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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
Q

indications for additional FHR assessment during stage 1 labor (6)

A

-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

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26
Q

what might hearing FHR above maternal umbilicus indicate

A

breech baby

27
Q

3 ways to promote labor progress

A

-position changes and movement
-pain management/comfort
-adequacy of contraction pattern (2-5/10 mins)

28
Q

graph for assessment of patterns of cervical dilation and fetal station over time

A

partogram

29
Q

nurses role during AROM

A

-assess FHR before, during and after
-assess fluid

30
Q

ongoing nursing care for mom during labor

A

-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
Q

ongoing nursing care for baby during labor

A

-maintain maternal oxygenation (O2 to mom)
-fetus will show signs of decreased O2 before mom will
-ROM: assess for prolapsed cord

32
Q

hygiene considerations for mom during labor

A

-clean linen and regular peri care
-showers, baths (if BOWI)
-socks/slippers
-elimination
-oral care: toothbrush, mouthwash, chapstick

33
Q

comfort measures for laboring mom

A

-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
Q

S+S intrauterine infection (chorioamnionitis/ IUI/ chorio)

A

-fetal tachycardia (>180)
-maternal fever

35
Q

what IV fluids do you need to limit for mom during labor

A

IV fluids with 5% dextrose
can cause fetal hyperglycemia

36
Q

emotional support measures for labor

A

-companionship
-eye contact
-praise
-distraction
-affirmation
-reassurance
-visualization
-attention focusing
-advocacy
-supporting husband/partner
-information/advice

37
Q

signs of complications during stage 1 labor

A

-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
Q

indicators of 2nd stage labor

A

-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
Q

vaginal exam findings during “lull” of 2nd stage labor

A

-10 cm dilated
-100% effaced
-0 station

40
Q

findings during active phase 2nd stage labor

A

-bloody show
-urge to push (fergusons reflex)
-grunting, expiratory vocalizations
-perineal bulging

41
Q

maternal assessments during 2nd stage of labor

A

-BP and P: q5-15mins
-constantly palpate bladder for distention
-constantly evaluating contractions
-constantly observing perineal area
-constantly observing amniotic fluid for change

42
Q

fetal assessments during 2nd stage of labor - how often?

A

latent: q15 mins
active pushing: q5-15mins

43
Q

2 ways of pushing during labor

A

-spontaneous/ open glottis (*don’t push for more than 6-8 seconds at a time)
-directed/ closed glottis (10 seconds pushing, no sound)

44
Q

2 types perineal trauma associated with labor

A

-tear: laceration
-incision: episiotomy

45
Q

classifications of perineal trauma

A

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
Q

risks for episiotomies

A

lateral: could extend to rectum
mediolateral: harder to heal, possibility of lifelong pain

47
Q

immediate care of newborn (4)

A

-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
Q

indicators of placental separation after birth

A

-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
Q

nursing assessments 3rd stage labor

A

-before placental separation: BP, IV site
-BP, P, R: q15mins

50
Q

what does 3rd stage labor include

A

delivery of placenta

51
Q

nursing interventions 3rd stage labor

A

-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
Q

what does 2nd stage labor include

A

delivery of baby

53
Q

3 interventions for reducing risk PPH during 3rd stage labor

A

-early admin pitocin (most important)
-traction on umbilical cord
-early clamping and cutting umbilical cord

54
Q

possible complications during 3rd stage labor (5)

A

-hemorrhage
-rupture of pre-existing cerebral aneurysm
-cardiac decompensation (if Hx of cardiac disorders)
-pulmonary embolism
-amniotic fluid embolism

55
Q

risk factors for PPH (7)

A

-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
Q

symptoms of uterine atony (3)

A

-soft, “boggy” fundus on palpation
-uterine fundus displaced above and to right of umbilicus
-excessive lochia rubra

57
Q

within 12 hours of birth where should fundus be?
where is fundus every 24 hours after that?

A

-at umbilicus
-1 cm below umbilicus consistent with # days postpartum

58
Q

nursing interventions for PPH

A

-perform fundal massage
-empty bladder (void or cath)
-recheck q15min for 1 hr, q30min for 2 hr

59
Q

when do you stop fundal massage for PPH

A

once it contracts

60
Q

assessment frequency 4th stage of labor

A

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
Q

what does postanesthesia recovery score (PAR) include (5)

A

-activity
-respirations
-BP
-LOC
-color

62
Q

when does 4th stage of labor begin

A

after placenta is delivered

63
Q

immediate care of woman after placenta is born

A

-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
Q

how to meet mom’s emotional needs during 4th stage labor

A

-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

OB (21 decks)

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