Chapter 13: Nursing Care During Labor and Birth, Nursing Care during labor and birth, Chapter 15 : Nursing care of a Family during Labor and Birth, OB CH 15: Nursing Care During Labor and Birth Review Questions

Fundal massage every ____mins

15

vital signs taken how often first hour after birth

15 minutes, then 30 for next hour

fetal tachycardia is a baseline FHR greater than what?

160 bpm lasting for 10 minutes or longer could be compensatory response to asphyxia

1st degree-4th degree lacerations

1st- extends through skin 2nd- through muscles 3rd- through anal sphincter muscle 4th- involves anterior rectal wall

When using the second Leopold's maneuver in fetal assessment, the nurse would palpate (the): a. both sides of the maternal abdomen. b. lower abdomen above the symphysis pubis. c. both upper quadrants of the maternal abdomen . d. lower abdomen for flexion of the presenting part.

ANS: A The second Leopold's maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

During labor a vaginal examination should be performed only when necessary because of the risk of: a. infection. b. fetal injury. c. discomfort. d. perineal trauma.

ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

The nurse thoroughly dries the infant immediately after birth primarily to: a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time d. Faster descent of the fetus e. An increase in frequency of contractions

ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body's signals. A brief slowing of contractions often occurs at the beginning of the second stage.

Which interventions are required following an amniotomy procedure? (Select all that apply.) a. Notation related to amount of fluid expelled b. Color and consistency of fluid c. Fetal heart rate d. Maternal blood pressure e. Maternal heart rate

ANS: A, B, C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a. Soft boggy uterus b. Maternal temperature of 99° F c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics e. Half of a lochia pad saturated in the first hour after birth

ANS: A, C, D Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a. Maternal hypotension b. Fetal heart rate of 140 to 150 bpm c. Meconium-stained amniotic fluid d. Maternal fever—38° C (100.4° F) or higher e. Complete uterine relaxation of more than 30 seconds between contractions

ANS: A, C, D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38° C [100.4° F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth? a. Bloody mucous discharge increases. b. The vulva bulges and encircles the fetal head. c. The membranes rupture during a contraction. d. The fetal head is felt at 0 station during the vaginal examination.

ANS: B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor? a. Length of second-stage labor is 2 hours. b. Client has received an epidural for pain control during the labor process. c. Client is using breathing techniques during contractions to maximize pain relief. d. Client is receiving parenteral fluids during the course of labor to maintain hydration.

ANS: B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head? a. Expulsion b. Restitution c. Internal rotation d. External rotation

ANS: B After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head.

Things to ask prior to going to labor/delivery room?

Do you want pain meds? Epidural? Determine family/mother expectations

Engagement

Engagement is when the widest part of the presenting part of the fetus has passed the inlet and station 0 in the pelvis.

What are the danger signs of labor effecting baby?

FHR >160 or <110 indicates fetal distress, meconium staining, and hyperactivity (signs of hypoxia).

Molding

Molding is the overlapping of skull bones along suture lines in the fetal skull to assist with passage through the woman`s pelvis.

Cephalic presentation

Most common presentation where the head presents first.

epidural complications? effects on fetus

N/V, hypotension, fever, pruritis, intravascular injection, maternal fever, allergic reaction, respiratory depression fetal distress secondary to maternal hypotension

criteria for category 2 FHR patterns

Not predictive of abnormal fetal acid-base status, but require evaluation and continued surveillance • Fetal tachycardia (>160 bpm) present • Bradycardia (<110 bpm) not accompanied by absent baseline variability • Absent baseline variability not accompanied by recurrent decelerations • Minimal or marked variability • Recurrent late decelerations with moderate baseline variability • Recurrent variable decelerations accompanied by minimal or moderate baseline variability, overshoots, or shoulders • Prolonged decelerations >2 min but <10 min

Which hormone works with prostaglandins to trigger contractions?

Oxytocin

physical exam of women presenting in labor includes what besides hydration status, vital signs, heart/lung sounds, height/weight

Pain level and coping behaviors demonstrated Uterine activity, including contraction frequency, duration, and intensity Fetal status, including heart rate, position, and station Cervical dilation and degree of effacement Status of membranes (intact or ruptured) Assess vital signs: temperature, pulse, respirations, & blood pressure Perform Leopold maneuvers to determine fetal lie Fundal height measurement Ability to ambulate safely

Leopold`s maneuver

Palpate the uterus to determine fetal presentaion and position.

criteria for category 3 FHR patterns

Predictive of abnormal fetus acid-base status and require intervention • Fetal bradycardia (<110 bpm) • Recurrent late decelerations • Recurrent variable decelerations—declining or absent • Sinusoidal pattern (smooth, undulating baseline)

criteria for category 1

Predictive of normal fetal acid-base status and do not require intervention • Baseline rate (110-160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations Can be monitored with intermittent auscultation during labor

Fetal presentation

This represent the portion of the fetus that eneters the pelvis of the mother first.

A vaginal birth after cesarean is often abbreviated __________

VBAC

Components of the admission assessment

Well being of mother and fetus fetal heart rate is #1 Maternal vital signs imminence of birth

variable decelerations are what

abrupt decreases in FHR below baseline, unpredictable shape on FHR baseline, no consistent relationship to uterine contractions most common deceleration pattern found in the laboring women, usually transient and correctable

umbilical cord blood analysis is a good indicator of what normal measurement?

acid-base analysis determines newborn's condition, presence of hypoxia and acidemia normal pH- 7.2-7.3 useful for planning interventions

what is the fern test

also tests if membranes have ruptured swab of vaginal fluid, put under microscope, fern pattern indicates amniotic fluid

when the fetal membranes rupture what should be assessed

amniotic fluid for color, odor, amount FHR

epidural analgesisa for labor/birth involves injection of what

anesthetic agent (lidocaine/buprivacaine) and opioid analgesic agent into lumbar epidural space catheter is passed through epidural nedle to provide continous access to epidural space for maintenance of analgesia throughout labor and birth relief of pain depends on volume/concentration

upon admission to labor and birth suite, highest priorities are what

assessing FHR assessing cervical dilation/effacement determining if membranes have ruptured or are intact

intermittent FHR monitoring involves what

auscultation via fetoscope or handheld doppler

if bradycardia is an isolated event it may be? if accompanied by decrease in baseline variability and late decelerations?

benign bad sign

compared to external monitoring what can internal monitoring detect

both short term changes and variability and FHR dysrhythmias maternal position changes and movement don't interfere with quality of the tracing

uterine contractions during labor are monitored how

by palpation and electronic monitoring

A primigravida is admitted in early labor. The nurse notices on the prenatal record that the position of the fetus is left occiput posterior. Because of this information, the nurse can anticipate

increased back pain with labor. When the fetus is in the posterior position, the labor may be longer and more uncomfortable. Back discomfort increases with contractions and will continue between contractions. The fetus may not be able to deliver until it rotates into the anterior position.

what is a pudendal nerve block

injection of local anesthetic agent into pudendal nerves near ischial spine provides pain relief in lower vagina, vulva, perineum used in second stage of labor, episiotomy, operative vaginal birth with forceps or vacuum needs to be administered 15 minutes prior transvaginal approach used to inject it

what is local infiltration

injection of local anesthetic like lidocaine into perineal nerves to numb area for episiotomy or suturing a laceration

neuraxial analgesia does not do what

interfere with progress or outcome of labor don't have to withold until active stage of labor

what is neuraxial analgesia/anesthesai

involve minimal motor blockade administration of opioids or anesthetic that is capable of producing a loss of sensation in an area of the body either continuously or intermittently into the epidural or intrathecal space to relieve pain low-dose, ultra-low dose, spinal analgesia and combined spinal-epidural analgesia replaced the traditional epidural

what is baseline variability

irregular fluctuations in the baseline FHR measured as the amplitude fo the peak to trough in bpm

what is artifact

irregular variations or absence of FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference

etiology of pain in first stage of labor? second stage?

ischemia of uterus during contraction 2nd- stretching of vagina and perineum and compression of pelvic structures

what interventions can be done to improve uteroplacental blood flow/perfusion?

lateral positioning increasing intravenous fluid rate administering O2 8-10 L/min by mask discontinuing oxytocin infusion observing for changes in tracing internal fetal monitoring perhaps

The nurse is preparing to auscultate the fetal heart rate using a Doppler transducer. When performing the Leopold maneuver, the nurse felt the buttocks near the fundus and the back along the left side of the mother. The best position for the Doppler would be in the mother's

left lower quadrant. The fetal heart is best heard through the fetus's upper back. Because this fetus is in a cephalic position, with the back toward the mother's left side, the Doppler should be placed in the left lower quadrant of the mother's abdomen.

what is effleurage

light stroking superficial touch of abdomen in rhythm with breathing during contractions relaxation and distraction technique

downsides of EFM

limits maternal movement encourages women to lie in supine position- reducing placentl pefusion BUT accurate for moment to moment printout of FHR status

1st stage of labor

longest stage that has 3 segments: Latent phase= ctx 15-30 mins/ dilation 0-3 Active phase= ctx 3-5 mins/ dilation 4-7 Transition phase= ctx 2-3 mins/ dilation 8-10 1st stage of labor starts from first contraction to waterbreak

assessment during third stage of labor includes

looking for signs of placenta seperation Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) Assessing for any perineal trauma, Inspecting the perineum for condition of episiotomy, if performed Assessing for perineal lacerations and ensuring repair by birth attendant

intermittent auscultation is an acceptable option for who

low-risk laboring women allows women to be mobile in first stage of labor b/c not attached to fetal monitor

pulse is usually what after birth

lower, 60-70 could suggest blood loss

signs of intrauterine infections include

maternal fever fetal and maternal tachycardia foul odor of vaginal discharge increase in WBC count

what are the leopold maneuvers

method for determining presentation, position, and lie of the fetus maneuver 1- what fetal part (head or buttocks) is located in the fundus? maneuver 2- on which maternal side is the fetal back located (fetal heart tones are best auscultated through the back of the fetus) maneuver 3- what is the presenting part? maneuver 4- is the fetal head flexed and engaged in the pelvis?

Labor down

natural laboring with contractions without pushing

opioids are associated with

newborn respiratory depression decreased alertness inhibited sucking delay in effective feeding

what is hydrotherapy

non-pharm measure may involve showering or soaking in regular tub or whirlpool warm water can be soothing promoting vasodilation contractions usually less painful in warm water

are early decelerations indicative of fetal distress? what interventions should be done?

not indicative of fetal distress no interventions required

parity

number of live births

Gravity

number of pregnancy

what is baseline FHR

occurs during 10 minutes excluding periodic/episodic rate changes like tachy/brady, when women has no contractions ranges 110-160 bpm

what drug categories may be used for systemic analgesia

opioids atarctics benzos

position changes can have an impact on

pain uterine activity uterine efficiency optimal presentation may be afforded supine positions may interfere with labor progress

how do you make sure not to confuse maternal heart rate with fetal?

palpate client's radial pulse simultaneously while FHR is being auscultated through the abdomen

why fetal heart rate often tachycardic in first trimester

parasympathetic system immature As this system matures in the fetus, it slows the intrinsic pacemaker of the fetal heart (in the right atrium, sino-atrial node).

what is PCEA

patient controlled epidural analgesia

what does internal monitoring involve

placement of spiral electrode into fetal presenting part to assess FHR and pressure transucer placed in uterus to record uterine contractions does not have to include both

primary objective of EFM

provide info about fetal oxygenation prevent fetal injury from impaired oxygenation most common etiology of fetal injury and death

Misoprostol (Cytotec), 50 mcg, has been ordered for a woman to assist with the ripening of the cervix. The nurse's action should be to

question the dosage amount. The normal dose of misoprostol for cervical ripening is 25 mcg. A 50-mcg dose is associated with hypertonic contractions.

what type of deceleration occur with > 50% of the contractions over 20 minutes

recurrent more worrisome intermittent- less than 50 percent

Which one of the following women can the nurse anticipate having difficulty dealing with labor pain?

A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. Previous experiences with pain can alter a woman's perception of labor pain. The woman with a prolonged labor and posterior position with the last birth will come to this labor anxious about the outcome and amount of pain. Preparation for labor and previous positive experiences will help the woman tolerate the pain. A support person who has been through the process and is encouraging can also assist the woman in a positive way.

Which of the following are important points when teaching a client the proper method for pushing during the second stage of labor? (Select all that apply). a. Begin and end by taking a deep breath and exhaling. b. Push for 4 to 6 seconds at a time. c. Take a deep breath and then push while holding her breath. d. Push at least five or six times with each contraction.

A, B Support the woman's spontaneous pushing techniques if they are effective. The woman should push with her abdominal muscles while relaxing her perineum. If she needs coaching, teach her to begin by taking a breath and exhaling and then to take another breath and exhale while pushing for 6 seconds at a time. Sustained pushing while holding a breath (Valsalva maneuver or "purple pushing") or pushing more than four times per contraction reduces blood flow to the placenta, increases intrathoracic pressure, is fatiguing and should be discouraged

An intravenous access is started in most labor clients because of which of the following? (Select all that apply). a. To have quick access if drugs are needed b. To provide fluids to prevent dehydration c. In case an epidural block is administered d. To provide a route for pain medications for the 48-hour postpartum period

A, B, C By 48 hours postpartum, mothers are expected to be on oral pain medication. An IV line provides quick access if fluids or medications are needed. Continuous fluid infusion prevents and reduces dehydration and is necessary if epidural analgesia is used. By 48 hours postpartum, mothers are expected to be on oral pain medication

Labor pain management may include which of the following interventions? (Select all that apply). a. Cool, damp washcloths on the face and neck b. Decreasing bright lights in the room c. Keeping the woman clean and dry d. Administering pain medication as ordered f. Offering simple snacks every 2 hours

A, B, C, D Providing comfort measures are important during labor. A laboring woman may have clear liquids by mouth but no solid food during active labor

During the labor process, the client's membranes rupture. Select all the assessments that are necessary for the nurse to carry out at this time. a. Color of amniotic fluid b. Odor of amniotic fluid c. Fetal heart rate d. Cervical dilatation e. Cervical effacement f. Time the membranes ruptured

A, B, C, F The time of rupture of membranes, fetal heart rate, color, odor, and quantity of the amniotic fluid are noted and charted.

Which assessment finding could indicate hemorrhage in the postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine d. The client's understanding of the event

ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client's understanding of the event would only need to be documented if it presents a problem.

Which comfort measure should a nurse use to assist a laboring woman to relax? a. Recommend frequent position changes. b. Palpate her filling bladder every 15 minutes. c. Offer warm wet cloths to use on the client's face and neck. d. Keep the room lights lit so the client and her coach can see everything.

ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

Which is an essential part of nursing care for a laboring client? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Feeling comfortable with the predictable nature of intrapartal care d. Sharing personal experiences regarding labor and birth to decrease her anxiety

ANS: A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.

ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a. 18-gauge b. 20-gauge c. 22-gauge d. 24-gauge

ANS: A The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to: a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position.

ANS: A The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

what are late decelerations associated with

uteroplacental insufficiency decreased perfusion resulting in fetal hypoxia/myocardial depression

what are early deccelerations?

visually apparent usually symmetrical characterized by gradual decrease in FHR in which nadir occurs at peak of contraction rarely decrease more than 30-40 bpm below baseline typically, onset, nadir and recovery of decel occur at same time as onset, peak, and recovery of contraction

what are late decelerations

visually apparent usually symmetrical transitory decreases in FHR that occur after peak of contraction FHR does not return to baseline until well after contraction has ended

what is a sinusoidal pattern

visually smooth sinewave-like undulating pattern in FHR baseline wtih cycle frequency of 3-5 bpm lasting longer than 20 minutes means derangement of CNS control severe hypoxia secondary to fetal anemia and hypovolemia category III pattern fetal intrauterine transfusion needed to correct

assessment during fourth stage of labor is focused on

vital signs status of uterine fundus and perineal area comfort level lochia amount bladder status

to reduce risk of respiratory depression with opioids birth should occur when after administration

within 1 hour or 4 hours

before 32 weeks an acceleration must have a peak of what and last for how long after 32

10 and 10 15 and 15 BUT less than 2 minutes

fetal bradycardia is when heart rate is what

110 or lower for 10 minutes or longer

Intensity of contraction

Mild intensity= uterus minimally tense Moderate intensity= uterus feels firm Strong intensity= uterus feels hard like a board

Effacement

The shortening and thinning of the cervical canal

Shoulder presentation

The shouler or side of the fetus presents first. Fetus is in a transverse lie and usually warrants a C-section.

Frequency of contraction

The time from the beggining of one contraction to the beginning of the next contraction.

Duration of contraction

The time from the beginning of one contraction to the end of the same contraction.

2nd stage of labor

The time span from full dilation to birth of the infant.

what does the apgar score assess?

(1) heart rate (absent, slow, or fast), (2) respiratory effort (absent, weak cry, or good strong yell), (3) muscle tone (limp, or lively and active), (4) response to irritation stimulus, and (5) color - that evaluate a newborn's cardiorespiratory adaptation after birth. The parameters are arranged from the most important (heart rate) to the least important (color). The newborn is assigned a score of 0 to 2 in each of the five parameters.

0% effacement, cervical canal is how long? 50% 100%?

0- 2 cm 50- 1 cm 100- obliterated

The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places. _____ mL

0.75

baseline must be for how long in a 10 minute segment to count as the baseline

2 minutes or else use previous 10 minutes

how long does a prolonged acceleration last

2-10 minutes

uterine contractions with intensity of what or higher indicate cervical dilation? in active labor intensity reaches what mmHg? resting tone is what?

30 or greater 50-80 between 5-10 at rest

FHR should be monitored how often during latent phase during active phase

30-60 minutes 15-30 minutes

First time void of PP

300-400

an umbilical artery pH of less than what and base deficit of what indicates a problem

7 12

Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? a. Fetal presenting part is 1 cm above the ischial spines. b. Effacement is 4 cm from completion . c. Dilation is 50% completed . d. Fetus has passed through the ischial spines.

A A station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of 0 would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged. Passage through the ischial spines with internal rotation would be indicated by a plus station, such as +1. Progress of effacement is referred to by percentages, with 100% indicating full effacement, and dilation by centimeters (cm), with 10 cm indicating full dilation.

A multigravida at 37 weeks of gestation is admitted to the labor room. She has contractions every 3 to 4 minutes lasting 40 to 50 seconds and no history of clear fluid leakage from the vagina, but complains of bright red bleeding for the past hour. The fetal heart rate is 145 beats/min (bpm). What should be the nurse's next intervention? a. Call the physician. b. Perform a vaginal exam to determine imminence of birth. c. Continue to monitor contractions and fetal heart rate. d. Administer an enema according to protocol of the agency.

A Bright red bleeding is a sign of complications, and the physician or primary health care provider should be notified immediately. Vaginal exams or enemas are contraindicated in the presence of bleeding. Continuing to monitor the mother and fetus is important after notifying the health care provider.

A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are: a. contraction pattern, amount of discomfort, and pregnancy history. b. fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. last food intake, when labor began, and cultural practices the couple desires. d. identification of ruptured membranes, the woman's gravida and para, and her support person.

ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time? a. Performing more frequent vaginal exams will not make the labor go any quicker. b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c. Tell the client that she will check every 30 minutes. d. Medicate the client as needed for anxiety so that the labor can progress.

ANS: B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client's anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour

ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

At 5 minutes after birth, the nurse assesses that the neonate's heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a. 7 b. 8 c. 9 d. 10

ANS: B The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a. Place the catheter as quickly as possible. b. Place a small pillow under the patient's left hip. c. Omit the use of a cleansing agent, such as Betadine. d. Set up the catheter tray before positioning the patient.

ANS: B To promote placental function, the nurse can place a small pillow or rolled blanket under the patient's left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

A nursing priority during admission of a laboring client who has not had prenatal care is: a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care.

ANS: B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed.

When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.) a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor.

ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed.

ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period.

A client at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: a. fetal movement. b. irregular contractions for 1 hour. c. a trickle of fluid from the vagina. d. thick pink or dark red vaginal mucus.

ANS: C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

The nurse is preparing to perform Leopold's maneuvers. Why are Leopold's maneuvers used by practitioners? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position

ANS: C Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior. d. Determine whether the mother is too fatigued to interact normally with her infant.

ANS: C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a. Obtain a fetal heart rate. b. Determine the estimated due date. c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat.

ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. The Apgar score for this infant is: a. 7. b. 8. c. 9. d. 10.

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time? a. To apply internal monitoring electrodes b. To assess for Goodell's sign c. To determine cervical dilation and effacement d. To determine strength of contractions

ANS: C The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodell's sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

The gynecologist performs an amniotomy. What will the nurse's role include immediately following the procedure? a. Assessing for ballottement b. Conducting a pH and/or fern test c. Labeling of specimens for chromosomal analysis d. Recording the character and amount of amniotic fluid

ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

The nurse has given the newborn an Apgar score of 5. She should then: a. begin ventilation and compressions. b. do nothing except place the infant under a radiant warmer. c. observe the infant and recheck the score after 10 minutes. d. gently stimulate by rubbing the infant's back while administering O2.

ANS: D An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborn's transition to extrauterine life.

Which client at term should go to the hospital or birth center the soonest after labor begins? a. Gravida 2, para 1, who lives 10 minutes away b. Gravida 1, para 0, who lives 40 minutes away c. Gravida 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours

ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

The nurse examines a primipara's cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action? a. Palpate her bladder for fullness. b. Assess the frequency and duration of her contractions. c. Determine who will stay with the patient for the birth. d. Encourage the patient to exhale in short breaths with contractions.

ANS: D Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient's urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be: a. discharged home with a sedative. b. admitted for extended observation. c. admitted and prepared for a cesarean birth. d. discharged home to await the onset of true labor.

ANS: D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely: a. abnormal labor. b. a sign that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

Which should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

Rupture of the membranes

Amnisure test or Nitrazine paper are used to confirm the rupture of membrane or " water breaking".

A 39-week primigravida calls the birthing center and tells the nurse she has contractions that are 10 to 15 minutes apart and had a small gush of fluid about 1 hour ago. The nurse should tell her to: a. Wait until the contractions are about 5 minutes apart and come to the center. b. Come to the birthing center now. c. Come to the birthing center in about an hour if she lives farther than 1 hour away. d. Come to the birthing center if the baby stops moving.

B A gush or trickle of fluid from the vagina should be evaluated as soon as possible. Waiting until the contractions are 5 minutes apart is appropriate for a primigravida if the membranes have not ruptured.

Which of the following findings during the fourth stage would require immediate interventions by the nurse? a. Fundus firm and at midline b. Fundus firm, deviated to the right, with slight distention over the symphysis pubis c. Blood pressure and pulse slightly lower than reading during second stage of labor d. Lochia is bright red, with a few small clots

B Even though the fundus is firm, it is not midline and the bladder is filling. A full bladder will interfere with contractions of the uterus and lead to increased bleeding. The rest of the answer choices are within normal limits for this stage.

After birth, the nurse assesses the newborn. The heart rate is 90 bpm, the body is flexed, there is vigorous movement, the newborn is actively crying when stimulated, and has bluish coloration in the feet and hands. The proper Apgar score for this newborn should be: a. 7. b. 8. c. 9. d. 10.

B The heart rate less than 100 bpm gets a score of 1, a lusty cry will give a score of 2 for both respiratory effort and reflex response, the flexed posture and vigorous movements gives a score of 2, and the bluish coloration of the hands and feet will give a score of 1.

When are H & H labs drawn for the mom?

Before and after delivery

3rd stage of labor

Begins with the birth of the infant and ends with birth of the placenta.

Breech presentation

Breech is where the buttocks of the fetus present first.

A pregnant client walks into the birthing center complaining of contractions. After getting her to bed, the first thing the nurse should do is: a. Assess the mother's pulse and respirations. b. Gather information about her medical history. c. Assess the fetal heart rate. d. Start an intravenous line.

C Assessment priorities on admission of a labor client are to determine the condition of the mother and fetus and whether birth is imminent. Checking the fetal heart rate is one of the first assessments that should be carried out. Along with assessing the fetus, the nurse should also check the maternal blood pressure and temperature.

A client is being discharged, having been diagnosed with false labor. The nursing diagnosis for her is Deficient Knowledge: characteristics of true labor. An appropriate expected outcome for this diagnosis is that the: a. Client will return to the hospital when she is in true labor. b. Client will define true labor. c. Client will describe reasons for returning to the hospital for evaluation. d. Client will be able to determine false from true labor.

C The client may not be able to determine true from false labor; however, she should be made aware of what signs to look for that may indicate the need for evaluation.

category 1 and 2 for intermittent ausculatation

Category 1 must include ALL of the following: Baseline 110-160 Regular rhythm Presence of increases/accelerations from the baseline Absence of decreases/decelerations from the baseline Category II includes ANY of the following Irregular rhythm Tachycardia (baseline > 160 for >10 minutes) Bradycardia (baseline <110 for >10 minutes) Presence of ANY gradual or abrupt decreases from the baseline

Which one(s) of the following would be an indication for a cesarean birth?

Cephalopelvic disproportion Active genital herpes Persistent nonreassuring FHR patters Possible indications for cesarean birth include, but are not limited to, the following: dystocia; cephalopelvic disproportion; hypertension, if prompt delivery is necessary; maternal diseases such as diabetes, heart disease, or cervical cancer, if labor is not advisable; active genital herpes; some previous uterine surgical procedures such as a classic cesarean incision or removal of fibroid tumors; persistent indeterminate or abnormal FHR patterns; prolapsed umbilical cord; fetal malpresentations such as breech or transverse lie; hemorrhagic conditions such as abruptio placentae or placenta previa; and maternal request.

Which one of the following measures will help prevent complications from an episiotomy?

Cold applications after birth Cold applications for the first 12 hours after birth may help prevent hematomas and edema. Pain medication helps treat, not prevent, the complication of pain. Early ambulation helps prevent other complications. Warm applications are contraindicated after birth; they may be used after 12 hours.

The technique of delaying pushing until the reflex urge to push occurs may be called _____________________.

Delayed pushing, laboring down, rest and descend, or passive pushing

Data assessment

Demographic Support person? SO? Status of membranes number of pregnancies/prior pregnancies/types of birth When was your expected date of delivery? Probs during preg? Allergies? Last oral intake? Pain with contractions? Prenatal care? When started? Tobacco? ETOH? Birth plan?

What are the 6 cardinal movements of the fetus during labor?

Descent (head descending into the pelvis), Flexion (featl head nods forward toward the chest), Internal Rotation (fetus is out of transverse position), Extension (allows the head to emerge after crowning), External rotation (last rotation of the fetus to get the shoulders out), and Expulsion (birth of the entire body).

signs typical of second stage of labor

Increase in apprehension or irritability Spontaneous rupture of membranes Sudden appearance of sweat on upper lip Increase in blood-tinged show Low grunting sounds from the woman Complaints of rectal and perineal pressure Beginning of involuntary bearing-down efforts

What are danger signs during labor effecting mom?

Increase or decrease in bp, pulse >100, ctx longer than 70 seconds, apprehension (sign of lack of o2 or hemorrhage).

What are the 3 phases of a contraction?

Increment= intensity of the contraction increases Acme= Strongest point of a contraction Decrement= intensity decreases

What are the 4 components of labor?

Remember the 4 P`s. Passage (pelvis), Passenger (fetus), Powers (uterine rhythm and strength), and Psyche (mental outlook on labor).

When pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput of the fetal head, it is termed the _______________

Ritgen maneuver

Station 0

Station 0 means the head is at the ischial spine of the mother`s pelvis. Point of engagement in the pelvis.

Fetal attitude

The degree of flexion a fetus assumes during labor (Remember complete flexion= chin to chest with knees drawn upward toward the chest)

Dilation

The enlargement or widening of the cervical canal to approx 10cm.

Minus station

The minus stations indicate the baby is "floating" and not engaged in the pelvis.

Plus station

The plus stations indicate the baby is "engaged" in the pelvis and is headed toward the outlet of the pelvis.

Station

The relationship of the presenting part of the fetus to the level of ischial spines represented by -4,-3,-2,-1,0,+1,+2,+3,+4.

Fetal position

The relationship of the presenting part to a specific quadrant and side of the pelvis.

Fetal lie

The relationship of the spine of the fetus to the spine of the mother.

advantages of external monitoring

can be used while membranes intact, and cervix not dilated- or membrances ruptured and dilating cervix non-invasive detects changes in pressure b/w resting tone and contractions provides permament record of FHR

categories of FHR patterns

category 1- predictive of normal fetal acid/base status, needs no intervention category 2- not predictive of abnormal fetal acid base status BUT requires evaluation and continued monitoring category 3- predictive of abnormal fetal acid-base status requires prompt evaluation and interventions

variable decelerations are associated with what? classified as what

cord compression either 2 or 3 depending on change in variability

what may a deceleration indicate

cord compression secondary to cord prolapse

how may opioids affect the FHR strip

decrease in FHR variability often transient

Leopold's maneuvers

determine position of baby for purposes of attaching fetal monitor. Get mother to empty bladder before procedure

downsides of intermittent auscultation

does not document how fetus responds to stress of labor (unless listening is done during contractions) best to listen at the end of the contraction so late decelerations could be detected but pressure of device uncomfortable for women during contraction can detect FHR baseline and rhythmn and changes from baseline but not variability and types of decelerations

when are early decelerations most often seen

during active stage of labor during pushing crowning vacuum extraction

what types of decels are gradual and take more than 30 seconds to get to nadir

early and late variable- abrupt

Nursing care during the third stage of labor primarily focuses on

immediate newborn care and assessment and observing for signs of placental separation, being available to assist with the delivery of the placenta, recording the time of expulsion and inspecting it for intactness. The nurse should also be assessing by palpating the uterus before and after placental expulsion

if there are recurrent or intermittent late decelerations what category are they always

either 2 or 3 they imply some degree of fetal hypoxia regardless of depth of deceleration acute episodes with moderate variability more likely to be correctable whereas chronic episodes with loss of variability less likely

what is EFM

electronic fetal monitoring

general anesthesia would be used when primary complication

emergency cesarean births if not enough time to provide spinal or epidural anesthesia fetal depression uterine relaxation potential maternal vomiting and aspiration

what is combined spinal-epidural analgesia

epidural needle goes into epidural space, then small needle goes into subarachnoid space opioid WITHOUT anesthetic is injected into space rapid pain relief- 3-5 minutes, last up to 3 hours motor function remains active pushing reflex not lost 'walking epidural"

what is fetal scalp stimulation why would it be done

evaluates fetal oxygenation and acid-base balance fetal stimulation performed to promote fetal movement and hope FHR accelerations will accompany the movement scalp stimulation or vibroacoustic stimulation

If babies aren't wiped off, they lose heat from process of: _____

evaporation

typically how often are blood pressure, pulse, and respirations assessed during latent labor? during active and transition phases?

every hour every 30 minutes temp every 4 hours and every 2 hours after membranes have ruptured

two types of EFM

external- two tranducers on belt, one on fundus measuring uterine contractions, other records baseline FHR, accelerations, decelerations- b/w umbilicus and symphysis pubis

absent or minimal variability is typically caused by what

fetal acidemia secondary to uteroplacental insuffiency cord compression preterm fetus maternal hypotension uterine hyperstimulation abruptio placenta fetal dysrhythmia

FHR is best heard where?

fetal back

early decelerations are thought to be due to

fetal head compression resulting in reflex vagal response with resultant slowing of FHR

when membranes rupture, it is important to assess what?

fetal heart rate to identify a deceleration also to find out when ruptured prolonged ruptured membranes could increase risk of infection

cause of fetal tachy

fetal hypoxia maternal fever maternal dehydration amnionitis drugs- cocaine, amphetamines... maternal hyperthyroidism maternal anxiety fetal anemia prematurity fetal infection chronic hypoxemia congenital anomalies fetal heart failure fetal arrhythmias

what may cause fetal bradycardia

fetal hypoxia prolonged maternal hypoglycemia fetal acidosis administration of analgesic drugs to mother hypothermia anesthetic agents- epidural maternal hypotension fetal hypothermia prolonged umbilical cord compression fetal congenital heart block

the fundus should be how after birth?

firm to prevent excessive postpartum bleeding if not firm, massage until firm

variability is described in what four categories

fluctuation range undetectable fluctuation range observed <5 bpm fluctuation range from 6-25 bpm fluctuation range >25 bpm

uterine contractions are monitored for what? how often during latent phase? how often during active phase? how often during transition?

frequency, duration, intensity every 30-60 minutes every 15-30 minutes every 15 minutes

what is GBS

gram positive organism that colonizes female genital tract/rectum, 10-30 percent of healthy women asymptomatic carriers can pass to baby- GBS disease should be screened at 35-37 weeks intrapartum antibiotics prescribed neonatal manifestations- pneumonia, sepsis

handheld doppler or fetoscope more accurate

handheld doppler has greater sensitivity

Babies lose a lot of heat from what part of their body?

head

continuous internal monitoring often indicated for who

high risk multiple gestation decreased fetal movement abnormal FHR on auscultation maternal fever preeclampsia preterm birth diabetes hypertension

nursing care when women first arrives, key interventions include what

identifying estimated date of birth prenatal history to identify fetal risks fundal height to validate dates/fetal growth perform leopold maneuvers checking FHR perform vaginal exam- effacement/dilation progress inform client about equipment/monitoring interpret fetal strips check FHR for baseline, accelerations... check amniotic fluid for meconium staining comfort client assess support system make careful assessment to avoid early admission to decrease adverse outcomes as compared to a women admitted in active labor

Nullipara

regular contractions 5 minutes apart for 1 hour 1st pregnancy? Come in now

Multipara

regular contractions; 10 minutes apart for 1 hour 2nd+ pregnancy come now

most common complication associated with systemic analgesia

respiratory depression opiods given close to time of birth can cause CNS depression in the newborn, then naloxone may be needed nearly all meds given during labor cross the placenta women should receive least amount that relieves her discomfort

external monitoring disadvantages

restricts mother's movements cannot detect short-term variability artifact disruptions due to maternal obesity, fetal malpresentation, fetal movement

Problems in 4th stage

rising pulse/falling BP, decreased urinary output is indicator of shock/hypovolemia

A gush or trickle of fluid from the vagina should be evaluated, regardless of whether contractions are occuring

ruptured membranes

what four criteria have to be met for continuous internal monitoring to be used

ruptured membranes cervical dilation of at least 2 cm presenting fetal part low enough to place scalp electrode skilled practitioner to insert electrode

if a women experiences what type of change in condition in labor should auscultation assessments be more frequent? in general how often should it be assessed in active labor? while pushing?

ruptured membranes onset of bleeding or before/after ambulation, vaginal examination, administration of pain medications every 15-30 minutes in active labor every 5-15 minutes while pushing

how do you determine if membranes have ruptured

sample of vaginal fluid nitrazine yellow dye swab vaginal fluid is acidic, amniotic fluid is alkaline so it turns blue false positive can occur b/c blood is also alkaline if women has a lot of bloody show likely intact if swab is yellow/olive-green, pH between 5 and 6 likely ruptured if swab turns blue-green, pH 6.5 to 7.5

epidural analgesia increases duration of what?

second stage of labor

vaginal exam involves

sterile gloves insert middle/index finger palpate cervix to assess dilation, effacement, position if cervix is open at all- presenting fetal part, fetal position, station, presence of molding membranes- intact, bulging, ruptured

nursing management in second stage of labor generally

support women and partner in decisions choices in pushing method not controlling, not directing pushing encourage women to push when she has s trong desire Nursing interventions during this stage focus on motivating the woman, assisting with positioning and encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress.

periodic baseline changes are what

temporary, recurrent changes made in response to stimulus like a contraction

Bright red bleeding should be evaluated promptly. What does normal bloody show look like?

thicker, pink, or dark red and mixed with mucus.

when palpating fundus, how would you describe mild, moderate, versus strong contractions

tip of nose- mild chin- moderate forehead- strong

what is a deceleration? how are they described?

transient fall in FHR caused by stimulation of parasympathetic nervous system described by shape and association to a uterine contraction early, late, variable

what are fetal accelerations

transitory abrupt increases in the FHR above the baseline lasting less than 30 seconds from onset to peak associate with sympathetic nervous system stimulation visually apparent, elevations of FHR of more than 15 bpm above baseline generally considered reassuring, require no interventions denote fetal movement, well-being

if possibility of fetal compromise, like category 2 or 3 FHR patterns, what other testing may be done

umbilical cord analysis fetal scalp stimulation

On admission to the labor suite, a woman begins to cry out loudly, "Lord help me, I am going to die." She repeats this phrase loudly with each contraction. The nurse's best response would be to

understand that this may be a cultural mannerism and accept her individual response to labor. Women should be encouraged to express themselves in any way they find comforting. The cultural diversity of their expressions must be respected. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Belittling her, praising her falsely, or trying to show her a "better way" of dealing with the pain will interfere with the therapeutic relationship and lower the woman's self-esteem.

how are antiemetics used

used in combo wtih opioid to decrease N/V lessen anxiety potentiate effectiveness of opioid so lower dose can be given could cause decrease in FHR variability and possible newborn depression

decrease in blood pressure after birth could suggest? elevation?

uterine hemorrhage preeclampsia

ischial spines are landmarks and are designated as what station?

zero