- Assist with contractions - Continue to coach breathing - Accept noncompliance - Accept irritability - Check woman who develops N & V here (usually means end of 1st stage)

Exam 1 (Nursing Care During Labor and Birth) Flashcards by Jonathan Adams

How do you tell True Labor from False Labor?

Look at contractions, cervix, and Fetus

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True Labor Contractions

Regular and strong, lasting longer & coming closer together.
More intense with walking.
Felt in lower back, radiating to abdomen.
Continue despite comfort measures.

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True Laboring Cervix

Shows progressive change
Dilation
Effacement
Bloody show
Continually moving to anterior position.

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True Laboring Fetus

Presenting part engaged.

Breathing easier but urinary frequency worse.

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False Labor Contractions

Irregular
Stop with walking or position change.
Occur in back or abdomen above umbilicus (naval).
Often stopped by comfort measures.

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False Labor Cervix

No change in effacement or dilation.
No bloody show.
Posterior in position.

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False Labor Fetus

Presenting part not engaged

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Which would be indicative true labor?

Anterior cervix position

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What color are nitrazene paper or stick when it touches Amniotic fluid?

Blue

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How do you determine if fluid leakage is amniotic fluid?

Amniotic fluid is alkaline - pH 6.4 or above.
Uses Nitrazine Sticks/Paper. Blue-green or deep blue color.
Fern testing.

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What does the Leopold Maneuvers convey?

Number of fetuses
Presenting part
Fetal lie
Fetal attitude
Degree of presenting part in the pelvis
Expected PMI of FHR

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What is the Leopold Maneuver?

Palpation of the fetus through the maternal abdomen.

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What can a vaginal examination determine?

False vs. true labor
Ruptured membranes
Prolapsed cord

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When should a vaginal examination be performed?

Admission
Significant change in uterine activity
Upon urge to bear down 
Rupture of membranes (to assess for prolapse)
Variable decelerations noted

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What kind of lubrication should be used when using Nitrazene strip?

Only water.

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What does an Urinalysis provide?

Provides info about hydration (specific gravity, color, amount), nutrition (ketones), infection (WBC’s), PIH (protein).

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What test determines fetus RH?

CBC

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What is an amniotomy (AROM) procedure?

manual breaking of the membrane

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How often should a nurse ask a maternity pt about voiding?

Every 2 hr

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When is catheterization common?

Common with epidural or spinal

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What should you do if a pt says they have to BM?

Check for dilation

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Stage 1 (0-3cm) support?

Provide encouragement
Encourage focus techniques
Teach breathing techniques–
Provide comfort measures
Assist with comfortable positioning
Explain procedures
Praise client
Offer fluids, ice chips as ordered

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Stage 1 (4-7cm) support?

Assist support with contractions
Encourage breathing techniques
Apply counterpressure to sacrococcygeal area
Offer analgesics
Check bladder and encourages voiding

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Stage 1 (8-10cm)

Assist with contractions
Continue to coach breathing
Accept noncompliance
Accept irritability
Check woman who develops N & V here (usually means end of 1st stage)

What is a sign of the end of the first stage?

Nausea and vomiting.

Stage 2 (Latent phase) support?

Listen to body. | Suggest upright position.

Stage 2 (Descent Phase) Support

- Encourage short breath holds - Discourage long breath holds - Reassure that vocal noises such as grunting are normal - Place in lateral recumbent position if descent is too fast

Stage 2 (Transition Phase) support?

Teach that “blowing away the contraction” facilitates slow birth of the head (less chance for fetal head injury)

What part of labor should a nurse begin teaching breathing techniques?

Latent (0-3cm)

When should the birth table be setup?

(8-10cm) for primigravidas | (4-7cm) for multiparas

Before delivery, what should you clean the vulva & perineum with?

Betadine or Hibiclens

What is crowning?

widest part of the head distends the vulva just before birth (you can see the baby’s head without touching the mother)

After delivery of the head, what should you immediately check for?

Check neck (nuchal) cord. These can be tight and impair oxygen to newborn.

What should a nurse do to the babies airway before delivery of the body?

Before the body is delivered clear airway with a bulb syringe to promote breathing efforts.

When does meconium occur?

Meconium occurs when fetus has BM in fluid before delivery.

What color is meconium?

Usually stained green in color

What can meconium cause?

Meconium aspiration syndrome. | Causes major respiratory complications after birth.

What kind of suctioning should be preformed on infants at term?

Only bulb suctioning.

What kind of suction should be used on depressed meconium stained infants?

Tracheal suctioning immediately after birth.

Does a infant have homeostasis when born?

No, it takes a few hours for an infant's body to maintain homeostasis

What are 1st degree lacerations?

Extends through skin & structures superficial to muscles.

What are 2nd degree lacerations?

Extends through muscles of the perineal body.

What are 3rd degree lacerations?

Continues through anal sphincter muscle.

What are 4th degree lacerations?

Involves the anterior rectal wall.

What are the two types of episiotomies?

1) Midline | 2) Mediolateral

What is a midline episiotomy?

- Most common. - Effective, easily repaired, & least painful. - Associated with higher 3rd & 4th degree lacerations.

What is a mediolateral episiotomy?

- When the need for 3rd & 4th degree extensions are likely. - 3rd degree lacerations may still tear. - Blood loss greater - Repair more difficult. - More painful.

What is the most important exercise after birth?

Kegel exercises!

What do kegel exercises help restore?

Help improve and restore perineal muscle tone and strength.

What can reduce the pain during healing of episiotomy?

Sitz baths, perineal rings (donut), & oral analgesics.

What is the first thing a nurse does during an emergency birth?

Place woman in lateral recumbent or (Sims) position.

What consists of the 3rd stage labor?

3rd stage is from birth of baby until expulsion of placenta.

What are oxytocics used for after delivery of placenta?

Help stimulate uterine contraction & prevent uterine hemorrhage.

Can oxytocics assist in the expulsion of the placenta?

Yes, oxytocics can be given after the birth of the anterior shoulder.

What side of the placenta is the mothers?

roughened side

What side of the placenta is the child's?

shiny side out

Oxytocics are given in 3rd stage of labor to do what?

Prevent maternal hemorrhage.

What assessments should be done to the baby during the third stage?

Weigh, measure, give eye prophylaxis, and Vitamin K injections to baby. Wrap in warm blankets & give to mother & partner for bonding.

Should skin-to-skin contact be allowed by mother and baby?

Yes! Also, promote breastfeeding.

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Exam 1 (Nursing Care During Labor and Birth) Flashcards

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