Labor
RAPID Reasoning
Suggested Answer Guidelines
Anne Jones, 17 years old
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% ✓
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, 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.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
After two hours of observation, her 2-3 cm/80%/0 indicates early labor and this is her first baby, so labor is
cervix is 2-3 cm/ 80% effacement/0 typically longer;12-24 hours is typical for a primigravida. No cervical
station change after 1 hour.
She began having contractions three Began three hours prior to coming to hospital and were 8-10 minutes
hours ago at 8 to 10-minute intervals with lasting 30 seconds, after 1 hour 4-5 lasting 60-70 secs, pain is mild,
contractions increased but pain is still mild.
each contraction lasting 30 seconds. She
states her pain is 3/10.
Mom is Rh- so she will need Rhogam shot after delivery (within 72
B- hours) if the baby is RH positive.
GBS positive She received antibiotic at 36 weeks and will need antibiotics during
labor. Penicillin G 5 million units loading and then 2.5 million units
every 4 until delivery or Ampicillin 2 grams loading and then 1 gram
every 4 until delivery.
Newborn will need to be monitored for signs of sepsis.
RELEVANT Data from Social History: Clinical Significance:
Anne’s mother is with her. Father of baby not involved, but her mother is supportive. Laboring
women need support to help decrease anxiety.
Anne is placed on a fetal monitor and
the nurse collects the following strip:
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
RAPID Reasoning
Suggested Answer Guidelines
Anne Jones, 17 years old
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% ✓
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, 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.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
After two hours of observation, her 2-3 cm/80%/0 indicates early labor and this is her first baby, so labor is
cervix is 2-3 cm/ 80% effacement/0 typically longer;12-24 hours is typical for a primigravida. No cervical
station change after 1 hour.
She began having contractions three Began three hours prior to coming to hospital and were 8-10 minutes
hours ago at 8 to 10-minute intervals with lasting 30 seconds, after 1 hour 4-5 lasting 60-70 secs, pain is mild,
contractions increased but pain is still mild.
each contraction lasting 30 seconds. She
states her pain is 3/10.
Mom is Rh- so she will need Rhogam shot after delivery (within 72
B- hours) if the baby is RH positive.
GBS positive She received antibiotic at 36 weeks and will need antibiotics during
labor. Penicillin G 5 million units loading and then 2.5 million units
every 4 until delivery or Ampicillin 2 grams loading and then 1 gram
every 4 until delivery.
Newborn will need to be monitored for signs of sepsis.
RELEVANT Data from Social History: Clinical Significance:
Anne’s mother is with her. Father of baby not involved, but her mother is supportive. Laboring
women need support to help decrease anxiety.
Anne is placed on a fetal monitor and
the nurse collects the following strip:
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
