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Maternal Child Nursing (Exam 1) > Exam 1 (Nursing Care During Labor and Birth) > Flashcards

Exam 1 (Nursing Care During Labor and Birth) Flashcards

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1
Q

How do you tell True Labor from False Labor?

A

Look at contractions, cervix, and Fetus

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2
Q

True Labor Contractions

A

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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3
Q

True Laboring Cervix

A 
Shows progressive change
Dilation
Effacement
Bloody show
Continually moving to anterior position.
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4
Q

True Laboring Fetus

A

Presenting part engaged.

Breathing easier but urinary frequency worse.

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5
Q

False Labor Contractions

A

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

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6
Q

False Labor Cervix

A

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

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7
Q

False Labor Fetus

A

Presenting part not engaged

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8
Q

Which would be indicative true labor?

A

Anterior cervix position

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9
Q

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

A

Blue

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10
Q

How do you determine if fluid leakage is amniotic fluid?

A

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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11
Q

What does the Leopold Maneuvers convey?

A 
Number of fetuses
Presenting part
Fetal lie
Fetal attitude
Degree of presenting part in the pelvis
Expected PMI of FHR
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12
Q

What is the Leopold Maneuver?

A

Palpation of the fetus through the maternal abdomen.

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13
Q

What can a vaginal examination determine?

A

False vs. true labor
Ruptured membranes
Prolapsed cord

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14
Q

When should a vaginal examination be performed?

A 
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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15
Q

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

A

Only water.

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16
Q

What does an Urinalysis provide?

A

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

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17
Q

What test determines fetus RH?

A

CBC

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18
Q

What is an amniotomy (AROM) procedure?

A

manual breaking of the membrane

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19
Q

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

A

Every 2 hr

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20
Q

When is catheterization common?

A

Common with epidural or spinal

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21
Q

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

A

Check for dilation

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22
Q

Stage 1 (0-3cm) support?

A
  • 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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23
Q

Stage 1 (4-7cm) support?

A
  • Assist support with contractions
  • Encourage breathing techniques
  • Apply counterpressure to sacrococcygeal area
  • Offer analgesics
  • Check bladder and encourages voiding
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24
Q

Stage 1 (8-10cm)

A
  • Assist with contractions
  • Continue to coach breathing
  • Accept noncompliance
  • Accept irritability
  • Check woman who develops N & V here (usually means end of 1st stage)
25
Q

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

A

Nausea and vomiting.

26
Q

Stage 2 (Latent phase) support?

A

Listen to body.

Suggest upright position.

27
Q

Stage 2 (Descent Phase) Support

A
  • 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
28
Q

Stage 2 (Transition Phase) support?

A

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

29
Q

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

A

Latent (0-3cm)

30
Q

When should the birth table be setup?

A

(8-10cm) for primigravidas

(4-7cm) for multiparas

31
Q

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

A

Betadine or Hibiclens

32
Q

What is crowning?

A

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

33
Q

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

A

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

34
Q

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

A

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

35
Q

When does meconium occur?

A

Meconium occurs when fetus has BM in fluid before delivery.

36
Q

What color is meconium?

A

Usually stained green in color

37
Q

What can meconium cause?

A

Meconium aspiration syndrome.

Causes major respiratory complications after birth.

38
Q

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

A

Only bulb suctioning.

39
Q

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

A

Tracheal suctioning immediately after birth.

40
Q

Does a infant have homeostasis when born?

A

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

41
Q

What are 1st degree lacerations?

A

Extends through skin & structures superficial to muscles.

42
Q

What are 2nd degree lacerations?

A

Extends through muscles of the perineal body.

43
Q

What are 3rd degree lacerations?

A

Continues through anal sphincter muscle.

44
Q

What are 4th degree lacerations?

A

Involves the anterior rectal wall.

45
Q

What are the two types of episiotomies?

A

1) Midline

2) Mediolateral

46
Q

What is a midline episiotomy?

A
  • Most common.
  • Effective, easily repaired, & least painful.
  • Associated with higher 3rd & 4th degree lacerations.
47
Q

What is a mediolateral episiotomy?

A
  • When the need for 3rd & 4th degree extensions are likely.
  • 3rd degree lacerations may still tear.
  • Blood loss greater
  • Repair more difficult.
  • More painful.
48
Q

What is the most important exercise after birth?

A

Kegel exercises!

49
Q

What do kegel exercises help restore?

A

Help improve and restore perineal muscle tone and strength.

50
Q

What can reduce the pain during healing of episiotomy?

A

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

51
Q

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

A

Place woman in lateral recumbent or (Sims) position.

52
Q

What consists of the 3rd stage labor?

A

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

53
Q

What are oxytocics used for after delivery of placenta?

A

Help stimulate uterine contraction & prevent uterine hemorrhage.

54
Q

Can oxytocics assist in the expulsion of the placenta?

A

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

55
Q

What side of the placenta is the mothers?

A

roughened side

56
Q

What side of the placenta is the child’s?

A

shiny side out

57
Q

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

A

Prevent maternal hemorrhage.

58
Q

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

A

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

59
Q

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

A

Yes! Also, promote breastfeeding.

Maternal Child Nursing (Exam 1) (11 decks)

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