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NR-NUR121 | Mother and Child Nursing (MCN) > [16] MIDTERMS | INTRAPARTUM PART 3B (STAGES OF LABOR) > Flashcards

[16] MIDTERMS | INTRAPARTUM PART 3B (STAGES OF LABOR) Flashcards

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1
Q

1ST STAGE OF LABOR - NURSING CARE

DURING ADMISSION:

  • ____ assessment
  • collecting ____ specimen
  • Other laboratory tests : ____ and ____, blood typing and cross matching ( ____ category), and ____
  • notifies the physician/certified nurse-midwife on the progress of labor (before or after completing the admission procedures)
A

DURING ADMISSION:

  • intrapartal assessment
  • collecting midstream urine specimen
  • Other laboratory tests : hemoglobin and hematocrit, blood typing and cross matching (high-risk category), and platelet count
  • notifies the physician/certified nurse-midwife on the progress of labor (before or after completing the admission procedures)
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2
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR:

  • continually assess the patient and her fetus to ensure a safe delivery
  • help to facilitate a ____ experience
  • assist in the satisfactory management of ____
  • advocate for the patient’s needs
A

DURING LABOR:

  • continually assess the patient and her fetus to ensure a safe delivery
  • help to facilitate a positive birth experience
  • assist in the satisfactory management of pain
  • advocate for the patient’s needs
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3
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR:

  • Maternal temperature is monitored ____ unless the temperature is over ____ ⁰C; in such case it is taken every hour.
  • BP, pulse, respirations, and response to pain are monitored ____. If the BP is ____ mm Hg or her pulse is more than ____, the nurse must notify the physician.
  • Monitor ____ level - can elevate the blood pressure and pulse, especially during contractions.
  • Palpate uterine contractions for frequency, intensity, and duration every ____ minutes.
A

DURING LABOR:

  • Maternal temperature is monitored q4h unless the temperature is over 37.5 ⁰C; in such case it is taken every hour.
  • BP, pulse, respirations, and response to pain are monitored q1h. If the BP is 135/85 mm Hg or her pulse is more than 100, the nurse must notify the physician.
  • Monitor pain level - can elevate the blood pressure and pulse, especially during contractions.
  • Palpate uterine contractions for frequency, intensity, and duration every 30 minutes.
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4
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: LATENT PHASE

  • teaching about ____ and other techniques for coping with labor contractions
  • encourage ____ when not contraindicated
  • offer fluids in the form of clear liquids or ice chips
  • ____ meal is allowed
A

DURING LABOR: LATENT PHASE

  • teaching about breathing and other techniques for coping with labor contractions
  • encourage ambulation when not contraindicated
  • offer fluids in the form of clear liquids or ice chips
  • Light meal is allowed
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5
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR:

  • Auscultates FHR ____ (low-risk women) and ____ (high-risk) as long as it remains between 110 and 160 bpm.
  • FHR should be auscultated throughout contraction and for about ____ seconds after the contraction to ensure that there are no decelerations.
A

DURING LABOR:

  • Auscultates FHR q30mins (low-risk women) and q15min (high-risk) as long as it remains between 110 and 160 bpm.
  • FHR should be auscultated throughout contraction and for about 15 seconds after the contraction to ensure that there are no decelerations.
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6
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: ACTIVE PHASE

  • Assist patient in ____ position (default position of delivery)
  • Palpate contractions ____
  • Cervix dilates from ____ cm, vaginal discharge and bloody show may increase = nurse needs to change the perineal pads more frequently
  • Encourage to void
  • Assess rupture of membranes and ____
  • Proper positioning; offer a back rub or provide ____
A

DURING LABOR: ACTIVE PHASE

  • Assist patient in semi-upright position (default position of delivery)
  • Palpate contractions q15-30mins
  • Cervix dilates from 4 -7 cm, vaginal discharge and bloody show may increase = nurse needs to change the perineal pads more frequently
  • Encourage to void
  • Assess rupture of membranes and prolapsed cord
  • Proper positioning; offer a back rub or provide effleurage
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7
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: TRANSITION PHASE

  • Palpate contractions ____
  • Offer small spoons of ice chips to moisten her mouth or by applying an ____ to dry lips
  • Encourage to rest between contractions and do ____
A

DURING LABOR: TRANSITION PHASE

  • Palpate contractions q15mins
  • Offer small spoons of ice chips to moisten her mouth or by applying an emollient to dry lips
  • Encourage to rest between contractions and do “pant-blow breathing”
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8
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR:

  • women are often encouraged to remain ____
  • Sitting in a chair and reclining on the side
  • rest on ____ side to facilitate optimal uteroplacental blood flow
  • avoid the ____ position
A

DURING LABOR:

  • women are often encouraged to remain ambulatory
  • Sitting in a chair and reclining on the side
  • rest on left side to facilitate optimal uteroplacental blood flow
  • avoid the supine position
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9
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: POSITION CHANGES

  • Walking/standing
  • ____
  • Hands and knees position
  • ____
  • Side-lying
  • ____
A

DURING LABOR: POSITION CHANGES

  • Walking/standing
  • Sitting
  • Hands and knees position
  • Squatting
  • Side-lying
  • Semi-fowler’s
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10
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: PERSONAL COMFORT MEASURES

  • E____
  • H____
  • E____
A

DURING LABOR: PERSONAL COMFORT MEASURES

  • Environment
  • Hygiene
  • Elimination
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11
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: REDUCING ANXIETY

  • Give information, establish rapport
  • Remaining with the woman
  • Praise for correct ____, ____ efforts, and ____ efforts
  • Keeping them (____) informed about the progress of labor
A

DURING LABOR: REDUCING ANXIETY

  • Give information, establish rapport
  • Remaining with the woman
  • Praise for correct breathing, relaxation efforts, and pushing efforts
  • Keeping them (woman’s partner) informed about the progress of labor
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12
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: PROVIDING INFORMATION

  • ____ of the discomfort
  • Describe the ____ of discomfort and ____ that will occur
  • A thorough explanation of surroundings, procedures, and equipment
A

DURING LABOR: PROVIDING INFORMATION

  • Nature of the discomfort
  • Describe the type of discomfort and specific sensations that will occur
  • A thorough explanation of surroundings, procedures, and equipment
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13
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: SUPPORTIVE RELAXATION TECHNIQUES

  • D____
  • E____
  • firm pressure on the lower back or ____ area
  • ____ techniques
  • ____ method
A

DURING LABOR: SUPPORTIVE RELAXATION TECHNIQUES

  • Distraction
  • Effleurage
  • firm pressure on the lower back or sacral area
  • Visualization techniques
  • Simple visualization method
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14
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: BREETHING TECHNIQUES

  • ____ breathing ( ____ )
  • Breathing Pattern Levels
    First level/slow paced/slow, deep breathing
  • begins and ends w/ a ____
  • inhaling through the ____ & exhaling through ____
  • rate is approx. ____ breaths/min or
    ____ breaths/15 sec
  • counts- one one thousand, two one thousand, three…
A

DURING LABOR: BREETHING TECHNIQUES

  • Patterned-paced breathing (Lamaze)
  • Breathing Pattern Levels
    First level/slow paced/slow, deep breathing
  • begins and ends w/ a cleansing breath
  • inhaling through the nose & exhaling through pursed lips
  • rate is approx. 6-9 breaths/min or
    2 breaths/15 sec
  • counts- one one thousand, two one thousand, three…
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15
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: BREATHING TECHNIQUES

  • Patterned-paced breathing (Lamaze)
  • Breathing Pattern Levels
    Second level/shallow/modified paced breathing
    • begins and ends w/ a ____
    • breaths through the mouth @ approx. ____ breaths/5
      sec
    • counts – “one and two and one and two …
    • woman ____ on the numbers and ____ on “and”
A

DURING LABOR: BREATHING TECHNIQUES

  • Patterned-paced breathing (Lamaze)
  • Breathing Pattern Levels
    Second level/shallow/modified paced breathing
    • begins and ends w/ a cleansing breath
    • breaths through the mouth @ approx. 4 breaths/5
      sec
    • counts – “one and two and one and two …
    • woman exhaling on the numbers and inhaling on “and”
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16
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: BREATHING TECHNIQUES

  • Patterned-paced breathing (Lamaze)
  • Breathing Pattern Levels
    Third level/pant-blow/pattern paced breathing
  • begins and ends w/ a cleansing breath
  • All breaths are through the ____
  • Exhalations are accompanied by a ____ or ____ sound in varying pattern which begins as ____, ____ or ____
A

DURING LABOR: BREATHING TECHNIQUES

  • Patterned-paced breathing (Lamaze)
  • Breathing Pattern Levels
    Third level/pant-blow/pattern paced breathing
  • begins and ends w/ a cleansing breath
  • All breaths are through the mouth
  • Exhalations are accompanied by a “hee” or “hoo” sound in varying pattern which begins as 3:1(hee hee hee hoo), 2:1 or 1:1
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17
Q

1ST STAGE OF LABOR - NURSING CARE

DURING LABOR: BREATHING TECHNIQUES

  • Abdominal breathing
  • Quick Method – abdominal breathing & ____
  • ____ may occur when a woman breathes very rapidly over a prolonged period of time.
A

DURING LABOR: BREATHING TECHNIQUES

  • Abdominal breathing
  • Quick Method – abdominal breathing & pant-pant-blow (2 short blows from mouth followed by longer blow)
  • Hyperventilation may occur when a woman breathes very rapidly over a prolonged period of time.
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18
Q

full dilatation and cervical effacement to birth of the infant

A

2ND STAGE OF LABOR

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19
Q

2ND STAGE OF LABOR

  • should be completed within ____ hours after the cervix becomes fully dilated for primigravidas; less than ____ hour and averages ____ minutes for multiparas
  • Contractions continue with
    frequency of about every
    ____ to ____ minutes, duration
    of ____ to ____ seconds, and
    ____ intensity.
  • ____ occurs
A
  • should be completed within 3 hours after the cervix becomes fully dilated for primigravidas; less than 1 hour and averages 15 minutes for multiparas
  • Contractions continue with
    frequency of about every
    1 1/2 to 2 minutes, duration
    of 60 to 90 seconds, and
    strong intensity.
  • Crowning occurs
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20
Q

2ND STAGE OF LABOR - NURSING DIAGNOSES

  • ____ r/t uterine contractions, the birth process, and/or perineal trauma from birth
  • ____ r/t to birth process
  • ____ r/t the outcome of the birth process
A
  • Acute Pain r/t uterine contractions, the birth process, and/or perineal trauma from birth
  • Ineffective coping r/t to birth process
  • Fear/Anxiety r/t the outcome of the birth process
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21
Q

2ND STAGE OF LABOR - NURSING CARE

  • Sterile ____ examinations
  • Mother may make a variety of sounds (“uhh”)
  • BP ____, FHT ____
  • Provide support, reassurance and clear directions for the woman to follow.
  • Begin pushing when the woman feels the natural urge to ____; rest between contractions
A
  • Sterile vaginal examinations
  • Mother may make a variety of sounds (“uhh”)
  • BP q30mins, FHT q15mins
  • Provide support, reassurance and clear directions for the woman to follow.
  • Begin pushing when the woman feels the natural urge to bear down; rest between contractions
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22
Q

2ND STAGE OF LABOR - NURSING CARE

  • When the contraction begins, the nurse tells the woman to take ____ breaths, then to take a ____ breath and hold it while pulling back on her ____ and pushing down with her ____ muscles.
  • Assist woman into a comfortable position for pushing
  • Assess the level of pain
  • Provide information regarding progress of her labor
A
  • When the contraction begins, the nurse tells the woman to take two breaths, then to take a third breath and hold it while pulling back on her knees and pushing down with her abdominal muscles.
  • Assist woman into a comfortable position for pushing
  • Assess the level of pain
  • Provide information regarding progress of her labor
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23
Q

2ND STAGE OF LABOR - NURSING CARE

  • Apply ____ cloths to the face and forehead
  • Provide privacy
  • Encourage to ____ all muscles between contractions
  • Assist into ____ position
  • Offer sips of fluids or ice chips
  • Provide positive reinforcement and encouragement
A
  • Apply cool cloths to the face and forehead
  • Provide privacy
  • Encourage to rest and relax all muscles between contractions
  • Assist into pushing position
  • Offer sips of fluids or ice chips
  • Provide positive reinforcement and encouragement
24
Q

2ND STAGE OF LABOR

ASSISTING DURING BIRTH

  • Prepare the equipment and materials
  • Healthcare provider should apply ____ precautions & perform appropriate ____ precautions
  • Assisting the woman and ____, physician/CNM ( ____ ) in preparing for the birth.
A

ASSISTING DURING BIRTH

  • Prepare the equipment and materials
  • Healthcare provider should apply standard precautions & perform appropriate barrier precautions
  • Assisting the woman and her partner, physician/CNM (Certified Nurse-Midwife) in preparing for the birth.
25
Q

2ND STAGE OF LABOR

BIRTHING POSITION

  • ____
  • ____ position
A

BIRTHING POSITION

  • Semi-upright
  • Left lateral position
26
Q

2ND STAGE OF LABOR

PERINEAL CARE

  • use of ____ water/ aseptic technique

Cleansing technique:
* beginning with the ____, the area is cleansed up to the ____

  • A second sponge is used to clean the ____ and ____ of one leg and a third is used to clean the other leg, moving ____ to avoid carrying material from surrounding areas to the vaginal outlet.
  • The last three sponges are used to clean the ____ and ____ with one ____ sweep each.
A

PERINEAL CARE

  • use of warm soapy water/ aseptic technique

Cleansing technique:
* beginning with the mons pubis, the area is cleansed up to the lower abdomen

  • A second sponge is used to clean the inner groin and thigh of one leg and a third is used to clean the other leg, moving upward to avoid carrying material from surrounding areas to the vaginal outlet.
  • The last three sponges are used to clean the labia and vestibule with one downward sweep each.
27
Q

2ND STAGE OF LABOR

  • surgical incision of the perineum
  • Midline/ mediolateral
A

EPISIOTOMY

28
Q

2ND STAGE OF LABOR

MECHANISMS / CARDINAL MOVEMENTS OF LABOR

  • D____
  • F____
  • I____
  • E____
  • E____
  • E____
A

MECHANISMS / CARDINAL MOVEMENTS OF LABOR

  • Descent
  • Flexion
  • Internal Rotation
  • Extension
  • External Rotation
  • Expulsion
29
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS

  • Head floating, before engagement
A

DESCENT

30
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS

Descent occurs because of four forces:
1. pressure of the ____,

  1. direct pressure of the ____ on the breech
  2. contraction of the ____ muscles
  3. ____ and ____ of the fetal body
A

CARDINAL MOVEMENTS

Descent occurs because of four forces:
1. pressure of the amniotic fluid,

  1. direct pressure of the uterine fundus on the breech
  2. contraction of the abdominal muscles
  3. extension and straightening of the fetal body
31
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS

  • Engagement
A

FLEXION

32
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS

  • Further Descent
A

INTERNAL ROTATION

33
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS

  • Denotes extracting the fetal head, using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other on the fetal occiput to control speed of delivery
A

RITGEN’S MANEUVER

34
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS: RITGEN’S MANEUVER

  • During delivery of the head, encourage woman to ____ pushing and breathe rapidly with ____
  • In cephalic presentation, keep one hand on the ____ as it advances during contractions while the other hand supports the ____
A

CARDINAL MOVEMENTS: RITGEN’S MANEUVER

  • During delivery of the head, encourage woman to stop pushing and breathe rapidly with mouth open
  • In cephalic presentation, keep one hand on the head as it advances during contractions while the other hand supports the perineum
35
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS - EXTERNAL ROTATION

  • A part of the amnion sometimes covering the head of a fetus at birth - is a thin, filmy membrane, the amnion, that can cover a newborn’s
A

CAUL

36
Q

2ND STAGE OF LABOR

CARDINAL MOVEMENTS

  • Do not suction unless the ____ are blocked with secretions or other materials (DOH Essential Newborn Care Protocol, 2010).
  • Check for ____
A

CARDINAL MOVEMENTS

  • Do not suction unless the mouth/nose are blocked with secretions or other materials (DOH Essential Newborn Care Protocol, 2010).
  • Check for nuchal cord
37
Q

2ND STAGE OF LABOR

BIRTH OF THE BABY

  • Call and note the ____ and ____ of the baby. Inform the mother of the outcome
    (Record when the ____ is born.)
  • Exclude 2nd baby by palpating the abdomen in preparation for giving ____
A

BIRTH OF THE BABY

  • Call and note the time of birth and sex of the baby. Inform the mother of the outcome
    (Record when the whole body is born.)
  • Exclude 2nd baby by palpating the abdomen in preparation for giving oxytocin
38
Q

2ND STAGE OF LABOR - NURSING CARE

CLAMPING AND CUTTING OF THE CORD

  • Properly-timed cord clamping ____ min or until ____ have stopped after birth.
  • Clamp the cord at ____ cm from the ____ base.
  • Clamp again at ____ cm from the base and cut the cord close to the plastic clamp
A

CLAMPING AND CUTTING OF THE CORD

  • Properly-timed cord clamping 1-3 min or until pulsations have stopped after birth.
  • Clamp the cord at 2 cm from the umbilical base.
  • Clamp again at 5 cm from the base and cut the cord close to the plastic clamp
39
Q

3RD STAGE OF LABOR

AMTSL

A

Active Management of the Third Stage (AMTSL)

40
Q

3RD STAGE OF LABOR

Active Management of the Third Stage (AMTSL)

  1. Administration of ____ within one minute of delivery of the baby
  2. Controlled ____ with ____ on the uterus
  3. ____ massage
A

Active Management of the Third Stage (AMTSL)

  1. Administration of uterotonic within one minute of delivery of the baby
  2. Controlled cord traction with counter traction on the uterus
  3. Uterine massage
41
Q

3RD STAGE OF LABOR

USE OF OXYTOCIN

  • Oxytocin (Pitocin), ____ units, may be added to an IV infusion or ____ units may be given intramuscularly (for uterine contraction and minimize bleeding)
  • assess and record ____ before and after administration of oxytocics and assess the amount of ____
A

USE OF OXYTOCIN

  • Oxytocin (Pitocin), 10 to 20 units, may be added to an IV infusion or 10 units may be given intramuscularly (for uterine contraction and minimize bleeding)
  • assess and record BP before and after administration of oxytocics and assess the amount of bleeding
42
Q

3RD STAGE OF LABOR

  • the ____ stage
  • begins with the birth of the infant and ends with the delivery of the ____
  • usually lasts ____ minutes; completed within ____ minutes after the birth of the infant
  • Phases:
    Placental ____
    Placental ____
A
  • the placental stage
  • begins with the birth of the infant and ends with the delivery of the placenta
  • usually lasts 5 to 10 minutes; completed within 30 minutes after the birth of the infant
  • Phases:
    Placental Separation
    Placental Expulsion
43
Q

3RD STAGE OF LABOR

SIGNS OF PLACENTAL SEPARATION

  1. ____ sign -uterine fundus rises in the ____
  2. Sudden gush of ____ from the vagina
  3. ____ of the umbilical cord
  4. Appearance of the ____ at the vaginal opening
A

SIGNS OF PLACENTAL SEPARATION

  1. Calkin’s sign - uterine fundus rises in the abdomen
  2. Sudden gush of blood from the vagina
  3. Lengthening of the umbilical cord
  4. Appearance of the placenta at the vaginal opening
44
Q

3RD STAGE OF LABOR

PLACENTAL EXPULSION/DELIVER

“Controlled Cord Traction with Counter Traction”

  • To be done after the administration of ____ (within ____ min. after delivery of the baby)
  • Pull the placenta along the axis of the vagina with ____ just above the symphysis pubis
A

PLACENTAL EXPULSION/DELIVER

“Controlled Cord Traction with Counter Traction”

  • To be done after the administration of Oxytocin (within 1 min. after delivery of the baby)
  • Pull the placenta along the axis of the vagina with simultaneous counter traction just above the symphysis pubis
45
Q

3RD STAGE OF LABOR

PLACENTAL EXPULSION/DELIVERY

“Controlled Cord Traction with Counter Traction”

  • Note: Do the cord traction only when the ____
  • Pulling the placenta during ____ of the uterus may lead to ____ (It’s the ____ of the uterus that separates the placenta from it & not the controlled traction of the practitioner.)
A

PLACENTAL EXPULSION/DELIVERY

“Controlled Cord Traction with Counter Traction”

  • Note: Do the cord traction only when the uterus is contracting
  • Pulling the placenta during relaxation of the uterus may lead to uterine inversion (It’s the contraction of the uterus that separates the placenta from it & not the controlled traction of the practitioner.)
46
Q

3RD STAGE OF LABOR

MECHANISMS OF PLACENTAL EXPULSION/DELIVERY

  • placenta separates from the inside to the outer margins, and it is delivered with the fetal side presenting first
  • most common method of placental expulsion
  • “shiny”
A

SCHULTZE

47
Q

3RD STAGE OF LABOR

MECHANISMS OF PLACENTAL EXPULSION/DELIVERY

  • placenta separates from the outer margins inward, it will roll up and present sideways with the maternal surface delivering first
  • “dirty”
A

DUNCAN

48
Q

3RD STAGE OF LABOR

PLACENTAL EXPULSION AND DELIVERY

  • Failure of the uterus to contract adequately with separation of the placenta can result in ____ or ____
  • A placenta is considered to be ____ if ____ min have elapsed from completion of the second stage of labor
A

PLACENTAL EXPULSION AND DELIVERY

  • Failure of the uterus to contract adequately with separation of the placenta can result in excessive blood loss or hemorrhage
  • A placenta is considered to be retained if 30 min have elapsed from completion of the second stage of labor
49
Q

3RD STAGE OF LABOR - NURSING CARE

PROVISION OF INITIAL NEWBORN CARE

  • check newborn’s ____ and ____
  • newborn ____
  • initiation of ____
A

PROVISION OF INITIAL NEWBORN CARE

  • check newborn’s breathing & color
  • newborn identification
  • initiation of attachment
50
Q

3RD STAGE OF LABOR - NURSING CARE

AFTER DELIVERY OF PLACENTA

  1. ____ the uterus immediately after delivery of placenta.
  2. Note ____ and ____ of placental expulsion
  3. Inspect birth canal for ____. Repair the ____.
  4. Inspect for the ____ of the placenta
  5. Early resumption of ____ (<6 hours after the delivery)
  6. _____ only for 3rd and 4th degree perineal tear
  7. Encourage ____ for uterine contraction.
A

AFTER DELIVERY OF PLACENTA

  1. Massage the uterus immediately after delivery of placenta.
  2. Note time and mechanism of placental expulsion
  3. Inspect birth canal for lacerations. Repair the lacerations.
  4. Inspect for the completeness of the placenta
  5. Early resumption of feeding (<6 hours after the delivery)
  6. Prophylactic antibiotics only for 3rd and 4th degree perineal tear
  7. Encourage BF for uterine contraction.
51
Q

3RD STAGE OF LABOR - NURSING CARE

CATEGORIES OF VAGINAL AND PERINEAL LACERATIONS

A
  • First Degree
  • Second Degree
  • Third Degree
  • Fourth Degree
52
Q

3RD STAGE OF LABOR - NURSING CARE

The following are NOT recommended:

  1. ____ pressure
  2. ____ of the uterus
  3. Use of ____
  4. Routine use of ____
A

The following are NOT recommended:

  1. Fundal pressure
  2. Manual exploration of the uterus
  3. Use of ice packs
  4. Routine use of oral methergine

Methergine - uterotonic agent used to help deliver the placenta and control bleeding after childbirth

53
Q

4TH STAGE OF LABOR

  • from ____ hours after birth
  • Blood loss ranges from ____ ml.
  • uterus remains contracted in the ____ of the abdomen; fundus is usually midway between the ____ and ____
A
  • from 1 to 4 hours after birth
  • Blood loss ranges from 250 to 500 ml.
  • uterus remains contracted in the midline of the abdomen; fundus is usually midway between the symphysis pubis and umbilicus
54
Q

4TH STAGE OF LABOR - NURSING CARE

  • Remove drapes after repair of ____
  • places clean absorbent pad beneath her and applies maternity pads
  • Advised ____ of uterus
  • Palpate uterus ____ for the first ____ hrs.
  • VS ____
  • Inspect the ____
A
  • Remove drapes after repair of laceration/episiotomy
  • places clean absorbent pad beneath her and applies maternity pads
  • Advised massage of uterus
  • Palpate uterus q15mins for the first 1-2 hrs.
  • VS q15mins
  • Inspect the lochia

Lochia - postpartum bleeding; normal vaginal discharge after childbirth (blood, mucus, & uterine tissue)

55
Q

4TH STAGE OF LABOR - NURSING CARE

  • A ____ = alleviate shivering
  • Encouraged to ____
A
  • A heated bath blanket /warm drink = alleviate shivering
  • Encouraged to rest

NR-NUR121 | Mother and Child Nursing (MCN) (18 decks)

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