University:
Rasmussen University
Course:
NUR 2633| Maternal Child Health Nursing
Academic year:

2020
Views:

483

Pages:

1
Author:

Hallie Randolph

NURSING CARE PLAN Risk for fetal injury related to prolonged labour. ASSESSMENT Mother states she is tired and does not know how much longer she is able to push. Labor prolonged to over 24 hours; mother getting tired and as such is pushing ineffectively. Fetus has not descended into birth canal. EXPECTED OUTCOMES INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION Maternal patient will participate in interventions to improve labour so that the baby is delivered within 12 hours. 1-Assess FHR electronically. Note variability, periodic changes, and baseline rate. 1-Detects abnormal responses which may indicate hypoxia or distress. Fetal patient will display a fetal heart rate within normal limits, with no late decelerations, and will show no distress for the duration of labour. 2-Monitor fetal descent in birth canal in relation to ischial spines. Maternal patient participated in the interventions to improve labour and the baby as successfully delivered 6 hours after mother was fully dilated and effaced. Fetal patiant maintained a normal range of heart rate and showed no decelerations or distress throughout the labour process. 3-Assess for malposition using Leopold’s maneuvers and findings on internal examination 4-Note odour and colour of amniotic fluid once 2- Lack of descent in the birth canal may indicate malposition. 3-In order to determine potential dysfunctional labour, it is necessary to determine the fetus’s lie and position within the birth canal. 4-This can rule out