Ch 14 Nursing Care During the Stages of Labor

Leopold Maneuvers

Used to determine position of fetus and estimate term fetal weight

A nurse is caring for a client in the 3rd stage of labor. Which of the following findings indicate that placental separation has occurred? (SATA) A. Lengthening of umbilical cord B. Swift gush of clear amniotic fluid C. Softening of lower uterine segment D. Appearance of dark blood from vagina E. Fundus is firm on palpation

A. Lengthening of umbilical cord D. Appearance of dark blood from vagina E. Fundus is firm on palpation

Nursing Interventions During Fourth Stage of Labor

Assess maternal vitals, fundus and lochia every 15 minutes for 1st hour then according to facility protocol Massage uterine fundus and/or administer oxytocics to maintain uterine tone and prevent hemorrhage Encourage voiding to avoid bladder distention Promote paternal-newborn bonding

A nurse is caring for a client who is in the transition stage 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 fecal impaction D. Encourage client to take deep, cleansing breath

B. Prepare for an impending delivery rationale: urge for BM indicates fetal descent

`Nursing Assessment During Second Stage of Labor

Begins with complete dilation and effacement Increase in bloody show Pushing efforts by client Vitals every 5-30 minutes FHR every 15 minutes Assess for perineal lacerations that occur as fetus is expulsed, defined in terms of depth

Culturally Competent Care: European Americans

Birth is public concern; focus on technology; partner expected to be involved; provider seen as head of health care team

Relaxation Measures During Labor

Breathing Effleurage Distraction (focal point or imagery)

A nurse is caring for a client and her partner during the 2nd 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? 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. "The vaginal area will bulge as the baby's head appears"

What is the single most important indicator of the progress of labor?

Cervical Dilation

Nursing Assessments During Third Stage

Check vitals every 15 minutes Check for signs of placental separation from uterus Assignment of 1 and 5 minute Apgar scores

Nursing Interventions During Second Stage of Labor

Continue to monitor fetus and client Assist in positioning for effective pushing Assist in partner involvement and encourage bearing down efforts Promote rest between contractions Provide comfort measures such as cold compress Cleanse client's perineum if feces is expelled during pushing Prepare for episiotomy if needed Provide feedback on labor progress Prepare for care of neonate -check oxygen flow and tank on warmer -preheat radiant warmer -lay out newborn stethoscope and bulb syringe -Have resuscitation equipment in working order and emergency equipment available -check suction apparatus

A nurse in L&D 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 indicate in the plan of care? A. Inspect the introitus for prolapsed cord B. Perform a test to identify ferning pattern C. Monitor station of presenting part D. Defer vaginal exams

D. Defer vaginal exams rationale: should not be performed until placenta privia and placenta abruptio has been ruled out as cause for bleeding

A nurse is caring for a client 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. distended bladder reduces pelvic space needed for birth

First Degree Lacerations

Extends through skin of perineum and doesn't involve muscles

Second Degree Lacerations

Extends through skin, muscles into perineum

Fourth Degree Lacerations

Extends through skin, muscles, anal sphincter and anterior rectal wall

Third Degree Lacerations

Extends through skin, muscles, perineum and anal sphincter muscle

Signs of Placental Separation from Uterus

Fundus firmly contracting Swift gush of dark blood from introitus Umbilical cord appears to lengthen as placenta descends Vaginal fullness on exam

When should vaginal exams during labor be avoided?

In presence of vaginal bleeding Until placenta previa or placenta abruptio is ruled out

Nursing Interventions During Third Stage of Labor

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

Nursing Assessments During First Stage

Leopold Maneuvers Vaginal exam as indicated to assess true labor and rupture of membranes Encourage client to take slow deep breaths prior to vag exam Monitor dilation and effacement Monitor station and fetal presenting part Prepare for impending delivery as the presenting part moves into + station and begins push against pelvic floor (crowning) Assessments related to Rupture of Membranes Assess FHR to ensure there is no fetal distress from possible umbilical cord prolapse which can occur with gush of amniotic fluid Verify presence of alkaline amniotic fluid using nitrazine paper (turns blue, pH 6.5-7.5) Obtain sample of fluid to view under microscope (amniotic fluid= frondlike ferning pattern), assess color and odor Perform Bladder Palpation Perform on regular basis to prevent distention which can impede fetal descent and can cause trauma to bladder Clients may not feel urge to void due to labor or anesthesia Encourage to void every 2 hrs Vitals, contractions and FHR monitoring Latent Phase: every 30 minutes Active Phase: Every 30 minutes Transition Phase: Every 15 minutes Temperature is taken every 4 hrs unless membranes are ruptured then they are taken every 1-2 hrs

Nursing Assessments During Fourth Stage of Labor

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

Culturally Competent Care: Asian American

May prefer mother to be present; partner is not an active participant; labor in silence; C-section undesirable

Culturally Competent Care: African American

Prefer female family members for support

Culturally Competent Care: Native American

Prefer female nursing personnel; family involved in birth; use of herbs during labor; squatting position for birth

Culturally Competent Care: Hispanic

Prefer mother to be present during birth rather than partner

Nursing Interventions During First Stage of Labor

Provide teaching to clients about what to expect during labor Implement relaxation measures Encourage upright position, application of warm/cold packs, ambulation, or hydrotherapy if not contraindicated Encourage voiding at least every 2 hrs During Active Phase: Client/fetal monitoring Frequent position changes Encourage voiding Encourage deep cleansing breaths/ relaxation Provide nonpharmacological comfort measures Provide pharmalogical pain relief as prescribed During Transition Phase: Continue to encourage voiding Continue monitoring/ supporting client and fetus Encourage rapid pant-pant-blow breathing Discourage pushing efforts until cervix is fully dilated Listen for client statements of bowel movements which is a sign of fetal descent and prepare for birth Observe for crowning Encourage bearing down when cervix is dilated