Ch. 16 Nursing care during labor

Question 1

How long does the 1st stage of labor last

Answer 1

Onset of regular uterine contraction ends with complete cervical effacement and dilation

Question 2

What is the criterion for the latent phase (1st)

Answer 2

Dilation= 0-3cm
Duration- 6-8hr
Contractions- mild/mod 5-30min apart (30-35sec)
Descent- 0 station
Show- brown discharge

Question 3

What is the criterion for the active phase (1st)

Answer 3

Dilation= 4-7cm
Duration- 3-6hr
Contractions- mod-strong, 3-5min apart (40-70sec)
Descent- +1, +2
Show- pink, bloody mucus scant

Question 4

What is the criterion for the transition phase (1st)

Answer 4

Dilation= 8-10cm 
Duration- 20-40min
Contractions- strong, 2-3min (45-90sec)
Descent- +2, +3 station
Show- bloody mucus

Question 5

What is the criterion for true labor

Answer 5

Contractions occur regular, strong, continue w/comfort measures, bloody show, softening, presenting part engaged in pelvis

Question 6

What is the criterion for false labor

Answer 6

Occur irregularly, stops w/walking, part not engaged in pelvis

Question 7

What is the purpose of the nitrazine fern test

Answer 7

Confirm the membranes are ruptured

Question 8

What is the purpose of Leopold maneuver

Answer 8

Identify # of fetuses, presenting part, fetal lie, fetal attitude, degree of descent, PMI

Question 9

Define amniotomy

Answer 9

Artificial rupture of membrane

Question 10

When does the 2nd stage of labor begin/end

Answer 10

Full dilation and. complete effacement (100%) ends with birth of fetus

Question 11

Define crowning

Answer 11

Widest part of hood (biparietal) descends the Velva just before birth

Question 12

What is an episiotomy

Answer 12

incision into the perineum to enlarge the vaginal outlet

Question 13

How long is the 3rd stage of labor

Answer 13

Birth of baby till placenta is expelled

Question 14

How long after the baby is born should the placenta be expelled

Answer 14

15min

Question 15

When is the placenta said to be retained

Answer 15

More than 30min, interventions are needed

Question 16

How long does the 4th stage last

Answer 16

1-2hr after birth

Question 17

How often are vitals assessed after birth

Answer 17

Every 15min, temp every hr.

Question 18

Why is it important to encourage woman to void every 2hrs

Answer 18

A distended bladder may impede descent of the presenting part , slow or stop uterine contractions, and lead to uterine atony after birth