ADVENTIST MEDICAL CENTER COLLEGE

BRGY. SAN MIGUEL, ILIGAN CITY

SCHOOL OF NURSING

CARE OF MOTHER, CHILD, AND ADOLSECENT – SECTION A

Related Learning Experience (Clinical: DR)
First Semester, AY 2021 – 2022

Name of Students: _____________________________________ Date: _______ Score: 40 pts

Case Scenario #7: Nursing Care of a Family During Labor and Birth

A WOMAN IN LABOR
Sally 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
5-minute 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 the baby for 7 months. Her close female friend is with her
to be a support person in labor. The client works as a 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 the 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.

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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.

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STUDY QUESTIONS:
1. Based on Sally’s health history, the best nursing diagnosis for her would be: (2 pts)
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 management of discomfort in labor.
D. Grief related to absence of baby’s father during labor.
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

2. 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? (2 pts)
A. Occipitofrontal
B. Suboccipitobregmatic
C. Occipitomental
D. Subfrontal bregmatic
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

3. Sally was told during an earlier assessment that her fetus has a good attitude. This
assessment finding implies which of the following? (2 pts)
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 “military position.”
D. The fetal head is well flexed forward.
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
4. Sally’s fetus is declared to be engaged. How should the nurse respond to this assessment
finding? (2 pts)
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.

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Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

5. Sally’s fetus is declared to be in an ROA position. The nurse should interpret this
assessment finding to mean which of the following? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

6. 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? (2 pts)
A. Flexion, right position, descent, left position, expulsion, natural birth
B. Descent, flexion, internal rotation, extension, external rotation, expulsion
C. Circling, settling, engagement, turning, flexion, continuation, birth
D. Flexion, extension, internal rotation, flexion, external rotation, expulsion
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

7. The maternity nurse is assessing the duration and course of Sally’s contractions. The nurse
should expect to observe what pattern? (2 pts)
A. Increment, relaxation, dissolution, wait period
B. Relaxation, acme, decrement, resolution
C. Increment, acme, decrement, relaxation
D. Acme, resolution, relaxation, increment
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
8. Sally has 80% cervical effacement. What will the nurse document upon performing a
vaginal examination? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
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9. The obstetrician has informed the care team that Sally is fully dilated. What is the
diameter of Sally’s cervix at this time? (2 pts)
A. 10 cm
B. 7 cm
C. 14 cm
D. 18 to 20 cm
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

10. Sally’s obstetrician asks you to assist with Leopold’s maneuvers. What nursing action
should you consequently take? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

11. 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? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
12. You detect variable decelerations on Sally’s fetal monitor. You should choose
interventions that address what potential complication? (2 pts)
A. Imminent uterine rupture
B. Presence of cord prolapse
C. Possible meconium aspiration
D. The presence of a fetal heart defect
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

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13. Suppose Sally is having long and hard uterine contractions. What length of contraction
would the nurse report as indicative of a potential safety risk? (2 pts)
A. Any length of contraction over 30 seconds
B. A contraction over 70 seconds in length
C. A contraction that peaks at 20 seconds
D. A contraction that appears intensely painful
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

14. During your early interactions with Sally, you emphasize voiding during labor. You would
provide what instruction to Sally? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
15. Sally’s membranes rupture as her dilation reaches 8 cm. Following this, it would be most
important to perform what assessment? (2 pts)
A. Assess Sally’s blood pressure.
B. Assess maternal pulse rate.
C. Assess Sally’s temperature.
D. Assess the fetal heart rate.
Answer (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
16. 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? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

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17. Sally’s obstetrician asks you to help with a vaginal exam. What nursing action should you
perform? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________
18. 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? (2 pts)
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 (letter only), Rationale of answer, & Reference (page from textbook):
______________________________________________________________________________

MULTIPLE RESPONSE QUESTION: (4 pts)

19. 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. (p. 345;P. 346)

Assessed by:

________________________
Name of Clinical Instructor