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HPA 3 > Exam 2: Intrapartum Care > Flashcards

Exam 2: Intrapartum Care Flashcards

1
Q

What assessment finding would cause the nurse to suspect false labor?

A

No cervical changes

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2
Q

First stage of labor

A

From the onset of true labor to full dilation of the cervix
Latent (0-6 cm dilated); >8 hours; mild contractions
Active (6-10 cm dilated); 4-6 hours; much stronger contractions

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3
Q

Second stage of labor

A

From full dilation of cervix to the birth of the infant
30 minutes-3 hours
Urge to push
Intense concentration on pushing

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4
Q

Third stage of labor

A

Delivery of the placenta
5-10 minutes
Excited, relieved

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5
Q

Fourth stage of labor

A

First four hours after delivery
Tired, excited, hungry

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6
Q

Cervical dilation

A

Widening or enlargement of cervix (0-10 cm)
Most conclusive sign that contractions are effective

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7
Q

Cervical effacement

A

Shortening and thinning of cervix (0%-100%)

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8
Q

Station

A

Relationship of fetal head to mother’s pelvis (+3 is head showing, about to be delivered)

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9
Q

5 P’s of labor

A

Power
Passenger
Passageway
Position
Psychological Response

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10
Q

Primary powers

A

Provided by uterine muscle

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11
Q

Secondary powers

A

Bearing down efforts of patient

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12
Q

Characteristics of contraction

A

Coordinated
Involuntary
Intermittent

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13
Q

Ideal way to deliver

A

Occiput anterior (OA)

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14
Q

Most common and favorable pelvis shape for vaginal birth

A

Gynecoid

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15
Q

Least favorable pelvis shape for vaginal birth

A

Platypelloid

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16
Q

Cultural considerations (pain)

A

Different cultures deal with pain in different ways
Do not make assumptions
Assess pain in all patients
Some PTs do not outwardly express their pain
Important to be able to communicate with patient

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17
Q

Non-pharmacologic pain management

A

Labor support
Doula support (therapeutic touch, guided imagery, breathing, massage)
Hydrotherapy
Acupuncture and acupressure
Heat and cold
TENS
Sterile water injections

18
Q

Nursing care during first stage of labor

A

Admission assessment
Monitor PT vitals
Monitor fetal heart rate
Comfort measures
Assist in intrapartum procedures
PT education
Psychosocial support
Documentation

19
Q

Acceleration

A

Fetal heart rate increases 15 beats for 15 seconds
Nursing interventions:
Be reassuring
No interventions required
Indicate reactive nonstress test

20
Q

Deceleration types

A

Early
Late
Variable

21
Q

Normal reassuring FHR

A

110-160 BPM with increases and decreases from baseline

22
Q

Tachycardia (fetus)

A

FHR greater than 160 BPM for 10 minutes or longer
Nursing interventions:
Administer prescribed antipyretics for maternal fever if present
Administer oxygen (10 L/min) via non-rebreather
Administer IV fluid bolus

23
Q

Bradycardia (fetus)

A

FHR less than 110 BPM for 10 minutes or longer
Nursing interventions:
Discontinue oxytocin if being administered
Assist client to side-lying position, administer oxygen (10 L/min) via non-rebreather
Insert IV catheter if not in place and administer maintenance IV fluids
Notify provider

24
Q

Early deceleration of FHR

A

Slowing of FHR at start of contraction with return of FHR to baseline at end of contraction
No nursing intervention required

25
Q

Late deceleration of FHR

A

Slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended
Nursing interventions:
Place PT in side-lying position
Insert IV catheter if not in place and increase rate of IV fluid administration
Discontinue oxytocin if being infused
Administer oxygen via non-rebreather
Elevate client’s legs
Notify provider
Prepare for expeditious delivery if pattern not resolved

26
Q

Variable deceleration of FHR

A

Transitory, abrupt slowing of FHR 15 BPM or more below baseline for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contractions
Nursing interventions:
Reposition PT from side to side or knee to chest
Discontinue oxytocin if being infused
Administer oxygen via non-rebreather

27
Q

Category I FHR Tracings

A

Considered normal and associated with fetal well being
Strongly predictive of normal fetal acid-base status
No interventions required

28
Q

Category II FHR Tracings

A

Indeterminate and not predictive of abnormal fetal acid-base status
Require evaluation and intervention

29
Q

Category III FHR Tracings

A

Abnormal and predictive of abnormal fetal acid-base status at the time of observation
Require prompt evaluation and intervention

30
Q

Category III FHR Interventions

A

Discontinue oxytocin or uterotonic agent (per protocol)
Turn PT to left or right lateral position or knee to chest (increases placental perfusion)
Increase isotonic IV fluid infusion to improve intervascular volume
Administer oxygen via non-rebreather
Notify provider of pattern and interventions
Assess PT for underlying cause
If pattern does not resolve in 30 minutes, prepare for expeditious deliver

31
Q

Periodic Change

A

Variable
Early
Acceleration
Late
Indicates placental insufficiency

32
Q

Underlying Cause

A

Cord
Head
Ok
Placenta

33
Q

How to time contractions

A

Time contractions from the beginning of one contraction to the beginning of the next (frequency)
Document frequency in minutes

34
Q

Normal uterine activity

A

5 or less contractions in a 10-minute segment averaged over a 30-minute period

35
Q

Abnormal uterine activity

A

Contractions occurring <q2 minutes (Tachysystole)
Lasting >90 seconds (Tetanic)
Unusually high resting tone (Hypertonus)

36
Q

Nursing care during second stage of labor

A

Assess patient and fetus (VS, FHR, pain)
Comfort measures
Positioning of PT
Psychosocial support
Prep of delivery table
Documentation

37
Q

Immediate care of newborn

A

Assess at delivery
Dry neonate, clear airway with blankets

38
Q

APGAR

A

Appearance
Pulse
Grimace
Activity
Respiration
Done at 1 and 5 minutes
Not used to guide resuscitation efforts
If resuscitation is needed it is done immediately

39
Q

Nursing care during third stage of labor

A

Assist in delivery of placenta
Assess for signs of potential PT problems
Assess newborn response
Parental/newborn bonding

40
Q

Signs of separating placenta

A

Lengthening of umbilical cord
Gush of vaginal blood
Globular shaped abdomen
PT feels urge to push
3rd stage of labor should last less than 40 minutes

41
Q

Nursing care during fourth stage of labor

A

Administer oxytocin (Pitocin) and assist in perineal repair
Assess:
PT vitals
Fundal checks q15’x4, q30x2, q1 hr until transfer to postpartum unit

HPA 3 (19 decks)

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