A nurse is assessing a multigravida client at 38 weeks gestation who has been in active labor for 8 hours. The cervix remains at 6 cm dilation with minimal change over the past 4 hours. Fetal heart rate is 140-150 bpm with good variability. Which assessment finding would be most indicative of cephalopelvic disproportion (CPD)?
1Maternal exhaustion and request for pain medication
2Irregular uterine contractions occurring every 2-3 minutes
3Fetal station remaining at -2 despite adequate contractions✓ 정답
4Cervical edema and anterior lip present during contractions
해설
Fetal station remaining at -2 despite adequate contractions is most indicative of CPD, as it shows mechanical obstruction preventing descent. Other findings (maternal exhaustion, irregular contractions, cervical edema) are less specific to CPD.
Core Nursing ExplanationKey Concept Analysis: This question assesses the recognition of a key sign of Cephalopelvic Disproportion (CPD), a condition where the fetal head is too large to pass through the maternal pelvis. It is a classic cause of Arrest of Descent or Prolonged Labor. The scenario describes a multigravida (woman who has had previous pregnancies) in active labor with no cervical progress for 4 hours, which meets the criteria for an Arrest of Active Phase. The fetal heart rate (FHR) is reassuring. The critical question is: which finding points specifically to a mechanical obstruction (CPD) rather than other causes of labor dystocia (e.g., inadequate contractions, maternal exhaustion)?
Answer Rationale: Key Point! The most specific indicator of CPD is the lack of fetal descent despite adequate uterine contractions. In this case, "Fetal station remaining at -2 despite adequate contractions" directly signals a mechanical barrier. Fetal station refers to the level of the presenting part (usually the head) in relation to the ischial spines (0 station). A station of -2 means the head is 2 cm above the spines. In active labor with adequate contractions, the station should progressively become lower (e.g., 0, +1, +2). No descent is a hallmark of disproportion.
Distractor Analysis:
Maternal exhaustion and request for pain medication: This is a consequence of prolonged labor, not a specific sign of CPD. Exhaustion can occur from many causes, including ineffective contractions or pain.
Irregular uterine contractions occurring every 2-3 minutes: This describes Watch out for confusion!Ineffective labor patterns (e.g., hypotonic dysfunction). The question stem implies "adequate contractions," making this finding contradictory and pointing toward a different problem (power issue, not passenger/passage issue).
Cervical edema and anterior lip present during contractions: This finding is more indicative of Cervical dystocia or uneven pressure from the fetal head, which can occur with malposition (like occiput posterior) or if the head is applied unevenly. While it can be associated with prolonged labor, it is not the most direct sign of a size mismatch (CPD).
Related Concepts: The "3 P's" of labor (Powers, Passenger, Passage) are essential for analyzing dystocia. CPD is a problem with the Passenger (fetal size/position) and Passage (maternal pelvis). Nursing management involves vigilant monitoring for signs of obstruction, notifying the provider, providing support, and preparing for possible interventions like cesarean section.
Concept Summary
Concept
Description
Key Nursing Implication
Cephalopelvic Disproportion (CPD)
Mechanical obstruction due to mismatch between fetal head size and maternal pelvic dimensions.
Monitor for arrest of descent. Prepare for possible cesarean delivery.
Arrest of Active Phase
No cervical change for ≥4 hours in a multipara (≥6 hours in a nullipara) with adequate contractions.
Requires comprehensive assessment of the 3 P's and provider notification.
Fetal Station
Level of the presenting part relative to the ischial spines (e.g., -3 to +3).
Progressive descent is a key indicator of normal labor progress.
Severe back pain. Prolonged active phase. Cervical edema/anterior lip possible.
Position changes (hands-and-knees), pain management. May require operative delivery.
Anatomy, Physiology & Pharmacology Points
Pelvic Inlet & Outlet: CPD can occur at the inlet (head not engaging) or the outlet (head descends but cannot be delivered). Station remaining high (-2) suggests inlet disproportion.
Fetal Head Molding & Caput: In prolonged labor, the fetal skull bones may overlap (molding) or scalp edema (caput) may form. Excessive molding is a warning sign of CPD.
Oxytocin (Pitocin): Contraindicated in true CPD, as it can lead to uterine rupture. It is only used for dystocia caused by inadequate contractions (powers).
Memory Tips
CPD = Can't Pass Down: Remember the key sign is the baby "Can't Pass Down" the birth canal.
The Station Stays Static: In CPD, the fetal station stays the same (static) no matter how strong the contractions are.
High-Frequency NCLEX Topics
CPD and labor dystocia are core Maternity Nursing topics. The NCLEX-RN loves to test your ability to differentiate between causes of prolonged labor and identify the priority nursing action (e.g., notify the provider vs. encourage ambulation). Knowing the specific signs of mechanical obstruction is crucial.
Watch Out for Question Variations!
Priority Intervention: "The nurse identifies CPD. What is the priority action?" (Answer: Notify the healthcare provider and prepare for possible cesarean section).
Contraindication: "Which order for a client with suspected CPD should the nurse question?" (Answer: An order to increase the oxytocin infusion rate).
Patient Education: "What information should the nurse provide to a client diagnosed with CPD?" (Answer: Explain the reason a cesarean birth may be necessary).
Nursing Clinical Practice GuideClinical Scenario: You are the labor nurse for Maria, a G3P2 at 39 weeks, who has been pushing for over 2 hours. The fetal monitor shows a reassuring pattern, but on vaginal exam, the baby's head is still at +1 station, and there is significant caput and molding. The obstetrician is concerned about possible outlet CPD.
Nursing Intervention Strategy:
Assessment: Continuously monitor FHR and uterine contractions. Document station, caput, and molding with each exam. Assess for signs of maternal exhaustion (vital signs, ability to follow commands) and bladder distention.
Communication & Advocacy: Clearly report your findings to the provider: "Doctor, despite strong maternal pushing for 2 hours, station is unchanged at +1 with significant caput and molding." Advocate for a time limit on the second stage to prevent maternal and fetal complications.
Support & Preparation: Provide emotional support to the laboring person and partner, explaining the situation without causing undue alarm. Physically prepare for a cesarean section: ensure the consent is signed, start a new IV if needed, administer preoperative antibiotics, and prepare for safe transport to the OR.
Evaluation: Evaluate the outcome: safe delivery of the newborn and physical/emotional recovery of the mother post-operatively.
Patient Safety and Precautions:
Avoid Fundal Pressure: Never apply fundal pressure if CPD is suspected, as it increases the risk of uterine rupture or fetal injury.
Monitor for Complications: Watch for signs of obstructed labor complications: Pathological retraction ring (Bandl's ring) (a visible ridge across the abdomen), fetal distress, or maternal tachycardia and fever indicating infection.
Pain Management: Provide effective pain relief options, as labor with CPD can be exceptionally painful and prolonged.
Nursing Procedure & Medication FlowPreparing for Cesarean Section for CPD:
1. Informed Consent: Verify the client understands the reason for surgery (baby won't fit) and the risks/benefits.
2. IV Access: Ensure at least one 18-gauge IV catheter is patent for fluid resuscitation and medication administration.
3. Medications:
- Pre-op Antibiotics (e.g., Cefazolin): Administer within 60 minutes before incision to prevent surgical site infection.
- Antacid (e.g., Sodium Citrate): Given to reduce gastric acidity and risk of aspiration.
- Hold Oxytocin: If an infusion is running, discontinue it as ordered.
4. Documentation: Clearly document the indication for surgery (Arrest of descent/CPD), all assessments, notifications, and preoperative preparations.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In labor and delivery, your skilled hands during a vaginal exam and your sharp eyes on the monitor are the first line of detection for problems like CPD. When you feel that fetal head stuck high, despite good contractions, you're not just collecting data—you're preventing a potential crisis. That critical thinking, connecting the 'static station' to the pathophysiology of CPD, is what makes an excellent nurse. On the NCLEX and in practice, always tie your assessment findings back to the 'why.' Why isn't the baby descending? It will lead you to the right answer and the right action."