Exam 2

Question 1

1. What are the factors that affect labor (5 p’s)

Answer 1

a. Passenger (fetus and placenta)
i. Size of fetal head
b. Passageway (birth canal)
c. Powers (contractions)
d. Position of the mother
e. Psychological responses

Question 2

2. What are fontanels and sutures?

Answer 2

Both make the skull flexible to accommodate infant brain

a. Fontanels: membrane-filled spaces where sutures intersect

Question 3

3. Define molding

Answer 3

slight overlapping of skull bones during birth. Assumes normal shape within 3 days of birth

Question 4

4. What is fetal position?

Answer 4

a. Relationship of fetal presenting part on 4 quadrants of moms pelvis. Ex: ROA
i. R or L pelvis
ii. Occiput, Sacrum, Mentum, Scapula
iii. Anterior, Posterior, or Transverse portion of maternal pelvis

Question 5

5. Define station and engagement

Answer 5

a. Station: relationship of presenting fetal part to an imaginary line between ischial spines. (measure of degree of descent)
Level of spines= 0. Birth is imminent at +4 or +5
b. Engagement: largest transverse diameter has passed thru pelvic inlet. Station 0.

Question 6

6. What do primary and secondary powers do?

Answer 6

• Primary powers: involuntary uterine contraction (beginning of labor). Frequency, duration, and intensity of contractions.
o Effacement: shortening and thinning of cervix during 1st stage. Measured in %.
o Dilation: enlargement/widening of cervical opening. 0-10cm.
• Secondary Powers: maternal pushing/bearing down efforts. 2nd stage.
o Expulsion of the fetus

Question 7

7. How does maternal position affect labor?

Answer 7

a. Upright position- gravity promotes descent of fetus, benefits moms cardiac output
b. “All fours” position- relieve backache if fetus is in an occipitoposterior position
c. Lithotomy position- compression of major vessels may result in supine hypotension that decreases placental perfusion. Least effective position.
d. Semirecumbent position- needs adequate body support to push effectively, cuz weight on sacrum. Sitting- abd muscles work in synchrony with contractions
e. Lateral position- help rotate fetus that is in a posterior position. Or need for less force to be used during bearing down, such as when need to control speed of a precipitate birth.

Question 8

8. What is lightening?

Answer 8

a. 2 weeks before term, dropping of fetus. Mom feels less congested and can breathe easier, but more bladder pressure.

Question 9

9. Describe the stages of labor, what is happening in each stage, and about how long they last. (Include the 4th stage).

Answer 9

a. 1st stage: onset of regular contractions to full effacement and dilation. Full dilation can occur in less than 1 hr for multips or 20 hr or more in 1st timers.
i. Latent phase: effacement, little descent. Onset of contractions to 3cm dilation.
ii. Active phase (4-7cm) and transition phase (8-10cm, descent): rapid dilation of cervix and rate of descent of presenting part
b. 2nd stage: fully effaced and dilated cervix to delivery of fetus. Avg of 20 min for multiparous and 50 min with nulliparous. Normal for up to 2 hours.
i. Latent phase: fetus rotate anterior position during contractions, continues to descend passively. Urge to bear down not strong. (station 0 to +2)
ii. Active phase: strong urge to bear down as presenting part descends and presses on stretch receptors of the pelvic floor. (station +2 to +4)
c. 3rd stage: birth of fetus to placenta. Placenta separates with 4th to 5th contraction. Usually within 10-15min. risk of hemorrhage increases as length increases.
d. 4th stage: lasts 1-2 hrs after placenta delivery. Homeostasis is reestablished. Watch for bleeding.

Question 10

10. What is the normal FHR range at term?

Answer 10

a. 110-160 BPM

Question 11

11. How is the GI system affected by labor?

Answer 11

During labor, GI motility and absorption of solid foods are decreased, and stomach-emptying times are slowed. N&V of undigested food eaten after onset of labor are common. Nausea and belching also occur as a reflex response to full cervical dilation. The woman may state that diarrhea accompanied the onset of labor, or the nurse may palpate the presence of hard or impacted stool in the rectum.

Question 12

1. Review the difference between visceral and somatic pain.

Answer 12

a. Visceral: pain from distention of lower uterine segment, stretching of cervical tissue, pressure on structures and nerves, and uterine ischemia. (during 1st stage of labor)
b. Somatic pain: intense, sharp, burning from stretching of perineal muscles (2nd stage of labor)

Question 13

2. Describe the gate-control theory of pain.

Answer 13

a. Pain sensations travel along sensory nerve pathways to the brain, limited messages can pass thru nerve pathways one at a time. Distraction, relaxation, massage, music, focal points can block capacity of nerve pathways to transmit pain.

Question 14

3. Review common methods of nonpharmacologic pain relief.

Answer 14

a. Attention focusing and distraction techniques
b. Imagery
c. Music therapy
d. Water therapy: releases endorphins, relaxes fibers, better circulation and oxygenation. Hands and knees position in tub may help facilitate fetal posterior or transverse occiput to anterior occiput.
e. TENS: continuous low intensity electrical impulses- tingling/buzzing.
f. Acupressure: pressure to points of increased density of neuroreceptors
g. Acupuncture: fine needles into areas to restore flow of E.
h. Also heat/cold, touch and massage, hypnosis (state of focused concentration, subconscious mind more easily accessed), intradermal water block (4 small injections- last 2 hours)

Question 15

4. When is slow-paced breathing, patterned-pace breathing and panting breathing used in labor?

Answer 15

a. Slow-paced breathing: half normal rate, can’t walk or talk thru contractions anymore. Relaxation and optimal oxygenation.
b. Modified-paced: remain alert and concentrate more fully on breathing. (do not exceed twice her RR)
c. Patterned-paced (pant-blow): most difficult time to control is at 8-10cm dilated. Panting and soft blow patterns.
i. Hyperventilation= breathe in a bag

Question 16

5. When is counter-pressure particularly beneficial for pain relief?

Answer 16

a. Steady pressure against sacrum, during 1st stage of labor, when back pain is caused by occiput in posterior position.

Question 17

6. When are sedatives most beneficial in labor? Which sedatives are generally avoided in labor and why

Answer 17

a. Sedatives: relieve anxiety and induce sleep. When prolonged latent phase= need to decrease anxiety and promote sleep.
i. Barbiturates: (ex: Seconal) can cause respiratory and vasomotor depression with mom and fetus. Avoid if birth is anticipated in 12-24 hours. If no analgesic given with it, pain will be magnified. Seldom used during labor
ii. Phenothiazine’s: (ex: promethazine (Phenergan), hydroxyzine (Vistaril)) decrease anxiety and apprehension, increase sedation and reduce N&V. Reglan and Zofran=antiemetics
iii. Benzodiazepines: diazepam (valium), lorazepam (Ativan)- with opioids= reduce pain, N&V. cause significant maternal amnesia=avoid during labor

Question 18

7. What are some effects of systemic analgesia on the fetus and newborn?

Answer 18

a. Crosses fetal blood-brain barrier more readily that maternal. Can cause: respiratory depression, decreased alertness, delayed sucking.

Question 19

8. Which is the preferred route of administration for systemic analgesics?

Answer 19

a. IV= quickest onset of action, more predictable

Question 20

9. Why are the negative effects greater on a fetus/newborn than on the laboring mother?

Answer 20

a. Crosses fetal blood-brain barrier more readily than maternal. Longer half-life in fetus.

Question 21

10. What are common opioid agonist analgesics used in labor?

Answer 21

Euphoria without amnesia, can slow down labor (can inhibit uterine contractions- give when labor well established). Stimulate major opioid receptors, mu and kappa. (rapid action with short duration)

a. Hydromorphone hydrochloride (Dilaudid)- onset 10-15 min, peak 15-30 min. duration 2-3 hours.
b. Meperidine (Demerol)- used to be common, accumulation= neonatal sedation and neurobehavior changes
c. Fentanyl (Sublimaze)
d. Sufentanil citrate (sufenta)

Question 22

11. What are some potential side effects of opioids?

Answer 22

a. Opioids decreases maternal HR, RR, and BP= affects fetal oxygenation. Neonatal CNS depression

Question 23

12. What are common opioid agonist-antagonists in labor and which side effect do they minimize compared to opioid agonists?

Answer 23

a. Butorphanol (stadol) and nalbuphine (nubain)
b. Agonist on kappa opioid receptors and antagonist to mu opioid receptors= adequate analgesia without respiratory depression, less likely to cause N&V.

Question 24

13. What is an important contraindication to agonist-antagonist use?

Answer 24

a. Women with an opioid dependence because antagonist action can cause withdrawal symptoms (abstinence syndrome)

Question 25

14. When might Narcan be given?

Answer 25

a. For CNS depression. Neonatal narcosis (CNS depression in newborn from narcotic)= opioid antagonist- blocks mu and kappa opioid receptors from effects of opioid agonists.

Question 26

15. What is the difference between a local perineal infiltrate and a pudendal nerve block?

Answer 26

a. Local perineal infiltrate: Episiotomy is to be performed, or suture lacerations (epinephrine added to constrict vessels= prevent bleeding and increase systemic absorption). Lidocaine= rapid anesthesia into sub-q perineal region
b. Pudendal nerve block: transvaginal anesthetic, late in 2nd stage of labor, if episiotomy, forceps or vacuum to be used. Bearing-down reflex lost.

Question 27

16. How are epidural and spinal blocks different?

Answer 27

a. Spinal anesthesia (block)- injected into 3rd, 4th, or 5th lumbar interspace into subarachnoid space where anesthetic solution mixes with CSF. For vaginal birth= (hips) T10 to feet (not suitable for labor), for C-section= nipple (T6) to feet. Must remain still during placement. Fixed within 5-10 minutes, lasts 1-3 hours. Marked hypotension(NS solution used to counteract- lie on side, feet up, give IV, IV vasopressor, give O2 nonrebreather 10-15L/min), impaired placental perfusion, and ineffective breathing pattern may occur.
b. Epidural anesthesia (block): injecting anesthetic and/or opioid analgesic between 4th and 5th lumbar vertebrae. Removes pain but not pressure sensations, large-bore needle. Lie on side and alternate every hour. Give as repeated injections, continuous, or PCEA

Question 28

17. What is a blood-patch used for?

Answer 28

a. Postdural puncture headache (PDPH)- caused by leakage of CSP from site of puncture of the dura mater. (spinal headache) more likely for epidural block. Supine position achieves relief.
b. Blood-patch: womens blood is injected slowly into the lumbar epidural space, creates a clot that patches the tear/whole in dura mater.

Question 29

18. What is a major concern for the wellbeing of mom and baby associated with spinal and epidural anesthesia? What are the nursing actions to prevent and manage this problem?

Answer 29

a. Maternal hypotension with decreased placental perfusion: S/S= 20% decrease in BP or <100mm Hg systolic. Fetal bradycardia, absent or minimal FHR variability.
b. Interventions: turn to lateral position, IV infusion, O2 10-12 L non rebreather mask, elevate legs, notify MD, administer IV vasopressor, remain with woman and check BP and FHR q5min until stable

Question 30

19. Describe nursing care associated with spinal nerve block regarding: IV management, bladder care, potential for injury and mobility/labor management

Answer 30

a. Prior to block: explain procedure, informed consent; assess vitals, hydration, labor progress, FHR and pattern. Start IV lines and bolus of fluid 15-20 min prior to induction. Obtain labs (hgb, hct) assess pain level, assist to void.
b. During initiation of block: back curved or modified sims position. Vitals and meds documented. Have O2 and suction available. Monitor for signs of local anesthetic toxicity.
c. While block in effect: continue to monitor vitals and FHR, maternal pain, bladder distention (assist with bedpan/toilet, cath if necessary), change from side to side every hour. Promote safety (side rails up, telephone and call light within reach, do not get out of bed without help, no prolonged pressure on anesthetized body parts. Keep insertion site clean and dry and continue to monitor for anesthetic side effects.
d. While block is wearing off after birth: assess return of sensory and motor function, vitals, bladder distention (encourage void q2h. distended bladder can inhibit uterine contractions and fetal descent, slows labor), promote safety, cath, insertion site clean and dry, continue to monitor for anesthetic side effects.

Question 31

1. How can fetal oxygen supply be decreased during labor?

Answer 31

• Reduction of blood flow thru maternal vessels (maternal htn, hypotension, or hypovolemia)
• Reduction of O2 content in the maternal blood from hemorrhage or anemia
• Alterations in fetal circulation (compressed umbilical cord, placenta detach, head compression)
• Reduction in blood flow to intervillous space in the placenta secondary to uterine hypertonus

Question 32

2. What is considered normal uterine activity in labor?

Answer 32

a. Frequency: 2-5/10 min during labor (lower in 1st stage, and higher in 2nd)
b. Duration: 45-80 sec
c. Intensity: 25-50 mm Hg (1st stage) and over 80 mm Hg (2nd stage)
d. Resting tone: avg during labor is 10 mm Hg. Palpate=soft
e. Montevideo units (MVUs): (only with internal monitoring) 100-250 MVUs in 1st stage, 300-400 in 2nd stage.

Question 33

3. What are the goals of FHR monitoring in labor?

Answer 33

a. Identify and differential normal (reassuring) patterns from abnormal (nonreassuring patterns), which can be indicative of fetal compromise

Question 34

4. Review Box 18-1, what do reassuring (normal) and non-reassuring (or abnormal) FHR patterns include?

Answer 34

Category I
• Baseline rate: 110-160 bpm
• Baseline FHR variability: moderate
• Late or variable d-cells: absent
• Early d-cells: either present or absent
• A-cells: either present or absent
Category II
• Baseline rate: brady (no absent baseline variability) or rachy
• Baseline FHR variability: minimal, absent (w/o recurrent d-cells), or marked baseline variability
• A-cells: none in response to fetal stimulation
• Periodic or episodic d-cells: recurrent variable d-cells with minimal or mod baseline variability, prolonged d-cells (b/t 2-10min), recurrent late d-cells with mod baseline variability, variable d-cells with slow return to baseline, “overshoots” or “shoulders”
Category III
• Absent variability with recurrent late d-cells, recurrent variable d-cells, or bradycardia
• Sinusoidal pattern

Question 35

5. What nurse to client staffing ratio should be used when intermittent auscultation is the primary form of FHR monitoring?

Answer 35

One-to-one nurse-to-client staffing ratio is required

Question 36

6. How would you describe a spiral electrode to a patient?

Answer 36

Placed on babies head to pick up their HR

Question 37

7. What are ultrasound transducers, tocotransducers, spiral electrodes and intrauterine pressure catheters (IUPC), when are they used?

Answer 37

Ultrasound transducer: high-frequency sound waves reflect mechanical action of the fetal heart. Noninvasive, external mode. Does not require ROM or cervical dilation. Used during antepartum and intrapartum.
Tocotransducer: monitors frequency and duration of contractions by means of a pressure-sensing device applied to the maternal abdomen. Used during antepartum and intrapartum periods. External mode.
Spiral electrode: converts fetal ECG from presenting part to the FHR via a cardiotachometer. Used only after ROM and cervix sufficiently dilated during intrapartum period. Electrode penetrates into fetal presenting part my 1.5 mm and must be attached securely for good signal.
Intrauterine pressure catheter: monitors frequency, duration, and intensity of contractions. Fluid-filled system or solid catheter. Measure IUP at cath tip and convert pressure into mm Hg on uterine activity panel of strip chart. Used only when ROM and cervix sufficiently dilated during intrapartum period.

Question 38

8. What controls the FHR?

Answer 38

Intrinsic rhythmicity of the fetal heart, CNS, and fetal autonomic nervous system control

Question 39

9. Define baseline fetal heart rate, variability, tachycardia, bradycardia, periodic changes and episodic changes, acceleration, deceleration, early deceleration, late deceleration, variable deceleration and prolonged deceleration.

Answer 39

• Baseline variability: avg. rate during a 10 min segment, excludes episodic changes, marked variability, and segments that differ more than 25 beats/min
• Variability Periodic changes: occur with UC
• Episodic changes: not associated with UC
• Acceleration: increase in FHR at least 15bpm for 15 sec or more. Indication of fetal well-being.
• Deceleration: dominance of parasympathetic NS
o Early deceleration: (gradual decrease and increase in FHR directly r/t UC) fetal head compression: during UC, vaginal exam, fundal pressure, or placement of internal mode of monitoring (normal)
o Late deceleration: (gradual decrease and return to baseline, d-cell begins after contraction started and lowest pt is after the peak) uteroplacental insufficiency (leads to fetal hypoxemia, metabolic academia, low apgar scores)
o Variable deceleration: abrupt (onset to lowest pt

Question 40

10. Describe nursing interventions for tachycardia, bradycardia, late decelerations, variable decelerations, and prolonged decelerations.

Answer 40

• Tachy: reduce maternal fever with antipyretics and cooling measures, O2 at 8-10L/min by nonrebreather mask, follow MD orders based on alleviating cause.
• Brady: dependent on cause
• Late d-cells: change to lateral position, correct maternal hypotension by elevating legs, increase IV rate, palpate uterus to assess for tachysystole, d/c oxytocin if infusing, administer O2 at 8-10L nonrebreather, notify physician or mid-wife, consider internal monitoring for more accurate fetal and uterine assessment, assist with birth if pattern cannot be corrected.
• Variable d-cells: change maternal position, d/c oxytocin if infusing, administer 8-10L nonrebreather, notify physician or mid-wife, ass with vaginal or speculum exam to assess for cord prolapse, assist with amniofusion if ordered, assist with birth (vag or c-sec) if pattern cannot be corrected
• Prolonged d-cells: notify physician or mid-wife immediately and initiate appropriate treatment of abnormal patterns when they see a prolonged d-cell.

Question 41

11. Describe management of abnormal fetal heart rate patterns.

Answer 41

Basic interventions:
• administer O2 nonrebreather 8-10L/min.
• assist to side-lying (lateral) position.
• Increase maternal blood volume by increasing the rate of the primary IV infusion
Interventions for specific problems:
Maternal hypotension:
• Increase rate of IV infusion
• Change to lateral or trendelenburg position
• Administer ephedrine or phenylephrine if other measures unsuccessful in increasing BP.
Uterine tachysystole: (more than 5 contractions in 10 min)
• Reduce or d/c dose of Pit
• Administer uterine relaxant (toxolytic) e.g. terbutaline (Brethine)
Abnormal FHR pattern during the 2nd stage of labor:
• Use open-glottis pushing
• Use fewer pushing efforts during each contraction
• Make individual pushing efforts shorter
• Push only with every other or every third contraction
• Push only with a perceived urge to push (in women with regional anesthesia)

Question 42

12. What can be the effect of the valsalva maneuver on maternal heart rate and blood pressure and fetal wellbeing?

Answer 42

Valsalva maneuver: holding breath and tightening abd muscles. Increases intrathoracic pressure, reduces venous return, and increases venous pressure. Cardiac output ad BP increase and pulse slows temporarily. Fetal hypoxia may occur. Process reversed when woman takes a breath.

Question 43

13. What is tocolytic therapy?

Answer 43

Relaxation of uterus by administering drugs that inhibit UCs. Terbutaline (Brethine) most commonly used. Management of fetal stress, when associated with increased UA. Tocolysis improves blood flow thru placenta by inhibiting UCs. Position change and d/c pit are used first. Used after c-sec decision made. If no improvement from therapy- cesarean birth may be needed.

Question 44

14. What is amnioinfusion and what is its value?

Answer 44

Infusion of room-temp isotonic fluid (NS or LR) into uterine cavity if the volume of amniotic fluid is low. Without the buffer of amniotic fluid the umbilical cord can easily become compressed, resulting in variable d-cells and transient fetal hypoxemia. Risks are over distention of the uterine cavity and increased uterine tone.

Question 45

15. Review client and family teaching for electronic fetal monitoring in box 18-9.

Answer 45

• Explain the purpose of monitoring
• Explain each procedure
• Provide rationale for maternal position other than supine
• Explain that fetal status can continuously be assessed by EFM, even during UCs
• Lower tracing on the monitor strip paper shows uterine activity; the upper tracing shows the FHR
• Reassure woman and partner that prepared childbirth teachniques can be implemented w/o difficulty
• Explain that during external monitoring effleurage can be performed on sides of abd or upper thighs
• Breathing patters based on the time and intensity of contractions can be enhanced by the observation of uterine activity on the monitor strip, which shows the onset of contractions
• Note peak of contraction; knowing that contraction will not get stroner and is halfway over is usually helpful
• Note diminishing intensity
• Coordinate with appropriate breathing and relaxation techniques
• Reassure woman and partner that the use of internal monitoring does not restrict movement, although she is confided to bed
• Reassure woman and partner that use of monitoring does not imply fetal jeopardy

Question 46

1. Describe the phases of the first stage of labor including characteristics of the contractions, expected cervical change, expected duration, and anticipated maternal psychological response.

Answer 46

1st stage begins with onset of regular uterine contractions and ends with full cervical effacement and dilation. (most variable: 1-20hrs)
• Latent phase: (about 6-8 hours) onset of contractions (mild to mod strength, irregular, 5-30 min apart and duration of 30-45 sec) to 3cm dilation.
o Little of no descent (nulli= 0 station. Multi= -2cm to 0).
o Show: scant, brownish discharge mucous plug.
o Behavior: excited, thoughts center on self, labor, and baby; fairly condiment; talkative or silent, calm or tense, some apprehension; pain controlled fairly well- able to talk and ambulate thru contractions; alert, follows directions readily; open to instructions.
• Active phase: (about 3-6 hours) 4-7cm of dilation
o Contractions: mod-strong, more regular, 3-5 min apart, 40-70 sec
o Show: pink to bloody mucus, scant to mod
o Behavior: More serious, quiet, doubtful of control of pain, more apprehensive; desires companionship and encouragement; attention more inwardly directed; fatigue evidenced; cheeks flushed; some difficulty following directions but accepts coaching; describes increasing discomfort.
• Transition phase: (about 20-40 min) 8-10 cm. descent.
o Contractions: strong to very strong, regular, 2-3 min apart, 45-90 sec.
o Descent: varies: +1 to +3
o Show: bloody mucus, copious
o Behavior: pain described severe; backache common; frustration; fear of loss of control, and irritability may be voiced; expresses doubt about ability to continue; vague in communications; amnesia b/t contractions; writhing with contractions; N&V, esp if hyperventilation; hyperesthesia; circumoral pallor, perspiration of forehead and upper lips; shaking tremor of thighs; feeling of need to defecate, pressure on anus.

Question 47

2. Describe techniques to differentiate true labor from false labor.

Answer 47

True Labor
• Contractions: regular, stronger, lasting longer, and closer together. More intense with walking, felt in low back and radiate to low abd. Continue despite comfort measures
• Cervix: progressive change (softening, effacement, and dilation- appearance of bloody show; moves to an increasingly anterior position)
• Fetus: presenting part becomes engaged in pelvis (easier breathing), presenting part presses downward and compressed bladder (urinary frequency)
False Labor
• Contractions: irregular, often stop with walking or position change, can be felt in the back or abdomen above the navel, can often be stopped thru use of comfort measures.
• Cervix: may be soft but no significant change in effacement or dilation or evidence of bloody show, often in a posterior position
• Fetus: presenting part is usually not engaged in pelvis

Question 48

3. What is EMTALA, and how does it affect nursing care of the woman in labor?

Answer 48

Emergency Medical Treatment and Active Labor Act (EMTALA)- federal regulation to ensure women get emergency treatment or active labor care when sought. True labor= emergency medical condition. Provide services to women with urgent pregnancy problem (e.g. labor, decreased fetal movement, rupture of membranes, recent trauma) and doc.

Question 49

4. Describe nitrazine paper testing for ROM. –What are the characteristics of amniotic fluid?

Answer 49

Nitrazine (pH) and fern test can confirm ROM. Cotton-tipped applicator with Nitrazine dye deep into vagina to pick up fluid.
• Membranes pry intact: vaginal and most body fluids that are acidic
o Yellow (pH 5.0); Olive-yellow (pH 5.5); Olive green (pH 6.0)
o False test possible b/c of presence of bloody show, insufficient amniotic fluid, or semen.
• Membranes pry ruptured: amniotic fluid is alkaline
o Blue-green (pH 6.5); Blue-gray (pH 7.0); Deep blue (pH7.5)

Question 50

5. List some important interventions the nurse can provide to assist a laboring woman who is a sexual abuse survivor.

Answer 50

Labor can trigger memories of sexual abuse, esp vag exams. Monitors, IVs, and epidurals can make woman feel “restrained” to bed.
Interventions: (care for all women in this manner, they may not disclose sexual abuse)
• Help survivor associate labor sensations with process of childbirth and not with past abuse
• Help maintain her sense of control by explaining all procedures and why needed, validating her needs, and paying close attention to her requests.
• Wait for permission to touch her, and accept her often extreme reactions to labor.
• Avoid words that abuser may have used (e.g. “open your legs,” “relax and it won’t hurt so much”)
• Limit # of invasive procedures (vag exams, cath, internal monitoring, forceps, or vacuum extractor) as much as possible.
• Encourage her to choose a person (e.g. doula, friend, family member) to be with for continuous support, comfort, and advocate.

Question 51

6. Define uterine contraction: frequency, intensity, duration and resting tone.

Answer 51

UC: primary powers that act involuntarily to expel fetus and placenta from uterus. It builds up, peaks, and lets down. Assessed by palpation, and external/internal monitoring
• Frequency: how often UCs occur, time from beginning on one contraction to beginning of next
• Intensity: strength of contraction at its peak
• Duration: time that elapses from onset to end of contraction
• Resting tone: tension in uterine muscles b/t contractions; relaxation of the uterus

Question 52

7. On page 448, review signs of potential complications in labor.

Answer 52

• IUP of >80 mm Hg or resting tone >20 mm Hg
• Contractions lasting > 90 sec
• Contractions more than 5 in 10 min (>q2min)
• Relaxation b/t contractions 38 C (100.4 F)
• Foul-smelling vaginal discharge
• Persistent bright or dark red vaginal bleeding

Question 53

8. Review table 19-2 for physical nursing care in labor.

Answer 53

General Hygiene
• Shower/bed bath/ jucuzzi bath: assess for progress in labor, supervise if in true labor
• Perinuem: cleanse frequently, esp after ROM and when show increases
• Oral hygiene: offer toothbrush or mouth wash, or ice-cold wet washcloth
• Hair: brush, braid per womans wishes
• Handwashing: washcloths or cleansing form before and after vdg and PRN
• Face: Cool washcloth
• Gowns and linens: Change as needed
Nutrient and Fluid Intake
• Oral: Offer fluids and solid foods as ordered by MD and desired by woman
• IV: establish and maintain IV as ordered
Elimination
• Voiding: encourage vdg at least q2h (full bladder may impede descent, cause bladder atony/injury, and make postpartum vdg difficult)
• Ambulatory woman: allow amb. According to order of MD if presenting part is engaged and no ROM, and woman not medicated
• Woman on bedrest: offer bedpan (upright position, tap water to run, hands in warm water or water over the vulva, pos suggestion), provide privacy, side rails up, call bell and phone w/I reach, washcloth or cleansing foam for hands, wash vulva area)
• Catheterization: cath according to MD or hospital protocol if measures to facilitate vdg are ineffective, insert cath b/t contractions, avoid force if obstacle to insertion is noted
• Bowel elimination- sensation of rectal pressure: perfor vag exam, help amb to bathroom or bedpan if rectal pressure is not from presenting part, cleanse perineum immediately after passage of stool

Question 54

9. Review Interventions for Emergencies on page 459. This has very helpful information that you should be familiar with.

Answer 54

• Nonreassuring/abnormal FHR and pattern: bradycardia (FHR10min), tachycardia (FHR>160 for >10min), irregular FHR, absent or minimal baseline FHR variability, late/variable/prolonged d-cells, absence of FHTs
o Interventions: notify MD, change position, d/c pit, start IV, increase fluid rate, O2 at 8-10 L non-rebreather, check temp, assist if amniofusion if ordered, perform fetal scalp stimulation/vibroacoustic stimulation as ordered/per protocol
• Inadequate Uterine Relaxation: IUP>80 mm Hr, contractions >90 sec, contractions>q2min
o Interventions: notify MD, d/c Pit, change to side-lying position, start IV, increase IV rate, administer O2 at 8-10L, palpale and evaluate contractions, give tocolytic (Brethine), as ordered per protocol
• Vaginal Bleeding: vag bleeding (bright red, dark red, excess amt), continuous vag bleeding with FHR changes, pain may/may not be present
o Interventions: notify MD, assist with US exam if performed, start IV, begin continuous FHR & contraction monitoring, anticipate stat c-section, do NOT perform a vag exam
• Infection: foul-smelling amniotic fluid, maternal temp>38 C with adequate hydration, fetal tach>160 for >10 min
o Interventions: notify MD, cooling measures, start IV, collect urine specimen, amniotic fluid sample and send to lab for urinalysis and culture, administer abx as ordered
• Prolapse of Cord: fetal brady with variable d-cells during UC, woman reports feeling the cord after membrane ruptures, cord lies alongside or below presenting part of fetus
o major predisposing factors: ROM with a gush, loose fit of presenting part in lower uterine segment, presenting part not yet engaged, breech position
o Interventions: call for assistance (do not leave woman alone), call MD immediately, glove fingers-> insert into vagina -> exert pressure on presenting part to relieve compression of cord, place rolled towel underneath hips, place in trendelenburg, modified sims, or knee-chest position, if cord protruding from vaginal wrap loosely in a sterile towel saturated with warm sterile NS, administer O2 at 8-10 til birth, start IV or increase rate, continue to monitor FHR by internal scalp electrode if possible, do not attempt to replace cord into cervix, prepare for immediate birth (vag or c-section)

Question 55

10. What is the Ferguson reflex?

Answer 55

Strong urges to bear down during phase of active pushing (descent), activates when presenting part presses on stretch receptors of the pelvic floor. Usually +1 station and anterior position= release of oxytocin, provokes stronger expulsive UCs

Question 56

11. What signs might the laboring woman show that indicate the onset of the second stage of labor?

Answer 56

Objective: inability to feel cervix during vag exam (= fully dilated and effaced)
Subjective:
• Urge to push and defecate (but can appear earlier in labor), if epidural may not feel signs.
• Sudden appearance of sweat on upper lip
• Episode of vomiting
• Increased bloody show
• Shaking of extremities
• Increased restlessness, verbalization (“I can’t go on”)
• Involuntary bearing-down efforts.

Question 57

12. Describe the normal length of time for 2nd and 3rd stages of labor.

Answer 57

• 2nd stage: median duration is 50 min in nulliparious and 20 min in multiparous.
o Latent phase (avg 10-30min) and active phase (duration varies)
• 3rd stage: within 10-15 min after birth of baby placenta expelled, assistance if not out in 30 min.

Question 58

13. Compare 1st, 2nd, 3rd, and 4th degree perineal lacerations.

Answer 58

• 1st degree: laceration extends thru skin and structures superficial to muscle
• 2nd degree: extends thru muscles of perineal boyd
• 3rd degree: laceration continues thru the anal sphincter muscle
• 4th degree: laceration also involves anterior rectal wall

Question 59

14. What are the signs of placental separation in the third stage of labor?

Answer 59

• Firmly contracting fundus
• Change in uterus from discoid to globular ovoid shape as placenta moves into lower uterine segment
• Sudden gush of blood from introitus
• Apparent lengthening of umbilical cord as placenta descends to the introitus
• Finding of vaginal fullness (the placenta) on vaginal or rectal exam or of fetal membranes at the introitus

Question 60

15. What is active management of the 3rd stage of labor

Answer 60

Administering Pit to hasten placental separation in order to decrease the incidence of postpartum hemorrhage and reduce total blood loss. Not been found to be superior.

Question 61

16. Describe nursing care in the fourth stage of labor. (first 1-2 hours after birth)

Answer 61

• Assess mom q15min (BP and P), temp at beginning of recovery and after 1st hour.
• Assess fundus and massage as needed
• Assess for bladder distention, assist to void, cath as needed
• Assess Lochia- on pads and on linen, observe perineum for source of bleeding
• Assess perineum- assess episiotomy or laceration, assess for hemorrhoids
• Diet- regular if all WNL, CL and ice chips after c-section