Brooke Bailey

L&D Case Study

Nursing III
Scenario:

You are the charge nurse working in labor and delivery at a local hospital. D.H. comes to
the unit having contractions and feeling somewhat uncomfortable. you take her to the
intake room to provide privacy, have her change into a gown, and ask her three initial
questions to determine your next course of action—that is, whether to do a vaginal
examination or to continue asking her more questions.

1. What three initial questions will you ask, and why?

 Has your water broken? If so, when?

 How far apart are your contractions and how long do they last?
 Have you had any pregnancy complications so far? Such as placenta previa?

2. D.H. has contractions 2 to 3 minutes apart and lasting 45 seconds. It is her third
pregnancy (gravida 3, para 2002). Her bag of waters is intact at this time. You
determine that it is appropriate to ask for further information before a vaginal
examination is done. What information do you need?

 When did the contractions begin?

 Do you have any allergies?

 Do you have any risk factors?

 How far along are you and when is your due date?

3. What assessment should you make to gain further information from D.H.?

 Obtain vital signs

 Begin to monitor FHR. Watch for any abnormalizes such as slowing or acceleration.
 Monitor contraction pattern (strength, frequency, duration)
 Check the pts. cervix to determine how dilated they are and what percent of effacement.
 Ensure the amniotic membranes are still intake.
 Provide comfort measures for the pt. and determine how they are handing the contractions.
 4. On examination, D.H. is 80% effaced and 4 cm dilated. The fetal heart rate (FHR) is
150 beats/min and regular. She is admitted to a labor and delivery room on the
unit. What nursing measures should be done at this time?

 Continue with the continuous fetal monitoring and contraction monitoring.

 Pt. should also be put on continuous B/P monitoring.
 Ask the pt. about questions they may have.
 Continue with comfort measures for the pt. such as relaxation and breathing techniques.

5. As part of your assessment, you review the fetal heart strip pictured here. What
will you do?

You would want to continue to monitor the pt. to determine if the decelerations are late or
variable. The provider should be notified.

6. List the stages of labor. D.H. is in what stage of labor?

 FIRST STAGE: Begins w/ true labor CTX & ends when the cervix is full dilated. 
o *Divided into 3 phases:
 1.Latent (preparatory) phase (0-3cm)
 2.Active phase (4-7cm)
 3.Transition phase (8-10cm)
 SECOND STAGE: Period when the cervix is completely dilated & effaced to the birth of the
infant. "pushing stage"
 THIRD STAGE: Begins w/ birth of baby & ends w/ the delivery of the placenta
 FOURTH STAGE: The period from 1 - 4 hours after birth. 

D.H. is in the active phase of the first stage of labor. During this phase, the cervix is beginning to
dilate Your cervix opens from 4 to 7 centimeters. This is when you should head to the hospital.
When you have contractions every 3 to 4 minutes and they each last about 60 seconds, it often
means that your cervix is opening faster (about 1 centimeter per hour).
 7. D.H. states that she is feeling discomfort and asks you whether there is alternative
therapy available before taking medication. List at least four alternative methods
to assist D.H. with controlling her discomfort.

 Change pt. position. Pillows can help with comfort.

 Ambulation or bouncing on a ball may help with discomfort

 Practice conscious breathing

 Cold or heat compress

8. As you assess both D.H. and the fetus during the active stage of labor, you will
look for abnormalities. Which of these are potential abnormalities during labor?
(Select all that apply.)

a. Unusual bleeding

b. Brown or greenish amniotic fluid

c. Contractions that last 40 to 70 seconds

d. Sudden, severe pain

e. Increased maternal fatigue

CASE STUDY PROGRESS:

Although D.H. continues to use alternative therapies for discomfort, she asks for pain
medication and receives a dose of meperidine (Demerol). Three hours later, D.H. is lying
on her back, and during contractions you notice a few late decelerations of the FHR. you
stay with D.H. to monitor her and her fetus and immediately call for someone to notify the
primary care provider.

9. Put these actions in order of priority:

a. Discontinue the oxytocin infusion 3

b. Turn D.H. onto her left side and elevate her legs 1

c. Increase the rate of the maintenance IV fluids 4

 d. Administer oxygen at 8 to 10 L/min by facemask 2

10. Decelerations occur in an early, variable, or late pattern. What is the significance
of these patterns? State what the nurse should do for each type.

 Early decelerations: caused by fetal head compression. This is a benign finding.

 Variable decelerations: caused by cord compression normally during the transition phase of
the first to the second stage of labor. The nurse should turn the pt. and monitor closely.

 Late deceleration: caused by fetal distress. If they are persistent and repetitive, it can
indicate fetal hypoxemia. The pt. should be closely monitored and may need an emergency
C-section.

11. As you monitor D.H., you observe for prolapse of the umbilical cord. Describe
what this is and what can happen to the fetus if this occurs.

It is when the cord is below the presenting part of the fetus. If the cord is compression, it causes
hypoxia to the fetus. This would cause newborn asphyxia, neurologic brain injury, or death. It is
important to put the pt. in knee to chest to decrease the chance of compression.

12. What would be done if you were to note that D.H. has a prolapsed cord?

 Call the physician

 Insert two gloved fingers into the vagina to the cervix and put upward pressure against the
presenting part to relieve compression of the cord. Place a towel under the pts. hip.

 Place the pt. into knee-chest position.

 Administer o2 via mask at 8-10 L/min.

 Reassure the pt. and explain what is going to happen.

 Monitor FHR.

 Ensure IV is functional and prepare for immediate vaginal birth or C-section.

CASE STUDY PROGRESS:

The decelerations stop, and the remainder of the labor is uneventful; D.H. has an
episiotomy to allow more room for the infant to emerge and delivers a male infant.

13. What is involved in the immediate care of the newborn?

Consists of Apgar score, resuscitation (if needed), providing neutral thermal environment,
assessing reflexes, proper identification of infant, parent/infant bonding, prophylactic (antibiotic)
care

14. As you assess the newborn, you observe for central nervous system (CNS)
depressant effects that might result because the mother received an opioid during
labor. What drug would be helpful to reverse signs of CNS depression in the
infant?

a. Carbamazepine (Tegretol)

b. Nalbuphine (Nubian)

c. Midazolam (Versed)

d. Naloxone (Narcan)

15. D.H. has her episiotomy repaired and the placenta delivered. What are the signs
that the placenta has released from the uterine wall?

 A firmly contracted uterus.

 The cord would be longer.

 A sudden release of blood from the vagina.

 Feeling of vaginal fullness on vaginal examination.

16. What assessments are important for D.H. after delivery?

 Take vital signs

 Check the fundus to make sure it is firm and to measure it.

 Assess and document lochia

 Assess the pts. episiotomy for bruising or edema.

 Document how the pt. feels and is doing emotionally.