CH 11 Labor And Delivery Processes

Question 1

Immediately following ROM what should the nurse assess

Answer 1

FHR for abrupt decelerations , which are indicative of fetal distress to rule out umbilical cord prolapse
Assessment of amniotic fluid- should be watery and clear and pale to straw yellow in color, odor should not be foul, volume should be between 500-1200 ml

Question 2

What should be used by the nurse to confirm ROM

Answer 2

Nitrazine paper should be used

Because u amniotic fluid is alkaline: nitrazine paper should be deep blue, indicating pH of,6.5-7.5.
Urine is slightly acidic: nitrazine paper will remain yellow

Question 3

What are the 5 P’s that affect and define the labor process

Answer 3

1. Passenger
2. Passageway
   3.powers
3. Position
   5 physiologic response

Question 4

What does passenger mean relating the the 5 P’s

Answer 4

Consists of the fetus and placenta. The size of the fetal head, fetal presentation, lie, attitude, and the position affect the ability of the fetus to navigate the birth canal

Question 5

What is lie

Answer 5

The relationship of the maternal longitudinal axis ( spine) to the fetal longitudinal axis ( spine)

Question 6

What is presentation

Answer 6

The part of the fetus that is entering the pelvic inlet first. It can be the back of the head ( occipital) chin ( mentum) shoulder ( scapula) or breech ( sacrum or feet)

Question 7

What is transverse

Answer 7

Fetal long axis is horizontal and forms a right angle to maternal axis and will not accommodate vaginal birth. The shoulder is the presenting part and may require delivery via C section

Question 8

What is attitude

Answer 8

Relationship of fetal body parts to one another

Question 9

What is fetal flexion

Answer 9

Chin flexed to chest, extremities flexed into torso

Question 10

What is fetal extension

Answer 10

Chin flexed away from chest, extremities extended

Question 11

What are physiologic changes preceding labor ( premonitory signs)

Answer 11

BACKACHE-a constant low backache caused by pelvic muscle relaxation
WEIGHT LOSS- 0.5-1.4 kg ( 1-3 lb weight loss)
LIGHTENING- fetal head descends into true pelvis abt 14 days before delivery, feeling that the fetus has dropped
CONTRACTIONS- begin with irregular uterine contractions ( Braxton hicks) that progress in strength and regularity
BLOODY SHOW- brownish or blood tinged mucus caused by expulsion of the cervical mucus plug resulting from the onset of cervical
Dilation and effacement
ENERGY BURST- Sometimes called the nesting response
GI CHANGES- less common, n/v indigestion
ROM- most commonly during the transition phase