A nurse is assessing a multigravida client at 39 weeks gesta… | 마이메르시 MyMerci
Maternal Newborn Health
문제

A nurse is assessing a multigravida client at 39 weeks gestation who has been in active labor for 12 hours. The nurse notes that cervical dilation has remained at 6 cm for the past 4 hours despite adequate uterine contractions occurring every 2-3 minutes lasting 60-90 seconds. Which assessment finding would be the priority concern indicating potential dystocia?

해설
Lack of cervical dilation progress despite adequate contractions is the classic sign of dystocia, indicating arrest of dilation. This requires immediate intervention to prevent maternal and fetal complications. Other findings (mild fever, normal FHR, stable BP) are less urgent concerns in this context.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to recognize the primary diagnostic sign of dystocia (abnormal or difficult labor) in the active phase. The core concept is arrest of dilation. According to standard obstetric definitions, an arrest of dilation is diagnosed when there is no cervical change for 2 hours or more in the active phase (typically defined as ≥6 cm dilation) despite adequate uterine contractions. The scenario presents a classic picture: a multigravida at 39 weeks, in active labor for 12 hours, with cervical dilation stalled at 6 cm for 4 hours despite contractions that are adequate in frequency (every 2-3 min) and duration (60-90 sec). This lack of progress is the problem itself. Answer Rationale: Key Point! The lack of cervical dilation progress over 4 hours with adequate contractions is not just a concerning finding; it is the definition of the problem—arrest of dilation, a type of dystocia. This is the priority concern because it signals that labor is not progressing normally, which can lead to maternal exhaustion, increased risk of infection, and potential fetal compromise if not addressed. Immediate nursing and medical interventions (e.g., evaluation for cephalopelvic disproportion (CPD), possible amniotomy, or augmentation with oxytocin (Pitocin)) are required based on this finding. Distractor Analysis: Watch out for confusion! Option ②, a maternal temperature of 99.2°F (37.3°C), indicates a very mild elevation. While a rising temperature can be a sign of intra-amniotic infection (chorioamnionitis), especially with prolonged rupture of membranes, it is not the primary indicator of dystocia in this scenario. The dystocia itself is the cause for concern that could lead to infection. Option ③, a fetal heart rate (FHR) baseline of 135 bpm with moderate variability, is a reassuring pattern. It indicates adequate fetal oxygenation and well-being at this moment. Although dystocia can eventually lead to non-reassuring FHR patterns, the normal FHR here does not negate the diagnosis of arrested labor. Option ④, a maternal blood pressure of 128/82 mmHg, is within normal limits. Blood pressure can fluctuate during labor but this reading is not indicative of an urgent problem like preeclampsia or hypotension. Related Concepts: Dystocia can be caused by problems with the powers (uterine contractions), passenger (fetus - size, position), passage (maternal pelvis), or psyche (maternal emotions). This scenario describes adequate "powers," so the nurse must next consider issues with the passenger (e.g., occiput posterior position, macrosomia) or passage.
Concept Summary
ConceptDefinitionClinical Significance
DystociaAbnormal or difficult labor/prolonged labor.Requires identification of cause and intervention to prevent maternal/fetal complications.
Arrest of DilationNo cervical change for ≥2 hours in the active phase (≥6 cm) despite adequate contractions.The key diagnostic finding in this question. Signals need for reassessment and possible intervention.
Adequate ContractionsFrequency q2-3 min, duration 60-90 sec, firm on palpation.Rules out "hypotonic" uterine dysfunction as the cause. Points to other causes of dystocia.
Prolonged LaborExceeds 20 hours for nulliparas or 14 hours for multiparas.Increases risks of infection, exhaustion, and operative delivery.

Side-by-Side Comparison!
Type of Labor DysfunctionKey FeatureTypical CauseNursing Action
Prolonged Latent PhaseLatent phase >20h (nullipara) or >14h (multipara).Often related to excessive sedation, poor timing, or false labor.Rest, hydration, evaluate if true labor.
Protraction Disorders (Slowed Progress)Rate of dilation

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the labor nurse for Maria, a G3P2 at 39 weeks, admitted in active labor. Her cervix was 6 cm dilated 4 hours ago. Upon reassessment, it remains at 6 cm. Her contractions are strong, every 2-3 minutes, lasting 70 seconds. She is becoming increasingly fatigued and anxious, asking, "Why is this taking so long?" Nursing Intervention Strategy: 1. Assessment: Confirm cervical status with a sterile vaginal exam. Continuously monitor uterine contraction pattern via tocodynamometer and fetal heart rate (FHR) via electronic fetal monitoring (EFM). Assess maternal vital signs, pain level, and coping. Evaluate for signs of CPD: assess fetal position (via Leopold's maneuvers), station, and caput/molding. 2. Action: Key Point! Immediately notify the physician or midwife of the arrest of dilation. This is a collaborative problem requiring medical diagnosis and decision-making. 3. Supportive Care: * Positioning: Assist the patient into positions that may aid fetal rotation and descent, such as hands-and-knees, lateral Sims, or squatting, to address a possible passenger (malposition) issue. * Hydration & Energy: Encourage clear fluids or provide IV fluids to prevent dehydration. Offer ice chips or clear liquids if permitted. * Emotional Support: Acknowledge her fatigue and anxiety. Explain the situation simply: "Your contractions are strong, which is good, but your cervix hasn't opened further in the expected time. The doctor/midwife will help us decide the next steps." 4. Prepare for Interventions: Based on provider orders, you may need to: * Assist with amniotomy (artificial rupture of membranes) if intact. * Initiate oxytocin augmentation per protocol, with vigilant monitoring for hyperstimulation and fetal distress. * Prepare for possible operative vaginal delivery (vacuum/forceps) or cesarean section. Patient Safety and Precautions: * Oxytocin Administration: Use an infusion pump. Start at a low dose and titrate slowly per protocol. Continuously monitor contraction frequency, duration, and resting tone, as well as FHR. Discontinue oxytocin and notify provider for signs of hyperstimulation (contractions >90 sec, frequency 100.4°F (38°C). * Maternal Exhaustion: Monitor for signs of ketosis (fruity breath, nausea). Provide encouragement and pain management options.
Nursing Procedure & Medication Flow Procedure: Assisting with Evaluation of Arrested Labor 1. Gather supplies: Sterile gloves, lubricant, fetal Doppler/ultrasound gel. 2. Explain the procedure to the client. 3. Perform Leopold's maneuvers to assess fetal position and presentation. 4. Perform a sterile vaginal exam to confirm cervical status, station, position, and presence of caput or molding. 5. Review EFM strip: Confirm adequate contraction pattern (q2-3 min, lasting 60-90 sec, firm palpation) and reassuring FHR (baseline 110-160, moderate variability, no recurrent decels). 6. Document findings objectively: "Cervix 6 cm, 100% effaced, 0 station, vertex, ROP position. No change in 4 hours. Contractions q2-3 min, duration 70 sec, strong by palpation. FHR 140s with moderate variability." 7. Report findings to provider. Medication: Oxytocin (Pitocin) for Augmentation * Action: Stimulates uterine contractions. * Indication: Hypotonic uterine dysfunction. Use in arrest disorders requires careful evaluation first. * Nursing Responsibility: * Use a pump for precise control (e.g., start at 0.5-1 mU/min). * Increase by 1-2 mU/min every 30-60 minutes until adequate labor pattern is established. * Monitor: Contractions (should not exceed q2 min or >90 sec duration), resting tone (should be soft between contractions), and FHR continuously. * Stop infusion and notify provider for tachysystole, hypertonus, or non-reassuring FHR.
A Word from Your Senior Nurse "Labor is a marathon, not a sprint, but sometimes the runner hits a wall. Your job as the nurse is to be the first to see that wall—the arrest of progress. It's more than just a number on a chart; it's a signal that mom and baby might need a different game plan. Never dismiss a 'stalled' labor. Your vigilant assessment and prompt communication are what trigger the team huddle that can lead to a safe amniotomy, a careful augmentation, or a timely decision for a C-section. In the delivery room, you are the eyes, ears, and advocate. Understanding the 'why' behind dystocia turns a textbook definition into a life-saving skill."

핵심 개념

  • Dystocia — Abnormal or difficult labor/prolonged labor, often categorized by issues with powers, passenger, passage, or psyche.
  • Arrest of Dilation — No change in cervical dilation for 2 hours or more during the active phase of labor (typically ≥6 cm) despite adequate uterine contractions.
  • Cephalopelvic Disproportion — A condition where the fetal head is too large or the maternal pelvis is too small to allow for vaginal delivery; a potential cause of arrest disorders.
  • Oxytocin — A hormone and medication used to induce or augment labor by stimulating uterine contractions. Requires careful titration and monitoring.
  • Electronic Fetal Monitoring — The use of equipment to continuously record the fetal heart rate and uterine contractions, essential for assessing fetal well-being during labor, especially in complicated cases.

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