Case Study: Mrs. Evelyn Reed
Client: Mrs. Evelyn Reed, 28-year-old G1P0, at 39 weeks gestation.
Presenting Complaint: Contractions every 3-4 minutes, lasting 60 seconds. States, "I cannot
handle this pain, and I feel the need to push."
Physical Exam: Blood Pressure (BP) 130/80 Heart Rate (HR) 95. Fetal heart rate (FHR) is 140
bpm, reassuring, with moderate variability.
Assessment: Cervical exam reveals 9 cm dilation, 100% effacement, and +1 station.
Question 1 (First Stage: Transition)
Based on the assessment, which phase of labor is the client currently in, and what is the
priority nursing action?Provide rationale for your answer.
The patient is in the transition phase of the first stage of labor as evidenced by verbalization of
difficulty coping with pain, contractions every 3-4 minutes, lasting ~60 seconds, the strong
sensation to push, and cervical dilation of 9 cm, 100% cervical effacement, and descent of the
presenting part of the fetus to +1 station; this stage is often described as the most intense phase,
marked by rapid cervical dilation and increased maternal discomfort, as described by Perry et al.
(2023).
The priority nursing action is to provide continuous support of Mrs. Reed during labor by staying
with her, coaching her through breathing techniques, providing reassurance and a calm
environment, and discourage pushing until full dilation is confirmed (Perry et al., 2023), Pushing
before complete dilation increases the risk of cervical edema or laceration, and can delay descent
and prolong labor; maintaining maternal focus on preventing premature pushing is a key
responsibility during the transition phase (Perry et al., 2023).
Question 2 (Second Stage: Delivery)
Thirty minutes later, the client is fully dilated (10 cm) and begins to push. The FHR shows
a late deceleration. Which action should the nurse take first? Provide rationales for your
answer.
The first nursing action should be the least invasive and fastest to perform, which is repositioning
the client to the left lateral/side-lying position; late decelerations indicate uteroplacental
insufficiency, compromising fetal oxygenation, and repositioning to this position improves
uterine blood flow, reduces compression of the maternal blood vessels, and can rapidly improve
fetal oxygenation (Perry et al., 2023).
Question 3 (Third Stage: Placenta)
The fetus is delivered successfully. The nurse is now focused on the third stage of labor.
Which finding would alert the nurse that the placenta is separating?What is the nurses
priority action when this occurs?
