OB ATI: Chapter 14 - Nursing Care During Stages of Labor

Temperature assessment every

4 hr (every 1 to 2 hr if membranes have ruptured)

A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the introitus for a prolapsed cord. B. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.

D

A nurse is caring for a client who is in the first stage of labor and encourages the client to void every 2 hr. The nurse explains that a A. full bladder increases the risk for fetal trauma. B. full bladder increases the risk for bladder infections. C. distended bladder will be traumatized by frequent pelvic exams. D. distended bladder reduces pelvic space needed for birth.

D

Nursing Assessments During the Fourth Stage

◯ Maternal vital signs ◯ Fundus ◯ Lochia ◯ Urinary output ◯ Baby-friendly activities of the family

Nursing Interventions During the First Stage of Labor

◯ Provide teaching to the client and her partner about what to expect during labor and on implementing relaxation measures: 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 a focal point, or imagery). ◯ Encourage upright positions, application of warm/cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort. ◯ Encourage voiding every 2 hr. ■ During first stage, active phase of labor ☐ Provide client/fetal monitoring. ☐ Encourage frequent position changes. ☐ Encourage voiding at least every 2 hr. ☐ Encourage deep cleansing breaths before and after modified paced breathing. ☐ Encourage relaxation. ☐ Provide nonpharmacological comfort measures. ☐ Provide pharmacological pain relief as prescribed. ■ During first stage, transition phase of labor ☐ Continue to encourage voiding every 2 hr. ☐ Continue to monitor and support the client and fetus. ☐ Encourage a rapid pant-pant-blow breathing pattern if the client has not learned a particular breathing pattern. ☐ Discourage pushing efforts until the cervix 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 descent. ☐ Prepare the client for the birth. ☐ Observe for perineal bulging or crowning (appearance of the fetal head at the perineum). ☐ Encourage the client to begin bearing down with contractions once the cervix is fully dilated.

A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation has occurred? (Select all that apply.) A. Lengthening of the umbilical cord. B. Swift gush of clear amniotic fluid. C. Softening of the lower uterine segment. D. Appearance of dark blood from the vagina. E. Fundus is firm upon palpation.

A, D, E

A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following is an appropriate nursing intervention? A. Assist the client to the bathroom. B. Prepare for an impending delivery. C. Prepare to remove a fecal impaction. D. Encourage the client to take deep, cleansing breaths.

B

A nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following is an appropriate response by the nurse? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C. "The vaginal area will bulge as the baby's head appears." D. "Your partner will report less rectal pressure."

C

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. ■ Clients may not feel the urge to void secondary to the labor process or anesthesia. ■ Encourage the client to void frequently.

Assessments related to possible rupture of membranes:

■ When there is suspected rupture of membranes, the nurse should first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid. ■ Verify presence of alkaline amniotic fluid using nitrazine paper (turns blue, pH 6.5 to 7.5). ■ A sample of the fluid may be obtained and viewed on a slide under a microscope. Amniotic fluid will exhibit a frondlike ferning pattern. Assess the amniotic fluid for color and odor: clear, straw color, and free of odor. Abnormal findings include the presence of meconium, abnormal color (yellow or port wine), a foul odor.

Nursing Interventions During the Fourth Stage

◯ Assess maternal vital signs every 15 min for the first hour and then according to facility protocol. ◯ Assess fundus and lochia every 15 min for the first hour and then according to facility protocol. ◯ Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and to prevent hemorrhage. ◯ Encourage voiding to prevent bladder distention. ◯ Promote an opportunity for parental-newborn bonding.

Nursing Assessments During the Third Stage

◯ Blood pressure, pulse, and respiration measurements every 15 min ◯ Signs of placental separation from the uterus as indicated by ■ Fundus firmly contracting ■ Swift gush of dark blood from introitus ■ Umbilical cord appears to lengthen as placenta descends ■ Vaginal fullness on exam ◯ Assignment of 1 and 5 min Apgar scores to the neonate

Nursing Assessments During the Second Stage (begins with complete dilation and effacement):

◯ Blood pressure, pulse, and respiration measurements every 5 to 30 min ◯ Uterine contractions ◯ Pushing efforts by client ◯ Increase in bloody show ◯ FHR every 15 min and immediately following birth ◯ Assessment for perineal lacerations, which usually occur as the fetal head is expulsed. Perineal lacerations are defined in terms of depth. ■ First degree - Laceration extends through the skin of the perineum and does not involve the muscles. ■ Second degree - Laceration extends through the skin and muscles into the perineum. ■ Third degree - Laceration extends through the skin, muscles, perineum, and anal sphincter muscle. ■ Fourth degree - Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall.

Nursing Interventions During the Second Stage

◯ Continue to monitor the client/fetus. ◯ Assist in positioning the client for effective pushing. ◯ Assist in partner involvement with pushing efforts and in encouraging bearing down efforts during contractions. ◯ Promote rest between contractions. ◯ Provide comfort measures such as cold compresses. ◯ Cleanse the client's perineum as needed if fecal material is expelled during pushing. ◯ Prepare for episiotomy, if needed. ◯ Provide feedback on labor progress to the client. ◯ Prepare for care of neonate. A nurse trained in neonatal resuscitation should be present at delivery. ■ Check oxygen flow and tank on warmer. ■ Preheat radiant warmer. ■ Lay out newborn stethoscope and bulb syringe. ■ Have resuscitation equipment in working order (resuscitation bag, laryngoscope) and emergency medications available. ■ Check suction apparatus.

Nursing Interventions During the Third Stage

◯ Instruct the client to push once signs of placental separation are indicated. ◯ Promote baby-friendly activities between the family and the newborn, which facilitates the release of endogenous maternal oxytocin. ◯ Administer analgesics as prescribed. ◯ Administer oxytocics once the placenta is expulsed to stimulate the uterus to contract and thus prevent hemorrhage. ◯ Gently cleanse the perineal area with warm water or 0.9% sodium chloride, and apply a perineal pad or ice pack to the perineum.

First Stage

◯ 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 whether membranes have ruptured. ■ Encourage the client to take slow, deep breaths prior to the vaginal exam. ■ Monitor the cervical dilation and effacement. ■ Monitor the station and fetal presentation. ■ Prepare for an impending delivery as the presenting part moves into positive stations and begins to push against the pelvic floor (crowning).

Assess the client:

☐ Conduct an admission history, review of antepartum care, and review of the birth plan. ☐ Obtain laboratory reports. ☐ Monitor baseline fetal heart tones and uterine contraction patterns for 20 to 30 min. ☐ Obtain maternal vital signs. ☐ Check the status of the amniotic membranes. ◯ Perform maternal and fetal assessments continuously throughout the labor process and immediately after birth. ◯ Avoid vaginal examinations in the presence of vaginal bleeding or until placenta previa or placenta abruptio is ruled out. If necessary, vaginal examinations should be done by the provider. ◯ Cervical dilation is the single most important indicator of the progress of labor. ◯ The progress of labor is affected by fetal lie, presentation, attitude, and fetal size in relationship to the mother's pelvis. ◯ The frequency, duration, and strength (intensity) of the uterine contractions cause fetal descent and cervical dilation.