Labor
SKINNY Reasoning
Anne Jones, 17 years old
NCLEX Client Need Categories Percentage of Items from Each
Category/Subcategory Covered in
Case Study
Safe and Effective Care Environment
• Management of Care 17-23%
• Safety and Infection Control 9-15%
Health Pr...
Primary Concept Pain
Interrelated Concepts (In order of emphasis)
Reproduction
Stress
Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
• Management of Care 17-23% ✓
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
• Basic Care and Comfort 6-12% ✓
• Pharmacological and Parenteral Therapies 12-18% ✓
• Reduction of Risk Potential 9-15% ✓
• Physiological Adaptation 11-17% ✓
, Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Anne is a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for
observation at 1200. She began having contractions three hours ago at 8 to 10-minute intervals with each
contraction lasting 30 seconds. She states her pain is 3/10. Her membranes are intact. On admission, a
vaginal exam indicates cervical dilation is 1 cm, 80% effacement, and 0 station.
After two hours of observation, her cervix is 2-3 cm/ 80% effacement/0 station and contractions are now 4-
5 minutes apart, lasting 60-70 seconds and pain remains 3/10. Fetal lie is longitudinal with a cephalic
presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS)
positive and received antibiotics at 36 weeks. Her blood type is B-.
Personal/Social History:
Anne’s mother is with her. Anne is not married and the father of the baby is not involved. She appears to be
relaxed although she states she is a bit nervous. She wants a natural non-medicated birth and her mother will
help coach her. She plans on breastfeeding for “awhile”. She attended childbirth preparation classes with her
mother.
(Reduction of Risk Potential) This study resource
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem:Clinical Significance:
was
Blood type: B- Mother will need RhoGam shot in case the baby is Rh positive.
Group Beta Strep positive – ABX @36 weeks ABX IV will be started about 4 hours before giving birth to protect baby.
RELEVANT Data from Social History:Clinical Significance:
-Teenage 1st time mom and father of the baby is -Nurse needs to assess Anne’s ability to learn, and what needs to still be planned
not involved. before discharged.
-Anne’s mom is her support. -Patient teaching will be applied to Anne and her mother.
-Wants a natural non-medicated birth. -Talk to Anne about her birth plan and ask when, or if, she would want to have
-Wants to breastfeed medication and to discuss the possibility of other plans. Teach about other
relaxation techniques, such as repositioning, massage, walking, slight bouncing
on a yoga ball.
-Teach proper breastfeeding technique.
Anne is placed on a fetal monitor and
the nurse collects the following strip:
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