# A multigravida client at 41 weeks gestation is admitted to the labor and delivery unit. During the initial assessment, the nurse notes that the client is having contractions every 2-3 minutes lasting 50-70 seconds with moderate to strong intensity. The cervix is 7 cm dilated, 80% effaced, and the fetal head is at 0 station. What is the most important assessment the nurse should prioritize at this time? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542998 > language: ko > subject: Maternal Newborn Health ## 문제 A multigravida client at 41 weeks gestation is admitted to the labor and delivery unit. During the initial assessment, the nurse notes that the client is having contractions every 2-3 minutes lasting 50-70 seconds with moderate to strong intensity. The cervix is 7 cm dilated, 80% effaced, and the fetal head is at 0 station. What is the most important assessment the nurse should prioritize at this time? A 28-year-old primigravida at 40 weeks gestation presents to labor and delivery with regular contractions. Assessment reveals contractions occurring every 3 minutes, lasting 60 seconds with strong intensity. Cervical examination shows 6 cm dilation, 90% effacement, and fetal station at -1. The client appears anxious and states she feels pressure but denies the urge to push. ## 보기 1. Assess the client's pain level using a 0-10 pain scale 2. Check the client's blood pressure and temperature 3. Monitor fetal heart rate and contraction pattern continuously **✔ 정답** 4. Evaluate the client's hydration status and urine output **정답: 3** ## 해설 Continuous fetal monitoring is the priority in active labor to detect fetal distress, as strong frequent contractions can compromise placental blood flow. Other assessments are important but secondary to ensuring fetal well-being. ## 심화 해설 Clinical Scenario Analysis The client is a multigravida at 41 weeks gestation in active labor. The assessment findings—contractions every 2-3 minutes, lasting 50-70 seconds, cervical dilation of 7 cm, 80% effacement, and fetal station 0—indicate that the client is in the active phase of the first stage of labor, progressing toward the transition phase. At this critical juncture, the fetus is undergoing significant physiological stress with each contraction, which intermittently reduces uteroplacental blood flow. The highest priority is continuous assessment of how the fetus is tolerating this stress. Why Continuous Fetal and Contraction Monitoring is the Priority Cardiotocography (CTG) provides simultaneous, real-time data on the fetal heart rate (FHR) and uterine contraction pattern. This is the most direct method to detect early signs of fetal compromise, such as late decelerations, variable decelerations, or reduced variability, which indicate fetal hypoxia and acidosis. The systematic review by Jha et al. confirms that CTG is widely applied for intrapartum fetal surveillance specifically to identify these early signs and guide timely intervention [1]. In a client at 41 weeks gestation, the placenta may be aging, which can reduce its functional reserve and make the fetus more vulnerable to hypoxic stress during strong, frequent contractions. Identifying an abnormal FHR pattern allows the nurse and healthcare team to initiate intrauterine resuscitation measures (e.g., maternal repositioning, oxygen administration, fluid bolus) or prepare for an emergency operative delivery, directly impacting neonatal outcomes. Analysis of Other Options - **Option 1: Assess pain level.** While pain management is an important aspect of nursing care, especially during the intense contractions of active labor, it is a comfort and psychosocial need. Physiologically, the fetus's oxygenation status takes precedence over maternal pain assessment. A non-pharmacological intervention like virtual reality, studied by Abdi et al., can be effective for managing fear and anxiety during examinations, but it does not address the immediate physiological risk of fetal hypoxia during labor . - **Option 2: Check blood pressure and temperature.** Vital sign assessment is a routine component of care. However, in the absence of any indication of infection or hypertensive crisis, this is not the most time-sensitive priority. The immediate, moment-to-moment risk is fetal compromise from the stress of labor, which is detected through continuous monitoring, not intermittent vital signs. - **Option 4: Evaluate hydration and urine output.** Maintaining hydration is important for maternal and fetal well-being, and assessing urine output can indicate hydration status or impending bladder distention, which can obstruct labor progress. However, this is a lower-priority assessment compared to the direct, continuous surveillance of fetal well-being. The question asks for the *most important* assessment to prioritize at this exact moment, which is the one that provides the most critical safety data for the fetus. The core principle here is the nursing process and prioritization. Using the ABC (Airway, Breathing, Circulation) framework adapted for obstetrics, fetal oxygenation is the immediate "circulation" concern. Continuous electronic fetal monitoring is the primary tool to assess this, as it provides the data needed to recognize a non-reassuring fetal status and intervene before permanent injury occurs [1]. References (research sources) - [1]Admission Cardiotocography in Term Pregnancies for Predicting Intrapartum Interventions and Early Neonatal Outcomes: A Systematic Review.Meta-analysis/systematic reviewJha SP, Kumari S, Sinha A, Roy R, Sanjita, Kumari S, Lata. (2026) · DOI: 10.7759/cureus.109070 ## 임상 시나리오 Clinical Practice Guide: Prioritizing Fetal Assessment in Active Labor A multigravida at 41 weeks with contractions every 2-3 minutes and cervical dilation of 7 cm is in active labor. The immediate nursing priority is continuous assessment of fetal tolerance to labor stress. Key Assessment Rationale - Strong, frequent contractions intermittently reduce uteroplacental blood flow, increasing the risk of fetal hypoxia. - Post-term gestation (41 weeks) is associated with potential placental aging and reduced functional reserve. - Continuous cardiotocography (CTG) is the standard for detecting early signs of fetal compromise such as late decelerations, variable decelerations, or reduced variability. Immediate Nursing Actions - **Initiate continuous electronic fetal monitoring** to simultaneously track fetal heart rate and contraction pattern. - **Evaluate the Category of the tracing** (Category I, II, or III) based on baseline rate, variability, accelerations, and decelerations. - **If non-reassuring patterns are observed**, implement intrauterine resuscitation measures: - Reposition the client to a left lateral position to maximize uterine blood flow. - Administer oxygen via non-rebreather mask at 10 L/min if ordered. - Increase IV fluid rate as prescribed to improve maternal circulating volume. - Notify the healthcare provider immediately for persistent Category II or any Category III tracing. - **Document** the tracing interpretation, interventions, and maternal-fetal response at regular intervals per institutional policy. Clinical Pearls - Pain assessment, vital signs, and hydration status are secondary priorities; they can be addressed concurrently but should not delay initiation of continuous fetal monitoring. - In a multigravida, labor may progress rapidly from active phase to delivery; continuous monitoring allows for timely recognition of the transition phase and prevents an unattended birth. - Always correlate cervical examination findings with the fetal monitor tracing to ensure the contraction pattern is adequate for the stage of labor. ## 핵심 개념 - **Cardiotocography (CTG)** — Electronic fetal monitoring that simultaneously records fetal heart rate and uterine contractions to assess fetal well-being during labor. - **Active Phase of Labor** — The phase of the first stage of labor characterized by more rapid cervical dilation, typically from 6 cm to 10 cm, with regular, strong contractions. - **Fetal Station** — The relationship of the presenting fetal part to the maternal ischial spines, measured in centimeters; 0 station indicates the part is at the level of the spines. - **Late Decelerations** — A visually apparent, gradual decrease in fetal heart rate with the nadir occurring after the peak of the contraction, indicating uteroplacental insufficiency. - **Intrauterine Resuscitation** — Interventions such as maternal repositioning, oxygen administration, or IV fluid bolus to improve fetal oxygenation when a non-reassuring heart rate pattern is identified. ## 같은 주제 문제 - [A primigravida client at 38 weeks gestation is admitted to the labor and delivery unit. 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