A primigravida at 40 weeks gestation has been in active labor for 14 hours. She reports severe back pain with each contraction. Her cervix is 7 cm dilated and has remained unchanged for the past 3 hours despite adequate uterine contractions occurring every 3-4 minutes lasting 50-70 seconds. The fetal head is at 0 station, and the membranes are intact. The fetal heart rate is 130-140 bpm with moderate variability. What is the nurse's priority assessment?
1Assess for signs of maternal exhaustion and dehydration
2Evaluate the adequacy of uterine contractions using an intrauterine pressure catheter
3Monitor fetal heart rate patterns for signs of fetal distress
4Assess fetal position and presentation through Leopold's maneuvers and vaginal examination✓ 정답
해설
With arrest of dilation and severe back pain, fetal malposition (e.g., occiput posterior) is a likely cause of dystocia. The priority is to assess fetal position via Leopold's maneuvers and vaginal exam to guide interventions. Other assessments (maternal exhaustion, contraction adequacy, FHR) are important but secondary to identifying the underlying cause.
Clinical Judgment
This question assesses the nurse's priority in a dystocia situation called Secondary Arrest of Dilation. The key clues are "no progress from 6 cm for 4 hours despite adequate uterine contractions (every 2-3 minutes, lasting 60-90 seconds)" and "severe back pain". This strongly suggests a fetal malposition, specifically an Occiput Posterior Position. Malposition is the most common mechanical cause of arrested labor, and without checking it first, other interventions (fatigue management, contraction assessment) may be ineffective. Therefore, the highest priority assessment is to determine the exact fetal position and attitude.
Memory TipBefore Anything Look at Position! (BALP)
When labor progress stops, before doing anything else (fatigue, contractions, fetal status), check the fetal Position first.
KR vs US
In Korea, when labor progress is delayed, it is common to report to the physician and then confirm fetal position via ultrasound. In the US NGN/CJMM, the emphasis is on the nurse independently assessing fetal position using Leopold's Maneuvers and a vaginal examination, and then, based on those findings, first attempting independent interventions such as position changes (hands-and-knees position). In other words, the core is the nurse's independent Clinical Judgment process of assessment-judgment-action.
임상 시나리오
Clinical Practice Guide
When secondary arrest of labor occurs (no progress for ≥4 hours at ≥6 cm dilation), the nurse systematically assesses the following:
1. Fetal position/presentation: Check for occiput posterior (OP) position, etc., using Leopold's maneuvers and vaginal examination.
2. Coping and fatigue: Evaluate the mother's energy level, anxiety, and pain control status.
3. Contraction quality: Assess effectiveness (ability to cause descent) in addition to frequency/duration. Consider IUPC if needed.
4. Fetal well-being: Monitor for signs of oxygen insufficiency through continuous FHR monitoring.
Caution
In SATA (Select All That Apply) questions asking for "Priority" or "First," choose the action that rules out risk or identifies the most likely cause. In this case, while all options are important, the assessment to find the root cause of dystocia (checking fetal position) should precede other supportive assessments (evaluating fatigue).
핵심 개념
Secondary Arrest of Dilation (이차성 분만 정지) — After entering the active phase (6 cm or more), this is a condition where cervical dilation does not progress for more than 4 hours despite adequate uterine contractions. It is a type of labor dystocia.
Occiput Posterior Position (후두후방위) — Fetal position where the back of the baby's head (occiput) faces toward the mother's sacrum. The incomplete flexion of the fetal head causes severe back pain for the mother and is a common cause of delayed labor progression.
Leopold's Maneuvers (레오폴드 수기법) — A four-step palpation method through the abdominal wall to assess fetal position, attitude, and descent of the presenting part. It is a noninvasive standard method for evaluating fetal status during labor.
Dystocia (분만 난산) — A condition where normal labor progression is delayed or halted. It occurs due to an imbalance among the birth canal (Passage), the fetus (Passenger), and uterine contractions (Powers), remembered as the 3Ps.
Station (-1) — The height of the fetal presenting part (usually the head) is indicated relative to the ischial spines (0 station). -1 means the presenting part is located 1 cm above the ischial spines, indicating that it is not yet fixed.