
MULTIPLE RESPONSE QUESTION:
25. During Sally’s labor, you are completing frequent assessments in order to identify potential
danger signs. Which of the following are danger signs to be alert for in labor? (Select all that
apply.)
a. A woman reports she is feeling no pain.
b. FHR is less than 110 beats/min.
c. The amniotic fluid is meconium stained.
d. Maternal blood pressure is above 160/90 mmHg.
e. A woman cries in pain with each contraction.
Answer B, C, D