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106 Cards in this Set

  • Front
  • Back
The 4 stages of labor are?
Dilation and Effacement
latent
active
transitional
Expulsion
Placental
Transitional Figuration
The primagravida stays in stage 1 (D&E) on the average of?
14 hours
The primagravida stays in stage 2 (E) an average of?
1.25 hours
The primagravida stays in stage 3 (P) an average of?
1-20 minutes
The multigravida stays in stage 1 (D&E) on the average?
8 hrs
The multigravida stays in stage 2 (E) on the average?
30 minutes
General observations and behavior of mother in latent phase?
Entertainment:
talkative
excited
apprehensive
alert
follows directions
has backache
thoughts center on self
may also be mute, calm, tense
General observations and behavior of mother in active phase?
Relaxation:
molar flush serious
doubtful
threatened
suspicious
apprehensive
desires company
has more difficulty in
following directions
attention span becomes more
inner-directed, tired,
flushed
General observations and behavior of mother in transition phase?
Transition:
growing in voice
perspiration
nausea
vomiting
membranes may rupture
hiccups
coughing
leg cramps
leg shaking
tremors
perspiration on lips and
forehead
facial flush
increases show increased apprehension
feel frustrateed
trapped
emotional
irritable
thoughts are on self
vague in commincations
amnesia between contractions
General observations and behavior of mother in stage 2?
Working: Presentation
position
episiotomy
forceps

patient usually feels relief, urge to push, sometimes panic when head reaches perineum
General observations and behavior of mother in stage 3?
Schultz - 80%
Duncan - 20%

1. uterus becomes globular
2. umbilical cord descends
3 or more inches further
out of vagina
3. sudden gush of blood

alert, often euphoric, (if not sedated)

proud, happy, and relieved
concerned over baby, maternal feelings may or maya not be evident at this time..may also weep or be angry
General observations and behavior of mother in stage 4?
chilled
euphoria
too exhausted to sleep
Dilations of cervix in latent phase?
0-3 cm
Dilations of cervix in active phase?
4-7 cm
Dilations of cervix in transition phase?
8-10 cm
Dilations of cervix in stage 2?
complete
Dilations of cervix in stage 3?
cervix is flabby and soft
Contractions in latent phase?
mild, brief, irregular
Contractions in active phase?
stronger, longer, closer
Contractions in transition phase?
intense, firm, hard
Contractions in stage 2 are?
expulsive
Frequency of contractions in latent phase are?
5-30 minutes
Frequency of contractions in active phase are?
3-5 minutes
Frequency of contractions in transition phase are?
2-3 minutes
Frequency of contractions in stage 2 are?
2.5 minutes (almost continuous)
Duration of contractions in latent phase are?
10-30 seconds
Duration of contractions in active phase are?
30-45 seconds
Duration of contractions in transition phase are?
60-90 seconds
Duration of contractions in stage 2 are?
90 seconds
Station of contraction in latent phase is?
-2 to 0
Station of contraction in active phase is?
+1 - +2
Station of contraction in transition phase is?
+2 - +3
Station of contraction in stage 2 is?
increases through expulsion
Take vital signs in latent phase every?
30 minutes to 1 hour
Take vital signs in active phase every?
15 minutes
Take vital signs in transition phase every?
5-10 minutes
Take vital signs in stage 2 every?
every contraction
Take vital signs in stage 3?
no
Take vital signs in stage 4?
fundus every 15 minutes for 1 hour or for 4 hours???

fundus every 15 x 4
Check fetal heart rate in latent phase?
tone: every 15 minutes
Check fetal heart rate in active phase?
tone: every 5 minutes
Check fetal heart rate in transition phase?
tone: every 5 minutes
Check fetal heart rate in stage 2?
after each contraction
Check fetal heart rate in stage 3?
no
Check fetal heart rate in stage 4?
30 x 2
Temperature, pulse, and respirations in latent phase?
every 4 hours unless otherwise indicated (check temp every 2 hrs after membranes rupture)
Blood pressure in latent phase?
every 1 hour and before medication immediately, then every 3-5 minutes after caudal, spinal, or epidural anesthesia
Pulse and respirations in stage 4?
every 15 minutes x 4;
every 30 minutes x 2
temperature - once
Bladder in all phases of stage 1?
encourage to void every 2 hours, check for distention
Bladder in stage 4?
every 15 minutes; check for distention or residual
Nutrition and hydration in latent phase?
clear liquids with CHO added if ordered by phsician
Nutrition and hydration in active phase?
usually NPO
Nutrition and hydration in transition phase?
ice chips if ordered by doctor
Nutrition and hydration in stage 2?
usually NPO
Nutrition and hydration in stage 4?
offer fluids and diet as tolerated
Fatigue in latent stage?
preserve strength, no bearing down every 30 minutes
Fatigue in active stage?
bear down every 15 minutes between amnesia
Fatigue in transition stage?
bear down every 5 minutes
Fatigue in stage 4?
sleepy and drowsy
Vaginal secretions in latency?
bloody show
Vaginal secretions in active
phase?
check every 30 minutes because membranes may or may not be present intact or ruptured (assess nature and amount)
Vaginal secretions in transition phase?
check every 15 minutes because membranes may or may not be present intact or ruptured (assess nature and amount)
heavy show means rupture???
Vaginal secretions in stage 4?
lochia and perineum every 15 minutes
Supportive measures companionship?
In all 3 stages, patient prefers to be dependent; husband or nurse should be present
In stage 4, the mother may prefer to be ______ to rest and/or _________
alone
sleep
The position mother takes in latent phase is?
any comfortable position
The position mother takes in active phase is?
relaxation position on side or back...keep body supported
The position mother takes in transition phase is?
semi-fowler..exaggerated Sims turned on opposite side from back of fetus (favors anterior rotation of the fetal head)
The position mother takes in stage 2 is?
sitting -llithotomy table...
for pushing support mother's legs with knees flexed upon abdomen
The position mother takes in stage 3 is?
delivery table or flat bed
The position mother takes in stage 4 is?
any comfortable position
Comfort measures in latent phase are?
read, listen to music, games, cards, instructions and teaching
Comfort measures in active and transition phase are?
cool wet cloth to forehead; back rubs, sacral pressure backache, clean and dry linens, quiet restful surroundings, analgesic drugs
Comfort measures in stage 2 and stage 3 are?
support legs, feet, hands, arms to help mother push more effectively
Comfort measures in stage 4 are?
keep mother warm, partial bath, change of gown, linens, etc
Relaxation and breathing exercises in latency are?
pelvic rocking for backache, practice controlled breathing
Relaxation and breathing exercises in active phase?
abdominal breathing until no longer able to walk or talk, then chest breathing.
Relaxation and breathing exercises in transition phase are?
costal breathing...panting to help control nausea and bearing down urge...oxygen for nausea
Relaxation and breathing exercises in stages 2 & 3?
pushing, panting to slow down descent of head...small short push to deliver baby's trunk after a waiting interval
Relaxation and breathing in stage 4?
post partum exercise
Interpretation, direction, and reassurance in latency?
explanation of birth process, illustrate with birth atlas, allay patient's fears, strengthen bond between mother and father; keep father informed about progress of labor
Interpretation, direction,
and reassurance in active phase?
same as procedure in early stage
explanation of birth process, illustrate with birth atlas, allay patient's fears, strengthen bond between mother and father; keep father informed about progress of labor
Interpretation, direction,
and reassurance in transition stage?
patient is becoming oblivious to surroundings, begins to think only of herself and her work of labor
Interpretation, direction,
and reassurance in stages 2 and 3?
feelingn of stretching in perineum as baby's head is delivered..may fear tearing and stop pushing...may become panicky
Interpretation, direction,
and reassurance in stage 4?
first question if awake "is it all right?" Wants to see the baby ASAP
The dilation stage begins with the onset of _____ _____
and ends with complete _____ of ______.
true labor
dilation
cervix
Transition phase usually lasts through _____ to _____ contractions?
10 to 20
The expulsive stage begins with complete ______ of cervix and ends with birth of baby.
dilation
The placental stage begins with birth of baby and ends with _______ of placenta and membranes
expulsion
The total time of stage 3 is anywhere from ____ to_____ minutes or more.
1-20
Total time of first stage is anywhere from ____ to_____ hours or more.
2 to 16
Characteristics of stage 1 latent phase?
in early phase, when cervix dilates 0 cm to 3 cm uterine contractions may follow a regular pattern and may be accompanied by:
abdominal cramps
backache
rupture of membranes
show (blood tinged mucoid vaginal discharge)
How she may feel in stage 1 latent phase?
in early phase, excited.
she may also feel a sense of anticipation, a sense of relief, happy and some apprehension
What she may do in stage 1 latent phase?
carry on with normal activities that are possible or keep diverted with other activities of interest; try pelvic rocking if back aches; try slow chest breathing for contractions; ask doctor when to to to hospital
Characteristics of stage 1 active phase?
in mid phase when cervix dilates 4 cm to 7 cm, uterine contractions become stronger, longer (30-45 sec), more frequent and may be accompanied by pain
How she may feel in stage 1 active phase?
in midphase, apprehension; she may also feel a growing seriousness, ill-defined doubts and fears...desire for companionship...uncertain if she can cope with contractions
What she may do in stage 1 active phase?
in mid phase, assume most comfortable position...try shallow chest breathing with contractions and breathe normal between contractions; try pelvic rocking or have back rubbed if it aches...ask for medications if unable to relax...when doctor does a recall examination, relax pelvic floor
Characteristics in stage 1 transition phase?
when cervix dilates 8 cm to 10 cm...uterine contractions may become stronger and longer 45-60-90 sec., and may be accompanied by:
amnesia between contractions
cramps in legs
generalized discomfort
hiccoughing
irritable abdomen
marked restlessness
nausea and possible vomiting
pain
perspiration on upper lip
and forehead
profuse, dark, heavy show
pulling or stretching sensation
deep in pelvis
severe, low backache
shaking of legs
How she may feel in stage 1 transition phase?
increasingly apprehensive;
bewildered by intensity of
contractions
irritable and unwilling to
be touched
frustrated and unable to cope
with contraction if left
alone; eager to be "put to
sleep"
What she may do in stage 1 transition phase?
relax as much as possible..
slow, deep chest breathing usually becomes immpossible at this time...
try pant blow breathing...
if nauseated, prevent vomiting by taking and holding a deep breath...
have pressure applied to small of back if this area aches
ask for medication to ease sharpness of contraction...
keep in mind that contractions have now reached maximum strength and that relief will soon come with pushing
Characteristics of stage 2
expulsive stage?
full dilation of the cervix, accompanied by:
increased show
expulsive grunt when exhaling
rectal bulging with flattening of perineum
increased amnesia between contractions
gradual appearance of presenting part of vaginal opening; the doctor may do an episiotomy to facilitate delivery of baby
How she may feel in stage 2 expulsive stage?
increasingly involved in birth process
relief because second stage has begun
desire to bear down or push..
tremendous satisfaction with each push
desire to move bowels
complete exhaustinon after each expulsive contraction
unable to follow direction readily
desire to particpate full in total birth process or conversely to be "put to sleep"
a splitting sensation due to vaginal stretching as baby is born
What she may do in stage 2 expulsion stage?
notify nurse of desire to bear down
respond to urge to push
if in own bed
take deep breath
bend knees, spread them apart and grasp them firmly while bringing them up toward shoulders
with mouth closed, pull back on knees while bearing down or pushing keeping hips flat on bed

if no energy reserve or epidural anesthesia limits mobility
grip hand rails on side of bed
with mouth closed, pull back on hand grips while bearing down or pushing, keeping hips flat and relaxing pelvic floor, continue to push down for as long as each contraction lasts
attendants to flex mother's kneees bringing them back toward
shoulders with each pushing effort or to place legs in support
rest completely between contraction
take anethesia as it is offered if necessary ask for anesthesia
pant when asked to do so or when asked to push
Characteristics stage 3 placental stage?
contractions temporarily cease upon birth of baby...
when they resume, they usually are painless and may be accompanied by:
upward rise of uterus in abdomen
uterus assuming globular shape visible lengthening of umbilical cord as placenta moves into vagina
trickle or gush of blood
How she may feel stage 3 placenta stage?
exhausted, but elated and proud of achievement...she may also feel
eager to hear and see the baby...
a sense of relief...
delight that abdomen is flat
ravenously hungry and thirsty
What she may do stage 3 placenta stage?
relieve tension by giving in to emotions
watch expulsion of placenta and membranes in overhead mirror
ask to have baby put to breast for a first feeding