A 32-year-old multigravida at 39 weeks gestation has been in… | 마이메르시 MyMerci
Maternal Newborn Health
문제

A 32-year-old multigravida at 39 weeks gestation has been in active labor for 14 hours. Her cervix is 6 cm dilated and has remained unchanged for the past 4 hours despite adequate uterine contractions. The fetal heart rate is reassuring. What is the most appropriate nursing intervention at this time?

해설
Secondary arrest of labor requires immediate medical evaluation. Other options may help but do not address the need for provider intervention.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the recognition and initial nursing action for secondary arrest of dilation. This is a type of dystocia (abnormal or difficult labor) where, despite adequate uterine contractions, cervical dilation stops for 2 hours or more in the active phase (typically defined as ≥6 cm). The scenario describes a classic case: a multigravida in active labor for 14 hours, with a cervix stuck at 6 cm for 4 hours despite adequate contractions. This is a significant deviation from the normal progress of labor and requires prompt medical evaluation to determine the cause (e.g., cephalopelvic disproportion (CPD), malposition, uterine exhaustion) and plan interventions (e.g., amniotomy, oxytocin augmentation, or cesarean section).

Answer Rationale: Key Point! The most appropriate nursing intervention is to Notify the healthcare provider immediately. This is a priority action because secondary arrest is a medical diagnosis that requires the provider's assessment and decision-making. The nurse's role is to recognize the abnormal pattern, document findings (including contraction pattern and fetal status), and communicate them promptly to the provider. The reassuring fetal heart rate is positive, but it does not negate the need for intervention for the stalled labor.

Distractor Analysis:
Watch out for confusion! Option ①, encouraging ambulation, is a non-pharmacological comfort measure and can be helpful in early labor or with a reassuring but slow progress. However, after 4 hours of no change in the active phase, it is insufficient as the primary intervention. The problem has moved beyond what simple ambulation can correct.
Option ③, increasing position changes, is similar to ambulation. While frequent position changes (e.g., hands-and-knees, lateral recumbent) can help optimize pelvic diameters and facilitate rotation of a malpositioned fetus, this is a nursing comfort measure and should be implemented *while* notifying the provider, not *instead of* notification.
Option ④, administering pain medication, is incorrect. While relaxation might theoretically help if tension were the cause, opioid analgesics can sometimes *slow* labor progress. More importantly, the administration of medication requires a provider's order, and the core issue is a pathological arrest that needs medical evaluation, not masked by sedation.

Related Concepts: This scenario highlights the difference between nursing comfort measures and required medical interventions. The nurse must understand the phases and stages of labor, normal vs. abnormal progress (using tools like a partogram), and the definitions of various dystocias (prolonged latent phase, protracted active phase, arrest disorders). The ultimate goal is safe care for both mother and fetus, which may involve augmentation of labor or surgical delivery. Concept Summary
ConceptDefinitionNursing Implication
Secondary Arrest of DilationNo cervical change for ≥2 hours in active phase (≥6 cm) despite adequate contractions.Requires immediate notification of healthcare provider for evaluation and intervention.
Active Phase of LaborFrom 6 cm to full (10 cm) cervical dilation. Faster progression expected, especially in multigravidas.Monitor progress closely (at least q2h vaginal exams). Slower than expected progress is a red flag.
Adequate Uterine ContractionsContractions q2-3 min, lasting 40-60 sec, of moderate to strong intensity by palpation or IUPC.If progress stalls despite adequate contractions, the cause is likely not hypotonic uterine activity.
DystociaAbnormal or difficult labor/progress. The "3 P's": Powers (contractions), Passenger (fetus), Passage (pelvis).Nursing assessment focuses on evaluating all three components and reporting findings.
Side-by-Side Comparison!
Labor DysfunctionDefinitionTypical Nursing Action (After Assessment)
Protracted Active PhaseSlower than normal rate of dilation (

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the labor nurse for Maria, G3P2 at 39 weeks. Her contractions are strong, every 2-3 minutes, lasting 60 seconds. Four hours ago, her cervix was 6 cm/100% effaced/-1 station. On your reassessment, it remains 6 cm/100% effaced/-1 station. The external fetal monitor shows a baseline of 140 with moderate variability and accelerations.

Nursing Intervention Strategy: 1. Assessment: Confirm contraction pattern (palpate or review IUPC data). Perform a careful vaginal exam to confirm no change in dilation, effacement, station, and fetal position (e.g., is it OP?). Reassess fetal heart rate (FHR) tracing for any new non-reassuring features. 2. Action: Immediately call the obstetrician or midwife. Report using SBAR: Situation (patient in active labor), Background (multip at 39 weeks), Assessment (cervix unchanged at 6 cm for 4 hours despite adequate contractions, reassuring FHR), Recommendation ("I need you to evaluate her for secondary arrest."). 3. Care & Monitoring: While awaiting the provider, continue supportive care: assist with position changes (left lateral, hands-and-knees), provide emotional support, maintain hydration (IV fluids), and monitor FHR and contractions continuously. Do not leave the patient unattended. 4. Education: Explain to the patient and her partner what is happening in simple terms: "Your contractions are strong, which is good, but your cervix hasn't opened further in the last few hours. This happens sometimes, and the doctor needs to check you to see what the best next step is for you and the baby."

Patient Safety and Precautions: * Never assume arrest is due to "maternal exhaustion" or anxiety without provider evaluation. * Do not administer any labor-stimulating interventions (like nipple stimulation) without an order, as they could cause uterine hyperstimulation. * Continuously monitor for signs of chorioamnionitis (maternal fever, fetal tachycardia, uterine tenderness, foul-smelling amniotic fluid), a risk with prolonged rupture of membranes and prolonged labor. Nursing Procedure & Medication Flow If the provider orders Oxytocin (Pitocin) augmentation: 1. Double-check the order: dose, rate, and increment schedule. 2. Use an infusion pump. Start at the ordered low dose (e.g., 1-2 mU/min). 3. Titrate per protocol, increasing gradually (e.g., every 30-40 minutes) until achieving adequate labor pattern (contractions q2-3 min, lasting 40-60 sec, with 60-sec rest periods). 4. Monitor continuously: One-to-one nursing is required. Assess maternal BP, pulse, contraction pattern (for tachysystole), and FHR pattern (for decelerations) before each rate increase and frequently thereafter. 5. Discontinue oxytocin and notify provider for non-reassuring FHR patterns or uterine tachysystole (more than 5 contractions in 10 minutes). A Word from Your Senior Nurse Labor and delivery nursing is about being a vigilant guardian of two lives. Trust your assessment skills. When you see a clear pattern of arrest like this, don't second-guess yourself or try to "fix it" with independent measures. Your most powerful tool is timely and accurate communication with the provider. By recognizing secondary arrest early and calling for help, you are initiating the chain of events that leads to a safe resolution, whether that's a successful augmented vaginal delivery or a timely cesarean section. On the NCLEX and in real life, knowing when to act independently and when to collaborate is the mark of a safe, competent nurse.

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