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67 Cards in this Set
- Front
- Back
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Stage 1 Phase 1 is the early or ___ phase of Labor. |
Latent |
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Latent labor is accompanied by generally ___ and ___ contractions that range from ___ to ___ minutes apart, and last ___ to ___ seconds. |
Mild and erratic 5 to 20 minutes apart 20 to 60 Seconds |
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During latent labor, the cervix is ___ and slowly dilating to ___ cm. |
Effacing 3 |
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During latent labor, the woman is usually feeling: |
Excited and relieved labor has begun Ambivalent about facing labor pain Pain that feels like strong menstrual cramps, usually able to cope with the pain through relaxation and breathing techniques |
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Medical interventions that are commonly ordered during early / latent labor are: |
Labs ◇ CBC ◇ Blood type ◇ Rh ◇ Urinalysis ◇ STI screen, depending on state laws
Other ◇ IV infusion of lactated Ringer's solution or normal saline to prevent dehydration in labor ◇ Intermittent or continuous fetal monitoring
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Nursing care for the early / latent labor patient includes: |
♡ Initial physical exam ♡ Cervical exam ♡ Pain assessment ♡ Admit patient to L&D unit ♡ Orient patient and her support person to the labor room ♡ Establish a therapeutic relationship by spending time with your patient and demonstrating a willingness to answer questions ♡ Inquire about concerns or questions ♡ Reassure the support person that the nurse will be assisting with providing Comfort measures and support for both of them during labor ♡ Reinforce relaxation techniques learned in childbirth classes for teaching simple relaxation techniques ♡ Insert IV or saline lock, if ordered ♡ Review lab results and notify the position, if necessary ♡ Administer penicillin G IV, if indicated, for Group B streptococcus ♡ Encourage fluid intake with clear fluid and ice chips ♡ Food may or may not be permitted by the healthcare provider ♡ Explain the fetal monitor and apply it for intermittent or continuous monitoring ♡ Provide ongoing assessment of Vital Signs, cervical dilation and effacement, fetal heart rate, and contractions |
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Patient teaching for the patient in early / latent labor includes: |
♤ Inform her that the contractions are mild at the beginning, but will get progressively stronger and last longer ♤ Encourage relaxation through music, massage, engaging in distractions ♤ Position changes are encouraged and walking is safe ♤ Encourage clear fluids to avoid dehydration ♤ If the HCP consents, she can eat light, easily digested food ♤ Encourage her to notify the nurse if her water breaks or any bleeding is noted |
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Which medications are typically ordered for GBS prophylaxis? |
Penicillin G, ampicillin, or, if the patient is allergic to penicillin, cefazolin, erythromycin, or clindamycin may be used |
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What is the typical initial dose of penicillin G for GBS prophylaxis? |
5 million units, IV |
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What is the typical initial dose of ampicillin for GBS prophylaxis? |
2 grams IV |
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Stage 1, Phase 2 is the ___ phase of Labor. |
Active |
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Active labor is characterized by contractions that are ___ to ___ minutes apart with a duration of about ___. Dilation increases to ___ cm to ___ cm. |
2 to 3 60 seconds 4 cm to 8 cm |
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Fetal descent progresses, which causes feelings of ___. |
Pelvic pressure |
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Hyperventilation can occur if a woman breaks too fast in too deep in response to pain in labor. Hyperventilation causes a decrease in ___ in the blood. |
carbon dioxide |
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Signs of hyperventilation include |
Anxiety A feeling she cannot get enough air Elevated heart rate Lightheadedness Vertigo Numbness or tingling of the fingers Chest tightness |
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How can we help a mom who is hyperventilating? |
Encourage the patient to slow down breathing and breathe through pursed lips as if blowing out a candle Encourage the patient to close her mouth and one nostril and breathe through one nostril only Encourage the patient to cover her nose and mouth with a paper bag and breathe in and out of the bag for a few breaths only or for about 15 seconds |
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What is an amniotomy? |
It is the artificial rupture of the uterine membranes with an amnio hook. |
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Medical interventions that may occur during active labor are: |
Amniotomy Orders for pain medication / epidural anesthesia Evaluation of the maternal condition and progression of Labor Evaluation of the fetal condition |
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Nursing care during the active phase of Labor may include |
Pain assessment Vaginal exams to monitor cervical dilation, fetal position, and descent Updating the woman and her support person on progress Emotional support Assist the support person to provide Comfort / encourage them to take a break if needed Encourage clear liquids VS q 30 min Monitor fetal heart rate and contractions Non-pharmacological pain management Administer pain meds Evaluate effectiveness of pain relief methods Encourage position changes Allow mom to walk if her membranes are intact Change disposable pad when needed Assist patient with elimination as a full bladder can slow The Descent of the fetus into the pelvis |
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Patient teaching for active labor should include: |
Contractions will be getting stronger and last longer Use breathing and relaxation techniques every contraction Encourage her to ask for what she needs She should change positions often, while avoiding lying on her back unless the head of the bed is raised 30 to 45 degrees It's important to urinate at least every 2 hours Instructor to call the nurse when membranes rupture |
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Stage 1, phase 3 is the ___ phase of Labor. |
Transition |
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The transition phase is the most intense phase of Labor. It leads to ___ effacement and dilation of the cervix to ___ cm. |
complete; 10 cm |
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The transition phase is characterized by ___ contractions that peak ___, are ___ apart, and last ___. |
painful; abruptly; 2-3 minutes apart; 60-90 seconds |
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The transition phase may last ___ for a first time mother and ___ for a subsequent labor and delivery. |
1 to 3 hours; a few minutes to an hour |
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During the transition phase of Labor, the use of pain medication should be done with caution because it ___. |
depresses the CNS and can subdue the respiratory center |
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To avoid having a sedated baby, ___ are administered and timing is controlled by the nurse to allow the ___ effect to have left the mother's system before the fetus is born. |
small doses of pain medication; peak |
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True or false: A women experiencing a fast-moving transition phase may not receive pain medication if it's not safe for the fetus. |
true |
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If the patient becomes nauseated, through nurse needs to ___. |
Assist her to a safe position to prevent aspiration if she vomits |
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Pushing too early can cause the cervix to___, causing ___ so the patient and support person should notify the nurse if she begins to push or bear down so the nurse can assess ___. |
swell; slowing of dilation; if she is fully dilated |
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During the transition phase of Labor, the nurse should assess: |
Fetal heart rate and contractions every 15 minutes Cervical dilation |
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During the transition phase of Labor, the nurse should communicate ___ to the ___. |
labor progress to the healthcare provider. |
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During the transition phase of Labor, the nurse should also |
Assist the patient with breathing techniques Provide Comfort measures and encouragement Remind her to urinate Assist for personal hygiene prepare the room for delivery Remain in the room with patient and family |
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The transition phase is the hardest but ___ phase of labor. |
Shortest |
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What is pant - blow breathing? |
Quick breathing in and out of the mouth. After every 3 to 5 quick breaths, the patient should do a longer exhale. |
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Even if an epidural has been administered, mother may experience ___ and ___, leg ___, and alternating ___ and ____. These need to be reported to the nurse as these are signs of transition. |
Nausea and vomiting; shakiness; chills and sweats |
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Pushing without a nurse or healthcare provider present could result in an unattended birth and can lead to ___. |
complications for the woman and her baby. |
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As soon as the cervix is completely dilated, the woman enters the ___ stage of labor. |
second |
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The second stage of Labor ends with the ___. |
Birth of the baby |
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During the second stage of labor, contractions may be ___ apart and last about ___. |
2 to 3 minutes apart; 60 seconds |
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True or false: The contractions during the second stage of Labor are not as intense as during the transition phase of Labor. |
True |
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What is "laboring down"? |
It is when the fetus will move slowly down the birth canal with the pressure from the contractions. |
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If a woman has chosen epidural anesthesia, they may not experience the urge to push and may be unable to actively push. If this is the case, what can be done? |
The medication may be decreased to allow her to feel and use the muscles required for pushing. |
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Medical interventions that may occur during the second stage of Labor include |
Perineal anesthesia Administration An episiotomy |
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What is an episiotomy? |
An incision to the perineum |
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true or false: an episiotomy can be done without the injection of anesthetic. |
True, but anesthesia is it necessary for a repair |
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What are the types of episiotomy that are ? |
Midline Mediolateral |
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Why would a healthcare provider massage the perineum? |
To assist with gentle stretching and to avoid large tears in the perineum |
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Have the head emerges from the birth canal, the healthcare provider will: |
Check for a tight cord around the neck Suction the mouth and Airway thoroughly before the chest emerges |
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Delaying clamping of the cord results in ___ and possibly allows for greater stores of ___ for the newborn. |
higher hemoglobin and hematocrit values Iron |
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Labs may be done with the cord blood specimen. These typically include which tests? |
CBC, blood type, Rh, and antibody screen |
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After the cord is cut, the infant should be ___ and placed ___ with the mother to promote ___. If the support person wishes to hold the baby, the baby should be ___ and the head ___ to maintain ___. |
thoroughly dried; skin to skin; bonding wrapped in a warm blanket; covered with a cap; warmth |
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During the second phase of Labor, the nurse should monitor ___. |
The fetal heart rate every 5 to 15 minutes |
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During the second phase of Labor, the nurse should also |
Provide Comfort measures and support, as well as perineal hygiene, remain with the patient, advocate for the patient's desires regarding her birth plan, assume care for the baby after the cord is cut |
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What is closed glottis pushing? |
The woman is directed to take a deep breath during a contraction and push with all of her energy for 10 seconds or more. |
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What is open glottis pushing? |
The woman is allowed to experience involuntary pushing when she feels the desire. She'll instinctively hold her breath and push for about 6 seconds. She'll follow pushing by taking several deep breaths and pushing again when she feels the urge to Bear Down. |
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The third stage of Labor is from the ___ until completed delivery of ___. |
Baby; placenta |
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The third stage of Labor is typically ___ and sometimes the mother may not ___. |
5 to 15 minutes; notice delivery of the placenta |
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Why do some health care providers order a bolus of oxytocin given IV or IM? |
To promote strong uterine contractions, leading to a faster placenta delivery |
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Deposition of nurse Midwife principles and over to inspect a maternal side to determine if ___. |
Any pieces are torn or missing. Missing pieces should be identified because they can lead to Hemorrhage or infection if left inside the uterus. |
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When is an episiotomy repaired? |
During the third stage of Labor |
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What is an apgar score? |
It is a quick, systematic method of assessing a newborn's physical condition at Birth |
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What physiological parameters are assessed with an apgar score? |
Heart rate Respiratory effort Muscle tone Reflex irritability Color |
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A 5 minute apgar score of ___ to ___ is considered normal. |
7 to 10 |
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A 5 minute apgar from ___ to ___ is intermediate and may be the result of physiological immaturity, maternal medications, the presence of congenital malformations, and other factors. |
4 to 6 |
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If the five-minute apgar score is below ___, the newborn should be assessed every ___ until the score is ___. |
7; 5 minutes; 7 or above |
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Nursing care during the third stage of Labor includes |
Administration of oxytocin, if ordered Five-minute apgar Providing assistance to the healthcare provider Assume care for the newborn with an emphasis on Airway and warmth Assess the umbilical cord for two arteries and one vein |
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What is uterine atony? |
A lack of normal uterine muscle tone |
