Conference One - Module 5 (Exam 2) 2

Question 1

Stage One Phases

Answer 1

1. Latent
2. Active
3. Transitional

Question 2

Latent Phase

Answer 2

Stage 1 Labor

• Cervix Dilation 0-3cms
• Effacement variable
• Frequency of contractions q 5-7 minutes
• Duration of contractions 30-40 seconds
• Mild to moderate intensity contractions

Question 3

Patient Response to Latent Phase

Answer 3

Stage 1 Labor

• Fear
• Relief
• Anxiety
• Confidence
• Sociability

Question 4

Nursing Interventions for Latent Phase

Answer 4

• Admission protocols
  
  • VS and FHR
  • Leopold’s Maneuvers
  • Ultrasound
  • Assess for ROM
• Contraction Pattern and fetal response
• Therapeutic interaction
• Hydration/Elimination
  
  • CLEARS ONLY DURING LABOR
• Ambulation to advance labor
• Comfort/Pain management
  
  • Non-pharmacologic NIs
  • Analgesia/anesthesia per patient preference and provider order

Question 5

Active Phase

Answer 5

• Cervix Dilation 4-7cms
• Effacement 50-100%
• Contractions are increasing to frequency q 2-5 minutes and duration 40-60 second
• Intensity of contractions is moderate to strong

Question 6

Patient Response to Active Phase

Answer 6

• Pain
• Anxiety
• Fatigue
• Questioning abilities
• Inward focus

Question 7

Nursing Interventions for Active Phase

Answer 7

• Assessments per protocol
• EFM per protocol/order
• Hydration/Elimination
• AROM/SROM: Assess FHR (if membranes rupture)
• Assess COAT
  
  • Color, Odor, Amount, Time of rupture
• Therapeutic Interaction
  
  • Giving of self
  • Anticipatory guidance
  • Partner/family support
• Comfort/Pain Management
  
  • Non-pharmacologic NIs
  • Analgesia/anesthesia per patient preference and provider order

Question 8

Transitional Phase

Answer 8

• Dilation 8-10cms
• Effacement complete
• Contractions increasing to frequency q 1.5-2 minutes and duration 60-90 seconds
• Counteract urge to push prior to 10cms: Pant or blow at acme of contraction

Question 9

Patient Response to Transitional Phase

Answer 9

• Fear
• Pain
• Agitation
• Irritability
• Withdrawal
• Contraction
• Decreased tolerance for interruption

Question 10

Nursing Interventions for Transitional Phase

Answer 10

• Assessments per protocol
• EFM per protocol/order
• Hydration/Elimination
• Therapeutic Interaction
  
  • Giving of self, continual presence
  • Anticipatory guidance
  • Parter/Family support
  • Teach that transition is very difficult but also relatively short
• Comfort/Pain Management
  
  • Non-pharmacological NIs
  • Analgesia/Anesthesia per patient preference and provider order

Question 11

Stage Two Labor Physiologic Focus

Answer 11

• Pushing and Birth
• Contractions: Frequency 2-3 minutes, Duration 40-60 seconds, Strong intensity
• Contraction pattern may diminish slightly as stage two begins to promote rest between contractions

Question 12

Patient Response to Stage Two

Answer 12

• Renewed enegy
• May be focused or confused
• May experience delay in ability to push effectively because of epidural anesthesia

Question 13

Nursing Interventions for Stage Two

Answer 13

• All stage 1 NIs continue
• Provide instructionsand assistance to push effectively
• Prepare for delivery

Question 14

Stage Three Labor Physiological Focus

Answer 14

• Placental Delivery
• Uterine Contraction, controlled bleeding

Question 15

Patient Response to Stage Three Labor

Answer 15

• Focus on neonate
• Elation
• Exhaustion

Question 16

Nursing Interventions for Stage Three Labor

Answer 16

• Observe for signs of placental separation
  
  • Lengthening ofcord
  • Globular abdominal contour
  • Gush of blood
• Oxytocic medication (pitocin) administration after placenta
• Neonatal stabilization
  
  • Transition to extrauterine environment
  • APGAR scoring
  • Identification
  • NYS-mandated meds
    
    • VIT K and Erythromycin

Question 17

Stage Four Labor Physiologic Focus

Answer 17

• Recovery
• Early puerperium

Question 18

Patient Response to Stage Four Labor

Answer 18

• Focus on neonate
• Elation
• Exhaustion
• Brief episode of uncontrollable shaking
  
  • Benign etiology
  • Manage symptomatically

Question 19

Nursing Interventions for Stage Four Labor

Answer 19

• Maternal/Neonatal VS and assessments per protocol
  
  • Fundal tone/lochia
  • Hydration/elimination
  • Comfort measures
• Facilitation of early bonding/feeding
• Family support
• Anticipatory guidance for early puerperium