Western Mindanao State University

COLLEGE OF NURSING
Zamboanga City

NCM 107 B: A Clinical Case Analysis

A 25 y/o woman in labor was admitted at 10:00 AM, she is a multigravida with an
obstetric history or GTPAL of 32002. Upon I.E. her cervix is 8 cm dilated and 80% effaced with
intact BOW. Vital signs as follows: T- 37˚C; PR-90 beats/min; RR- 20 breaths/min and BP-
110/90mmHg; FHT is 140 beats/min at LLQ; pain scale is 8. Uterine contractions were strong
and noted every 2-3 minutes with a 70-80 seconds duration on each event. At 11:30 AM,
client’s cervix is fully dilated and the BOW ruptured spontaneously revealing a clear amniotic
fluid.

1. What is labor?
2. Interpret the client’s obstetric history or GTPAL.
3. Based on the initial findings of the mother, what stage of labor is this? Are all these
findings within normal parameters?
4. What will you record in the client’s partograph? After graphing the cervical findings, did
it reach the alert line?
5. Is the client’s uterine contraction normal?
6. What can be your priority nursing diagnosis? Suggest independent nursing interventions
to manage this.