Part I Flashcards
(23 cards)
What are signs of True Labor?
o Regular contraction pattern
*Intervals shorten (true labor is typically 4-6 minutes apart)
*Duration (30-60 minutes contraction duration with true labor) and intensity increase
o Progressive dilatation and effacement
o Contractions do not decrease with rest
o Contractions intensity increase with walking
o Discomfort felt in the back and front
Define intervals of contractions.
Interval - the rest period between contractions (we want at least 1 minute so that the baby will have enough 02)
Define duration of contractions.
Duration of contractions - time from first contraction to last contraction
What are signs of false labor (also known as pre-labor)?
o Irregular/weak contractions
o Little or no change in contraction interval and duration
o Minimal to no cervical change
o Contraction not affected by walking
o Rest decreases contractions
o Discomfort only felt in front
When Should a Pregnant Patient Come to the Hospital?
o With any suspected or known leakage of fluid vaginally
o With bright red vaginally bleeding like a period
o With a decrease in fetal movement
o If contractions are 5 minutes apart for 1 hour-primipara
o If contractions are 6-8 minutes apart for 1 hour-multipara
o If a patient cannot walk or talk through contractions
o Any other intense pain or gut feeling that something is wrong
What is the assessment/nursing intervention for impending birth?
- Fetal Heart Tones (FHT) and Maternal vitals!! **Initially most critical!! If membranes are ruptured, FHT are the way to assess for a cord prolapse so appropriate!!
*PRIORITY - is baby coming out?, FHT, and mom’s vitals
o Status of membranes, cervix, contraction patterns, pain
o EDD/Prenatal Care History-Assess for risk factors
o Leopold’s for fetal position confirmation-
What are Leopold’s maneuvers used for?
Helps nurse know fetal position; helps determine where to put external monitors (baby’s back is where we want it)
What are the Nursing Priorities with Membrane Rupture?
*Cord prolapse assessment/fetal well-being should be #1 priority for a known or suspected membrane rupture!
(This is true with a SROM or AROM)
*Fetal heart tones must be monitored for signs/symptoms of NRFHT as the nurse’s first priority.
What is SROM?
SROM=Spontaneous rupture of membrane. Happens with no intentional intervention.
What is AROM?
AROM=Artificial rupture of membranes. Intentional rupture completed by the care provider.
What is PROM?
PROM=Prelabor rupture of membranes. Leakage of amniotic fluid before labor at ANY gestational age but no labor happening yet. (water broke but no other signs of labor)
Does NOT necessarily mean that the pregnancy is preterm!!
What is considered prolonged rupture of membranes?
24 hours - more than 24 hrs is prolonged rupture of membranes or prolonged labor
What is included in psychosociocultural Assessments?
o Emotional/Mental Health Status
o Previous Ideas, Fears, and Knowledge About CB
o Psychosocial History-Physical or Sexual Assault?
o Transcultural Nursing Assessment-Values and Beliefs
o Support Systems-Who, if anyone, is in her life for consistent support?
o Adequacy of Resources-Food, shelter, transportation, healthcare, childcare…
What are the 5 critical P’s that impact labor success?
5 critical P’s
o Passageway
o Passenger (baby)
o Powers (contraction and pushing)
o Position (maternal)
o Psychological
What are 5 additional client-focused P’s that can influence labor?
o Philosophy
o Partner
o Patience
o Patient preparation
o Pain management
What is the cervical assessment to evaluate labor progress?
Cervical Assessment:
o Effacement, dilation, and station-membrane status and fluid characteristics
o Multiple contraindications to a digital exam
o Sterility critical once membranes rupture
o No exam schedule-look for clues!!
What are some major contraindications for digital exams (messing with Cervix)?
Never mess with the cervix if - Bleeding, known placenta premia, preterm labor
_________ means the top of the fetal head is equal to or lower than the ischial spines of the maternal pelvis. This is also called “Zero Station.”
engaged
How is the cervix measured?
measured as the percentage that is gone
how long is the average length of a non-effaced cervix?
avg. about 4 cm
________ is how deep in the pelvis the top of the head is sitting.
Station
*A baby whose head is about 1 cm higher than the ischial spines is -1 station.
*A baby whose head is equal with the ischial spines is at zero station.
*If the station is a positive number, this means the top of the head is that many cm lower than the ischial spines.
true or false - If there is a positive station, the nurse can be positive the baby is coming out… this is because the baby is below the ischial spines.
true
What is the difference between Contraction Duration and Contraction Frequency?
Contraction Duration: beginning to end of contraction
Contraction Frequency: how often the contraction occurs (beginning to beginning)
