Exam #3--OB
What are the cardinal movements of labor in order?
Descent, Engagement, Station, Flexion, Internal Rotation, Extension, Restitution, External Rotation, Expulsion
What is Friedman's Curve?
-Often used to graph the progress of cervical dilation and fetal descent -Used as a guide to assess and manage the normal progress of labor
What is internal version?
-Physician inserts hand into uterus to change the presentation to cephalic of podalic. (fetus is born in breech presentation) -Used to delivery 2nd fetus in twin gestation
What is the latent phase?
0-6 cm dilated
What is Cytotec?
1/4 tablet inserted into vagina; ripens the cervix; can be repeated every 3-6 hours; no Pictocin is given if less than 4 hours since last dose of Cytotec.
What is the normal FHR?
110-160 bpm
How long does it take for the placenta to expel?
15 mins
A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used. a. Acme. b. Decrement. c. Increment. d. Relaxation.
1c, 2a, 3b, 4d Increment, Acme, Decrement, Relaxation
What is the active phase?
6-10 cm dilated
How should the nurse document the duration of contractions based on the strip below? (flip for tracing)
60 seconds
What is the management for multiple gestation?
Prenatal visits early and more frequent; prevention of premature labor is the goal
What are accelerations?
Acceleration is a visually apparent abrupt change in FHR above the baseline rate. The increase is >15 bpm and lasts 15 seconds or more, but returns to the baseline less than two minutes from the beginning of the acceleration. Most of the time these occur when there if fetal activity = good sign.
What is a pudenal nerve block?
Administered transvaginal and blocks the pudenal nerve; not associated with hypotension/doesn't effect VS or FHT--BUT can cause a hematoma or damage to the sciatic nerve.
What do sutures allow for during birth?
Allows the skull to overlap during delivery (molding) which aids in the delivery of the head as it passes through the pelvis.
What are late decelerations?
An ominous and potentially disastrous non-reassuring sign. Indicates uteroplacental insufficiency. Uniform shape of deceleration that occurs toward the end of contractions and recovery occurs after end of contraction. Decel's don't go past 100 bpm; decreased blood flow to fetus.
What is vacuum assisted birth?
Attachment of vacuum cup to fetal head, using negative pressure to assist birth of head; if more than 3 pop offs, d/c procedure. Only used with a occiput (head down) presentation.
What are some signs of hemorrhage?
BP drops and HR increases; firmness of the fundus
What can be given for false labor?
Barbiturates; secobarbital
What color will the nitrazine paper turn if amniotic fluid is present?
Blue
What will the doctor usually do if the fetus is in brow presentation?
C/S
What will the doctor usually do if baby is in the breech position?
C/S (90%); if rupture of membrane, watch for prolapsed cord especially with footling.
What should the nurse do if the fetus is in the face presentation?
Call the doctor! Will most likely deliver C/S; the fetus develops edema and will have more petechiae and ecchymoses in facial area.
What fetal presentation do we want?
Cephalic
What is vertex presentation? (what we want)
Cephalic presentation where head is sharply flexed and chin is touching chest
What are some symptoms of intrauterine death?
Cessation of movement (first sign), Spaldings sign DX confirmed by absence of heart activity on US
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the FHR for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurse's first priority?
Change the woman's position.
Which client would not be a suitable candidate for internal EFM?
Client who still has intact membranes
What should you always note with amniotic fluid?
Color, odor, amount, and if cord has prolapsed
What are variable decelerations?
Common pattern with rapid decelerations that is variable in duration, depth, and fall, and timing relative to the contraction cycle. Something is wrong with the CORD. SHORT CORD, KNOT IN CORD, PROLAPSED CORD.
What is true labor?
Contractions are regular and increasing and are not relieved by change in position. Discomfort in back radiates around to abdomen. Bloody show. Progressive effacement and dilation.
Which statement best describes a normal uterine activity pattern in labor?
Contractions every 2 to 5 minutes
What are some signs of complications of pregnancy?
Contractions lasting >90 seconds More than 5 contractions in a 10 min period Relaxation of contractions lasting <30 seconds
What is cord prolapse?
Cord presents before the head during labor (can cause sudden decelerations)
What are prolonged decelerations?
Deceleration lasting longer than 2 minutes but less than 10 minutes; PROLAPSED CORD.
What are decelerations?
Decelerations are a visually apparent change in the FHR below the baseline. They can be benign or nonreassuring.
What are early decelerations?
Decelerations that begin with the beginning of contractions or with contractions that symbolize a benign pattern caused by HEAD COMPRESSION. Slowly decelerates and returns to baseline. No treatment necessary.
Once the woman has progressed to 5-6 cm, what should happen with the Pitocin?
Decrease in the same increments as increased.
What are some fetal complications for multiple gestation?
Decreased intrauterine growth for each fetus; increased risk for prematurity
What is false labor?
Do not produce cervical effacement & dilation. Irregular contractions. Do not increase in frequency, duration, or intensity. Relieved by ambulation, changes in position, resting, hot bath, or shower.
While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?
Duration, frequency, and intensity
A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?
Early decelerations
What should the mother do if symptoms of preterm labor appear?
Empty bladder, lie on left side, drink 3-4 8 oz cups of fluid, palpate for contractions (if 10 min apart or less for 1 hour, notify HCP), soak in warm tub with uterus completely submerged, rest for 30 mins after symptoms have subsided and gradually resume activity, call HCP if symptoms persist
What is the goal with Pitocin?
Get 3 contractions in 10 mins
What is some nursing care for the gel, cervidil, and cytotec?
Get fetal monitoring 30 mins prior; Good FHR pattern; Reactive NST
What medication can be given if the mother has hypotension from an epidural?
Ephedrine
How often should the maternal temp be monitored?
Every 2 hours
What is fetal bradycardia?
FHR < 110 bpm for duration of 10 minutes or longer
What is fetal tachycardia?
FHR > 160 bpm for duration of 10 minutes or longer
What does moderate contractions feel like?
Feels like pressing a finger to the chin
What does strong contractions feel like?
Feels like pressing a finger to the forehead
What does mild contractions feel like?
Feels like pressing a finger to the tip of the nose
What is intrauterine death?
Fetal demise
What is the shiny Schultz?
Fetal membrane surface of the placenta
The area where two bones meet on the skull is called what?
Fontanels
What can the nurse do in the absence of a doctor when amniotic embolism is present?
Give O2 under positive pressure, IV, and CPR if arrest occurs (tilt woman 30 degrees to her side to displace uterus before CPR)
What pelvis shape is favorable for a vaginal delivery?
Gynecoid
If the fetus passes their first stool while still in utero, what should be readily available when giving birth?
Have at least one person capable of performing endotracheal intubation on the newborn present at birth
What is a common side effect for local anesthetics used during labor?
Hypotension
What is some nursing care for shock?
IV fluids, assess uterus every 15 mins, vital signs, record amount of vaginal bleeding, insert indwelling catheter (monitor output), NPO until stable
What are the initial measures to stop preterm labor?
Identifying and treating infections; activity restrictions and sexual activity restrictions; hydration
What is the management of a stuck shoulder during birth?
If difficulty extracting shoulder, will use McRoberts maneuver--flax the mother's thighs against abdomen and apply suprapubic pressure over the anterior shoulder; always note the total time it took to resolve the shoulder dystocia.
When will version be d/c?
If severe maternal pain or significant FHR bradycardia or decelerations.
When should the nurse only suction the nose and mouth?
If the baby has strong respiratory efforts, good muscle tone, and HR greater than 100
If rupture of membranes occurs, what should the woman do?
Immediately go to the hospital
The nurse is evaluating the EFM tracing of the client who is in active labor. Suddenly, the FHR drops from its baseline of 125 down to 80 beats per minute. The mother is repositioned, and the nurse provides oxygen, increased IV fluids, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take next?
Immediately notify the care provider.
What is cervical ripening?
Increases cervical readiness for labor through promotion of cervical softening, dilation and effacement; uses prostaglandin gels.
What types of episiotomy are there?
Midline (straight down, less common) or Mediolateral (45 degree angle, more common)
What should the nurse monitor after an epidural has been given?
Monitor BP every 1-2 mins
What is fetal distress?
Insufficient oxygen supply to meet the demands of the fetus; uteroplacental insufficiency; placental abnormalities (late decels)
What is a second degree perineal laceration?
Involve the vagina and the muscles of the perineal body, but not involving the anal sphincter. Suturing is necessary.
What is a third degree perineal laceration?
Involve the vagina, the perineal body, and the anal sphincter but not the rectal mucosa. Suturing is necessary to avoid anal incontinence.
What is a first degree perineal laceration?
Involves the superficial vaginal mucosa or perineal skin (skin only)
What is bloody show?
It is a small amount of blood at the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate.
What interventions are important for a client with third or fourth degree laceration?
Keep client clean, perform sitz baths, pain management, help them to go to the bathroom.
What should the nurse do when the mother receives an amnioinfusion?
Keep the pad changed for comfort; keep on bedrest.
What is preterm labor?
Labor that occurs after 20 and before 37 weeks of gestation.
Which FHR finding is the most concerning to the nurse who is providing care to a laboring client?
Late decelerations
Which characteristic correctly matches the type of deceleration with its likely cause?
Late deceleration—uteroplacental insufficiency
After a tablet or gel is inserted into the mother, what should she do?
Lie supine with right hip wedge for at least 30 mins-1 hour; 2 hours for Cervidil.
What is Cervadil?
Looks like a shoe string; inserted intravaginally; left in place for slow release over 12 hours; can be easily removed if needed in case of fetal distress; removed if N/V occurs or contractions occur more frequently than every 2 mins or lasts longer than 75 seconds.
What is most commonly used during active labor for pain?
Lumbar epidural block
What is a disadvantage of a lumbar epidural block?
Maternal Hypotension--can be minimized by preload of bolus IV fluid.
Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur?
Maternal fever
What is a cause of fetal tachycardia?
Maternal fever (100.4 or greater)
The nurse observes a sudden increase in variability on the ERM tracing. Which class of medications may cause this finding?
Methamphetamines
What is a medication you can give if the mother is bleeding excessively?
Methrogen
Do you use gel for the TOCO?
NO
Should Butorphanol be given to a pregnant woman with high BP or preeclampsia?
NO
If a woman has a classic vertical incision, can she have a trial of labor?
No
Will we use lubricant when testing for amniotic fluid?
No
Any pregnancy that lasts longer than 40 weeks must may require:
Nonstress test, amniotic fluid index, biophysical profiles, kick counts
During labor a fetus displays an average FHR of 135 beats per minute over a 10-minute period. Which statement best describes the status of this fetus?
Normal baseline heart rate
What position do we want the baby to be in for L&D?
OA position
What should the nurse do when the baby is born?
Obtain a sample of blood from the umbilical cord to be used to determine the baby's blood type and Rh status.
What is amniotic emboilsm?
Occurs when a small tear in the amnion or chorion occurs and amniotic fluid enters the maternal circulation and eventually reaches the pulmonary capillaries.
How should Pitocin be administered?
On a pump, IV piggyback
What does Fentanyl do for pregnant women?
Opioid agonist analgesic (pain med); for moderate to severe labor pain and postoperative pain after C-section. Naloxone should be available as an antidote!
What is the correct placement of the tocotransducer for effective EFM?
Over the uterine fundus
After the baby is delivered, the nurse will give what medication?
Oxytocin (helps to push out the placenta)
What is the treatment for uterus inversion?
Patient will be placed under general anesthesia, pain medications, may need tocolytics, may need hysterectomy
Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?
Place the client in a Trendelenburg position.
What are some contraindications for tocolytic therapy?
Preeclampsia, bleeding with instability, non-reassuring fetal status, fetal death, chorioamnionitis
In which clinical situation would the nurse most likely anticipate a fetal bradycardia?
Prolonged umbilical cord compression
What does morphine do for pregnant women?
Provides sedation and comfort, does NOT decrease pain intensity. Baby should be birthed within 1 hour or 4 hours after dose.
What is something that you should NEVER do when a woman is giving birth?
Pull on the cord
What do you do for fetal bradycardia?
Put mom on left side, give oxygen with nonrebreather mask; fetal scalp stimulation
What is preterm prelabor?
ROM before 37 weeks
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #1
Reactive NST
What is procardia used for?
Relaxes muscles to prevent contractions
If hyperstimulation, sustain contractions, or non-reassuring fetal status occurs with Cervidil administration; What is the nursing action?
Remove Cervidil! Turn on left side with O2; may give Terbutaline.
What are some symptoms of amniotic embolism?
Resp. distress, circulatory collapse, and acute hemorrhage; FROTHY SPUTUM
What does the fetal position of ROP mean?
Right occipitoposterior (the baby is facing us)
What must happen for a mother to have an IUPC?
Rupture of membranes
What should be monitored with magnesium sulfate?
SOB, respirations, reflexes (go away), urinary output
What is effacement?
Shortening and thinning of the cervix (0-100%)
What increases fetal lung maturity?
Steroids (Betamethasone)
What is terbutaline used for?
Stop preterm labor; given no longer than 24 hours; causes tachycardia in the mother and fetus
What is Indomethacin used for?
Stopping preterm labor by suppressing contractions; causes reduction in amniotic fluid; may cause premature closing of DA in fetus causing fetal death; only used in gestation <32 weeks.
What are the bones of the fetal head connected by?
Sutures
What is uterus inversion?
The uterus turns inside out after delivery of the infant
What should be readily available when using Cervadil?
The doctor; should only be used when the doctor is readily available in case needed for C/S.
What is CPD (cephalopelvic disproportion)?
The fetus is larger than the pelvic diameters; due to macrosomia (large infant)
During a nonstress test (NST), a nurse notes three fetal heart rate (FHR) increases of 20 beats/minute, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest?
The fetus is not in distress at this time.
What happens if the cord prolapses?
The head will obstruct the blood flow to the fetus--MUST KEEP THE HEAD OFF THE CORD UNTIL DELIVERY. Keep your hand in the vagina and keep head off of cord--place in knee chest/Trendelenburg position.
What is general flexion?
The ideal fetal attitude. It is when: -the head of the baby is flexed with chin to chest - thighs flexed to abdomen - legs are flexed at the knees - arms are crossed over thorax - umbilical cord is inbetween legs If there is a deviation from this ideal, for example if head is presenting part and it is extended rather then flexed to chin then the diameter of the head may exceed the limits of the mom's pelvis.
Which alteration in the FHR pattern would indicate the potential need for an amnioinfusion?
Variable decelerations
What is an incomplete uterine rupture?
Through the uterine wall but stops in the peritoneum. The peritoneal cavity is still intact
What is a complete uterine rupture?
Through the uterine wall into the peritoneal cavity
What is the third stage of labor?
Time between fetal expulsion and delivery of placenta
What is the second stage of labor?
Time from complete cervical dilation to delivery of baby
What is the first stage of labor?
Time from onset of labor to complete dilation of the cervix
In which situation would the nurse be called on to stimulate the fetal scalp?
To elicit an acceleration in the FHR
T/F Full cervical dilations marks the end of the first stage of labor.
True
What do you do for fetal tachycardia?
Turn mom on left side and may give O2 through nonrebreather mask; elevate HOB; give antipyretics if mother has a fever
What are some corrective measures that should be taken immediately for fetal distress?
Turn mom onto left side, increase IV rate, give O2 10 L per facial mask, fetal scalp stimulation If these measures fail, will need to deliver immediately!
What is the most likely cause for variable FHR decelerations?
Umbilical cord compression
What should the mother do when the fetus is in OP?
Use different positions to try to rotate the fetus such as knee to chest and side lying.
What is cervical readiness?
Using the Bishop score--the higher the score the greater chance of success (8 or greater indicates a good chance of successful vaginal delivery)
What are some risks of Pitocin?
Uterine tachysystole (too frequent uterine contractions)--decreased placental profusion and fetal distress Uterine rupture Water intoxication
The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations. Which clinical finding might be the cause for these late decelerations?
Uteroplacental insufficiency
What does VEAL CHOP stand for?
V-Variables (C-Cord Compressions) E-Early (H-Head Compressions) A-Acels (O-Okay) L-Late (P-Placenta)
What is a sinusoidal pattern?
Visually apparent smooth, sine wave-like undulating pattern in FHR baseline w/ cycle frequency of 3-5 minutes that persists for >=20 mins Associated w/ fetal anemia, HYPOXIA, and acidosis (cases- occult cord prolapse, pre-eclampic Mom w/ partial abruption) Poor prognosis Autonomic nervous system turned off by hypoxia
What does a uterine or placental souffle sound like?
Washing machine or swooshing sound (synchronous with maternal pulse)
When are forceps used?
When any condition threatens the mother or fetus condition and delivery is needed immediately.
When should the nurse suction the trachea using the endotracheal tube connected to a meconium aspiration device and suction source?
When the baby has depressed respirations, decreased muscle tone, and HR less than 100
What is longitudinal or vertical lie?
When the mom and baby's spine are parallel
What is a precipitous birth?
When there is no trained medical attendant at birth; Dr. or CNM doesn't make it and the nurse delivers the baby.
Can Narcan be given to the mom and baby?
YES. If given to baby, make sure it is diluted. Reverses opioid induced resp. depression.
When performing version, will the mother receive Rhogam?
Yes
What is uterine atony?
a soft boggy poorly contracted uterus and most commonly causes early PPH
What is an episiotomy?
a surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues.
What is APGAR?
appearance, pulse, grimace, activity, respiration
What is amniotomy?
artificial rupture of membranes (AROM); do after engagement and MUST deliver within 24 hours due to high risk of infection
What are the secondary powers?
bearing down efforts (push with contractions)
What is the frequency of contractions?
beginning of one contraction to the beginning of the next
What are the different types of breech presentation?
complete, frank, footling
What are hypotonic labor patterns?
characterized by fewer than 2-3 contractions in 10 mins; contractions are not strong enough to cause dilation Assess for protracted labor (less than 1 cm dilation/hr and for arrest of progress which is no cervical change for 2 hours)
What should amniotic fluid look/smell like?
clear and odorless
What are the primary powers?
contractions, effacement, and dilation
What is the most likely cause of the following fetal heart rate pattern? (flip for tracing) #6
cord compression
What is dystocia?
difficulty giving birth
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #3
early decelerations
What is the treatment for uterine rupture?
emergency c-section; possible hysterectomy
How should the nurse document the frequency of contractions based on the strip below? (flip for tracing)
every 2 minutes
What is a fourth degree perineal laceration?
extends through the anal spinster into the rectal mucosa
What does green meconium stained fluid mean?
fetal distress (baby had bowel movement)
What is the duration of contractions?
from the beginning of one contraction to the end of the same contraction
What is Prepidil?
gel that is like the cervidil; can be repeated every 6 hours for a max dose of 3 times within 24 hours
What is the most likely cause of the following fetal heart rate pattern? (flip for tracing)
head compression
What are hypertonic labor patterns?
increase in tone but poor quality and uncoordinated; least common and occur at the onset of labor in the latent phase; painful but ineffective in dilating and effacing the cervix
What are the 3 phases of a contraction?
increment, acme, decrement
What does an odor of amniotic fluid mean?
infection
What is an amnioinfusion?
infusion of fluid into the amniotic cavity through dilated cervix; relieves pressure on a compressed umbilical cord; SEEN WITH VARIABLE DECELS
What is induction during pregnancy?
intentional initiation of labor before it begins naturally
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #7
late decelerations
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #4
marked variabilty
What is the Dirty Duncan?
maternal side of placenta
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #2
minimal variability
What variability do we want to see?
moderate
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #5
moderative variability
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #8
no variability
What fetal position is ideal for L&D?
occipitoanterior (ROA or LOA) (baby is facing away from us)
What is the most common fetal malposition?
occiput posterior (OP)--face up
What is dilation?
opening of cervix (0-10cm)
What should you do before you administer medications to a pregnant woman in labor?
perform a vaginal exam; check dilation
What is external version?
procedure used to change fetal presentation from breech to cephalic; most common; US will be performed.
What is the most likely cause of the following fetal heart rate pattern? (flip for tracing) #2
prolapsed cord
What does a funic souffle sound like?
purring sound heard over the uterus, same rate as FHR
What is tocolytic therapy?
relaxation of the uterus, administration of drugs that inhibit contractions; goal is to stop contractions and to keep the fetus in utero until lungs are mature enough; can give Magnesium Sulfate as the drug of choice for neuro protection.
What is softening of the cervix called?
ripening
What is lightening?
settling of fetal head into brim of pelvis
What is augmentation?
stimulation of contractions after they have begun naturally
What is the intensity of contractions?
strength of contraction at peak
What is a cesarean section?
surgical delivery of a baby by making an incision through the abdomen and into the uterus
What are forceps?
surgical instruments used to assist in the birth of the fetus by providing either traction or means of rotating the head to an OA position.
What is Pitocin? What does it do?
synthetic form of oxytocin; initiates contractions or to enhance ineffective contractions
What is version?
turning of the fetus from one presentation to another
What is the most likely cause of the following fetal heart rate pattern? (flip for tracing) #9
uteroplacental insufficiency
How should the nurse interpret the variability of this fetal heart tracing? (flip for tracing) #10
variable decelerations
