Medical 2-23-Intrapartal Nursing

Front 1

First stage of labor normal vital signs?

Back 1

blood pressure:
less than 135 systolic and less that 85 systolic in adult 18 years or no more
than 15-20 mmHg rise in systolic pressure over baseline bp

pulse: 60-90 bpm

respirations: 14-22 min

pulse 95% or greater

temperature: 98-99.6F

Front 2

First stage of labor normal weight?

Back 2

25-35 lb greater than prepregnant weight

Front 3

First stage of labor normal findings?

Back 3

normal breath sounds, clear, and equal

fundus: at 40 weeks' gestation just below xiphoid process

edema: slight amount of dependent edema

hydration: normal skin turgor, elastic

perineum: tissues smooth, pink color; clear mucus; may be blood tinged with earthy or human odor
presence of small amount of bloody show that gradually increases with further cervical dilatation

Front 4

First stage of labor normal labor status?

Back 4

uternine contractions: regular pattern

cervical dilatation: progressive cervical dilatation from size of fingertip to 10 cm

cervical effacement: progressive thinning of cervix

fetal descent: progressive descent of fetal presenting part from station -5 to +4

membranes: may rupture before or during labor

findings on nitrazine test paper: pH 5.0 to 6.0
intact membranes

pH 6.5 to 7.5
ruptured membranes
alkaline

amniotic fluid clear, with earthy or human odor, no foul-smelling odor

Front 5

First stage of labor normal fetal status?

Back 5

FHR: 110-160 bpm

presentation: cephalic 97%
breech 3%

position: left-occiput-anterior (LOA) most common

activity: fetal movement

Front 6

First stage of labor laboratory evaluation..
hematologic tests..
hemoglobin?

Back 6

12-16 g/dL

Front 7

First stage of labor
lab evaluation..
hematologic tests
hematocrit?

Back 7

38%-47%

Front 8

First stage of labor laboratory evaluation..
hematologic tests..
RBC?

Back 8

4.2 - 5.4 million/mm3

Front 9

First stage of labor laboratory evaluation..
hematologic tests..
WBC?

Back 9

4500-11,000/mm3, although leukocytosis to 20,000/mm3 is not unusual

Front 10

First stage of labor laboratory evaluation..
hematologic tests..
platelets?

Back 10

150,000 - 400,000/mm3

Front 11

First stage of labor laboratory evaluation..
hematologic tests..
Serologic testing
STS or VDRL test?
Rh

Back 11

nonreactive

Front 12

First stage of labor laboratory evaluation..
hematologic tests..
urinalysis?
glucose?
ketones?
proteins?
rbcs?
wbcs?

Back 12

all negative

Front 13

Contractions Characteristics
in latent phase?

Back 13

every 10-30 min x 20-40 sec; mild, progressing toevery 5-7 min x 30-40 sec; moderate

Front 14

Contractions Characteristics
in active phase?

Back 14

every 2-3 min x 40-60 sec; moderate to strong

Front 15

Contractions Characteristics
in transition phase?

Back 15

every 1.5 to 2 min x 60-90 sec; strong

Front 16

Labor Progress Characteristics in primipara:

Back 16

1.2 cm/hr dilatation
1 cm/hr descent
less than 2 hr in second
stage

Front 17

Labor Progress Characteristics in multipara:

Back 17

1.5 cm/hr dilatation
2 cm/hr descent
less than hr in second stage

Front 18

What kind of tape test to use in performing an intrapartal vaginal exam if there has been fluid leakage reported or noted?

Back 18

Nitrazine pH test paper

Front 19

When performing an intrapartal vaginal examination, perform exam during and between contractions because?

Back 19

cervical effacement, dilatation, and fetal station are affected by presence of contraction

Front 20

When performing an intrapartal vaginal examination, palpate the presenting part because?

Back 20

doing that is necessary to assess the position of the fetus and to evaluate fetal descent

Front 21

When performing an intrapartal vaginal examination, assess fetal descent and station by identifying?

Back 21

position of posterior fontanelle

Front 22

When performing an intrapartal vaginal examination, positioning hand with wrist straight and elbow tilted downward allows fingertips to point toward the ________ and find the __________.

Back 22

umbilicus
cervix

Front 23

When performing an intrapartal vaginal examination, position the woman with ________ flexed and abducted...put _____ of _____ together

Back 23

thighs
heels
feet

Front 24

When performing an intrapartal vaginal examination and woman has ruptured membranes, use ______ exam if she's not in active labor.

Back 24

digital

Front 25

Before labor begins, what is cervix like?

Back 25

long about 2.5 cm
sides feel thick
cervical canal is closed
(examining finger can't be
inserted)

Front 26

How does nurse gauge cervical dilatation?

Back 26

places index and middle fingers against cervix and determines the size of the opening

Front 27

Assess FHR prior to?

Back 27

initiation of labor-enhancing procedures
ex: artificial rupture of membranes

periods of ambulation

medication administration

initiation of analgesia/anesthesia administration

Front 28

Assess FHR following?

Back 28

rupture of membranes
recognition of abnormal
uterine activity patterns,
such as increased basal
tone or tachysystole
evaluation of oxytocin
(maintenance, increase, or
decrease of dosage)
administration of medications
(at time of peak action)
expulsion of enema
urinary catheterization
vaginal examination
periods of ambulation
evaluation of analgesia
and/or anesthesia (main-
tenance, increase, or
decrease of dosage)

Front 29

Define electonic fetal monitoring (EFM)?

Back 29

provides continuous tracing of FHR..recording 2 successive FHBs...
ex: interval between 2 beats is 0.5 seconds, rate for one full minute would be 120 bpm

Front 30

Define Leopold's maneuvers?
600

Back 30

systematic way to evaluate maternal abdomen...difficult to assess on obese or hydroamnios...have woman empty bladder...complete procedure between contractions...includes 4 maneuvers

Front 31

First maneuver of Leopold?

Back 31

fetal head: firm, hard, round, moves independently

looking for what occupies fundus....
breech: feels softer and symmetric and has small bony prominences...moves with trunk

Front 32

Second maneuver of Leopold?
(after finding what occupies fundus in first maneuver, head or breech butt)
Put on your breeches! :)

Back 32

find fetal back and if it's on left or right side of abdomen...use deep, gentle pressure, using palms...
fetal back feels firm and smooth and should connect what was found in fundus with a mass in inlet... after back located, palpate fetal extremities on opposite side of abdomen

Front 33

Third maneuver of Leopold?
(after finding back and extremities)

Back 33

grasp underneath belly just above symphysis pubis with thumb and fingers of right hand and find which fetal part is lying above inlet...validates presenting part

Front 34

Fourth maneuver of Leopold?
(after finding presenting part under belly...look for cephalic prominence which is the brow)

Back 34

so, if first cephalic prominence palpated is on the same side as the back, head is not flexed...
if the first prominence found is opposite the back, head is well flexed

Front 35

Advantages of telemetry?

Back 35

continual strapped monitoring and woman can ambulate...monitors direct and indirect FHR, indirect monitoring uterine pressure, dual FHR monitoring twins

Front 36

Define baseline rate?

Back 36

refers to range of FHR observed between contractions during a continuous 10-minute period of monitoring...does not include rate during contractions; normal baseline 110 to 160

Front 37

Mild tachycardia?

Back 37

161 to 180 bpm

Front 38

Severe tachycardia?

Back 38

181 bpm and up

Front 39

Possible causes of fetal tachycardia?

Back 39

hypoxia..stimulates SNS
maternal fever..fetus
metabolism accelerates
betasympathomimetic drugs
have cardiac stimulant
effect
maternal hyperthyroidism may
cross placenta stimulating
FHR
fetal anemia - heart rate
increases to improve tissue
perfusion
dehydration

an ominous sign if coupled with other FHR patterns

Front 40

Define baseline variability?

Back 40

a measure of the interplay .."push-pull" effect between SNS (which acts to increase heart rate) and PNS (which acts to decrease heart rate

Front 41

Define fetal bradycardia?

Back 41

FHR of less than 110 to 120 bpm continuing for 10 minutes or more...can be a benign or ominous sign

Front 42

Define moderate bradycardia?

Back 42

FHR of 80 to 110 bpm

Front 43

Define severe bradycardia?

Back 43

FHR of less than 80 bpm for 2 to 3 minutes

Front 44

Causes of fetal bradycardia?

Back 44

late (profound) fetal asphysxia...there is depression of myocardial activity

maternal hypotension...maternal hypotension results in decreased blood flow to the fetus

prolonged umbilical cord compression...fetal baroreceptors are activated by cord compression, which produces vagal stimulation, and in turn decreases FHR

felal arrhythmia..associated with complete heart block in the fetus

Front 45

When is fetal bradycardia benign?

Back 45

if average variability is present...AV is 6-25 bpm

Front 46

When is fetal bradycardia ominous?

Back 46

when it's with:
decreased variability 0-5 bpm
late decelerations
or both

Front 47

Define long-term variability (LTV)?

Back 47

refers to the larger rhythmic fluctuations of the FHR that occur from 3 to 5 cycles per minute with a normal range of 6 to 10 bpm...refers to difference between lowest FHR and highest FHR in each cycle within 1 minute...increased by fetal movement and decreasd or absent when fetus is in a sleep cycle...

classified into decreased/minimal
variability 0-5 bpm
moderate/average variability
6-25 bpm
marked variability
(saltatory) greater than
25 bpm

Front 48

Define saltatory pattern (marked variability greater than 25 bpm)?

Back 48

a type of LTV...characterized by rapid variations in FHR that have a bizarre appearance...
occurs with a cycle frequency of 2 to 5 per minute and amplitude greater than 25 bpm..etiology uncertain but not thought to be bad for fetus

Front 49

Amplitude of LTV tracings are classified into?

Back 49

0-5 bpm MV
6-25 bpm AV
greater than 25 bpm
saltatory

Front 50

Define sinusoidal patterns?

Back 50

unusual...undulant sine wave that is equally distributed above and below baseline...FHR ranges between 120 and 160 bpm..amplitude 5 to 15 bpm (like AV)...oscillates in 2 to 5 cycles per minute...ominous for fetus

Front 51

The sinusoidal pattern is associated with?

Back 51

severe asphyxia
Rh isoimmunization
severe anemia
abruptio placentae
fetal-maternal hemorrhage
severe fetal acidosis

a transient sinusoidal pattern might be sign in a bening labor

pseudosinusoidal pattern might be seen in med administration

if ominous ones seen on external monitoring, switch to internal monitor and consider c-section

Front 52

Define short-term variability (STV)?

Back 52

refers to the differences between successive heartbeats as measured by the R-R wave interval of QRS cardiac cycle and therefore represents actual fluctuations from one beartbeat to the next...classified as either present or absent...accuracy on internal monitors only...indicates appropriate fetal CNS function...so if listed as present, it's a good thing...oxygen deficit, then STV absent, bad...

Front 53

Define accelerations?

Back 53

<spontaneous ones occur with fetal monitoring and are reassuring>
<uniform ones may indicate partial umbilical cord compression (vein), benign pattern>
transient increases in FHR...nonperiodic ones are normally caused by fetal movement...if baby moves, heart rate goes up (exercise)...baby quiets down then FHR goes down...so when uterus contracts, baby moves and fetal heart rate increases...

may also be compression of cord during uterine contractions which cuts off maternal blood supply briefly causing FHR to compensate by increasing cardiac output

Front 54

Define decelerations?

Back 54

periodic decreases in FHR from normal baseline..can be early, late, variable according to when they occur in contraction cycle and to their waveform

Front 55

Define early decelerations?

(For exam, know descriptions of early, late, and variable decelerations, nursing actions, and causes
ex: head compression vs uteroplacental insufficiency or cord compression

Back 55

<causes vagal response to head compression>
due to pressure on fetal head as it progresses down the birth canal...<they have a uniform appearance that inversely mirrors that of the corresponding contraction>...benign at 4-7cm unless seen with lack of descent of fetal head

Front 56

Define late decelerations?

Back 56

<begin after the peak of contraction, return to baseline after contraction is over>
<uniform shape>
<due to uteroplacental insufficiency>...result of decreases in blood flow that impede oxygen transfer to fetus through intervillous space during uterine contractions, causing hypoxemia...ominous...supine mother may be cause...<nurse can help by raising mother's upper trunk or turning her to the side to displace pressure of gravid uterus on inferior vena cava (syndrome)>
<INCREASE FETAL 02 ANDN UTEROPLACENTAL PERFUSION
*maternal position change
*check bp, increase IV
*O2 via face mask @ 8-10L
DECREASE UTERNINE ACTIVITY
*by stopping pitocin (oxy),
hydrate, tocolytics
CALL DOCTOR!! GET HELP!!>

Front 57

Immediate nursing interventions regarding late decelerations might include?

Back 57

changing maternal position
providing oxygen to mother
via face mask
increasing administration of
IV fluids
stop pitocin (oxytocin) if

Front 58

Define variable decelerations?

Back 58

<variable in shape, occurrence and look like a "v"...may/may not occur with contractions>
vary in their onset, occurrence, duration, intensity, and waveform...visible abrupt decrease in FHR...may be <cord occlusion>, cord around neck, short cord...if it persists, then could be ominous....get acid-base status of fetus because c-section, forceps, or vacuum may be indicated

membrane rupture causes variable decelerations

Front 59

Define prolonged decelerations?

Back 59

<those in which the FHR DECREASES (BELOW BASELINE) from baseline for 2 to 10 minutes....may be seen with sudden occult or frank prolapse of cord, regional anesthesia due to maternal hypotension, abruptio placentae, uterine hypertonus, hyperstimulus, drug reactions, terminal fetal conditions, maternal seizures, maternal death....nurse should investigate...intervention may be as simple as position change

Front 60

Define combined decelerations?

Back 60

may be seen occasionally when two different deceleration patterns occur together..deal with the most ominous pattern first

Front 61

"It is important for you to turn on your left side right now because the baby is having a little difficulty. I'll explain what is happening in just a few moments."

Back 61

Look at the mother when speaking to her...not the machines. The mother is the central focus.

Front 62

Doppler or intermittent fetal monitoring is used typically for?

Back 62

<low risk patients>
<used to detect FHR>

Front 63

The tocodynanometer is a device used to?

Back 63

<assess uterine contractions
U/C's or UC's>

Front 64

Components of the fetal monitor tracing?

Back 64

<fetal heart rate/tones
*rate, presence of
periodic changes
*top line on monitor strip
paper

uterine contraction pattern
*frequency, duration
*bottom line on monitor
strip paper
*looks like upside down
U

time interval
*in US, fetal monitor
paper printing speed is
3 cms per minute

Front 65

Intensity can only be measured with which monitor?

Back 65

<IUPC>

Front 66

What is resting tone?

Back 66

<the uterine tone between UC (where is the bottom line when she is not contracting)>

Front 67

How is intensity measured?

Back 67

<in mmHG if using an IUPC...values are read from strip readout>

Front 68

With an external monitor, intensity/pressure is assessed by ______ and reported as _______, _______,
_________.

Back 68

<palpation

mild, moderate, firm>

Front 69

Fetal heart rate graph shows?

Back 69

<FHR printed out as a continuous line on top graph of paper...
horizontal lines denote 10 bpm increments...
paper has FHR value printed periodically to assist in ready determination of FHR>

Front 70

The FIRST thing to assess with FHR is the?

Back 70

<baseline...determined by evaluating rate between UC and between any periodic change...normal baseline FHR is 120-160 bpm>

Front 71

The SECOND thing to assess is?

Back 71

variability...which is the fluctuation of heart rate in two periods of time

Short term variability (STV):
the "grass-like" appearance of the FHR baseline

Long-term variability (LTV): the "rollercoaster" appearance of the FHR tracing