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30 Cards in this Set
- Front
- Back
Emergency Delivery |
rapid, uncontrolled delivery is a nonsterile or unassisted delivery that can be managed w/out complications to mother or fetus |
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Emergency Delivery Nursing Assessment |
-bulging perineum -woman screaming that the baby is coming -presenting part visible at introitus |
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Emergency Delivery Nursing Plans |
-do NOT leave client alone -get precipitous delivery basin from ER or closet if birth is occuring in labor room -place clean towel under buttocks -have client use hee-blow or blow blow breathing to slow expulsion of head over perineum |
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Emergency Delivery
If amnion is present |
rupture with fingers or clean implement when head crowns |
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Emergency Delivery To Prevent fetus from popping over the perineum, which can lacerate tissue and cause fetal cerebral trauma |
Apply gentle counterpressure against presenting part |
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Emergency Delivery Check for cord around neck and remove if loose; cut if tight Deliver ___ first by gently pressing DOWNWARD under symphysis |
anterior shoulder first Then, apply UPWARD pressure over perineum to deliver posterior shoulder |
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Deliver entire body, holding baby slightly ___ position to facilitate mucus drainage |
head down |
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Emergency Delivery Suction baby with ____ quickly, mouth and nares. Dry infant and cover with blanket or towel. |
bulb syringe |
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Emergency Delivery Clamp cord in 2 places, and cut in between. If sterile supplies are not available, leave in tact. Do not ___ the cord |
milk |
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Emergency Delivery
When signs of placental separation are seen (gush of blood, lengthening of cord), ask woman to : |
gently push placenta out |
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Emergency Delivery Where do you place the baby to contract the uterus? |
to mother's breast |
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C-Section Complications |
-anesthesia complications -usual abdom surgery complications -sepsis -thromboemobolism -injury to urinary tract |
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C-sections The rate of c-section births is more than ___ in the US and increasing. Vag birth after c-section is decreasing due to complications after the procedure |
30% |
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C-sections Assessment |
-elective or repeat c-section birth scheduled -emergency c-section birth performed to prevent harm to mother/fetus |
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C-sections Nursing care Before c-section |
-encourage couple to attend c-section birth class -if emergency c-section is necessary, obtain informed consent*** -inform anesthesiologist of need for preoperative assessment -assist with anesthesia, usually epidural -shave abdomen from xiphoid to 1/4 way down thigh, including pubic area -insert foley |
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C-sections Admin preop meds |
-usually because fetus is in utero, no analgesia or sedative is prescribed preop -client may receive antacid to alkalize stomach contents or a drug such as histamine receptor antagonist ,, which is a gastric antisecretory drug that reduces the production of gastric secretions |
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C-sections Obtain lab studies |
-type and crossmatch for 2 units packed RBCS, CBC, and chemistry obtain urinalysis |
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C-sections Interventions |
Have client remove dentures, contact lenses, rings, and fingernail polish. Notify nursery, neonatologist, and ped of impending c-section Allow presence of support person in operative suite |
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C-sections Intraoperative care Before abdom preperation: |
-place wedge under one hip to displace uterus laterally -keep client warm with blankets -monitor and doc fetal heart tones continously |
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C-sections Intraoperative Care |
-apply grounding pad to leg -perform abdom scrub -perform circulating nurse duties per institutional protocol -if client is awake, assess and meet psychosocial needs |
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After c-section |
-receive complete birth report, including the type of uterine incision performed -fundal height and consistency assessment may be difficult due to abdom bandage abdom pain -assess temp every hr in recovery room, then every 4 hrs for 24 hrs, then every 8 hrs -assess HR, resp, breath sounds, bowel sounds, and SaO2 -begin I&O assessment every 8 hrs |
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After c-section, admin pain med: |
-PCA and postoperative epidural analgesia with morphine sulfate, fentanyl citrate |
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After c-section, to prevent respiratory complications |
-demonstrate splinting of abdom -coughing -deep breathing -incentive spirometer due to stasis of lung secretions |
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C-section Maintain aseptic technique to prevent sepsis |
-teach handwashing -assess incisional healing every 8 hrs -perform scrupulous perineaum care and pad changes -assess lochia for foul odor |
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If woman is medicated, who signs the necessary consent forms? |
responsible adult accompanying her, per state law |
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Babies delivered abdominally miss out on the vaginal squeeze and are born with more fluid in their lungs, predisposing them to ____ and resp distress |
transient tachypnea |
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The ______ incision results in less postop pain, less bleeding, and fewer incidents of ruptured uterus. |
low transverse uterine incision |
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The ____ incision of the uterus may involve part of the fundus, resulting in more postop pain, more bleeding, and increased change of uterine rupture |
classical vertical incision |
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How do c-section lochia changes, placental site healing, and aseptic needs compare to vaginal clients? |
They are the same. Amount of lochia may be scant due to the exploration and cleaning of the uterus just after delivery of the placenta. |
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A lapartomy of any kind, including c-section birth, predisposes the client to postoperative _______. What intervention is necessary? |
paralystic ileus
When the bowel is manipulated during surgery, it ceases peristalsis, and this condition may persist. (absent bowel sounds, abdom distention, n/v, tymphany on percussion) early ambulation |