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. Sally’s labor is progressing normally. She asks to learn more about her role in labor.
She does not exhibit clear signs of fear or anxiety.
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. Women need fluid during labor to remain hydrated. She is separated from the baby’s
father. Coughing or blowing her nose will not affect her labor or the birth. Iron supplements are
not indicated at this time.
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. 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 labor and delivery nurse should plan interventions in light of the narrowest
anteroposterior diameter of the fetal skull. Which diameter is smallest and least likely to cause
perineal trauma?
a. Occipitofrontal
b. Suboccipitobregmatic
c. Occipitomental
d. Subfrontal bregmatic
Answer: b. The suboccipitobregmatic diameter is only 9.5 cm, whereas the occipitofrontal is 12
cm and the occipitomental is 13.5 cm.
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. A fetus with the head flexed is in a good attitude for passage through the birth canal.
If the head is not flexed, this is a “bad” attitude.
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. Engagement means the fetal head has settled into the inlet of the pelvis or is at the
ischial spines. This usually happens about 2 weeks prebirth in a primipara and at the beginning
of labor in multiparas.
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. In an ROA position, the back of the head (occiput) points to the right anterior pelvis.
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. The fetus descends, flexes the head, rotates and extends, rotates back to the original
position, and then is expulsed or born.
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. 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. 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. Effacement means the cervix thins, an action which allows it to dilate.
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. A fully dilated cervix is 10 cm in diameter.
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. Leopold’s movements discern fetal presentation and position through abdominal
palpation.
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. As the contraction puts pressure on the fetal head, the FHR slows. As the contraction
ends, the FHR rises back to baseline.
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. If the fetal head presses against the umbilical cord, variable decelerations (lowered
FHR separate from contractions) can occurs. This does not suggest uterine prolapse, meconium
aspiration, or a fetal heart defect.
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. As a rule, women can ambulate in labor. If membranes rupture before the head is
engaged, however, there is increased danger of umbilical cord prolapse. The use of a birthing
ball would thus be contraindicated.
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. Keeping the bladder empty is important to best allow descent of the fetal head.
Voiding once or twice each hour may be unrealistic.
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. There is a danger of cord prolapse following rupture of the membranes. This is best
detected by listening for a fetal heart rate.
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. The sensation of having to move the bowels means the fetal head has descended to
the perineum and second stage labor has begun.
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. Sally should feel pressure, not pain. Gloves should be sterile not just clean. No
speculum is needed. The cervix is felt, not visualized.
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. A baby is considered born when the total baby is born.
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: As a rule of thumb, the more women know about labor, the easier it is for them because
they can more actively participate in decisions about their own care. It is becoming more and
more rare to encounter a woman who knows nothing about labor because of the educational
opportunities available at prenatal settings and all the information available on the Internet.
Exploring with Sally why she didn’t prepare at all would be a good first point to investigate. Is
she unsure if she wants to keep this baby? Early in labor, explaining and demonstrating breathing
patterns and how these 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?
Answer: Most practitioners recommend that women lie on their sides, walk about, or sit in a
chair because this frees up the vena cava, ensuring a good blood supply to the uterus and fetus.
Occasionally, a woman will lie on her back after monitors are attached because she believes they
will come loose if she turns on her side or not record accurately in that position. As a rule, urge
women to assume a side-lying position while in bed and assure them fetal and uterine monitors
also record accurately in standing or sitting positions.
FILL IN THE BLANK QUESTIONS:
23. The frequency of uterine contractions is measured from the __________ of one contraction
to the ________________ of the next.
Answer: beginning; beginning
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. If a woman were using effective breathing exercises, she might not experience
pain with contractions. At the same time, the presence of pain does not necessarily suggest a
complication.