Labor-Vaginal Delivery
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Pain
Interrelated Concepts (In order of emphasis)
1. Perfusion
2. Stress
3. Anxiety
4. Reproduction
5. Clinical Judgment
6. Communication
7. Collaboration
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:
Blood type is B- Rh negative mother needs to be administered RhoGAM to prevent
isoimmunization if the fetus if Rh positive.
GBS positive Fetal transmission can lead to invasive GBS infection with permanent
neurological issues
Intact membranes
She’s not in active labor
Cephalic presentation
RELEVANT Data from Social History: Clinical Significance:
Adolescent pregnancy, lack of paternal Anne may face challenges raising an infant without the support of the
involvement, but her mother is present child’s father. However, her mother is a reliable source of support and will
be able to share her experience and knowledge.
Attended prenatal classes She may be more prepared for childbirth & have realistic expectation. She
shows readiness to learn.
Willingness to breastfeed Patient education regarding breastfeeding; teach her about the timeline and
relevance of nutrition.
Anne is placed on a fetal monitor and
the nurse collects the following strip:
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Pain
Interrelated Concepts (In order of emphasis)
1. Perfusion
2. Stress
3. Anxiety
4. Reproduction
5. Clinical Judgment
6. Communication
7. Collaboration
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:
Blood type is B- Rh negative mother needs to be administered RhoGAM to prevent
isoimmunization if the fetus if Rh positive.
GBS positive Fetal transmission can lead to invasive GBS infection with permanent
neurological issues
Intact membranes
She’s not in active labor
Cephalic presentation
RELEVANT Data from Social History: Clinical Significance:
Adolescent pregnancy, lack of paternal Anne may face challenges raising an infant without the support of the
involvement, but her mother is present child’s father. However, her mother is a reliable source of support and will
be able to share her experience and knowledge.
Attended prenatal classes She may be more prepared for childbirth & have realistic expectation. She
shows readiness to learn.
Willingness to breastfeed Patient education regarding breastfeeding; teach her about the timeline and
relevance of nutrition.
Anne is placed on a fetal monitor and
the nurse collects the following strip:
