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OB > ch 19 intrapartum nursing care stages 1-4 > Flashcards

ch 19 intrapartum nursing care stages 1-4 Flashcards

1
Q

status of 3 things in screening assessment intrapartum

A

-woman
-fetus
-labor

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2
Q

sources of data in screening assessment intrapartum (4)

A

-interview
-focused physical assessment
-lab results
-prenatal record

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3
Q

what is included in status of the woman in screening assessment

A

-general appearance
-use of breathing techniques, pain scale
-support person accompanying
-report of current and past medical and OB Hxs
-VS
-auscultate heart/lungs
-DTRs
-urine: dip for protein and glucose
-review for risk factors

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4
Q

what is included in status of the fetus in screening assessment

A

-report of EDB, current gestational age
-report of fetal movement (how often, changed?)
-size and shape maternal abdomen
-palpation for fetal movement and position
-FHR (20-30 min EFM tracing)
-review for risk factors

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5
Q

limits for protein and glucose in labor (dip test)

A

+1 protein
+1 glucose

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6
Q

what is included in status of labor in screening assessment

A

-membrane status (time, amount, color, odor)
-observation of vaginal fluid/bleeding
-report of contractions (frequency, duration, intensity, toco 20-30 mins)
-palpation of uterine activity
-vaginal exam (cervical status, fetal presentation and position, verification of membranes)
-review for risk factors

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7
Q

abnormal amniotic fluid

A

-malodorous
-actively bleeding
-green/brown color

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8
Q

when would you defer the vaginal exam in evaluating status of labor in screening assessment

A

if active bleeding (may have placenta previa)

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9
Q

2 tests for verification of membranes

A

-nitrazine: pH paper (amniotic fluid turns it blue)
-ferning: pattern seen under microscope, indicates amniotic fluid presence

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10
Q

what things besides amniotic fluid could turn the nitrazine paper blue (2)

A

-blood
-semen

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11
Q

when should complete admission assessment (after screening assessment) be completed and documented by RN

A

within first hour of admission
(unless active bleeding or delivery occurs)

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12
Q

can UAP help with admission assessment

A

-can do maternal VS
-can’t do fetal VS (which includes analyzing data)
-can’t put mom back on monitors

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13
Q

important consideration when obtaining obstetrical history

A

interview mom alone (no one else in room)

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14
Q

assessment of birth plan (5)

A

-EFM vs intermittent auscultation and palpation
-support person(s)/ birth attendant(s)
-pain management plan/ prep for labor and birth
-pediatric provider
-individual/cultural considerations

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15
Q

psych and emotional factors in patient interview of admission assessment

A

-language preference/barrier
-observation of general appearance and nonverbal comm
-domestic violence screen
-concerns/fears of labor and birth
-“ideal” birth experience
-learning needs of pt and family

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16
Q

what is included on physical exam in admission assessment

A

-heart, lungs
-skin
-edema (hands, face, sacrum, legs)
-DTRs
-FHR and uterine activity patterns

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17
Q

what labs are done for admission assessment

A

-urinalysis (possible culture and sensitivity)
-CBC (for Hct and Hgb)
-blood type and Rh

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18
Q

plan of care for stage 1 of labor

A

-ongoing assessments
-interventions (pain management, guidance)

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19
Q

what does stage 1 of labor include

A

dilation 1-10 cm
(latent 0-6 cm and active 6-10 cm)

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20
Q

how often to collect VS for laboring woman: low risk, latent phase (BP/P/R, T, FHR/UA, vag exam, psycho/emo)

A

-BP, P, R: q30-60mins
-T: q4h if BOWI, q2h if ROM, q1h if PROM
-FHR/UA: q30-60mins
-vag exam: PRN
-psycho/emo +partner: q30mins

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21
Q

what does the frequency of taking temperature in stage 1 labor depend on

A

membrane status
(monitors possibility of infection)

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22
Q

how often to collect VS for laboring woman: low risk, active phase (BP/P/R, T, FHR/UA, vag exam, psycho/emo)

A

-BP, P, R: q30mins
-T: q4h if BOWI, q2h if ROM, q1h if PROM
-FHR/UA: q15-30mins
-vag exam: PRN
-psycho/emo + partner: q15mins

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23
Q

when should you look at FHR

A

before and after contraction
-looking for early/late decels

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24
Q

1st nursing action after ROM

A

FHR (rapid decrease means prolapsed cord)
-then assess amniotic fluid

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25
indications for additional FHR assessment during stage 1 labor (6)
-ROM (rule out prolapsed cord) -sudden change in contraction pattern -before and after maternal med and at peak of med -any indication of complication -listen to FHR through contraction -consider EFM if periodic changes noted
26
what might hearing FHR above maternal umbilicus indicate
breech baby
27
3 ways to promote labor progress
-position changes and movement -pain management/comfort -adequacy of contraction pattern (2-5/10 mins)
28
graph for assessment of patterns of cervical dilation and fetal station over time
partogram
29
nurses role during AROM
-assess FHR before, during and after -assess fluid
30
ongoing nursing care for mom during labor
-maintain cardiac output (position, hydration) -control anxiety and fear -control hyperventilation and adequate RR -safety and comfort and regulation, sensation, perception (hygiene, oral care, pain management) -infection control -watch for Sx infection: fetal tachycardia, maternal T -psych support and anticipatory guidance -social: partner/support person
31
ongoing nursing care for baby during labor
-maintain maternal oxygenation (O2 to mom) -fetus will show signs of decreased O2 before mom will -ROM: assess for prolapsed cord
32
hygiene considerations for mom during labor
-clean linen and regular peri care -showers, baths (if BOWI) -socks/slippers -elimination -oral care: toothbrush, mouthwash, chapstick
33
comfort measures for laboring mom
-holding -application of hot/cold -giving ice chips, oral care, lip balm -helping with personal hygiene (esp peri care) -massage -hydrotherapy -helping with positioning -assisting with ambulation
34
S+S intrauterine infection (chorioamnionitis/ IUI/ chorio)
-fetal tachycardia (>180) -maternal fever
35
what IV fluids do you need to limit for mom during labor
IV fluids with 5% dextrose can cause fetal hyperglycemia
36
emotional support measures for labor
-companionship -eye contact -praise -distraction -affirmation -reassurance -visualization -attention focusing -advocacy -supporting husband/partner -information/advice
37
signs of complications during stage 1 labor
-intrauterine pressure >80 mmHg -resting tone >20 mmHg -contractions >90 sec duration ->5 contractions in 10 mins -relaxation time between contractions <30 sec -FHR baseline <110 or >160 -FHR variability absent or minimal -FHR late, variable, or prolonged decels -irregular FHR (suspected fetal arrhythmias) -MSF or bloody -ceased cervical change and/or descent of fetus -maternal temp >38 C (100.4 F) -foul smelling vaginal discharge -persistent bright/dark red vaginal bleeding
38
indicators of 2nd stage labor
-brief "lull" followed by increased frequency and intensity contractions -urge to push, feel need to have bm, involuntary bearing down -vomiting -increased bloody show (not heavy. mixed with fluid and mucus) -shaking/shivering -restlessness, verbalizations
39
vaginal exam findings during "lull" of 2nd stage labor
-10 cm dilated -100% effaced -0 station
40
findings during active phase 2nd stage labor
-bloody show -urge to push (fergusons reflex) -grunting, expiratory vocalizations -perineal bulging
41
maternal assessments during 2nd stage of labor
-BP and P: q5-15mins -constantly palpate bladder for distention -constantly evaluating contractions -constantly observing perineal area -constantly observing amniotic fluid for change
42
fetal assessments during 2nd stage of labor - how often?
latent: q15 mins active pushing: q5-15mins
43
2 ways of pushing during labor
-spontaneous/ open glottis (*don't push for more than 6-8 seconds at a time) -directed/ closed glottis (10 seconds pushing, no sound)
44
2 types perineal trauma associated with labor
-tear: laceration -incision: episiotomy
45
classifications of perineal trauma
1st degree: through skin and vaginal mucosa 2nd degree: through fascia and muscles 3rd degree: through external anal sphincter 4th degree: through anterior wall of rectum
46
risks for episiotomies
lateral: could extend to rectum mediolateral: harder to heal, possibility of lifelong pain
47
immediate care of newborn (4)
-document exact time of birth -immediate skin to skin -delayed cord clamping (atleast 3 mins) -immediate assessment and interventions (apgar, airway, resp effort support, thermoregulation support)
48
indicators of placental separation after birth
-firmly contracting fundus -change in uterus from discoid to globular shape -sudden gush dark blood -apparent lengthening of umbilical -finding of vaginal fullness on vaginal exam
49
nursing assessments 3rd stage labor
-before placental separation: BP, IV site -BP, P, R: q15mins
50
what does 3rd stage labor include
delivery of placenta
51
nursing interventions 3rd stage labor
-gentle push -administer oxytocin per protocol -pain management -ask hcp for blood loss and document -collect umbilical cord blood for lab -document assessments and interventions -promote family attachment
52
what does 2nd stage labor include
delivery of baby
53
3 interventions for reducing risk PPH during 3rd stage labor
-early admin pitocin (most important) -traction on umbilical cord -early clamping and cutting umbilical cord
54
possible complications during 3rd stage labor (5)
-hemorrhage -rupture of pre-existing cerebral aneurysm -cardiac decompensation (if Hx of cardiac disorders) -pulmonary embolism -amniotic fluid embolism
55
risk factors for PPH (7)
-bladder distention -uterine overdistention (multiple babies, big baby, polyhydramnios) -regional anesthesia -pitocin induction/augmentation -uterine tachysystole (frequent contractions) -magnesium sulfate therapy (smooth muscle relaxant) -dystocia (difficult labor)
56
symptoms of uterine atony (3)
-soft, "boggy" fundus on palpation -uterine fundus displaced above and to right of umbilicus -excessive lochia rubra
57
within 12 hours of birth where should fundus be? where is fundus every 24 hours after that?
-at umbilicus -1 cm below umbilicus consistent with # days postpartum
58
nursing interventions for PPH
-perform fundal massage -empty bladder (void or cath) -recheck q15min for 1 hr, q30min for 2 hr
59
when do you stop fundal massage for PPH
once it contracts
60
assessment frequency 4th stage of labor
q15min for 1 hr, then q30min for 1 hr: -P -BP -fundus -bladder -lochia -perineum -pain -PAR -add T at 1 hr and 2 hr
61
what does postanesthesia recovery score (PAR) include (5)
-activity -respirations -BP -LOC -color
62
when does 4th stage of labor begin
after placenta is delivered
63
immediate care of woman after placenta is born
-clean patient (bed and gown) -PO fluids, food (if not C/S) -assist woman to hold and position baby for eye-to-eye contact, assist with breastfeeding -assess VS, fundus, lochia, pain, sensory and motor function q15mins -promote elimination -maintain comfort, safety, hygiene -assess episiotomy or laceration repair, apply ice -meet emotional needs
64
how to meet mom's emotional needs during 4th stage labor
-listen to birth story/concerns -encourage family members to visit -support interactions with baby -support feelings of shock, disbelief, grief -promote family time with SO and baby

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