Test 2 - Nursing Care during delivery PPT

Question 1

If the fetus is at the ischial spines what station is that?

Answer 1

zero

Question 2

If the fetus is not past pelvic bone and ballottement occurs what station is that?

Answer 2

-3

Question 3

If the fetus is engaged and ballottement does not occur what station is that?

Answer 3

+3

Question 4

Term for the degree of descent presenting above of below the ischial spines?

Answer 4

Fetal Station

Question 5

When the head is no longer moving in and out when the mom is pushing is is considered: ________

Answer 5

Engaged

Question 6

3 descriptors of Lochia:

Answer 6

Rubra
Serosa
Alba

Question 7

The type of lochia seen immediately after birth and for about 3 days following?

Answer 7

Rubra

Question 8

The type of lochia that becomes pink or brown after 3-4 days?

Answer 8

Serosa

Question 9

The type of lochia 10-14 days after birth when the drainage becomes yellow to white?

Answer 9

Alba

Question 10

When does “lightening” occur?

Answer 10

2-3 weeks before onset of labor

Question 11

-Uterine contractions:
feels like tip of nose
-Uterine contractions:
feels like chin
-Uterine contractions:
 feels like forehead

Answer 11

Mild
Moderate
Strong

Question 12

What do you do if you do not have a resting tone between contractions?

Answer 12

Stop Pitocin

Give Fluids

Question 13

Explain Leopold’s Maneuver Box 19-5 pg 441

Answer 13

1. palpate fundus (fetal part) 2. determine fetal back
2. fetal presenting part
3. cephalic prominence, ID attitude of head

Question 14

nitrazine test:

If there is fluid to be found the strip will turn:
If only urine, the strip will turn:

Answer 14

used to detect the presence of amniotic fluid in vaginal secretions.
Blue

Yellow

Question 15

With ROM immediately check ____ for ___?

Answer 15

FHR

change in variability

Question 16

The longer the membranes are ruptured, the greater risk for____?

Answer 16

Infection!

Question 17

After rupture of membranes temp is checked q ___ hours

Answer 17

2

Question 18

If membranes are ruptured what is woman given after 24 hours?

Answer 18

prophylactic antibiotics

Question 19

What do we do less of after rupture of membranes?

Answer 19

Sterile vag exam

Question 20

What is the word for artificial rupture of membranes?

Answer 20

amniotomy

Question 21

Normal amniotic fluid looks like:

Answer 21

Pale
straw colored
flecks of vernix caseosa
Scalp hair
Characteristic Odor

Question 22

Amniotic fluid that is another color means:
Green/brown:
Dark yellow stained:
Port Wine Color:

Thick, cloudy, foul odor:

Answer 22

• Meconium
• infection
• Bleeding, possible abruption, premature separation of the placenta

-infection

Question 23

Begins with onset of regular uterine contractions cervical effacement and dilation
Ends with cervix 100% effaced and dilated to 10 cm.

Answer 23

First Stage of Labor

Question 24

Three Phases of first stage of labor:

Answer 24

Latent phase: up to 3 cm of dilation
Active phase: 4 to 7 cm of dilation
Transition phase: 8 to 10 cm of dilation

Question 25

``` Nursing care in latent phase of first stage of labor = BP/HR/RR: Temp: UC: FHR ```

Answer 25

- BP/HR/RR q 1 h - Temp q 4h, q 1-2 h after ROM - q 30 min (low) q 15 min (hi) - FHR sontinuous or q 1 h low risk

Question 26

Word for gentle stroking of abdomen by pregnant mom:

Answer 26

effleurrage

Question 27

``` Nursing care in active phase of first stage of labor = BP/HR/RR: Temp: UC: FHR ```

Answer 27

q 30 min q 30 min If regular epidural allowed

Question 28

``` Transition phase of labor: Cervix: UC freq: UC dur: UC intensity: Station: Urge to: ```

Answer 28

``` 8-10 q2-3 min 45-90 sec strong +2 - +3 push ```

Question 29

Nursing care in transition phase of first stage of labor Assist with: Encourage not to:

Answer 29

Breathing, voiding, informing and stay with client Push yet

Question 30

Only certain sign that the second stage of labor has begun is the inability to feel the ________ during vaginal examination, indicating that it is completely ______ and ________.

Answer 30

cervix dilated effaced

Question 31

3 phases of second stage of labor:

Answer 31

Latent Descent Transition

Question 32

Which phase of stage 2 is this: | Calm with passive descent of baby through birth canal (laboring down)

Answer 32

Latent

Question 33

Which phase of stage 2 is this: | Active pushing and urges to bear down (Ferguson reflex )

Answer 33

Descent

Question 34

Which phase of stage 2 is this: | Presenting part is on perineum, and bearing-down efforts effective for promoting birth

Answer 34

Transition

Question 35

Nursing actions during second stage of labor:

Answer 35

- Position for pushing efforts widen - Assess FHR with each UC - Assess UC for duration/ relaxation phase (at least 30 seconds) - Administer any meds during UC so amount to fetus minimized - Monitor VS p maintenance dose of analgesic

Question 36

If there is a hypotensive episode after analgesia what do we do:

Answer 36

- Turn off Pitocin (if infusing) - Increase Primary IV fluids - O2 by Mask - Elevate client’s legs slightly (10-20*) - Turn client to lateral position - Notify physician and/or anesthesia personnel - Be prepared: ephedrine may be ordered - Remain with client

Question 37

What do you do for maternal hyperventilation?

Answer 37

1. Teach cupped hands breathing or breath into paper bag or slow open glottis breathing 2. Demonstrate breathing for several UC to establish rate/rhythm

Question 38

When the widest part of the baby's head distends the vulva just before birth it is called:

Answer 38

crowning

Question 39

Term for vagina that has been cut through the rectal wall.

Answer 39

episiproc

Question 40

Laceration that affects the epidermis:

Answer 40

1st degree

Question 41

Laceration that affects the epidermis and muscle

Answer 41

2nd degree

Question 42

Laceration that Extends into rectal sphincter

Answer 42

3rd degree

Question 43

Laceration that extends through rectal mucosa

Answer 43

4th degree

Question 44

A perineal incision to enlarge the vagina:

Answer 44

Episiotomy

Question 45

Type of episiotomy that is 1-2 cm incision straight from vagina toward the rectum Type of episiotomy that is 4-5 cm. incision left or right

Answer 45

Midline Mediolateral

Question 46

What happens in the 3rd stage of labor?

Answer 46

1. Placental separation and expulsion 2. Fundus firmly contracting 3. Change in shape of uterus to globular 4. Gush of dark blood from introitus 5. Apparent lengthening of umbilical cord

Question 47

Fetal Assessment: Pulse –_____ to ____ (may be irregular) Respirations – ___ to ___ Temp - > ___._ Umbilical Cord – ___ vessels

Answer 47

110 - 160 30-60 97.7 3

Question 48

What does APGAR stand for?

Answer 48

``` Appearance Pulse Grimace Activity Respirations ```

Question 49

What is stage 4?

Answer 49

Recovery

Question 50

Nursing care during stage 4: | Monitor q 15 minutes first hour past birth:

Answer 50

``` Fundus Lochia Perineum PAR record Breastfeeding and Bonding ```

Question 51

Where should fundus be after birth? How should it feel?

Answer 51

Firm, midline and halfway between umbilicus and symphysis pubis

Question 52

What should lochia be after birth?

Answer 52

color rubra; No large clots

Question 53

How do we assess perimeum after birth?

Answer 53

REEDA system

Question 54

What is monitored as a part of PAR?

Answer 54

activity, respirations, blood pressure, LOC, color (Mother) | O2 sats if had general anesthesia

Question 55

What could you do if you were in a situation outside a hospital with an emergency birth and needed to get the uterus to contract after the birth?

Answer 55

Stimulate nipple

Question 56

Nurse assumes legal responsibility for: Assessing - Keeping - FHR and pattern fetal response to

Answer 56

- progress of labor - primary health care provider informed about progress in labor and deviations from expected findings - stress of labor

Question 57

_______-______ amniotic fluid may be indicative of fetal distress associated with hypoxia

Answer 57

Meconium stained

Question 58

Assessment of laboring woman’s urinary output and bladder is critical to ensure _______ of labor and to prevent ______to bladder

Answer 58

- progress | - injury

Question 59

When responding to rhythmic nature of second stage of labor, woman normally:

Answer 59

- Changes body positions - Bears down spontaneously - Vocalizes (open-glottis pushing) when she perceives urge to push (Ferguson reflex)

Question 60

Closed glottis pushing should be avoided because:

Answer 60

oxygen transport to fetus will be inhibited