A primigravida client at 39 weeks gestation is admitted to t… | 마이메르시 MyMerci
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Maternal Newborn Health
문제

A primigravida client at 39 weeks gestation is admitted to the labor and delivery unit. Her cervix is 6 cm dilated, 90% effaced, and the fetal head is at -1 station. She is experiencing strong, regular contractions every 2-3 minutes lasting 60-90 seconds. The client is restless, irritable, and states "I can't do this anymore, I want to go home." What is the priority nursing intervention at this time?

해설
The client shows signs of transition phase (restlessness, irritability, statements of inability to continue). Priority is providing reassurance and education that these feelings are normal, addressing immediate psychological needs and normalizing the experience.
같은 주제 다음 문제A multigravida client at 41 weeks gestation is admitted to the labor and delivery unit. Du…

심화 해설

Understanding the Scenario and the Client's Phase of Labor

The client's assessment findings are classic indicators of the transition phase of the first stage of labor. Her cervix is 6 cm dilated, which, combined with strong contractions occurring every 2-3 minutes and lasting 60-90 seconds, signals the rapid progression from the active phase into transition. This phase is typically the most intense part of labor, characterized by cervical dilation from 8 to 10 centimeters. The psychological markers are equally critical: restlessness, irritability, and expressions of being overwhelmed, such as stating "I can't do this anymore," are hallmark emotional responses to the peak intensity of contractions and the physical demands of this stage.

Prioritizing Nursing Intervention: Psychological Support as a Foundation

The priority nursing intervention is to provide reassurance and explain that these feelings are normal for the transition phase. This approach directly addresses the client's acute psychological distress, which is the most immediate threat to her coping ability. The rationale is rooted in the understanding that a loss of control and heightened anxiety can trigger a cascade of physiological responses, including increased catecholamine release, which can counteract endogenous oxytocin and potentially prolong labor. By normalizing her experience, the nurse validates her feelings and reduces the sense of isolation and panic. This intervention aligns with the core principles of Watson's Human Caring Theory, where creating a supportive, reassuring environment is a fundamental carative factor that directly impacts the client's experience [2]. The nurse's presence and explanation act as a cognitive anchor, helping the client reframe her distress as a manageable, expected, and transient part of the labor process.

Why Other Interventions Are Not the Priority

Administering prescribed pain medication immediately is not the priority because a full assessment of the client's psychological state and coping mechanisms must precede pharmacological intervention. While pain is a significant component, the client's verbal and behavioral cues point more toward a crisis of confidence than a purely sensory pain crisis. Furthermore, at 6 cm dilation, the client is in the active phase, and administering certain analgesics or anesthesia too early could slow labor progression. The immediate need is to enhance her internal coping strategies before considering external agents.

Contacting the healthcare provider to discuss cesarean delivery options is inappropriate. The fetal head is at -1 station, indicating the fetus is still descending and not yet engaged at the ischial spines (0 station). This is a normal finding for a primigravida at 6 cm dilation, and there are no indications of fetal distress or labor dystocia that would necessitate a surgical delivery. Suggesting a cesarean section in response to a normal emotional reaction would be a profound disservice and could undermine the client's long-term birth satisfaction.

While encouraging the client to use breathing techniques and change positions is a valuable non-pharmacological comfort measure, it is secondary to providing reassurance. A client in a state of panic and hopelessness is unlikely to effectively employ learned coping techniques. The foundational step is to first stabilize her emotional state through therapeutic communication and validation. Once she feels heard and understands that her feelings are a normal sign of progress, she will be more receptive to guided breathing and position changes. A nurse-led childbirth preparedness study confirms that enhancing a woman's confidence and self-efficacy is crucial for her to effectively utilize coping strategies during labor .

Integrating Evidence into Practice

The emphasis on psychological reassurance is strongly supported by evidence linking nursing care to improved maternal outcomes. A study on nurse-led childbirth preparedness demonstrated that interventions designed to boost a woman's childbirth self-efficacy—her confidence in her ability to cope with labor—can significantly reduce anxiety and improve the overall birth experience . When a client expresses a desire to give up, her self-efficacy has plummeted. The nurse's immediate role is to restore that confidence by reframing the experience. Similarly, a randomized controlled trial on the application of Watson's Human Caring Theory found that a nursing care program focused on humanistic, caring interactions during birth had a positive effect on mothers' fear of childbirth and their overall birth experience [2]. The intervention of providing reassurance and normalizing the client's feelings is a direct, practical application of this caring science, making it the most impactful and immediate action the nurse can take to support a positive physiological and psychological labor trajectory.
References (research sources)
  • [2]
    Effects of Watson's Human Caring Theory-based nursing care on fear of childbirth and birth experience: a randomized controlled trial.RCT/clinical trialEmir C, Ozturk C. (2026) · DOI: 10.1186/s12912-026-04571-6

임상 시나리오

A primigravida at 39 weeks presents with 6 cm dilation, 90% effacement, and fetal head at -1 station. Contractions are strong, every 2-3 minutes, lasting 60-90 seconds. She is restless, irritable, and states, "I can't do this anymore." The nurse recognizes these as classic signs of the transition phase of the first stage of labor. The priority is to provide psychological support by reassuring the client that her feelings are normal and expected during this intense phase. This intervention directly reduces anxiety, prevents a stress-induced catecholamine surge that could inhibit oxytocin and prolong labor, and helps the client regain a sense of control. Administering pain medication or contacting the provider for cesarean delivery are not first-line responses to this expected emotional response. Encouraging breathing and position changes is a secondary supportive measure after addressing the immediate psychological distress.

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