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133 Cards in this Set
- Front
- Back
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The onset of Labor is the transition from pregnancy to _______and fetus to ________ |
Pregnancy to MotherhoodFetus to newborn |
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We know labor is multi-dimensional, so other than Dimensions what four things work together to create the miracle of birth progressing in orderly and predictable sequence? |
Powers passageway passenger Psych |
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What is the 2 basic roles of the nurse related to nursing care during labor and birth? |
Facilitate the labor process ensure safe passage of woman and fetus |
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It is critical for the nurse to be able to recognize and Report __________ of the labor process, and also give intensive _________ to the laboring woman and her partner or coach |
Complications, support |
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The role of the nurse during admission of the laboring woman is to monitor which 4 events immediately? |
Birth Eminence, fetal status, risk factors, and maternal status |
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When does observing signs that birth is imminent begin? |
The moment the woman arrives in labor and delivery unit |
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What is a sign considering woman's physical appearance she is in advanced stage of Labor? |
If the woman is introverted and stops to breathe or pant with each contraction |
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What are three statements made by the laboring woman that would infer she is in the second stage of Labor and the baby will be born soon? |
I feel a lot of pressure, the baby coming, I want to have a bowel movement |
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What are two more signs that the birth is imminent if she was sitting in a wc and how she is handling contractions? |
The woman is sitting on one buttock if the woman (presents in a wheelchair), and bearing down or grunting with contractions |
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In an emergency birth what should be stated to the laboring woman to help her cope with the situation?
And what should you instruct the mother to do to control birthing of the baby? |
1 Instruct the woman to remain calm and reassure her that you know what to do to assist with the delivery 2 instruct her to blow out through her lips in little Puffs as if she were blowing out candles so that she will not forcibly expel the baby in an uncontrolled manner |
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Once the baby is delivered is it necessary to cut the umbilical cord? |
No it is not immediate |
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In most facilities what is the protocol with the umbilical cord after delivery? |
Is two double clamp the cord and cut between the clamps |
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What are 3 interventions to prevent heat loss in the newborn? |
1To dry thoroughly and 2place him under the radiant warmer or 3skin to skin contact with his mother and cover them both in a blanket |
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What are 2 signs that placental separation has occurred? |
A gush of blood, lengthening of the cord at the introitus |
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If placental separation has occurred upon delivery what is the most important plan of action? And what are two ways to go about it involving contraction of the uterus? |
To prevent excessive blood loss 1 after the placenta is delivered massage the uterus to facilitate contraction 2 place the newborn to the woman's breast because the suckling action stimulates release of oxytocin which helps the uterus contract |
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A nurse must be prepared to recognize and Report _________ that may arise during the laboring process it is also critical to be prepared to give intensive _________ to the laboring woman and her partner or coach. |
Complications, support |
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The nurse's role during admission of a laboring woman includes which four focuses immediately? |
Birth Eminence, fetal status, risk factors, maternal status |
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Observing for signs that birth is imminent begins from the moment the woman what? |
Arrives in the labor and delivery unit |
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Determining birth imminent. the nurse observes the laboring woman as introverted and stops to breathe or pant with each contraction you can infer that she is in which stage of Labor? |
In advanced stage |
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When determining birth imminent . What are three quotes a laboring woman might state in the second stage of Labor and indicates the baby will be born soon? |
The baby is coming, I feel a lot of pressure, I want to have a bowel movement |
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When a laboring woman presents to the hospital with advanced Signs what are the first two interventions of the nursing staff if the presenting part is not visible yet? |
Assist to labor bed perform a vaginal examination |
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Determining birth imminent . In the occasion of an emergency birth with limited supplies and staff how will you approach in regards to calming the woman? |
1 instruct the woman to remain calm and reassure her that you know what to do to assist with the delivery2 To instruct her to blow out through her lips in little Puffs as if she were blowing out candles |
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Birth imminent. However in most facilities the protocol with an umbilical cord after delivery consists of what? |
Double clamp the cord and cut between the clamps |
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Birth imminent . What are the signs of placental separation has occurred? |
Gush of blood, lengthening of the cord at the introitus |
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Birth imminent. Why is Contracting of the uterus initiated after delivery of the placenta? |
To control bleeding and prevent blood loss |
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A woman in labor arrives at the hospital determining which is the priority nursing intervention? |
Fetal status |
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Once the laboring woman arrives to her delivery Suite what is she placed on? and what are two other methods within accepted standards for the low-risk women? |
Fetal monitor for continuous monitoring Check fetal heart rate by fetoscope Check fetal heart rate by Doppler ultrasonography |
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The FHR ( fetal heart rate) should have a Rate, Rhythm, and Quality of which? |
110 and 160 bpm, strong and regular |
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Which assessment is performed after fetal status AKA "bag of waters"? And describe what it determines. |
Risk assessment, status of membranes |
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What is an indication involving the vagina, signals the membranes have ruptured of a laboring woman? |
a gush or continual leaking of warm fluid from the vagina |
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One test to determine rupturing of membranes includes the use of a SPECULUM what does this check for to determine rupture? |
Checks for pooling of fluid in vagina |
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Another test to determine ruptured membranes includes placing NITRAZINE PAPER in the fluid this determines what? and explain results. |
to determine pH. Positive tests turn DARK BLUE= alkaline amniotic fluid is present, and rupture has occurred |
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If status of the membranes is still in question after Nitrazine test what is the next test to be performed? How is fluid examined? What is the criteria of a positive(ruptured) result? |
FERN TEST. smears fluid sample on a slide and examines under microscope, if there is a ferning pattern present this means the test is positive and rupture has occurred |
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When the membranes rupture what are 2 characteristics the amniotic fluid should present without microscope exam? |
Clear No foul odor
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If several hours has passed since the membranes have ruptured, assess the woman for signs of infection, what are three signs? |
Elevated temp (mom) Cloudy or foul smelling fluid Fetal tachycardia |
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What color of amniotic fluid indicates you to report the findings to the RN immediately and why? |
Green, signals the presence of meconium in the amniotic sac and may indicate the fetus is distressed |
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Define meconium |
Dark green substance forming the first feces of a newborn |
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When assessing other risks of the laboring woman observe for vaginal bleeding the presence of bloody show is an expected finding but what is not normal regarding blood? |
Heavy bleeding heavier than a normal menstrual. |
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If you are to discover heavy bleeding within a laboring mother what 5 pieces of information should you gather, so you can report sufficiently to the RN about the problem? |
FHR, color, amount, time began associated pain, |
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When making observations to determine if there are any risk factors with the pregnancy why is this done regarding safe delivery of the child? |
Might require a specialist to be present at the delivery |
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A quick________ _________ of the woman's status app upon admission to the hospital is crucial |
Physical assessment |
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If there is time before the delivery what would a full physical assessment of a laboring woman include?(measure what? And check for which 3 conditions?) |
Vital signs Signs of --infection, HTN, or shock |
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If there's not enough time to do a full physical assessment before delivery what is the most critical and immediate measurement needed? Which BP measurement should be reported immediately? |
Blood pressure140/ 90 |
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What are the 5 minimum supplies needed for an emergency delivery? |
One pair gloves gloves forceps One pair sterile scissorsO ne bulb syringe Blankets or towels |
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What are four recommended actions of nursing staff during an emergency delivery in which will provide a safe and uncomplicated delivery? |
quick Keep perineum in view Do not collapse the foot section of the bed Try to deliver the baby between contractions |
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During the physical assessment of a laboring woman why is it important to obtain a current weight and compare it with her weight at her most recent prenatal visit? (To watch for ? Cuz it could indicate ? Which could cause(not edema!)?) |
Sudden weight gain indicates fluid retention and could signal the onset of preeclampsia |
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During labor which Vital sign measurement can you expect a slight increase in? And what measurement should not elevate during relaxation phase? |
Pulse to increase slightly Blood pressure |
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During physical assessment of a laboring woman a urine specimen is collected, screening for the presence of which five substances? |
Protein Ketones Glucose Blood cells Bacteria |
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When the RN is performing a head-to-toe physical assessment on a laboring woman, what are five critical measurements to include? |
Lung sounds
Pain in RUQ of abdomen?
Brisk deep tendon reflexes (DTR)(homeostasis b/w cerebral cortex and spinal cord, disruptions= hyperreflexia or hyporeflexia)
Clonus- repeated, rhythmic, muscle contractions
Edema |
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When monitoring labor status, which palpating technique can be used to determine FETAL PRESENTATION,(fetal lie/long axis comparison), POSITION, and ATTITUDE (presenting part lined up with cervix)? |
Leopold maneuvers ( four steps in palpating uterus) |
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Record results of vaginal examinations in the pregnant woman's clinical record, such as, dialation or fetal position, so they can be compared to determine what? And this also aids in the diagnosis of which two conditions? |
progress of labor
arrest of dilation arrest of descent of fetus |
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What is one way to graph results of cervical examinations? and describe which measurement and location is charted on the graph. |
Partograph Dilation and Fetal head position |
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Give three ways a partograph can represent progressive labor is not going as planned? -data reaches certain line - no change - failure of |
The "alert line", when woman's data reaches this line "Arrest of dilation" No cervical change in 2 hours during active labor Failure of the fetus to descend in a primigravida |
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What is the difference between a primigravida and a multigravida regarding dilation and Descent of fetus? |
Multigravida fetus may not descend until full dilation and then it will rapidly move down the birth canal |
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Give two purposes to Leopold maneuvers (Assess which 3 things) (Locate what of the fetus before applying monitor) |
Assess fetal presentation, position, and attitude Locate the fetal back before applying fetal monitor |
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1 of 4. The first step of Leopold Maneuvers is to stand beside the woman, facing her. Place both hands on the uterine fundus and palpate the fundus. In a normal pregnancy while palpating the fundus what should be felt? |
fetus's buttocks soft, irregular object that does not move easily |
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If a pregnant woman's fetus is in a breech presentation What will the fundus feel like during palpation? |
Fetus's head Smooth, hard, round, mobile object |
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2 of 4. Step 2 involves determining position of the fetus how do you go about this? |
You palpate each side of the abdomen, while supporting the opposite side during palpation of the other. You try to determine the location of the fetal back and extremities in relationship to the maternal pelvis |
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In Step number 2 when trying to determine a fetus's position how will the back feel compared to the extremities during palpation? |
The back will feel hard and smooth The extremities will feel irregular and knobby |
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If your baby's head is engaged what does this mean? |
That your baby's head is near the cervix and is in position for labor |
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3 of 4. Step 3 includes confirming presentation or confirming where the head is. Place one hand over the symphysis pubis and attempt to Grab the part that is presenting to the pelvis between your thumb and fingers of one hand, what should be felt ? and if the baby is breech what is felt? |
Should feel a hard, round fetal head Breech you will feel a soft irregular object just above the symphysis pubic |
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During step 3 of Leopold maneuvers you can also feel is the baby's head is engaged or unengaged, how? |
If the fetal head is movable or not |
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What does the fourth Leopold maneuver determine? Which part of the nurse's hands is used and which direction do you palpate in? |
Attitude, use finger pads of the first three fingers of each hand, palpate in a downward motion in the direction of the symphysis pubis |
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During step number four of Leopold Maneuvers how can you determine if you have located the fetal brow? And which attitude would it reflect? |
If you feel a hard bony prominence on the side opposite the fetal back Attitude of flexion |
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During palpation with the fourth step of Leopold maneuvers, If the bony prominence is found on the same side as the fetal back what are you palpating? And what is expressing (A or B)? Name the attitude. |
Occiput Attitude of extension |
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Which 2 serological tests are drawn to determine if the woman has developed a syphilis infection? Which test is to detect HIV antibodies? |
VDRL or RPR
ELISA |
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During the admission a complete blood count is drawn, hemoglobin is monitored for signs of which condition? and what are the levels of HgB expressed in this condition? |
Iron deficiency anemia HGB levels below 11 g/dL |
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White blood cell count may increase to which level with stress of Labor? But levels above this number may indicate infection |
20,000 mm3 |
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How might you reassure a woman who is embarrassed or upset about not being in true labor when reported to the hospital and being discharged home? |
Reassure her that it is normal for a woman to present several times to the hospital before she goes into true labor |
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When using an EFM a ___________ (_____) measures contraction frequency and duration. |
Tocodynamometer |
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Other than contraction frequency and duration, what else does the EFM monitor? |
Fetal heart rate |
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Unless the woman has an internal uterine pressure catheter, you must ________ the contractions to evaluate _________. |
Palpate, intensity |
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1An EFM print out can give you an estimate of contraction intensity, how? 2However, many factors can affect the reading of intensity on the graph. Give an example.
3For reasons affecting the reading of intensity, what is the accurate method of determining contraction intensity? |
1Height of contraction on printout
2Weight. Thin person- mild contractions may appear to be very intense on EFM & Obese- intense contractions may appear to be very mild on EFM
3 Palpate contractions |
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What are the three classes of contractions that Express it's level of of intensity? |
Mild, moderate, strong |
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Explain how a MILD contraction would feel at its peak while palpating the fundus ? |
It would feel like the tip of your nose |
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Explain how a MODERATE contraction would feel at its peak while palpating the fundus? |
Firmer, similar to your chin |
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Explain how a strong contraction would feel at its peak while palpating the fundus? |
Feels like you're pushing on your forehead |
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What may an intrauterine pressure catheter (an internal method of measuring uterine contractions,) be beneficial for? (2 things) |
When the laboring woman has had a previous cesarean delivery
Or when receiving an oxytocin infusion to induce her |
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What is the most common method of monitoring FHR in low-risk pregnancies? Give two examples. |
Intermittent auscultation of FHR such as Doppler device or fetoscope |
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What is the most common practiced procedure for monitoring fhr? And what is the outcome if the fhr pattern is reassuring? |
Is to place the woman on an external fetal monitor for 20 minutes to get a Baseline of fhr fetoscope or handheld doppler device or the EFM is used to monitor at internment intervals |
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Within an intermittent auscultation of FHR, explain how it is auscultated. |
Auscltated for one full minute throughout a complete contraction |
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What are two advantages to intermittent auscultation of FHR? |
Gives the mother more freedom to move around Nurses focus on the laboring woman and supporting her rather than on technology |
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What is one disadvantages of IA of FHR? And another involving fear of nursing staff? |
The process takes more time
Providers fear of missing and irregular a FHR |
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An external EFM monitor works on the principle of what? |
Ultrasound |
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How is fhr displayed through an external EFM? (2 ways) |
Video display or continuous print out |
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An external EFM includes two devices that partake in monitoring the laboring woman, what are the two devices and which do they monitor? |
Toco -monitors contractions Transducer -monitors fhr pattern |
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What are 4 potential problems or disadvantages of using an external EFM? |
Small fetus Active fetus Obese mother
Uncomfortable |
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Some external efms include a _______ _________which provides wireless transmission of fhr patterns and uterine activity without the attachment of cables, how does this benefit the laboring woman? |
Telemetry unit Gives the woman more freedom to move around and cope |
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With internal EFM it is easier to obtain _______ _______ regardless of fetal activity and maternal positioning |
Consistent tracing |
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When internal EFM techniques are used, what is the most common combination? |
Internal fetal scalp electrode with external Toco to record the contraction pattern |
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When should internal EFM techniques be used considering the risk for infection and chorioamnionitis? |
When the healthcare provider determines the benefit clearly outweighs the risk |
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Guarding fetal heart rate very ability, Define absent. |
No fluctuations of fhr |
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Regarding fetal heart rate variability definitions, Define minimal. |
Less than 5 beats per minute from Baseline fhr |
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Regarding fetal heart rate variability definitions, Define moderate (or normal.) |
6 to 25 beats per minute from Baseline fhr |
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Regarding fetal heart rate variability definitions, Define marked. |
Greater than 25 beats per minute from Baseline fhr |
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What should the LPN be able to recognize regarding fhr patterns? |
Recognize reassuring and nonreassuring signs in order to get help when indicated |
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1 interpreting a fetal monitor tracing, the first element to evaluate is what? And this is measured during a ___#___ minute period. And the normally accepted rate is between _______&________. |
Fhr Baseline 10 minute. 110 and 160 |
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When a non-reassuring fhr pattern is recognized it can often be remedied by correcting the ________ ________. Give an example. |
Maternal condition.
Maternal Hypotension or epidural anesthesia may result in Fetal bradycardia
And some medications can cause decreased variability |
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Regarding evaluation of fhr patterns, Define periodic changes. |
Variations in the fhr pattern that occur in conjunction with uterine contractions and episodic changes |
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Regarding evaluation of fhr patterns Define episodic changes |
Variations in the fhr pattern not associated with uterine contractions |
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What is the periodic change in this fhr pattern? What do they resemble ? and what is it caused by? |
Early decelerations mirror uterine contractions And caused by head compression |
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What is the periodic change and what is it caused by? |
Variable decelerations in timing and shape caused by cord compression |
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What is the periodic change in the fhr pattern and what is it caused by? |
Late decelerations are offset from uterine contractionsCaused by uteroplacental insufficiency |
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What type of periodic change is considered spontaneous elevations of the fhr, accelerations above the Baseline by at least 15 beats per minute? |
Reassuring periodic changes |
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Benign periodic changes are considered early deceleration in fhr pattern or slowing of the fhr, which three criteria of contractions, classify the deceleration as early? |
1 When contraction starts fhr slows down 2 when contraction reaches Acme the nadir of fhr coincides(does the same) 3 one contraction ends so does fhr deceleration
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What are two requirements, regarding FHR baseline and variability, determine early decelerations as benign? |
Baseline remains within normal limits and the variability is good |
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Define early deceleration regarding relationship between FHR pattern and contraction pattern? Which periodic change is this characterized as? |
When fhr's nadir mirrors a uterine contraction (U shape) Benign periodic change |
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When early decelerations are determined as benign, what is the role of the nurse at this time? - to continue with---- - and to watch for development of----- |
Continue to Monitor the tracing and watch for the development of non reassuring patterns |
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A variable deceleration may occur at any point during a contraction, what periodic change is it categorized as? And how does it appear on the fetal monitor tracing?
And what three letters may it resemble on the tracing? |
Non reassuring periodic change
Jagged erratic shape
U, V, W |
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Variable decelerations in fhr pattern indicates some type of acute umbilical cord compression, what are two examples of how umbilical cord compression can occur? |
The cord is wrapped around the baby's body part Oligohydramnios- decreased amount of amniotic fluid |
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What is important to note about cord compression during variable decelerations? What if it is? What are two signs of this? |
That it is not continuous Prolonged deceleration and bradycardia |
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What term describes infusion of normal saline into the uterus, to cushion the umbilical cord and relieve compression during non-reassuring periodic changes? |
Amnioinfusion |
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What is the difference between early decelerations and late decelerations? *explain when late deceleration begins and ends |
Late decelerations begin late in the contraction and recover after the contraction has ended |
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Late deceleration interventions include trying a variety of different positions of the mother and improving ________ and ________ to the placenta |
Blood flow and oxygenation |
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What medication may be ordered as an attempt to improve blood flow to the placenta by the effect of relaxing the uterus? |
Tocolytics |
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Why is late deceleration of more concern than early deceleration? |
Because late deceleration is associated with diminished blood flow to uterus and placenta |
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How does late deceleration appear on the fetal monitoring tracing? |
A smooth U |
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Which two fhr variability are considered non reassuring signs? |
Absent or minimal variability |
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Describe fetal tachycardia |
Greater than 160 beats per minute for at least |
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Describe fetal bradycardia |
less than 110 beats per minute for at least 2 minutes |
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What is the fhr Baseline of a reassuring periodic change? *regarding accelerations |
Accelerations greater than 15 beats per minute |
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What are the seven signs of an increasingly distressed fetus listed in order of least distressed to most distressed? These signs are indictative of worsening hypoxia. |
1 absent accelerations 2 gradual increase in fhr Baseline 3 loss of Baseline variability
4 late deceleration pattern develop 5 decelerations gradually increase in length and take longer to recover to Baseline 6 persistent bradycardia 7 Death |
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What stage of Labor is the most difficult phase and a woman must resist if she has a strong urge to push? What stage includes when fetal descent is most pronounced and indicates when the woman should push when she feels the urge? |
Transition phase of first stage Second stage of birth |
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Which stage is defined as from birth through delivery of the placenta? What are three signs of placental separation during this stage? |
Third stage: delivery of placenta
Gush of blood, longer cord, fundus becomes globular(rounded) |
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Which stage occurs from after delivery of the placenta through Post delivery of 2 to 4 hours?
within this stage after-pains are felt which two types of women are they more noticeable in?
How might the woman act regarding behaviors in this stage? |
Recovery fourth stage
Multigravida and breastfeeding
Talkative, wants to touch baby, episodes of crying even though happy, cold and shivering, shaky |
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In order what are the three phases of the first stage of Labor? What is the approximate cervical dilation of each phase? And which phase do contractions of true labor start? |
Latent phase-4cm active phase-8cm transition phase-10cm Contractions Start in latent phase |
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Which stage of Labor is defined as complete cervical dilation through birth, and when the woman feels more in control, able to rest between contractions, and is less irritable? |
Second stage birth |
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So name the four stages and include the three phases of the first stage in order. |
First stage of Labor, dilation latent dilation latent phase, active phase, transition phase Second stage of Labor, birth Third stage of Labor, delivery of placenta Fourth stage of Labor, recovery |
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First stage interventions |
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Second stage interventions |
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Third stage interventions |
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Fourth stage interventions |
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Danger signs during labor |
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