# A primigravida client at 40 weeks gestation is admitted to the labor and delivery unit. During the initial assessment, the nurse notes that the client is experiencing regular contractions every 3-4 minutes lasting 60-70 seconds, with moderate to strong intensity. The cervix is 6 cm dilated, 90% effaced, and the fetal head is at -1 station. What is the most important nursing assessment priority for this client at this time?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543000  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A primigravida client at 40 weeks gestation is admitted to the labor and delivery unit. During the initial assessment, the nurse notes that the client is experiencing regular contractions every 3-4 minutes lasting 60-70 seconds, with moderate to strong intensity. The cervix is 6 cm dilated, 90% effaced, and the fetal head is at -1 station. What is the most important nursing assessment priority for this client at this time?

## 보기

1. Continuous fetal heart rate monitoring to assess fetal well-being **✔ 정답**
2. Maternal vital signs including blood pressure, pulse, and temperature every 15 minutes
3. Cervical dilation and effacement assessment every 2 hours to monitor labor progression
4. Pain assessment using a standardized pain scale to determine need for analgesic intervention

**정답: 1**

## 해설

Continuous fetal heart rate monitoring is the priority in active labor to detect early signs of fetal compromise. Other assessments like vital signs or pain management are important but secondary to fetal safety.

## 심화 해설

Clinical Context and Initial Analysis

The client is a primigravida at term (40 weeks) in active labor, as evidenced by regular contractions every 3-4 minutes, cervical dilation of 6 cm, and 90% effacement. The fetal head is at -1 station, indicating that descent is still in progress. In this dynamic phase of the first stage of labor, the highest priority is to monitor how the fetus is tolerating the stress of strong, frequent contractions, which temporarily reduce uteroplacental perfusion.

Rationale for the Priority: Continuous Fetal Monitoring

The most important nursing assessment priority is continuous fetal heart rate (FHR) monitoring. The primary goal of intrapartum fetal surveillance is the early detection of non-reassuring fetal heart rate patterns, which are critical indicators of potential fetal hypoxia and acidemia [1]. A study on the prevalence of these patterns highlights that they are a leading cause of preventable neonatal mortality and that early identification is essential for timely intervention to avert adverse outcomes [1]. During active labor with moderate to strong contractions occurring every 3-4 minutes, the fetus experiences repetitive, transient interruptions in oxygen supply. Continuous electronic fetal monitoring allows the nurse to assess the FHR baseline, variability, accelerations, and decelerations in real-time, providing a direct window into fetal oxygenation status and autonomic nervous system integrity.

Analysis of Other Options

While the other assessments are important components of intrapartum care, they do not take precedence over direct fetal surveillance at this specific moment.

-   Maternal vital signs (Option 2): Monitoring maternal blood pressure, pulse, and temperature is a standard of care, but in a low-risk labor without signs of infection or hypertensive emergency, the frequency of every 15 minutes is not the immediate priority over the continuous, beat-to-beat assessment of the fetus. The fetus provides the most vulnerable and rapidly changing physiological data.

-   Cervical assessment every 2 hours (Option 3): Evaluating labor progression through serial cervical exams is necessary to diagnose labor dystocia. However, the decision to augment labor, a cornerstone of intrapartum care used to expedite delivery, depends on the stage of labor and carries risks . Before any consideration of augmentation, it is paramount to first ensure fetal well-being. Augmentation increases contraction strength and frequency, which can further compromise a fetus that is already exhibiting non-reassuring patterns. Therefore, FHR assessment logically precedes and guides decisions about labor progression interventions.

-   Pain assessment (Option 4): Assessing pain to determine the need for analgesia is a key nursing responsibility. Non-pharmacological interventions, such as labor dance, have been studied for their effects on labor duration and maternal anxiety . However, pain management, while important for maternal satisfaction and experience , is secondary to the physiological safety of the fetus. A fetus in distress must be identified and managed before or concurrently with addressing maternal comfort, as some analgesic interventions can also affect the fetal heart rate pattern.

The nurse’s immediate clinical judgment must prioritize the detection of fetal compromise. The information from continuous FHR monitoring forms the basis for all subsequent decisions, including the safety of continuing labor, the need for intrauterine resuscitation, or the decision to proceed with augmentation or operative delivery.References (research sources)

- [1]Prevalence of non-reassuring fetal heart rate patterns and associated factors among labouring mothers at public hospitals in Wolaita Zone, Southern Ethiopia, 2024: A cross-sectional study.Research articleFiseha F, Assefa G, Tekalign T, Nima L, Kidane H, Alemu BM, Dadi HH, Ali YY, Tessema YN, Gebeyehu NA, Assfaw BB. (2026) · DOI: 10.1136/bmjopen-2025-109077

## 임상 시나리오

Clinical Practice Guide: Intrapartum Fetal Surveillance in Active Labor

**Scenario:** A primigravida at 40 weeks presents with contractions every 3-4 minutes, cervix 6 cm dilated, 90% effaced, and fetal head at -1 station. The priority is continuous assessment of fetal tolerance to labor.

1. Fetal Heart Rate Monitoring Standards

- **Method:** Continuous electronic fetal monitoring is indicated for active labor to detect non-reassuring patterns early.

- **Assessment Components:** Evaluate baseline rate (110-160 bpm), moderate variability, presence of accelerations, and absence of recurrent decelerations.

- **Documentation:** Review and document the tracing at least every 15-30 minutes during active labor per institutional policy.

2. Interpreting Non-reassuring Patterns

- **Late Decelerations:** Symmetric decrease in FHR beginning after the contraction peak, suggesting uteroplacental insufficiency.

- **Variable Decelerations:** Abrupt decreases in FHR, often due to cord compression; assess depth and duration.

- **Minimal or Absent Variability:** A critical sign of possible fetal acidemia requiring immediate intervention.

3. Nursing Interventions for Category II/III Tracings

- Initiate intrauterine resuscitation: maternal repositioning (left lateral), IV fluid bolus, and oxygen administration per protocol.

- Notify the provider immediately if patterns do not resolve or if recurrent late decelerations or bradycardia occur.

- Prepare for possible expedited delivery if fetal compromise is suspected.

4. Coordinated Assessments

- **Maternal Vital Signs:** Assess blood pressure and pulse every 30-60 minutes during active labor, or more frequently if abnormalities arise.

- **Cervical Progress:** Perform vaginal examinations as clinically indicated to track dilation and descent, not on a rigid schedule.

- **Pain Management:** Address pain using a standardized scale after confirming fetal well-being; analgesic options depend on maternal and fetal status.

## 핵심 개념

- **Active Labor** — The phase of the first stage of labor characterized by cervical dilation from 6 to 10 cm, regular contractions, and more rapid descent of the presenting part.
- **Station** — The relationship of the fetal presenting part to the maternal ischial spines, measured in centimeters; -1 indicates the head is 1 cm above the spines.
- **Non-reassuring Fetal Heart Rate Patterns** — Abnormal FHR tracings such as late decelerations, severe variable decelerations, or absent variability that suggest fetal hypoxia or acidemia.
- **Uteroplacental Perfusion** — The flow of maternal blood through the uterine arteries to the placenta, which is temporarily reduced during uterine contractions.

## 같은 주제 문제

- [A multigravida client at 41 weeks gestation is admitted to the labor and delivery unit. Du…](https://mymerci.kr/pages/nclex_q.php?qn_id=542998)
- [A primigravida client at 38 weeks gestation is admitted to the labor and delivery unit. Du…](https://mymerci.kr/pages/nclex_q.php?qn_id=542999)
- [A multigravida client at 40 weeks gestation is admitted to the labor and delivery unit. Du…](https://mymerci.kr/pages/nclex_q.php?qn_id=543001)
- [A primigravida client at 38 weeks gestation is admitted to the labor and delivery unit. Th…](https://mymerci.kr/pages/nclex_q.php?qn_id=543002)
- [A primigravida client at 39 weeks gestation is admitted to the labor and delivery unit. He…](https://mymerci.kr/pages/nclex_q.php?qn_id=543003)
- [A 32-year-old primigravida client at 38 weeks gestation is admitted to the labor and deliv…](https://mymerci.kr/pages/nclex_q.php?qn_id=543004)
- [A primigravida at 41 weeks gestation is admitted to the labor unit with strong, regular co…](https://mymerci.kr/pages/nclex_q.php?qn_id=543005)
- [A primigravida at 39 weeks gestation is in active labor. Her cervix is 6 cm dilated, 80% e…](https://mymerci.kr/pages/nclex_q.php?qn_id=543006)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._