Mindanao State University – Iligan Institute of Technology
Student: ___Alinea, Kylemhor Cate P______ Group: __
Identified Problem: Active Labor
Nursing Diagnosis: Health-seeking behaviors related to role in labor.
CUES
Subjective:
28-year-old,
G1P0,
41 weeks pregnant woman.
The patient states “I’m in labor.
Tell me what I’m supposed to
do.”
Objective:
height: 5 ft 5 in.;
weight: 142 lb;
temperature: 38°C;
BP: 112/70 mmHg
respiratory rate: 20 breaths/min;
heart rate: 70 beats/min
Fundal height at 35 cm;
fetus palpable in ROA position;
FHR: 150 beats/min
Cervix 6 cm dilated;
100% effaced;
station +1
Maternal and Child Nursing
OBJECTIVES
Short Term Objectives:
After 5 minutes of health
teaching and nursing
intervention the patient will be
able to:
*Participates in health
teaching for delivery and labor
Long Term Objectives:
After 20 to 60 minutes the
patient will be able to:
*Take action in performing
appropriate breathing
techniques during delivery.
NURSING CARE PLAN
INTERVENTIONS
Independent:
*Encourage her to drink fluids so she doesn’t
become dehydrated during labor.
*Teach the patient in use of appropriate
breathing/relaxation techniques and in
abdominal effleurage.
*Teach and provide written information about
signs of labor and the difference between true
and false labor. also relieves some of the anxiety
that women frequently have about this issue.
*Teach about the stages of labor.
*Encourage the the patient to empty the bladder.
Inclusive Dates of Duty: ______________________________
Patient: __________________________ Room No.: _______
RATIONALE EVALUATION
Short Term:
*Women need fluid during labor to After 5 minutes of health teaching
remain hydrate. and nursing intervention the
patient has been able to:
*Describe signs of labor.
*Facilitates progression of normal
labor. May block pain impulses in *Differentiate between true and
cerebral cortex through conditioned false labor.
response and cutaneous
stimulation. *Verbalize being prepared for
labor and birth.
*This information helps ensure that
the woman/couple
will know when to go to the birthing
unit.
It
*Teaching reinforces correct
information the woman may already
have and relieves anxiety by
correcting any misinformation. It
also allows role rehearsal in
advance of labor and birth.
Keeping the bladder empty is
important to best allow descent of Long Term:
the fetal head. Voiding once or After 20 to 60 minutes the patient
twice each hour may be unrealistic has been able to take action in
 performing appropriate breathing
techniques during delivery.
Dependent:

Collaborative: