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139 Cards in this Set
- Front
- Back
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What are the 5 critical elements of labor?
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1. Fetus
2. Pelvis Passage 3. Physiologic forces 4. Psychosocial 5. Relation of fetus and pelvis |
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What is the fetal lie?
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relationship of long axis of body to long axis of mother
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What are the fetal lies?
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Longitudinal or Transverse
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What is presentation?
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Fetal structure entering pelvis first
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What are the three presentations?
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1. Cephalic (96%)
2. Breech (3%) 3. shoulder (.2%) |
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What is caput succedaneum?
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1. Swelling of infant's scalp
2. no damage to brain or cranial bones 3. relatively harmless 4. can increase jaundice |
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What is cephalohematoma?
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1. bleeding under the scalp
2. serious condition |
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What is molding?
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the way the fetus' head is shaped through childbirth
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What is the fetal position?
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Location of presenting part in relation to 4 quandrants of maternal pelvis
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What is the fetal attitude?
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fetal parts' relations to each other part
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What are the three letter systems for Fetal position?
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1. L or Right for right or left side of pelvis
2. O for occiput, M for mentum, A for acromion, S for sacrum, Sc for scapula 3. A for anterior, T for transverse, or P for posterior |
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What are premonitory signs of labor?
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1. lightening
2. Braxton-hicks contractions 3. bloody show 4. spontaneous rupture of membranes |
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what is lightening?
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1. fetus beginning to setle in inlet
2. leg cramps, pelvic pressure, increased urination |
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What is bloody show?
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1. blood expelled from mucuous plug at cervical canal
2. labor can begin in 24-48 hrs |
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what is a frank breech?
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1. fetal hips flexed and knees extended
2. fetal buttocks presents |
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What is a footling breech?
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1. fetal hips and legs extended
2. feet of fetus presents |
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What maternal pelvises are good for labor?
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1. gynecoid and antrhopoid
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What pelvises are bad for labor?
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1. android and platypelloid
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Strong signs of true labor?
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1. regular contractions
2. shortening intervals 3. increasing intensity 4. back to abdomen pain 5. bloody show |
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What is the first stage of labor?
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1. beginning of labor to complete cervical dilation
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What is the latent phase?
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1. 0-3 cm
2. 3-30 min apart contractions lasting 30-40 sec |
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What is the active phase?
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1. 4-7 cm dilation
2. 2-5 min apart, 40-60 sec long |
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What is the transition phase?
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1. 8-10 cm
2. 1.5-2 min apart for 60-90 sec 3. very strong |
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What is the second stage of labor?
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1. Complete cervical dilation to birth of child
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What are some physiological changes preceding labor?
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1. backache
2. Slight weight loss 3. Energy burst |
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What should nurse do immediately following a rupture of membranes?
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check fetal heart rate for decelerations
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What occurs after ROM and FHR check?
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assessment of amniotic fluids
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What is a normal finding for amniotic fluids?
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1. watery, clear, pale-straw yellow color
2. no foul odor 3. volume between 500-1200ml 4. Nitrazine paper used to confirm amniotic fluid presence |
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Normal findings for nitrazine test?
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1. Amniotic fluid is alkaline
2. Nitrazine paper should turn deep blue 3. Yellow paper means slightly acidic (negative test)` |
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What is fetal flexion?
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chin flexed to chest, extremities flexed to torso
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What is fetal extension?
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chin extended away from chest, extremities extended
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What is fetal station?
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1. fetal descent in centimeters
2. 0 point is level at ischial spines 3. negative value is superior to spines |
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How should a woman position herself in labor?
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different movements and positions based on body
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What are some nursing actions during pre-procedure of labor and birth?
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1. leopold maneuvers
2. External electronic monitoring 3. External fetal monitoring |
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Explain leopold maneuvers
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1. abdominal palpation of number of fetuses
2. presenting part, lie, attitude, descent 3. find possible fetal heart tone position |
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What is the electronic monitoring tocotansducer?
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1. applied to maternal abdomen over fundus to measure uterine activity
2. shows contraction patterns 3. can be applied by nurse |
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What is the external fetal monitor?
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transducer applied to abdomen to assess FHR during labor and birth
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What laboratory tests are done pre-procedure for birth and labor?
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1. Group B streptococcus (36-37 weeks ideally)
2. Urinalysis 3. Blood tests |
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What happens if the Group B Strep is positive?
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1. IV prophylactic antibiotics prescribed
2. Doesn't matter for a caesarean birth |
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What is the purpose of a Intrapartum urinalysis?
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1. Hydration status (specific gravity)
2. Nutritional status (ketones) 3. Proteinuria, indicative of gestational hypertension 4. UTI w/ bacteria count |
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What is the purpose of an intrapartum blood test?
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1. Hct level
2. ABO typing and Rh-factor |
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What are some nursing assessments during intrapartum?
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1. Vital sings
2. FHR 3. Labor contraction characteristics by palpation 4. Vaginal Examine (physician or qualified nurse) |
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When is maternal temperature assessed once ROM occurs?
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1-2 hrs
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What must occur before electrode placement for EFM?
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cervical dilation and ROM
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Where are labor contractions palpated?
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hand over the fundus
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What are some abnormal findings for labor contraction assessment?
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1. too long (over 90 seconds)
2. too frequent ( >5 in 10 minute period and <30 sec between) |
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What is a possible effect of abnormal labor contractions?
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fetal hypoxia and decreased FHR
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What are some adaptations a fetus makes through the birth canal?
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1. Fetal head flexes to present a smaller diameter
2. Fetus should rotate to a lateral anterior position (corkscrew motion) 3. Extension upon passing symphysis pubis |
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What is the normal duration of the first stage of labor?
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12.5 hrs roughly
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What is the normal duration of the latent phase and maternal characteristics?
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1. 4-6 hrs
2. talkative and eager |
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What is the normal duration of the active phase?
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1. 2-3hr
2. anxiety, restlessness |
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What is the normal duration of the transition phase?
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1. 20-40 min
2. tired, irritable, nausea, urge to push, rectal pressure |
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How long is the second stage of labor?
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30 min- 2hr or 5-30 min
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How long for third stage of labor?
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5-30 min
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What is a schultz presentation?
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shiny fetal surface of placenta first
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What is a duncan presentation?
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dull maternal surface of placenta emerges first
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What is the nursing assessment during fourth stage of labor?
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1. Vital signs
2. Fundus 3. Lochia 4. Perineum 5. Urinary Output 6. Mother-baby interaction |
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What are some nursing interventions during fourth stage of labor?
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1. vitals q15 min for first hour
2. fundus and lochia q15 for first hour 3. Massage uterine fundus or administer oxytoics as presscribed to prevent hemorrage 4. Assess client's perineum 5. Encourage voiding 6. Promote bonding |
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What causes pain during first stage of labor?
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1. dilation, effacement, distention, contractions
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What causes pain during the second stage of labor?
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distention of vagina and perineum and pressure on pelvic structures
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When do spinal blocks start to work?
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second stage of labor
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When do epidurals begin to work?
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Active phase of labor
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When does pudendal work?
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second stage of labor
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What are some non-pharmological pain interventions?
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1. patterned breathing
2. Aromatherapy, breathing, music, lighting changes 3. Back rubs, effleurage, sacral counterpressure 4. hydrotherapy |
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When are sedatives used?
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1. during early or latent phases, but not during birth
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What are some sedatives for pain?
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seconal, nembutal, and luminal
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What are some opioids for pain management?
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demerol, sublimaze, stadol, nubain
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Which opioids provide pain relief without respiratory distress?
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stadol and nubain
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What are some nursing interventions before opioids are given?
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1. verify labor is well established
2. cervical dilation at least 4cm with engagement 3. administer antiemetics 4. monitor vitals, contrations, and FHR |
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What is used for reversal of opioid-induced respiratory depression?
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Narcan
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What helps relieve nausea form opioids?
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Zofran and Reglan
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What are some adverse effects of epidural block?
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constipation, bradycardia/tachycardi, hypotension, respiratory depression, pruritis
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When is an epidural block administered?
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active labor w/ 4cm dilation
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Nursing interventions with an epidural block?
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1. IV fluid bolus
2. Position client into proper positions 3. Side-lying position after insertion of epidural catheter 4. Monitor vitals 5. monitor FHR 6. prepare for orthostatic hypotension with IV vasopressor |
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When to auscultate for FHR in low risk women?
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1. latent phase = q1hr
2. Active phase = q30 min 3. Second stage = q15 min |
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When to auscultate for FHR in high-risk women?
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1. latent = q30 min
2. active = q15 min 3. second = q5 min |
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When does a nurse need to assess FHR?
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1. ROM
2. Before and After ambulation 3. Before and after analgesia medications 4. Peak of anesthesia 5. after vaginal examination 6. after expulsion of an enema 7. after catheterization 8. any abnormal contractions |
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What is a normal FHR?
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110-160 w/ increases and decreases from baseline
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What are some indications for continual fetal monitoring?
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1. multiple gestations or augmentation of labor
2. placenta previa 3. fetal bradycardia 4. maternal complications 5. intrauterine growth restriction 6. postterm 7. active labor 8. meconium-stained amniotic fluid 9. abruption placenta 10. abnormal nonstress test 11. abnormal contractions 12. fetal distress |
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What is normal FHR pattern?
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1. marked variability within 10 min window
2. 2 min of baseline segments in 10 min window |
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What are the classifications of variability?
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1. absent or undetectable variability
2. minimal (less than 5/min) 3. moderate variability (6 to 25/min) 4. Marked variability (>25/min) |
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What is a category I FHR?
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1. normal HR
2. moderate variability 3. accelerations present or absent 4. early decelerations are present or absent 5. variable or late decelerations are absent |
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What is a category II FHR?
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1. anything that isnt category I or III
2. tachycardia 3. bradycardia w/o absent variability 4. minimal variaiblity or marked 5. Decelerations greater from 2-10/min |
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What is category III FHR?
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1. sinusoidal pattern
2. Absent baseline heart rate variability w/ variable decelerations, bradycardia, or late decelerations |
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What are some non-reassuring FHR patterns?
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1. bradycardia/tachycardia
2. Absence of variability 3. Late decelerations 4. Variable decelerations |
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What does a non-reassuring FHR pattern indicate?
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possible fetal hypoxia
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What can cause Fetal bradycardia?
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1. uteroplacental insufficiency
2. umbilical cord prolapse 3. maternal hypotension 4. umbilical cord compression 5. heart block 6. anesthesia |
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What are the nursing interventions for fetal bradycardia?
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1. discontinue pitocin
2. assist client to side-lying position 3. administer oxygen mask 8-10L 4. Insert IV catheter 5. administer tocolytic meds if prescribed |
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What can cause fetal tachycardia?
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1. infection
2. anemia 3. fetal heart failure 4. fetal cardiac arrhythmia 5. Maternal drug use 6. Maternal Dehydration |
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What are some nursing interventions for fetal tachycardia?
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1. antipyretics for fever
2. oxygen 8-10 L 3. IV fluid bolus |
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What are some causes of decreased FHR variability?
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1. medications
2. hypoxemia w/acidosis 3. congenital abnormalities |
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What are some interventions for decreased FHR variaiblity?
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1. stimulate fetal scalp
2. assist provider with scale electrode 3. place client in left-lateral position |
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What are some causes of early FHR variability?
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1. compression of fetal head
2. a vaginal exam 3. fundal pressure |
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What are some interventions for early FHR deceleration?
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none required
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What are some causes of late deceleration of FHR?
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1. Uteroplacental insufficiency
2. maternal hypotension 3. abruptio placentae 4. uterine hyperstimulation from pitocin |
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What are some nursing interventions for late decelerations of FHR?
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1. side-lying position
2. Insert IV catheter and increase IV fluids 3. Stop Pitocin 4. Administer oxygen 5. prepare for assisted vaginal or cesarean birth |
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What are some causes of variable decelerations of FHR?
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1. cord compression
2. short cord 3. prolapsed cord 4. nuchal cord (cord around fetal neck) 5. Oligohydramiios |
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What are some interventions for variable decelerations of FHR?
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1. reposition client from side-side or knee-chest
2. discontinue pitocin 3. administer oxygen 8-10 L 4. perform or assist with vaginal examination 5. assist with amnioinfusion if necessary |
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First nursing intervention on suspicion of ROM?
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FHR monitor
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Second nursing intervention after FHR monitor after ROM?
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1. nitrazine paper test (turns blue is positive)
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What are the nursing assessments during first stage of labor?
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1. Leopold maneuvers
2. Vaginal examination 3. ROM assessments 4. Bladder palpation 5. Encourage patient to void frequently 6. Vitals, FHR monitoring |
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Why is bladder palpation done during first stage?
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1. prevent distention
2. fetal descent can be impeded by distention |
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Nursing interventions during active stage of labor?
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1. deep cleansing breaths
2. effleurage 3. upright positions, abulation, hydrotherapy 4. voiding q2hr 5. position changes 6. paced breathing with deep cleansing breaths |
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Nursing interventions during transitional stage of labor?
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1. pant-pant-blow breathing pattern
2. discourage pushing until full cervix dilation |
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what client statement can indicate complete dilation and fetal descent?
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a strong urge to have a bowel movement
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What are some nursing assessments during second stage of labor?
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1. Vitals q5-30 min
2. uterine contractions 3. FHR q15 and immediately after birth 4. assess perineum |
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What are the degrees of perineum lacerations?
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1. through skin but no muscle tear
2. through skin and muscles of perineum 3. through skin, muscles, perineum, and anal sphincter 4. skin, muscles, perineum, sphincter, and rectal wall |
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What are some nursing interventions during second stage?
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1. assist in positioning
2. promote rest between contractions 3. cleanse perineum as needed 4. prepare for epistomosy as needed 5. Prepare for birth of child |
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How does the nurse prepare for the birth of the child?
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1. oxygen flow and tank on warmer
2. preheat radiant warmer 3. available stethoscope and bulb syringe 4. resuscitation equipment ready |
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What nursing assessments during third stage of labor?
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1. Vitals q15 min
2. signs of placental separation from uterus 3. APGAR scores of neonate |
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What are some signs of placental separation from uterus?
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1. fundus firmly contracting
2. swift gush of dark blood 3. umbilical cord appears to lengthen 4. vaginal fullness on exam |
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What are some nursing interventions during third stage of labor?
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1. have patient push once placental separation is indicated
2. promote mother-baby activities 3. drugs as needed 4. oxytocis to stimulate uterus contraction (prevent hemorrhage) 5. Cleanse the perineal area and apply pad or icepack |
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What are some nursing assessments during the fourth stage of labor?
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1. Vitals
2. Fundus 3. Lochia 4. Urinary Output 5. family interaction |
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What are some nursing interventions during 4th stage of labor?
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1. assess vitals q15 for first hour
2. asses fundus and lochia q15 for first hour 3. massage fundus and administer oxytocics 4. encourage voiding to prevent bladder distention |
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What are some indications for induction of labor?
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1. postterm pregnancy
2. dystocia from inadequate contractions 3. prolonged rupture of membranes 4. Maternal diabetes, pulmonary disease, gestational hypotension 5. fetal danger 6. chorioamnionitis |
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Nursing interventions for administration of pitocin?
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1. fetus engaged and station of 0
2. pitocin is piggy-backed to main IV line 3. vitals q30 and change in dose 4. I/Os 5. Bishop score rating |
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When to discontinue oxytocin?
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1. frequency >q2min
2. duration > 90 sec 3. Uterine Pressure greater than 90 mm Hg 4. No relaxation between contractions |
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Intevernations for pitocin complications?
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1. position client in side-lying position
2. IV line fluid bolus 3. adminster O2 4. Tocolytic (brethine) subcutaneous as prescribed 5. monitor FHR |
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Indications for amnioinfusion?
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1. oligohydramnios
2. fetal cord compression secondary to postmaturity of fetus |
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Indications for cervical ripening?
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1. failure to dilate or efface
2. diminished progression 3. any condition indicating augmentation or induction |
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What is a bishop score?
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1. used to determine maternal readiness for labor
2. 5 factors assigned values 0-3 3. greater than 8 for multiparous and 10 for nulliparous client |
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What are the 5 factors for a bishop score?
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1. dilation
2. effacement 3. cervical consistency 4. cervical position 5. station of presenting part |
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Indications for external cephalic version?
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1. Malpositioned fetus in brech or transverse position after 27 weeks gestation
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Contraindications for external cephalic version?
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1. Uterine anomalies
2. previous cesarean births 3. cephalopelvic disproportion 4. placenta previa 5. multiple gestations 6. oligohydramnios |
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indications for vacuum-assisted delivery?
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1. Maternal exhaustion, ineffective pushing
2. Fetal distress during second stage |
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Indications for a forceps-assisted birth?
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1. fetal distress during labor
2. abnormal presentation, breech position requiring delivery of head 3. arrest of rotation |
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indications of episiotomy?
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1. shortening of second stage
2. facilitate forceps or vacuum assisted delivery 3. prevent cerebral hemmorrhage 4. facilitate birth of a large fetus |
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What is a median episiotomy used for?
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1. easier to repair
2. less blood loss 3. can increase third/fourth degree lacerations |
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What is a mediolateral episiotomy for?
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1. larger blood loss, more difficult repair
2. used when posterior extension is likely |
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What is a prolapses umbilical cord?
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cord is displaced, preceding presenting part, or protruding through cervix
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Evidence for a prolpased umbilical cord?
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1. patient reports something through vagina
2. visulaization or palpation of cord 3. FHR monitor with variable or prolonged deceleration |
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Nursing care for prolapsed umbilical cord?
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1. call for assistance
2. sterile glove to apply finger pressure in vagina to separate cord from presenting part 3. client in a knee-to-chest, trendelenburg, or side-lying position 4. continuous FHR monitoring 5. oxygen 8-10L 6. IV acess with fluids 7. prepare for possible cesarean brith |
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What is meconium-stained amniotic fluid?
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sign of hypoxia, because vagal nerve causes meconium to be defecated into amniotic fluid
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Signs of meconium-stained amniotic fluid?
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1. black, green, yellow, or brown fluid
2. bad when accompanied by variable or late decelerations 3. prepare for possible neonatal resuscitation |
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What is fetal distress?
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1. Bradycardia or tachycardia
2. FHR with decreased or no variability 3. Hyperactivity or no activity |
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Nursing care for fetal distress?
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1. left side-lying reclining position, legs elevated
2. 8-10L of oxygen 3. discontinue oxytocin 4. increase IV fluids |
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What is an amniotic fluid embolism?
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amniotic fluid enters maternal circulation and obstructs pulmonary vessels
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Signs of amniotic fluid embolism?
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1. chest pain
2. maternal restlessness, cyanosis, dyspnea, pulmonary edema 3. Hypotension, shock, cardiac arrest |
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Nursing interventions for amniotic fluid embolism?
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1. Oxygen 8-10L
2. assist with intubation and mechanical ventilation 3. CPR if necessary 4. IV fluids 5. client on side, pelvis at 30 degrees to displace uterus 6. indwelling catheter |
