ANSWER
Anne Jones, a 39-week pregnant 17-year-old woman, was admitted to the labor room for observation. She has been having contractions at 8-10 minute intervals for three hours, and her cervical dilation is 1 cm with 80% effacement and 0 station. Her cervix is 2-3 cm with 80% effacement and 0 station after two hours of observation, and contractions are 4-5 minutes apart, lasting 60-70 seconds with a pain level of 3/10. Her fetal presentation is longitudinal cephalic. Anne has GBS and was given antibiotics at 36 weeks; her blood type is B-. Anne prefers a natural, non-medicated birth and has taken childbirth classes with her mother, who will be present during the delivery. She is nervous but relaxed, and she intends to breastfeed for some time.
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QUESTION
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 Category/Subcategory Covered in 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%  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.