T2 - Nursing Care of Family (Josh) Flashcards Preview

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Flashcards in T2 - Nursing Care of Family (Josh) Deck (46):
1

When does lightening occur?

2-3 wks before onset of labor

2

Signs of impending labor?

Lightening

Braxton Hicks

Ripening of cervix

Expulsion of mucous plug

Bloody show

Energy Surge

3

Which type of contractions are felt in the back and above the umbilicus?

False UC

***true start in back and radiate to lower abdomen

4

Palpating UC:

- Mild =
- Moderate =
- Strong =

Mild = nose

Moderate = chin

Strong = forehead

5

If there is no Resting Tone, what should we do?

Stop Pitocin

Increase Fluids

Give Terbutaline

***resting tone is important b/c it is time when placenta perfuses

6

What three questions does Leopold's Maneuvers answer?

1) What fetal part is in the fundus?

2) Where is the fetal back located?

3) What is presenting fetal part?

7

After ROM or membranes, how often should we measure TEMP?

q 1-2 hr

8

What is the risk for membranes ruptured longer than 24 hrs?

infection

***prophylactic antibiotics

9

Abnormal AF:

What does Greenish Brown Color indicate?

meconium

10

Abnormal AF:

What does Yellow, Stained color indicate?

breech presentation (sign of pressure on fetal abdomine during descent)

11

Abnormal AF:

What does Port Wine color indicate?

bleeding, possible abruption, premature separation of placenta

12

Abnormal AF:

What does thick, cloudy, foul odor indicate?

intrauterine infection

13

What color would normal AF look?

pale or straw colored

- with flecks of vernix caseosa, lanugo, and scalp hair

14

When does First Stage begin?

End?

onset of regular UC

100% effaced and 10 cm

15

How often are vitals taken during Latent Phase of First Stage?

q 1 hr

***Temp q4hr if membranes intact and q 1-2 hr after ROM

16

During Latent Phase, how often are UC?

q 30 mins for low risk

q 15 mins for high risk

17

How often should VS be taken during Active Phase of First Stage?

q 30 mins for low risk

q 15 mins for high risk

18

When can the epidural be given?

when UC pattern is established and cervis is 5 cm

19

Why should we encourage voiding?

full bladder can impede labor progress and result in trauma to bladder

20

During Active Phase, what is the frequency of UC?

q 2-3 mins

***duration is 45-90 secs

21

What is fetal station during Transition phase?

+2 to +3

22

Nursing Care during Transition Phase?

Assist w/ breathing

Encourage to rest b/t UC

Encourage voiding

23

What is the only CERTAIN sign that the Second Stage of Labor has began?

inability to feel the cervix during vaginal exam (indicating it is completely dilated and effaced)

24

How long should duration of each UC be during Second Stage?

90 secs max w/ at least 30 secs of rest for perfusion

25

What symptoms should alert us to Maternal Alkalosis?

hyperventilation

syncope

vertigo

***breathe in cupped hands

26

What is Crowning?

perineum bulges and thins as fetal presenting part presses downward onto perneum

***head should stay, not slide back in

27

How is an Epesiotomy measured?

How is a Laseration measured?

location: midline, right, left

degrees: 1st - 4th

28

Perineal Lacerations:

1st Degree =
2nd Degree =
3rd Degree =
4th Degree =

1st Degree = epidermis

2nd Degree = epidermis and muscle

3rd Degree = extends into rectal sphincter

4th Degree = extends through rectal mucosa

29

Should we pull on cord?

no, let it come to you

30

What should we administer post delivery?

Pitocin

- causes uterus to clamp down to expel everything out

31

What is normal FHR?

110-160

32

What is normal Fetal Resp?

30 - 60

33

What is normal Fetal Temp?

97.7

34

What is measured w/ APGAR?

Appearance
Pulse
Grimace/Cry
Activity (Tone/Motion)
Respirations (good, strong cry)

35

At 1 minute, should a baby get an APGAR of 10?

no, because they will not be totally pink due to blood flow to outer extremities

36

APGAR Score:

Appearace

Blue/Pale = 0

Body Pink/Extremities Blue = 1

Completely Pink = 2

37

APGAR Score:

Pulse

Absent = 0

100 = 2

38

APGAR Score:

Grimace

No Response = 0

Grimace = 1

Cry = 2

39

APGAR Score:

Activity

Flaccid = 0

Some flexion of extremities = 1

Well Flexed = 2

40

APGAR Score:

Respirations

Absent = 0

Slow, weak cry = 1

Good cry = 2

41

During Recovery Stage, which time is most critical regarding hemorrhage?

1st hr

***Monitor q 15 mins

42

Where should the Fundus be during Recovery Stage

firm, midline, and halfway b/t umbilicus and symphysis pubis

43

What should Lochia look like during Recovery Stage?

rubra (bright red) w/ NO large clots

44

What does REEDA stand for in regards to the Recovery Stage?

Redness
Edema
Ecchymosis
Discharge
Approximation

***Used to evaluate the perineum

45

During Latent Phase of Stage 1, what is best place for mom to be?

home

***stay home as long as possible

46

Which type of pushing should be avoided?

closed-glottis pushing

***inhibits O2 transport to fetus