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Maternity week 4-1 Flashcards

(78 cards)

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1
Q

Initial Assessment of Patient

A

Admit patient to triage
POC (point of care - bedside): Urine dip
Initiate fetal monitoring
Obtain VS
Characteristics of Labor (contractions? bleeding? leaking fluid? is your baby moving?)
Assess for VB
Assess FM: Subjective
Check for Ruptured Membranes/Dilation
Prenatal Record
Physical Exam: Including high risk s/sx
Report to provider

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2
Q

Admit or Send Home

A

Is pt in active labor?
ROM? GBS status?
Coping well?
Labor Hx?
High risk dx?
Fetal concerns?
Earlier admission= intervention
Delayed admission= Less labor augmentation, c/s, antibiotics and internal monitors.

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3
Q

Diagnosing Rupture of Membranes

A

PROM - premature rupture of membrane

PPROM - premature or prelabor before 37 weeks

SROM - spontaneous

AROM - artificial

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4
Q

latenent - how many cm? (latent at zero)

A

0-5 cm

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5
Q

dilation

A
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6
Q

10 cm is

A

complete

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7
Q

normal cervix is how long?

A

3 cm long

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8
Q

station is measured in

A

cm. minus stations are above.

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9
Q

Diagnosing Rupture of Membranes

A

Nitrazine + Pooling + Fern (pattern on strip test) Test - this means their water broke.
Speculum exam
Cervical fluid collected and viewed under microscope
Pooling:
Ferning: Crystallization of
proteins + salt

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10
Q

Nitrazine Testing for ROM - what pH is not ruptured? (don’t rupture before age 6.5)

A

ACIDIC: NOT RUPTURED Yellow = pH 5.0
Olive-yellow =pH5.5
Olive-green =pH 6.0
ALKALINE = MEMBRANES RUPTURED
Blue-green = pH 6.5

this is rupture:
ALKALINE = MEMBRANES RUPTURED 7.1 - 7.3 or 7.5
Blue-gray = pH7.0
Deep blue = pH 7.5

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11
Q

Assessment of
Vaginal bleeding - what amount is normal?

A

Bloody show
Scant bleeding normal after SVE
Report any VB to MD/CNM
Closely monitor mod to heavy bleeding (pad counts/weights)
Sources of abnormal bleeding:
Placentia previa
Placental abruption

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12
Q

Assessment of uterine activity

A

Subjective assessment: questions? how often? how long? pain? (pain in lower back sign of preg)
Objective assessment
Palpation: “nose, chin, forehead”: mild, mod, strong
Observation
Tocometer
IUPC

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13
Q

SVE - sterile vaginal exam - do what first?

A

spectacle exam to get specimen before you insert something w/ bacteria

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14
Q

Signs of Possible
Intrapartum Complications - contractions and pressure - the numbers?

A

Increased IUP (intra uterine pressure?)
Contractions lasting > 90
Tachysystole: More than 5 UCs/10 min averaged over 30 min

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15
Q

Common intrapartum
NURSING interventions

A

Assessments/Monitoring
Fluid intake: oral/IV
Bladder/bowel evacuations
Pain management
Ambulation & Position changes
Nutritional needs
Emotional Support
Integrating care team (includes other providers, family/friend support, doulas etc.)

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16
Q

Components of Nursing care: stage 1

A

Review: What comprises the first stage of labor?
Monitoring the labor pt: VS, screenings, assessments
Fetal assessment
Pain management/Labor support
Communication with team
Consider Maslow’s Hierarchy

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17
Q

Nursing care in the first stage of labor:
Pain management

A

Part of a normal process: nothing bad is happening

Intensity increases as labor progresses

Occurs in a predictable pattern with regular respite (in a normal labor)

Ends with the birth of the baby

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18
Q

Sources of Pain: Stage 1 (stretch on stage 1)

A

Uterine Anoxia

Stretching of the cervix

Stretching of the uterine ligaments

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19
Q

when does baby get oxygen during labor?***

A

in between contractions

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20
Q

Sources of Pain: Stage 2 (vaginas and pressure on stage 2)

A

Distention of the vagina and perineum
Pressure of the baby on tissue and organs (bladder, rectum, etc)

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21
Q

Sources of Pain: Stage 3 (the cramps on stage 3)

A

Uterine Cramping

Lacerations

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22
Q

Factors that Influence Pain

A

Fear and Anxiety
Fatigue
Individual pain tolerance
Support
Cultural expression of pain
Psychosocial factors
Preparation
Previous experience (self and others)
Information/Lack of
Length of labor

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23
Q

Signs the patient is coping well may include: (with pain) (rocking w/ pain is good)

A

States they are coping well
Rhythmic activity during UCs, such as rocking, swaying
Focused inward
Rhythmic breathing
Able to relax between UC
Vocalization, such as moaning, chanting, counting

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24
Q

not coping with pain - signs

A

States she is NOT coping
Crying, tearfulness, tremulous voice
Inability to focus or concentrate
Panicked activity during contractions
Jitteriness, thrashing in bed
Tense, sweaty

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25
Options for managing intrapartum pain
Non-pharmacologic Pharmacologic Center patient in decision-making process around interventions for pain. movements.
26
Non-Pharmacological Management Cont’d
Hydrotherapy Aromatherapy Guided relaxation/breathing Massage/Effleurage Position Changes/Ambulation Sacral Pressure (Counter Pressure) Hip Squeeze
27
Doulas
Professional, trained birth attendant Patients half as likely to have complications Reduced rates of intervention Greater client satisfaction with birth Outcomes linked to emotional, physical support, and information given.
28
types of agents
Systemic Analgesics Inhaled Analgesics Local Anesthesia Regional Analgesia/Anesthesia General Anesthesia
29
check slide
49
30
Opioids: - Morphine
Morphine: Early labor Therapeutic effect: 4-6 hours 12-15 mg IM w/ Hydroxizine
31
Fentanyl
Active labor and/or severe pain 50-100mcg IVP Therapeutic effect: 30-60 min
32
Hydroxyzine (hydro w/ morphine)
Hydroxyzine: 50-100mg IM IM w/ Morphine Potentiates opioid, antihistamine/antiemetic Promethezine: antiemetic/antihistamine w/ opioid
33
Pharmacological Management
Nursing Care : considerations
Assess labor progress Assess pain and coping Assess patient’s labor goals and expected outcomes Assess FHR Parenteral Route Efficacy Document Narcan (naloxone)
34
Precautions with N20 (what about the fetus?)
Current vitamin B12 deficiency Abnormal FHR tracing Hemodynamic instability and/or impaired oxygenation Observe for respiratory depression Covid +/other respiratory illness
35
Contraindications to N20
Acute drug or alcohol intoxication or impaired consciousness Inability to hold face mask Some medical conditions, such as pneumothorax or increased intracranial pressure
36
EPIDURAL - how quickly does it work? (lepi takes a loooong time)
20-30 min
37
SPINAL ANESTHESIA (don't use when?)
Imminent vaginal delivery or C/S, not suitable for labor Risk of spinal (post-dural) H/A Risk for  BP Rapid onset: full effect=5-10 min
38
COMBINED SPINAL-EPIDURAL (CSE)
Spinal/Epidural administered during same procedure Provides rapid/continuous anesthesia/analgesia Labor or C/S
39
DISADVANTAGES OF EPIDURAL ANESTHESIA (think decreased breathing and baby)
 BP: may affect placental perfusion Urinary retention Limited mobility May  2nd stage  risk of low forceps or vacuum assisted
40
Contraindications 
to
regional anesthesia (clot in one spot)
Clotting disorders including thrombocytopenia Medication allergy Anatomical problems: scoliosis, spinal fusion/anomalies Unable to place
41
pre-EPIDURAL PLACEMENT - nursing care (think of fluids)
Educate patient Confirm consents completed Pre-hydrate: IV bolus/prevent hypotension Obtain medication/equipment Position patient/place BP cuff/pulsox Time out Continue labor support/maintain fetal monitoring
42
NURSING CARE: 
 EPIDURAL PLACEMENT
Safety Independent double checks Pharmacy prepared meds Clearly label solutions and lines Patient Monitoring Documentation
43
time out (3 things - think of the OR)
Verify: Correct pt Correct procedure Correct site
44
NURSING CARE: 
POST EPIDURAL PLACEMENT (change positioning?)
Assess VS Monitor FHR/UCs Assess pain level Place foley catheter Order clear diet Change patient position q 30-60 min: lateral or tilt
45
General Anesthesia - when to use
Administered by Anesthesiologist (MD) or CRNA Not for labor: C/S only! Not routine: emergency, failed regional anesthesia, contraindication to regional anesthesia Combination of agents may include: Fentanyl, versed, propofol, ketamine etc. Pt recovered in PACU
46
Labor
Stages 2-4
2nd stage: 10 cm dilation-delivery, “pushing” 3rd stage: Delivery of placenta 4th stage: After delivery of placenta until up to 4 hours after (“recovery”)
47
2nd Stage:
Nursing assessments - how often to assess vital signs and contractions?
VS: “per protocol”, per Ricci: q-5-15 FHR: q5-15 dependent on risk level UCs: document q5-15 Coping/pain Fetal descent
48
2nd Stage:
Nursing interventions
Prepare room for delivery Communicate with providers PRN (OB, NICU etc.) Support patient with every pushing effort Continue comfort measures D/C Foley Ensure adequate hydration Respond to abnormal assessment findings Assist w/ delivery
49
3rd stage
assessments - think what happens in the 3rd stage
VS: q 15 Apgars: 1 min, 5 min Observe for placental separation Assess fundus/lochia following delivery of placenta
50
bonding
it's just the parent.
51
look at slide
85
52
3rd stage:
nursing interventions
Respond to abnormal assessment findings Administer uterotonics PRN/as ordered Active management of the 3rd stage Assist with BRF & Monitor NB Post: assist w/ repair, pain meds, ice to perineum PRN
53
4th stage: nursing assessment (after birth, what drops?)
Fundal check/lochia assessment: Q 15 x 4 Q 30 x 2 Vitals/Pain assessment NB admission exam
54
4th stage:
nursing interventions
Pain interventions prn Hydrate/provide nutrition Facilitate voiding ASAP Promote rest Assist w/ first amb/assess for readiness to amb post-anesthesia Education
55
4th stage:
nursing interventions
Newborn (NB)
Assist w/ NB feeding Administer NB meds Infant security Education
56
Nursing Diagnoses:
Stages 2-4
Risk for injury to patient and fetus/NB Knowledge deficit Pain Ineffective coping Anxiety Risk for infection Risk for fluid volume deficit/excessive blood loss
57
Fetal assessment
Subjective: pt report, “kick counts’ Objective: Continuous fetal monitoring EFM FSE Intermittent auscultation
58
Assessment frequency
Stage 1 Low risk: early labor Q 1 hour, active labor Q30 min High risk: early labor Q 30 min, active labor Q15 min Stage 2 Low risk: Q 15 min High risk: Q 5 min
59
Intermittent auscultation
Low risk patients Assess maternal pulse Associated with lower rate of c/s/unnecessary intervention Equal perinatal outcomes in low risk pt Auscultate 3-5 min through UC, one min after Assessment frequency=cont. monitoring
60
Fetal Monitor Tracing Interpretation
NICHD: Standardized terminology Visual interpretation Identify FHR baseline Identify variability Identify accels/decels Determine UC pattern Intervene PRN
61
Variability
Variability: Irregular fluctuations in baseline FHR Sympathetic/Parasympathetic interplay Normal variability=CNS WNL & absence of acidemia (CO2 buildup) Absent: undetectable Minimal: < 5 bpm Moderate: 6-25 bpm Marked: >25 bpm
62
Accelerations
Abrupt inc: 15 x 15 at 32 weeks or > < 32 weeks: 10 x 10 ok > 10 min= new baseline
63
Early decelerations - how long is onset to nadar? (30 is early)
Associated w/ Ucs Gradual dec in baseline, mirrors UC Onset to nadir > 30 sec
64
Variable decelerations (V is for variable) and what causes it?
Abrupt drop from baseline, < 30 sec onset to nadir May occur w/out UC “V” shaped At least 15 x 15. cause is cord compression.
65
Late decelerations (onset to nadar time - it's 30 again) and what causes it?
Associated w/ Ucs Gradual dec in baseline, nadir after UC peak Onset to nadir > 30 sec Return to baseline after UC. cause - placential insufficiency
66
Early decel
Early decel: head compression/vagus nerve stimulation
67
Late decel
Late decel: uteroplacental insufficiency, interruption in “oxygen pathway”
68
Accel - is normal or abnormal?
Accel: acid/base status wnl
69
Variable decel - causes (C causes V)
Variable decel: cord compression
70
FHR categories - what number is good and bad? (backwards for you)
1 is good, 3 is bad.
71
FHR - CAT III (the 3 are late, variable, brady and sinus)
CAT III, Includes at least one of the following: Absent variability with recurrent late decels Absent variability with recurrent variable decels Absent variability with bradycardia Sinusoidal Pattern
72
FHR - cat. 1 (1 cat does not decelerate)
CAT I: FHR wnl, Accels may or may not be present Decels are absent Predictive of normal acid/base balance
73
FHR - cat 2 (2 cats just don't fit)
CAT II: Tracings that don’t fit in CAT I or III Not predictive of normal acid/base balance Indeterminate significance; cont to monitor
74
contractions - Tachysystole (you already know this)
Tachysystole: > 5 UCs/10 min averaged over 30 min
75
Nursing interventions for abnormal FHR - what drug?
Intrauterine resuscitation Change pt position IV fluid bolus: PL/LR Treat hypotension Turn of pitocin O2 not evidenced based (listed as intervention in Ricci, 5th ed.) Tocolytic administration: Terbutaline: 0.25 mg SC: tachycardia, half-life=3 hours, smooth muscle relaxant Rapid delivery PRN
76
Terbutaline effects - what is normal?
can cause fetal tachycardia, but it is transient. this is NORMAL.
77
intrapartum complications - Cat tracings
Abnormal fetal heart tracing: Cat II or III Amniotic fluid: Meconium-stained, Cloudy, Foul-smelling Labor dystocia (Failure to progress/FTP)
78
intrapartum complications - temperature - what is an abnormal temp in the mother?
Maternal Temp > 38 Foul smelling discharge, Continuous bright red bleeding

XIO (400 decks)

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