Chapter 19

Question 1

Labor

Answer 1

Begins with the first true labor contraction and ends with complete dilation of the cervix

Forces involved in bringing about cervical changes

Question 2

Latent Phase

Answer 2

Up to 3 cm of dilation

Cervix moves anterior, softens, ripens, thins

Woman experiences cramping, pressure, and pain

Nurse should help with hygiene, nutrition/fluids, elimination, ambulation, and positioning

Question 3

Active Phase

Answer 3

4-7 cm of dilation

Contractions increase in length, intensity, and frequency

Non-pharmacological comfort measures are offtered

Question 4

Transition Phase

Answer 4

8-10 cm of dilation

Contractions increase in length, strength, and frequency

Increased pressure, sudden nausea, loss of control, bloody show

Nurse should perform maternal-fetal assessment, assist with breathing and positioning

DO NOT LET MOM PUSH unless cervix is fully dilated

Question 5

Assessment and Diagnosis of First Stage of Labor

Answer 5

Frequency, duration, and intensity of uterine contractions

Cervical effacement, dilation, and fetal descent

Assessment of FHR and pattern

Vital signs, general systems assessed

Urine specimen, blood tests, amniotic fluid

Question 6

True Contractions

Answer 6

Begin in lower back and extend from back to abdomen

Increase in intensity, frequency, and duration

Change in cervix (softening, effacement, dilation, more anterior position)

Question 7

False Contractions

Answer 7

Confined to lower abdomen

Do not increase in intensity, frequency, or duration

No change in cervix

Walking may relieve discomfort

Presenting part may not be engaged

Question 8

Second Stage of Labor

Answer 8

Station +2 –> +4

Ferguson’s reflex, bulging perineum, labial separation, visible caput, obvious descent

Nurse should encourage bearing down efforts and position, perform maternal-fetal assessment, give a resting phase, direct pushing only as indicated, give fluids, facilitate descent

Question 9

Nulliparous Women in Second Stage of Labor

Answer 9

2 hours without anesthesia, 3 hours with anesthesia

Question 10

Multiparous Women in Second Stage of Labor

Answer 10

1 hour without anesthesia, 2 hours with anesthesia

Question 11

Optimal Conditions for Descent

Answer 11

Spontaneous urge

Position: rotating to occipitoanterior

Quality contractions

Station greater than +1

Question 12

Signs of Placental Separation

Answer 12

Lengthening of the umbilical cord, gush of blood from vagina, change in shape of fundus

Question 13

Third Stage of Labor

Answer 13

Active Management has been shown to reduce total blood loss

Abdominal hand secures uterine fundus to prevent inversion while the other hand exerts sustained downward traction on umbilical cord

Question 14

Nursing Responsibilities

Answer 14

SKIN TO SKIN WITH MOTHER, NEWBORN AND MATERNAL WELL BEING

APGAR

Assess fundus and bleeding, vital signs, NEWBORN THERMOREGULATION, breastfeeding, comfort, physiological assessments for both

Question 15

First Degree Perineal Laceration

Answer 15

Extends through the skin and vaginal mucous membrane but not the fascia or muscle

Question 16

Second Degree Perineal Laceration

Answer 16

Extends through the fascia and muscles of perineal body, but not the sphincter

Question 17

Third Degree Perineal Laceration

Answer 17

Involves external anal sphincter

Question 18

Fourth Degree Perineal Laceration

Answer 18

Extends completely through rectal mucosa, disrupting external and internal anal sphincters

Question 19

Fourth Stage of Labor

Answer 19

First 1-2 hours after birth

Note excessive blood loss or alterations in vital signs/consciousness