ATI - Nursing Care During Stages of Labor
During the first sage, active phase of labor what your nursing interventions would you implement?
-provide client/fetal monitoring -encourage frequent position changes -encourage voiding at least every 2 horus -encourage deep cleansing breaths before and after modified paced breathing -encourage relaxation -provide nonpharmacological comfort measures -provide pharmacological pain relief as measured
What are some nursing interventions you can implement during the 1st stage of labor?
-provide teaching to client and her partner about what to expect during labor and implement relaxation measures -encourage upright positions, application of warm/cold packs, ambulation or hydrotherapy if not contraindicated to promote comfort -encourage voiding every 2 hours
What should the nurse first do when there is supected rupture of membranes?
assess the fetal heart rate to ensure there is nof etal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid -verify presence of alkaline amniotic fluid using nitrazine paper -a sample of fluid may be obtained and viewed on a slide under a microscope.
What is the African American like?
perfer female family members for support
what are some relaxation measures you can implement during the 1st stage of labor?
-breathing (deep cleansing breaths help divert focus away from contractions) -effleurage (gentle circular stroking of the abdomen in rhythm with breathing during contractions) -diversional activities (distraction, concentration on focal point, imagery)
During the second stage, transitional phase of labor what nursing interventions would you implement?
-continue to encourage voiding every 2 hours -continue to monitor and support the client and fetus -encourage a rapid pant pant bow breathing pattern if the client has not learned a particular breathing pattern -discourage pushing efforts until the ccervix is fully dilated -listen for client statements expressing the need to have a bowel movement. this sensation is a sign of complete dilation and fetal descnet. -prepare the client for birth -observe for perinal bulging or crowning -encourage the client to begin bearing down with contractions once cervix is fully dilated
What is the Asian American like?
may prefer mother be present; partner not an active participant; labor in silence; cesarean birth undesirable
what is second degree laceration?
extends through skin and muscle in the perineum
what is third degree laceration?
extends through skin, muscles, perineum and anal sphincter
What is the fourth degree of laceration?
extends through, skin, muscles, and sphincter and rectal wall
What is European american like?
birth is public concern; focus on technology; partner expected to be involved; provider seen as head of health care team
What would you assess during the 2nd stage of labor?
-blood pressure, pulse and respiration every 5 to 30 minutes -uteirne contractions -pushing efforts by clinet -increase in bloody show -FHR every 15 minutes and immediately after birth -assessment for perineal lacerations which usually occur as the fetal head is expulsed
What are the nursing assessments during the first stage of labor?
-leopold maneuvers performed -perform a vaginal examination as indicated (if no evidence of progress) to allow the examiner to assess whether client is in true labor and wether membranes have ruptured) -perform bladder palpation on a regular basis to prevent bladder distention, which can impede fetal descent through the birth canal and cause trauma to the bladder -blood pressure, pulse, and respiration measurements -temperature every 4 hours -contraction monitoring -FHR monitoring
what is a first degree laeration?
extends through skin of perineum and does not involve muscles.
What is the Native American like?
perfer female nurse; family involved in birth; use of herbs during labor; squatting position for birth
What is the Hispanic Culture like?
prefer mother to be present rather than partner
