labor and delivery nursing care

Ferguson Reflex is the term to describe which of the following actions during labour? Involuntary contractions or primary powers Desire to bear down Shortening and thinning of the cervix Pathological retraction or Bandl's ring

desire to bear down

Following the delivery, the mother immediately asks if her baby boy is normal. What is be the most appropriate response? "Most babies are normal." "He is fine, listen to his strong cry." "He must be, there were no complications during birth." "Let us both look him over."

"Let us both look him over."

Which of the following statements are true about the labour and delivery process? Compensation during contractions occurs in healthy fetus who have adequate uterofetoplacental circulation. The weight of the fetus is a major factor in the birthing process. The head size of the fetus is a major factor in the birthing process. Society of Obstetricians and Gynecologists of Canada (SOGC) recommends passive management when delivering the placenta. As woman progresses through labour, various body systems adapt to the birth process.

- Compensation during contractions occurs in healthy fetus who have adequate uterofetoplacental circulation - The head size of the fetus is a major factor in the birthing process. - As woman progresses through labour, various body systems adapt to the birth process.

_ hours post-delivery, the fundus is expected to be at the level of the umbilicus If it is higher and not firm, then the nurse perrforms a _ . Another important assessment is if the fundus is soft (aka "boggy") the nurse massages until it firms up and lochial flow decreases before measuring the fundal height in relation to the umbilicus.

12-24 fundal massage

Ms. Chang is in labour with her first baby. Her contraction started at 8:12:15 and ends at 8:13:25. The next contractions starts at 8:15:15 and ends at 8:16:25. The fundus is difficult to indent with finger-tips during the contraction and soft between contractions. Frequency: _ minutes apart Duration: _ seconds Strength: _

3 70 moderate

During birth, the slight overlapping of cerebral bones can occur, causing molding of the fetus's head. How many days does it take for most newborns to assume their normal shape?

3 days

Ms. Singh is in labour with her second baby. Her contraction started at 12:45:10 and ends at 12:46:40. The next contractions starts at 12:48:40 and ends at 12:50:10. The fundus is board-like and cannot be indented with the finger-tips during the contraction and soft between contractions. Frequency: _ minutes apart Length: _ seconds Strength: _

3.5 90 strong

The labour process starts with the first uterine contraction causing cervical dilatation, and ends one to two hours after birth. In that span of time, there are _ stages of labour.

4

The nurse weighs the absorbent pads that were removed after a woman delivered her baby. The weight was 800 grams. How much blood loss did the woman have? 200 ml 400 ml 800 ml 1600 ml

800

In the second stage of labour, the fetal heart rate is monitored closely. It is common for the nurse to assess fetal heart rate and pattern every 5 minutes. Immediate intervention is required for atypical or abnormal patterns. What are two common interventions that normalize the fetal heart rate?

Administer high flow oxygen via a face mask to increase oxygenation. Place the labouring woman in the left lateral position to promote utero-placental blood flowdecrease pressure on the vena cava and aorta.

A woman who is 34 weeks gestation feels a gush of fluid between her legs. What should be the first action of the nurse? Note the time and document immediately. Assess the perineum and the fetal heart rate. Perform a vaginal exam. Check that the fluid is amniotic and not urine.

Assess the perineum and the fetal heart rate

A pregnant woman is in the labour-assessment room. She is G1 P0. Her contractions are every 6 minutes that last 30 seconds and is 2 cm dilated. She tells the nurse she is having strong pain during contractions. She is breathing rapidly and groaning. What intervention should the nurse provide first? Notify the health care provider for an analgesic order. Assist with breathing and relaxation instructions. Provide education regarding the pain progression during labour. Assist the client to change her position.

Assist with breathing and relaxation instructions.

Identify the symptoms in a newborn that would be appropriate for the nurse to suction the newborn's trachea with an endotracheal tube connected to a meconium aspiration device. (Click to check your answer)

Depressed respirations Decreased muscle tone Heart rate <100pbm

Ms. Smith delivers a 4,330g baby boy. During the examination of this baby boy, the nurse should check for the following symptoms. (Click to check your answer)

Full or partial lack of movement of the arm A weakened hand grip Numbness of the arm An odd position (the arm may bend toward the body or hang limp)

Review the signs, and identify the ones that suggest the placenta is ready to separate the start of the third stage of labour. (Select all that apply) Shortening of the umbilical cord. Gush of dark blood from the vagina. Palpable soft fundus. Vaginal fullness. Lengthening of the umbilical cord. Gush of clear fluid from the uterus. Firm, contracted fundus.

Gush of dark blood from the vagina, vaginal fullness, lengthening of the umbilical cord, and firm, contracted fundus

What are some of the positions the nurse might assist Ms. Smith into to resolve the shoulder dystocia? (Click to check your answer)

Hands and knees position. Squatting position. Lateral recumbent position.

A woman who is Rh- and is given Rho (D) immune globulin post-delivery. What is the purpose of Rho(D) immune globulin? It expands the antibody pool in the mother. It prevents antibody formation in the mother. It suppresses the activity of Rh- negative antibodies. It accelerates the mother's production of immune bodies.

It prevents antibody formation in the mother.

A pregnant woman has an epidural for pain while in labour. Which of the following actions is the nurse expected to perform? Label the infusion. Monitor the status of the woman and fetus. Initiate the epidural. Change the concentration of the infusion. Stop the infusion and initiate emergency measures.

Label the infusion. Monitor the status of the woman and fetus. Stop the infusion and initiate emergency measures.

On assessment the fetal heart tones were variable and there was the a visible umbilical cord protruding from Ms. McLeod's vagina. What should be the nurses' priority action? (Click to check your answer)

MOST IMPORTANT: Put a sterile glove in the vagina and hold the baby's presenting part off the umbilical cord. others: Assist into a Trendelenburg or knee-chest position to allow for gravity to keep the presenting part from compressing the cord. Notify the HCP immediately. Prepare for emergent Caesarean section.

After the head is delivered, does the nurse suction the newborn's nose and mouth? (Click to check your answer)

No. The Canadian Pediatric Society does not recommend routine suctioning of the newborn's nose and mouth on the perineum followed by endotracheal suctioning after birth. Instead the recommendation is to assess the newborn's condition then provide appropriate interventions as needed.

A labouring woman tells you she felt wetness on her pad. On inspection the nurse notes the presence of an umbilical cord protruding from the woman's vagina. The initial action of the nurse should be: Notify the physician stat. Monitor the fetal heart rate. Transfer the client to the delivery room. Place the client in trendelenburg position.

Place the client in trendelenburg position.

A pregnant woman is in the labour-assessment room. She is G1 P0. Her contractions are every 6 minutes that last 30 seconds and is 2 cm dilated. She tells the nurse she is having strong pain during contractions. What is the most important thing the nurse should consider when responding? The need to offer analgesic. The importance of assessing vital signs to determine response to pain. Recognize that pain is subjective. Organization of care so the client is not disturbed frequently.

Recognize that pain is subjective.

Ms. Smith is full term and is in labour. Her baby is estimated to be about 4500g. The baby's head starts to emerge then begins to retract (turtle sign). What could this be a warning sign of? (Click to check your answer)

Shoulder dystocia. Turtle sign is a warning sign the birth of the shoulders may be difficult.

Which pelvic type increases the mother's risk of having a caesarean section?

android

What is the major risk with meconium-stained amniotic fluid?

The development of meconium aspiration syndrome in the newborn. This can cause a severe form of aspiration pneumonia.

A 38 week laboring woman, Ms Tang, is admitted to the labour & delivery unit and tells the nurse she felt a gush of fluid between her legs. The nurse checks her to find the following: FHR 156 BP 122/74 P88 R 18 T 36.1 Vaginal discharge: large amount, thin, green colour What should the nurse consider? What is the cause? (Click to check your answer)

The nurse should consider meconium-stained amniotic fluid caused by the fetus passing meconium or the first stool in utero.

Ms. McLeod a full term primigravida has just arrived to the labour and delivery unit. Soon after being admitted, her membranes ruptured. What should be the first action of the nurse? (Click to check your answer)

assess fetal heart tones

_ stage in first stage of labor uterine contractions more frequent and strong 3-5 minutes, 1 minute long 6-8 cm nullipara: 4.6 multipara: 2.4 mom is not talking anymore, in pain, and losing track of time ROM can happen here

active

_ stage of first stage of labor A primigravida who has contractions 3 minutes apart that last for 90 seconds, and is 8 cm dilated.

active

_ stage of first stage of labor A primigravida who has contractions 5 minutes apart that last for 45 seconds and is 6 cm dilated.

active

placenta delivery _ approach administer oxytocin clamp and cut umbilical cord within 3 minutes of birth controlled cord traction after a contraction of the uterus

active

The relation of the fetal body parts to one another.

attitude

is the relation of the fetal parts to each other

attitude

what could be the cause of Full or partial lack of movement of the arm A weakened hand grip Numbness of the arm An odd position (the arm may bend toward the body or hang limp)

brachial plexus injury

_ techniques can help to increase relaxation and increase control during a contraction. How can the nurse assist with this strategy? Breathe together with the labouring woman to facilitate a focus on breathing. Encourage a deep cleansing breath at the beginning and end of every contraction. Be familiar with paced breathing techniques and which ones are appropriate at each stage of labour.

breathing

seven _ movements of the fetus through the birth canal: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion

cardinal

signs of _ with labor pain states they are coping rhythmic activity during contraction rhythmic breathing focused relaxes between contractions controlled moaning/counting/chanting

coping

7 cardinal movements of the fetus: _: the babys head moving downward into the pelvis cavity _ : after the babys head passes the pelvic cavity, it comes in contact with pelvis muscles, the babys head pulls in (flexes) and chin goes to chest _: when head enters the inlet, head should go through it in transverse position, widest part is side to side at inlet, when it gets to the outlet, it needs to turn its face to the back (occiput anterior) _: no pressure on the head and so it is going to extend _: no movement _: since the widest part of the outlet is front to back, the shoulders must move and be aligned with the front to back so that the head is going to turn to the side and teh shoulders will go through _: use force to wiggle up and down ward and this delivers the rest of the baby

decent flexion internal rotation extension restitution external rotation expulsion

the moment when the presenting part's largest transverse diameter has passed through the maternal pelvic brim presenting part's largest transverse diameter reaches 0 (zero) station. Zero station is determined by drawing an imaginary line between the maternal ischial spines

engagement

What is the nurse's responsibility related to caring for a client in labour with _ ? Monitor the client's status including the fetus. Assess the epidural catheter and site on a regular basis. Replace infusion as ordered. Stop the medication and start emergency measures as needed. Educate the client on expected outcomes as a result of the epidural catheter. Notify the primary care provider with any concerns. Monitor urinary bladder. Frequent position changes. Maintain skin integrity. Assess epidural block level.

epidural

What are signs associated with potential adverse effects of _? Hypotension Lightheadedness Dizziness Tinnitus Metallic taste Numbness of tongue/mouth Bizarre behaviour Slurred speech Convulsions Loss of consciousness High or total spinal anesthesia Fever Urinary retention Pruritus Limited movement Longer second-stage labour Increased use of oxytocin Increased likelihood of forceps Postdural punctural headache

epidural anesthesia

_ labor: cervix: no evidence of bloody show, posterior position, soft, no significant change in dilation or effacement contractions: pain felt above naval, stop with walking, irregular

false

sign of true labor? The fetus has dropped.

false (The baby dropping (lightening) into position is a sign that the baby is getting ready for the labour process but is not an indicator of true labour)

signs of true labor There is a spontaneous rupture of membranes? _

false (The rupture of membranes often occur with the first stage of labour, but is not an indicator of true labour.)

signs of true labor: loss of mucus plug? _

false (The time between the loss of the mucous plug and true labour varies for each woman)

5 essential components in evaluating _ Baseline rate Baseline variability Accelerations Decelerations Changes in trends over time (periodic or episodic)

fhr

There are three ways the _ is monitored during labour: intermittent fetal monitoring, external fetal monitoring and internal fetal monitoring. All methods are used to assess the FHR.

fhr

What is your evaluation of the _ tracing? Baseline: 135 (but need to confirm on a 10 min strip) Baseline variability: 5-10 beats Decelerations: None Accelerations: None Changes over time: None Uterine contractions: Regular uterine contractions noted every 1.6 minutes apart What is the nursing action? Why? There is no regular corresponding fetal heart rate response to the contractions. Therefore, further assessment is needed. The contractions indicated on the monitor appears to be strong but intensity needs to be confirmed by palpation. If the contractions are strong, then further assessment of the fetus is needed.

fhr

_ is assessed by intermittent auscultation or by electronic fetal monitoring. The best location to hear the fetal heartbeat is at the fetal back. Leopold's maneuvers are used to help determine the fetal position and where the fetal back is located. Once the fetal heart rate is located, it is assessed for rate and any abnormal rhythms. Higher or lower rates is a potential sign the fetus is having difficulty with labour. The ability to accurately assess fetal heart rate changes is an important skill for nurses who work in labour and delivery.

fhr

The _ stage of labour begins with the onset of regular uterine contractions and ends with complete cervical effacement and dilatation Within the first stage of labour are two phases: latent phase and active phase. It is important for the nurse to recognize the symptoms associated with each phase. there is also a transition phase

first

The _ stage of labour occurs over a longer period compared to the other stages. Intermittent assessments are required to monitor both the mother's and baby's condition. It is important for the nurse to know what changes are expected and to identify challenges early. Early detection and appropriate interventions are the key to optimal outcomes for both the mother and baby.

first

In the _ stage of labour, the nurse regularly assesses the mother's fundus and lochia. Fundal consistency is directly related to amount of lochial flow. When assessing the fundal height, the mother's bladder should be empty. She is placed in a supine position with her knees flexed to relax abdominal muscles. The fundal height is always measured in relation to the umbilicus (u).

fourth

The _ stage of labour is considered the first one to two hours after delivery.

fourth

A mother loses 1,000 ml of blood post-delivery. What should the nurse do? Document as normal post-delivery blood loss. Further assess the client. Call the primary care provider. Reassess in 15 minutes.

further assess the client

Which pelvic type is the most common in women and is conducive to vaginal births?

gynecoid

position: _ Relieves backache due to back labour caused by fetal occipitoposterior position. Facilitates fetal internal rotation by increasing coccyx motility.

hands and knees

_ can reduce pain by relieving muscle ischemia and increase blood flow and cold can reduce muscle spasms. How can the nurse assist with this strategy? Provide a layer of cloth between the woman's skin and the hot or cold pack. Alternate cold and hot therapy.

heat

Which positions allow for gravity to aid in the fetal descent during labour? Lithotomy Kneeling Lateral recumbent Sitting Standing

kneeling sitting standing

_ stage in first stage of labor uterine contractions every 6-10 minutes 0-6 cm nullipara: 8.6 multipara: 5.3 mom is talking through contractions, excited, nesting (energy)

latent

_ stage of first stage of labor A multigravida who has contractions 10 minutes apart that last for 30 seconds and is 3 cm dilated.

latent

position: Enhances uteroplacental perfusion by decreasing pressure on vena cava. Takes pressure off perineum. Facilitates fetal internal rotation: posterior to anterior position.

lateral recumbent

The relation of the long axis (spine) of the fetus compared to the long axis (spine) of the mother.

lie

the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother is the fetal:

lie

The position of the _ has the potential to facilitate or hinder descent of the fetus in the birth canal. Regular position changes during labour can relieve maternal fatigue, increase comfort and improve circulation.

mother

signs of _ with labor pain states not coping tearful unable to focus thrashing in bed tense panicked during contractions trembling voice

not coping

_ experienced during labour is often unpleasant but also highly individualized for each patient, and comfort measures provided are either non-pharmacological or pharmacological.

pain

The _ is the bony pelvis and soft tissues of the cervix, pelvic floor and vagina. The labour and delivery nurse assesses the woman's cervix, vagina and perineum when indicated, in order to determine the potential for healthy progression of the baby through the birth canal. When the nurse assesses the cervix, presenting fetal part and membranes, the findings must include the following: Dilatation Effacement Station Position Consistency Presenting part Status of membranes

passageway

The _ is the fetus and the placenta that must pass through the birth canal. The way the fetus goes through the birth canal is affected by the size of the fetal head, the fetal presentation, the fetal lie, fetal attitude and fetal position

passenger

There are five factors that affect the labour and delivery process. They are often called the 5 Ps: _ (fetus and placenta); _ (birth canal); _ (contractions); _ of the mother; _ response. These factors affect the progression of labour and the birthing process, and each one will be expanded on in the following sections.

passenger passageway powers position physiological

placenta delivery _ approach observe for signs use of gravity nipple stimulation skin to skin

passive

The relation of the presenting part to the four quadrants of the mother's pelvis.

position

fetal _ is also identified in terms of engagement and station

position

is the presenting parts relation to the four quadrants of the mother's pelvis.

position

_ is needed to promote fetal descent and to expel the fetus and placenta from the uterus. There are two types of powers during the labour process: _ powers are involuntary uterine contractions, _ powers are voluntary efforts.

powers primary secondary

The part of the fetus that enters the pelvic inlet first and leads through the birth canal.

presentation

is the first part of the fetus that enters the pelvis inlet.

presentation

The nurse educates a pregnant woman on signs of _ and when she should seek medical care. What physiological signs should the nurse include? Bad cramps or stomach pains that don't go away Blood or fluid (trickle or gush) from the vagina Lower back pain/pressure, or a change in lower backache Feeling like the baby is pushing down Contractions or changes in the strength or number of contractions An increase in amount of vaginal discharge A feeling that "something is not quite right"

preterm labor

primary or secondary powers involuntary contractions during labor process of shortening or thinning of cervix (effacement) the process of dilation of the cervix until it is fully dilated (10 cm)

primary

_ can help with pain management Provide a quiet environment by controlling noise on monitors, speaking in a quiet voice, keeping the door closed if possible. Care for the client in a calm, unhurried approach whenever possible. Create a relaxed environment by dimming the lights, controlling the temperature, providing quiet relaxing music.

relaxation

if the uterus is not midline, ask the women to _

relieve bladder

The _ stage of labour occurs over a shorter period of time compared to the first stage, but during this time there are many potential risks to both the mother and baby. Constant care is required, with frequent monitoring of both the mother's and baby's condition. Identifying challenges is the key to optimal outcomes.

second

The _ stage of labour starts with full cervical dilation which is 10 cm and ends with the baby's birth. In a short time frame, 20 to 60 minutes, the stage concludes with the baby's birth!

second

primary or secondary powers valsalva maneuver adds force to uterine contractions to augment the forces of involuntary contractions voluntary pushing effort during labor feeling of wanting to bear down

secondary

position: More convenient for external fetal monitoring. Some gravity pressure exerted to promote fetal descent.

semirecumbent

a measure of the descent of the presenting part in the birth canal (e.g., how far the presenting part has progressed into the pelvis). relationship of the presenting part to the imaginary line.

station

What enables the fetus's skull to adapt to the maternal pelvis during the birthing process? The cerebral _ and the two _ (anterior and posterior).

sutures fontanels

The _ stage of labour starts with the baby's birth and ends with the delivery of the placenta. This usually takes about fifteen minutes, but can take up to thirty minutes.

third

The _ and _ stages of labour is a crucial time for both the mother and baby. In this section, we have focused on maternal care. In clinical practice, the nurse assesses the mother and baby for any complications and facilitates the bond between them.

third fourth

_ can be an effective way to reduce tension, distract the labouring mother and improve comfort. Identify the mother's preference related to touch, i.e. who can touch her and where. Offer head, foot, back and shoulder massage. Offer light massage or effleurage on the abdomen. Provide counter pressure or a steady pressure in the sacral area to reduce lower back pain

touch and massage

_ stage of first stage of labor UC every 2-3 minutes, severe (forehead) 8-10 cm nullipara: 3 multipara: less than 1 n/v vaginal pressure, INDESCICIVE

transition

_ labor: cervix: anterior position, effacement and dilation, bloody show contractions: continue despite comfort measures, increase in intensity with walking, increase in severity and frequency

true

sign of true labor? The cervix is dilating.

true

sign of true labor? Contractions are getting stronger and closer together.

true

position: Most effective use of gravity pressure. Gravity promotes fetal descent. Increases impulses from the cervix to the pituitary gland, making primary powers more effective and efficient.

upright

signs that indicate progression from first stage of labor to second stage of labor feeling like you need to have a bowel movement? feeling like you need to void? feeling really hungry, feeling like you need to eat something? increasingly restless? burst of energy? vomit? shaking of extremities?

yes no no yes no yes yes