Intrapartum Nursing Care Flashcards
(38 cards)
List five prodromal signs of labor the nurse might teach the client.
Lightening, Braxton Hicks contractions, increased bloody show loss of mucus plug, burst of energy, and nesting behaviors.
How is true labor discriminated from false labor?
- True labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back, and cervical changes
- False labor: irregular rhythm, abdominal pain (not in back) that decreases with ambulation
State two ways to determine whether the membranes have truly ruptured.
- Nitrazine testing: paper turns dark blue or black
- Demonstration of fluid ferning under microscope
Are psychoprophylactic breathing techniques prescribed for use according to the stage and phase of labor?
No. Clients should use these techniques according to their discomfort level and should change techniques when one is no longer working for relaxation.
Identify two reasons to withhhold anesthesia and analgesia until the midactive phase of stage 1 labor.
If analgesia and anesthesia are given too early, they can retard labor; if given too late, they can cause fetal distress.
Hyperventilation often occurs in the laboring client. What results from hyperventilation, and what actions should the nurse take to relieve the condition?
Respiratory alkalosis occurs; it is caused by blowing off CO2 and is relieved by breathing into a paper bag or cupped hands
Describe the maternal changes that characterize the transition phase of labor.
Irritability and unwillingness to be touched, but does not want to be left alone; nausea, vomiting, and hiccuping
When should a laboring client be examined vaginally?
Vaginal examinations should be done prior to analgesia and anesthesia to rule out cord prolapse, to determine labor progress if it is questioned, and to determine when pushing can begin.
Define cervical effacement.
The taking up of the lower cervical segment into the upper segment; the shortening of the cervix expressed in percentages from 0% to 100%, or complete effacement.
Where is the FHR best heard?
Through the fetal back in vertex, OA positions
Normal FHR during labor is___.
110 to 160 bpm
Normal maternal BP during labor is___.
<140/90
Normal maternal pulse during labor is____.
<100 bpm
Normal maternal temperature during labor is___
<100.4 F
List four nursing actions for the second stage of labor.
- Make sure cervix is completely dilated before pushing is allowed
- Assess FHR with each contraction
- Teach woman to hold breath for no longer than 10 seconds
- Teach pushing technique
List three signs of placental separation.
- Gush of blood
- Lengthening of cord
- Globular shape of uterus
When should the postpartum dosage of oxytocin (Pitocin) be administered? Why is it administered?
Give immediately after placenta is delivered to prevent postpartum hemorrhage and atony
State one contraindication to the use of ergot drugs (Methergine).
Hypertension
State five symptoms of respiratory distress in the newborn.
Tachypnea, dusky color, flaring nares, retractions, and grunting
If meconium was passed in utero, what action must the nurse take in the delivery room?
Arrange for immediate endotrachial tube observation to determine the presence of meconium below the vocal cords (prevents pneumonitis and meconium aspiration syndrome)
What is considered a good Apgar score?
7 to 10
What is the purpose of eye prophylaxis in the newborn?
To prevent opthalmia neonatorum, which results from exposure to gonorrhea in the vagina
What is the danger associated with regional blocks?
Hypotension resulting from vasodilation below the block, which pools blood in periphery, reducing venous return
What is the major cause of maternal death when general anesthesia is administered?
Aspiration of gastric contents
