A primigravida client at 38 weeks gestation is admitted to t… | 마이메르시 MyMerci
Maternal Newborn Health
문제

A primigravida client at 38 weeks gestation is admitted to the labor and delivery unit. The nurse assesses that the client is in the active phase of the first stage of labor with cervical dilation of 7 cm, 90% effacement, and contractions occurring every 4 minutes lasting 50 seconds. The fetal heart rate shows a baseline of 130 bpm with moderate variability. Which nursing intervention should the nurse prioritize at this time?

The client reports increasing discomfort and asks for pain relief options. Her membranes are intact, and she is requesting to ambulate. The nurse notes the client is becoming increasingly anxious about the labor process.
해설
Ambulation and comfort measures are prioritized in active labor to enhance progress and reduce discomfort safely. Other options like bed rest or membrane rupture are not indicated without specific risks.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to prioritize safe, evidence-based nursing interventions during the Active phase of the first stage of labor. The core principle is promoting normal, physiologic labor while ensuring maternal and fetal safety. The client is at 7 cm dilation, which is active labor, with intact membranes, a reassuring fetal heart rate (FHR), and a desire to ambulate. The priority is to support the client's coping mechanisms and labor progress through non-pharmacological comfort measures and mobility, as long as it is safe to do so.

Answer Rationale: Key Point! Option ④ is correct because it integrates multiple best practices. Ambulation in early active labor with intact membranes can help utilize gravity to promote fetal descent, may improve contraction effectiveness, and provides a sense of control, which can reduce anxiety. Providing comfort measures (e.g., position changes, back pressure, breathing techniques) is a first-line intervention for pain and anxiety. Continuously monitoring maternal and fetal status ensures safety is maintained, aligning with the nursing process of assessment and intervention.

Distractor Analysis: Watch out for confusion! Option ① is incorrect. Placing a laboring client in a supine position is contraindicated as it can cause supine hypotensive syndrome (aortocaval compression), reducing placental blood flow. Continuous electronic fetal monitoring (EFM) is not routinely required for a low-risk client with a reassuring FHR; intermittent monitoring is appropriate to allow for mobility.
Option ② is incorrect. Administering narcotic analgesics at 7 cm dilation in a primigravida is often too late in the active phase. These medications can cross the placenta and may cause neonatal respiratory depression if delivery is imminent. Non-pharmacological methods should be maximized first, and if pharmacological relief is needed, regional anesthesia (e.g., epidural) is typically more appropriate at this stage.
Option ③ is incorrect. Artificial rupture of membranes (AROM) is an intervention that should not be performed without a specific medical indication (e.g., to place an internal monitor or augment a prolonged labor). It commits the client to a delivery timeframe (increased risk of infection after 24 hours) and can increase contraction intensity suddenly, potentially causing fetal distress. It is not a first-line comfort measure.

Related Concepts: This scenario highlights the principles of family-centered maternity care and promoting a positive birth experience. The nurse's role is to be a coach and advocate, facilitating the client's own coping strategies while vigilantly assessing for any deviations from normal labor progress or fetal well-being.
Concept Summary
ConceptKey Takeaway
Stages of LaborFirst Stage (Latent, Active, Transition); Second Stage (Pushing/Birth); Third Stage (Placenta). Client is in Active Phase (4-7 cm).
Fetal Heart Rate (FHR) MonitoringBaseline 110-160 bpm with moderate variability is reassuring. Allows for intermittent monitoring in low-risk labor.
Non-Pharmacological Pain ReliefFirst-line: Ambulation, position changes, hydrotherapy, massage, breathing techniques, focal points.
Pharmacological Pain ReliefNarcotics (e.g., fentanyl) often used in early labor. Epidural common in active labor. Timing is critical for safety.
Nursing Priority in Normal LaborSupport physiologic process, ensure safety (maternal/fetal), provide comfort, reduce anxiety, empower the client.

Side-by-Side Comparison!
InterventionWhen It's Appropriate / IndicatedWhen It's Contraindicated / Not Priority
Encouraging AmbulationLow-risk labor, intact membranes, reassuring FHR, client desires to move. Promotes labor progress and comfort.Membranes ruptured with non-engaged presenting part (cord prolapse risk), maternal hypotension, non-reassuring FHR requiring continuous monitoring.
Administering Systemic NarcoticsEarly latent phase (e.g.,

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse assigned to Maya, a 24-year-old primigravida at 38 weeks. She is in active labor, dilated to 7 cm. She is tearful, clutching the bed rails with each contraction, and says, "I can't do this anymore. I need to walk, but I'm scared something will happen to the baby." Her partner looks equally anxious.

Nursing Intervention Strategy: 1. Assessment & Reassurance: First, validate her feelings: "It's normal to feel overwhelmed. You're doing great, and your baby's heart rate looks perfect." Show her the monitor strip with the reassuring FHR pattern. This builds trust and reduces anxiety. 2. Facilitating Ambulation: Help her sit up slowly at the edge of the bed. Ensure her IV line (if present) is long enough and secure. Have her partner or you support her as she stands. Encourage slow walking in the room or hallway. Ambulation often helps contractions feel more productive and less painful. 3. Providing Comfort Measures: While walking or in between, apply firm counter-pressure to her lower back during contractions. Offer a birth ball to sit and rock on. Use a cool cloth on her forehead. Encourage slow, deep "cleansing" breaths. 4. Continuous Monitoring: Use a handheld Doppler or telemetry unit to listen to the FHR every 15-30 minutes during active labor, as per protocol, and after any position change. Continuously assess contraction pattern, maternal vital signs, and coping. 5. Collaboration & Education: Discuss pain relief options factually. "Walking is helping a lot right now. If you feel you need more help, we can talk about an epidural. Let's see how you feel in 30 minutes." This empowers her in the decision-making process.

Patient Safety and Precautions: • Contraindication to Ambulation: If membranes rupture and the presenting part is not engaged, keep the client on bedrest and assess for cord prolapse (sudden FHR deceleration, palpable cord in vagina)—an obstetric emergency. • Medication Caution: If narcotics are administered, monitor maternal respiratory rate and sedation level closely. Have naloxone (Narcan) and neonatal resuscitation equipment available. • Key Monitoring Points: Any change in FHR pattern (loss of variability, decelerations), maternal fever (sign of infection post-rupture), or lack of labor progress over 1-2 hours in active phase.
Nursing Procedure & Medication Flow Procedure: Assisting with Ambulation in Labor 1. Perform safety assessment: Verify provider order for "ambulate as tolerated," confirm reassuring FHR, intact membranes or engaged presenting part if ruptured. 2. Prepare equipment: Secure IV pump on a pole, ensure non-slip footwear for client. 3. Assist client to sitting position at bedside, "dangle" legs for 1-2 minutes to assess for dizziness. 4. With assistance, help client stand. Have one person in front and one behind for initial support if needed. 5. Encourage slow walking. Remain at client's side. Time ambulation for between contractions. 6. Return to bed or chair if client fatigues, FHR requires monitoring, or contractions intensify significantly. 7. Re-assess FHR and maternal vital signs after position change. Medication: Opioid Analgesics (e.g., Morphine Sulfate IV) • Indication: Moderate to severe pain in early labor (

핵심 개념

  • Active Phase of Labor — The part of the first stage of labor from approximately 4-7 cm cervical dilation. Contractions become stronger, longer, and closer together. This is when labor progress typically accelerates.
  • Effacement — The thinning and shortening of the cervix, expressed as a percentage (0% = thick, 100% = completely thin). Effacement often occurs before significant dilation in primigravidas.
  • Fetal Heart Rate Variability — The irregular fluctuations in the baseline FHR. Moderate variability is a key indicator of adequate fetal oxygenation and a healthy autonomic nervous system, and is considered reassuring.
  • Non-Pharmacological Pain Management — First-line interventions for labor pain that do not involve medication. Includes ambulation, position changes, hydrotherapy, massage, breathing techniques, and therapeutic touch.
  • Supine Hypotensive Syndrome — A condition in pregnant women where the gravid uterus compresses the inferior vena cava when supine, reducing venous return, cardiac output, and blood pressure, leading to maternal dizziness and fetal hypoxia.

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