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NURS ADN004 Maternity > Week 4 Labor Management > Flashcards

Week 4 Labor Management Flashcards

1
Q

0-3/4 cm is the ___________ phase

A

Latent

Onset- begins with ROM onset of contractions

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2
Q

Contractions are what in latent phase?

A

Generally short, mild , and irregular

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3
Q

Cervical dilation in latent phase is

A

0 to 3/4 cm

Effacement is 0-100%

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4
Q

Other signs in Latent Phase

A

Bloody show
Cramping
Loose stools

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5
Q

Emotions in latent phase of labor

A

Excited apprehensive, mild discomfort, good time for teaching

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6
Q

Nullipara dilate is

A

1cm per hour

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7
Q

Multipara dilate is

A

1.5 cm/ hour

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8
Q

LOA

A

Occiput is area over the occipital bone on posterior part of the fetal part of the bone

Left anterior quadrant of the woman’s pelvis

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9
Q

When fetus is LOA

A

Posterior fontanelle is in upper left quadrant of maternal pelvis

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10
Q

LOP

A

Posterior fontanelle is in the lower left quadrant of maternal pelvis

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11
Q

ROA

A

Posterior fontanelle is in upper right quadrant of the maternal pelvis

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12
Q

ROP

A

Posterior fontanelle is in lower right quadrant of female pelvis

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13
Q

Anterior fontanelle is

A

Diamond shape because of roundness of the fetal head

Only portion that can be seen and is triangular view

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14
Q

Fetal head progresses through the pelvis and the change the nurse will feel detect what upon palpitation?

A

Occiput through the cervix.

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15
Q

What maneuvers determines fetal positioning and presentation?

A

Leopold’s maneuver

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16
Q

First maneuver of Leopold’s Maneuver

A

Facing the woman palpate upper abdomen with both hands

Note shape, consistency, and mobility of the palpated part

fetal head is firm and round and moves independently of the trunk. Buttock feel softer and moves with the trunk.

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17
Q

Second maneuver of Leopold’s

A

Moving hands on the pelvis and palpate the abdomen with gentle but deep pressure

Fetal back on one side of the abdomen and feels smooth. And extremities are knobby on the other side.

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18
Q

Third maneuver of Leopold’s

A

Place one hand don the pubic symphysis

Note whether part is palpated feels like head or the breech and whether is engaged

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19
Q

Fourth maneuver of Leopold’s maneuver

A

Facing the woman’s feet, place both hands on the lower portion of the abdomen and move hands gently down the side of the uterus toward the pubis.

Note cephalic prominence or brow.

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20
Q

First stage assessments include

A

VS- if normal is low risk

BP, pulse, and respirations every 60 min

Temp every 4 hours if intact and every 2 if ROM

Use nursing judgement for regarding activity, need for continous monitoring, IV, medications, etc

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21
Q

FHR and uterine contraction pattern assessed every ____ min and documented assessment in 1st stage

A

15 min

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22
Q

FHR and Uterine contraction assessments include

A

Baseline
Baseline variability
Periodic changes
Fetal oxygenation and well being

UCs- frequency, duration, intensity

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23
Q

If normal findings continue this can be accomplished by

A

1st stage assessment FHR

handheld doppler and allowing pt ambulate in hallway or around the room

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24
Q

Assessment 1st stage of SVE

A

Least amount of SVE
If pt needs meds
If pt needs need for BM
If FHR indicates need
If SROM
change in behavior of the pt

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25
Interventions include:
Continuous assessment of changes in PT behaviors, contractions, and FHR established Activity - Encourage ambulation for uncomplicated labor - Bedrest if preterm labor, abnormal bleeding, SROM, and presenting part is not engaged, administration of narcotics for pain, Pt request
26
Interventions while in bed include
Frequent position changes optimal position is lateral recumbent Continuous monitoring of FHR and contractions Great time for teaching and paper work if necessary
27
Nutrition interventions include
Slowed gastric activity Clear fluids and light fluids during labor Hydration is very important can affect contractility of the uterus
28
Side rails up at all times Practice universal precautions at all times Aseptic technique Privacy Cultural Keep pt and family members informed - HIPPA established early and who will be informed
Safety
28
Elimination interventions include
Assess bladder and encourage voiding every two hours Periodic testing for ketones In and out cath, only if can't void
29
Active phase of labor includes
Contractions- stronger and longer Cervical dilation- 4-7 cm effacement- 0-100%
30
Other signs of active stage of labor
Increased introversion, increased blood show, ROM Emotions- increased discomfort and decreased ability to cope Duration- Nullipara- 1cm/hour Multipara- 1.5 cm/ hour
31
What are the assessments for the active phase of labor?
Same as latent but more often
32
Name some nursing dx for active phase of labor
Impaired gas exchange rt Ineffective breathing pattern Altered patterns of elimination Vomiting
33
Interventions for active phase of labor
Continuous assessment for fetal status Assess for labor progress - Bloody show increase, increased introversion, strength of uterine contractions ROM Activity - Frequent position changes and avoid supine hypotension Continue ambulation as long as safe and tolerable
34
Nutrition interventions for Active Phase
Maintain IVF, may bolus if needed Check with provider, clear fluid diet or npo with ice chips or strict NPO Elimination Same as latent every 2 hours Monitor output
35
Non Narcotic measures for pain management
Sacral massage Breathing techniques - Slow chest breathing Relaxation Shower if safe Birthing ball at bedside
36
Nursing support for pain management
Stay at bedside Keep bed clean, dry Feed support person Anticipatory teaching
37
What is the distribution of labor pain during the later phase of first stage and early of second?
Most pain below umbilical and these contractions are intense. Pain also near the cervical area. Intense pain in the lower back area as well.
38
Name medication for labor management
Pitocin- IV 1mlu per minute Stadol- IVP, 1 mg per hr Fentanyl- 100mcg per hr, IVP Nubain- 10 mg every 2-3 hr, IVP Give IVP meds slowly over 2 contractions Do not let patient ambulate alone with these medications
39
What is the timing of meds for pain management?
nullipara at 4-5 cm up to 8 cm multipara at about 3-4 cm up to about 7 cm
40
Demerol usually dose is
25 mg IVP 50-100 mg IM every 4 hrs
41
How must nursing documentation must be ?
Chronological Current, take charting with you in room Use the strip for documenting in current time
42
Evaluation includes
Evidence of adequate fetal oxygen SVE for progress of labor Pt coping with labor Documentation procedures, IV, meds, VS, Interventions, provider input or contacts
43
Transitional phase contractions are
Very strong and last 60-90 seconds UC's frequent abdomen board like
44
Cervical dilation of transitional phase is
8-10 cm 100% effacement
45
Other signs of transitional phase include
Increased bloody show Leg shakes nausea and vomiting low back pain increased diaphoresis May need to push
46
Emotions of transitional phase is
Very irritable and uncomfortable May panic if left alone
47
Duration of nullipara
Generally no longer than 3 hours average 45-60 min
48
Duration for multipara is
No longer than 1 hour average 10-30 min
49
Assessments for 1st stage of transitional
VS every 30 min Temp could be elevated 100.4 ok Continue all other assessments
50
Interventions for Transitional
Everything more intense SVE only when needed but more often
51
Nursing care for transitional phase
Same as latent and active Increase IVF if needed Get ready for delivery room and supplies
52
Second stage of labor begins with
Complete dilatation of cervix and ends with birth of infant Contractions are strong, frequent, and long Maternal expulsion efforts aid the force of contractions 100% effacement
53
Other signs of second stage labor
Heavy bloody show Progressive bulging of perineum Opening of the introitus
54
Emotions of 2nd stage of labor
Most patients feel better and in control and need support for pushing Efforts may complain of burning and tearing sensation of perineum when fetal head fully distends the area
55
2nd stage of labor duration nullipara is
no longer than 3 hours avg 1-2 hours
56
2nd stage of labor duration for multipara is
no longer than 2 hours and average of 15 mm - 1 hour
57
2nd stage assessment includes
SVE determines complete dilation tell HCP Continuous FHR monitoring VS every 15 min Watch appearance for fetal head
58
Name interventions for 2nd stage
Assist with pushing, labor progress, pushing only with UC's Privacy Fetal status assist with monitoring at all times Discomfort is generally less than transition May get back feeling now from epidural May get pudendal for pain relief
59
Neonatal care includes
Infant placed mother's chest for skin to skin On warmed resuscitation bed Towel dried, hat on head, suction mouth and nose to open airway APGAR at 1 and 5 min Brief overview for anomalies Note number of vessels in cord ID bands on bay and parents Erythromycin to eyes and Vit k to leg
60
Third stage back to mom includes
birth of placenta Contractions decrease
61
Other signs of placental separation include
Gush of blood from the introitus Lengthen of cord Globular shape of uterus Emotion is tired and glad it is over Duration is 30-40 min for all patients
62
Name two types of mechanism for placental separation
Duncan Schultze
63
Third stage nursing implications include
Time placenta is delivered and document Add 20 units of Pitocin to 1000 ml LR and open wide Assist with suturing if needed Monitor bleeding- crucial time for PP hemorrhage
64
Onset begins right after birth of placenta and ends 1-2 hours after delivery with transfer to pp floor
4th stage Contractions are mild, cramping, afterbirth pains
65
In the 4th stage the uterus can become?
Boggy and need massage Perineal repair may be needed in progress, need to be assessed for bladder distention Emotions are tired, excited, want to hold infant, hungry, may have perineal discomfort
66
The assessment for 4th stage is every 15 min to 1hr
True VS more often if not stable Fundus- Assess firmness and position Lochia- Type, amount, any clots Perineum: Swelling, bleeding from repaired site, hematoma formation Bladder: Distention, up to void
67
Episiotomy types include
Mid line Medio lateral
68
Laceration Types
1st: Skin of perineum and vaginal mucosa 2nd: Muscles of perineum and the above 3rd: Involves depth of the fascia of the anal sphincter tissue 4th: Laceration into the rectum
69
4th stage interventions include
Documentation if heavy bleeding, pad count, and clots Maintain IVF with Pitocin Massage boggy fundus Ice pack to perineum Medications for pain Assist with breastfeeding
70
APGAR score measures
HR Respiratory Muscle tone Reflex irritability Color
71
Management of Hemorrhage/Shock
Massage fundus Increase IV Pitocin Empty bladder Evaluate VS and O2 saturation - Apply o2 Call HCP Code Crimson - Alert and activate emergency - Alert Lab Establish second IV line for massive transfusion with large gauge
72
How to manage eclamptic seizure?
Protect pt from injury Call for help Prepare administration of Mag Sulfate bolus and infusion if ordered by MD
73
Profound allergic type reaction and possibly to amniotic fluid embolus Causes rapid deterioration and can cause sudden maternal death
AFE
74
This result of massive loss of clotting factors from blood loss, sepsis, or HELLP Syndrome causing arteriolar blood clotting with concomitant hemorrhage
DIC May be treated with blood, FFP, Platelets, and anticoagulant therapy

NURS ADN004 Maternity (11 decks)

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