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Question
Chapter 16 Case Study Erin is an 18-year-old primigravida who calls the intrapartum unit because she thinks she may be in labor.
1. What information should the nurse obtain to help determine whether Erin is in true labor? The nurse decides that Erin may be in true labor and tells her to come to the birth center. On arrival, Erin says she thinks her "water broke."
2. What is the priority nursing care at this time?
3. What tests might the nurse use to verify that Erin's membranes have indeed ruptured? The nurse determines that Erin's contractions are every 5 minutes, of moderate intensity, and last 40 seconds. The fetal heart rate is 135 to 145 beats per minute (bpm), and it accelerates when the fetus moves. Amniotic fluid is light green with small white flecks in it. The vaginal examination reveals that the cervix is dilated 5 cm and is completely effaced. The fetal presenting part is hard and round, and a small triangular depression on the head can be felt in Erin's right posterior pelvis.
4. What stage (and phase, if applicable) of labor is Erin in?
5. How should the fetal heart rate be interpreted?
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