Conference One - Module 5 (Exam 2) 2 Flashcards Preview

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Flashcards in Conference One - Module 5 (Exam 2) 2 Deck (19)
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1

Stage One Phases

  1. Latent
  2. Active
  3. Transitional

2

Latent Phase

Stage 1 Labor

  • Cervix Dilation 0-3cms
  • Effacement variable
  • Frequency of contractions q 5-7 minutes
  • Duration of contractions 30-40 seconds
  • Mild to moderate intensity contractions

3

Patient Response to Latent Phase

Stage 1 Labor

  • Fear
  • Relief
  • Anxiety
  • Confidence
  • Sociability

4

Nursing Interventions for Latent Phase

  • Admission protocols
    • VS and FHR
    • Leopold's Maneuvers
    • Ultrasound
    • Assess for ROM
  • Contraction Pattern and fetal response
  • Therapeutic interaction
  • Hydration/Elimination
    • CLEARS ONLY DURING LABOR
  • Ambulation to advance labor
  • Comfort/Pain management
    • Non-pharmacologic NIs
    • Analgesia/anesthesia per patient preference and provider order

5

Active Phase

  • Cervix Dilation 4-7cms
  • Effacement 50-100%
  • Contractions are increasing to frequency q 2-5 minutes and duration 40-60 second
  • Intensity of contractions is moderate to strong

6

Patient Response to Active Phase

  • Pain
  • Anxiety
  • Fatigue
  • Questioning abilities
  • Inward focus

7

Nursing Interventions for Active Phase

  • Assessments per protocol
  • EFM per protocol/order
  • Hydration/Elimination
  • AROM/SROM: Assess FHR (if membranes rupture)
  • Assess COAT
    • Color, Odor, Amount, Time of rupture
  • Therapeutic Interaction
    • Giving of self
    • Anticipatory guidance
    • Partner/family support
  • Comfort/Pain Management
    • Non-pharmacologic NIs
    • Analgesia/anesthesia per patient preference and provider order

8

Transitional Phase

  • Dilation 8-10cms
  • Effacement complete
  • Contractions increasing to frequency q 1.5-2 minutes and duration 60-90 seconds
  • Counteract urge to push prior to 10cms: Pant or blow at acme of contraction

9

Patient Response to Transitional Phase

  • Fear
  • Pain
  • Agitation
  • Irritability
  • Withdrawal
  • Contraction
  • Decreased tolerance for interruption

10

Nursing Interventions for Transitional Phase

  • Assessments per protocol
  • EFM per protocol/order
  • Hydration/Elimination
  • Therapeutic Interaction
    • Giving of self, continual presence
    • Anticipatory guidance
    • Parter/Family support
    • Teach that transition is very difficult but also relatively short
  • Comfort/Pain Management
    • Non-pharmacological NIs
    • Analgesia/Anesthesia per patient preference and provider order

11

Stage Two Labor Physiologic Focus

  • Pushing and Birth
  • Contractions: Frequency 2-3 minutes, Duration 40-60 seconds, Strong intensity
  • Contraction pattern may diminish slightly as stage two begins to promote rest between contractions

12

Patient Response to Stage Two

  • Renewed enegy
  • May be focused or confused
  • May experience delay in ability to push effectively because of epidural anesthesia

13

Nursing Interventions for Stage Two

  • All stage 1 NIs continue
  • Provide instructionsand assistance to push effectively
  • Prepare for delivery

14

Stage Three Labor Physiological Focus

  • Placental Delivery
  • Uterine Contraction, controlled bleeding

15

Patient Response to Stage Three Labor

  • Focus on neonate
  • Elation
  • Exhaustion

16

Nursing Interventions for Stage Three Labor

  • Observe for signs of placental separation
    • Lengthening ofcord
    • Globular abdominal contour
    • Gush of blood
  • Oxytocic medication (pitocin) administration after placenta
  • Neonatal stabilization
    • Transition to extrauterine environment
    • APGAR scoring
    • Identification
    • NYS-mandated meds
      • VIT K and Erythromycin

17

Stage Four Labor Physiologic Focus

  • Recovery
  • Early puerperium

18

Patient Response to Stage Four Labor

  • Focus on neonate
  • Elation
  • Exhaustion
  • Brief episode of uncontrollable shaking
    • Benign etiology
    • Manage symptomatically

19

Nursing Interventions for Stage Four Labor

  • Maternal/Neonatal VS and assessments per protocol
    • Fundal tone/lochia
    • Hydration/elimination
    • Comfort measures
  • Facilitation of early bonding/feeding
  • Family support
  • Anticipatory guidance for early puerperium

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