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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
Q

Interventions include:

A

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

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26
Q

Interventions while in bed include

A

Frequent position changes
optimal position is lateral recumbent
Continuous monitoring of FHR and contractions

Great time for teaching and paper work if necessary

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27
Q

Nutrition interventions include

A

Slowed gastric activity
Clear fluids and light fluids during labor
Hydration is very important can affect contractility of the uterus

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28
Q

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
A

Safety

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28
Q

Elimination interventions include

A

Assess bladder and encourage voiding every two hours

Periodic testing for ketones

In and out cath, only if can’t void

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29
Q

Active phase of labor includes

A

Contractions- stronger and longer

Cervical dilation- 4-7 cm
effacement- 0-100%

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30
Q

Other signs of active stage of labor

A

Increased introversion, increased blood show, ROM

Emotions- increased discomfort and decreased ability to cope

Duration- Nullipara- 1cm/hour
Multipara- 1.5 cm/ hour

31
Q

What are the assessments for the active phase of labor?

A

Same as latent but more often

32
Q

Name some nursing dx for active phase of labor

A

Impaired gas exchange rt
Ineffective breathing pattern
Altered patterns of elimination
Vomiting

33
Q

Interventions for active phase of labor

A

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
Q

Nutrition interventions for Active Phase

A

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
Q

Non Narcotic measures for pain management

A

Sacral massage
Breathing techniques - Slow chest breathing
Relaxation
Shower if safe
Birthing ball at bedside

36
Q

Nursing support for pain management

A

Stay at bedside
Keep bed clean, dry
Feed support person
Anticipatory teaching

37
Q

What is the distribution of labor pain during the later phase of first stage and early of second?

A

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
Q

Name medication for labor management

A

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
Q

What is the timing of meds for pain management?

A

nullipara at 4-5 cm up to 8 cm

multipara at about 3-4 cm up to about 7 cm

40
Q

Demerol usually dose is

A

25 mg IVP

50-100 mg IM every 4 hrs

41
Q

How must nursing documentation must be ?

A

Chronological
Current, take charting with you in room
Use the strip for documenting in current time

42
Q

Evaluation includes

A

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
Q

Transitional phase contractions are

A

Very strong and last 60-90 seconds
UC’s frequent abdomen board like

44
Q

Cervical dilation of transitional phase is

A

8-10 cm
100% effacement

45
Q

Other signs of transitional phase include

A

Increased bloody show
Leg shakes
nausea and vomiting
low back pain
increased diaphoresis
May need to push

46
Q

Emotions of transitional phase is

A

Very irritable and uncomfortable
May panic if left alone

47
Q

Duration of nullipara

A

Generally no longer than 3 hours
average 45-60 min

48
Q

Duration for multipara is

A

No longer than 1 hour

average 10-30 min

49
Q

Assessments for 1st stage of transitional

A

VS every 30 min
Temp could be elevated
100.4 ok
Continue all other assessments

50
Q

Interventions for Transitional

A

Everything more intense
SVE only when needed but more often

51
Q

Nursing care for transitional phase

A

Same as latent and active
Increase IVF if needed
Get ready for delivery room and supplies

52
Q

Second stage of labor begins with

A

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
Q

Other signs of second stage labor

A

Heavy bloody show
Progressive bulging of perineum
Opening of the introitus

54
Q

Emotions of 2nd stage of labor

A

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
Q

2nd stage of labor duration nullipara is

A

no longer than 3 hours avg 1-2 hours

56
Q

2nd stage of labor duration for multipara is

A

no longer than 2 hours and average of 15 mm - 1 hour

57
Q

2nd stage assessment includes

A

SVE determines complete dilation tell HCP
Continuous FHR monitoring
VS every 15 min

Watch appearance for fetal head

58
Q

Name interventions for 2nd stage

A

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
Q

Neonatal care includes

A

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
Q

Third stage back to mom includes

A

birth of placenta

Contractions decrease

61
Q

Other signs of placental separation include

A

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
Q

Name two types of mechanism for placental separation

A

Duncan
Schultze

63
Q

Third stage nursing implications include

A

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
Q

Onset begins right after birth of placenta and ends 1-2 hours after delivery with transfer to pp floor

A

4th stage

Contractions are mild, cramping, afterbirth pains

65
Q

In the 4th stage the uterus can become?

A

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
Q

The assessment for 4th stage is every 15 min to 1hr

A

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
Q

Episiotomy types include

A

Mid line
Medio lateral

68
Q

Laceration Types

A

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
Q

4th stage interventions include

A

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
Q

APGAR score measures

A

HR
Respiratory
Muscle tone
Reflex irritability
Color

71
Q

Management of Hemorrhage/Shock

A

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
Q

How to manage eclamptic seizure?

A

Protect pt from injury
Call for help
Prepare administration of Mag Sulfate bolus and infusion if ordered by MD

73
Q

Profound allergic type reaction and possibly to amniotic fluid embolus

Causes rapid deterioration and can cause sudden maternal death

A

AFE

74
Q

This result of massive loss of clotting factors from blood loss, sepsis, or HELLP Syndrome causing arteriolar blood clotting with concomitant hemorrhage

A

DIC

May be treated with blood, FFP, Platelets, and anticoagulant therapy

NURS ADN004 Maternity (11 decks)

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