Question

Patient is a 29-year-old female at her 38 weeks gestation admitted with contractions. Reports contraction every 5 minutes starting at 5 am and increasing to every 2-3 minutes. Very painful. Patient denies LOF (elective abortion), DFM (Maternal perception of decreased fetal movement). She is a G4P0A2 L1.)

Please list the nursing assessment for this patient?

Answer 1

As the patient is having contractions increased to every two to three minutes ,it indicates she is in first stage (transition phase) of labour .The nursing assessment for this patient during this stage are

• Monitor the vital signs of the patient (Baseline status of patient can be assessed because any changes in body functions are first projected through altered vital signs )
• Assess the fetal heart rate
• Assess the intensity and duration of the contractions ,to know the progress of labour
• Assess for rupture of amniotic sac or any discharge or bleeding
• Pelvic examination for dilation of cervix as per the hospital's guidelines whether it can be done by nurse or not.