Exam 2 Flashcards
What is break through pain?
It is when the regular, scheduled medications are not working as well as they should and the patient is still having pain
Which phase of labor is the longest?
Latent Phase- Stage 1
What are signs of placental separation?
1- the uterus contracts and becomes globular and hard
2- gush of bright red blood
3-uterus rises in abd
4- Cord lengthening
Describe the medical model
focus on DELIVERY, more interventions with less times for natural processes. “abnormal until proven normal”
Describe the physiologic care model
focus is on the BIRTH. process as normal, natural and healthy, interventions only when it becomes dangerous
What is the practice evidence paradox?
When something is done in practice but doesn’t make sense. caused but the tension between the two models of care
When you have a mother come to the hospital, what are your 3 options?
1- Send her home
2- Observe her- vitals with a 20min strip, walking and a vaginal exam after two hours
3- Admit her, hopefully in active phase
What are the three stages of Reva Rubin’s maternal role attainment?
1- Taking in
2- Taking hold
3- Letting go
What happens during Taking-in? How long does it last?
This starts at the birth of baby and this can be for 24-48 hrs
the mother is thinking about herself, her pain, her friends and family and steps she should take.
Sometimes seems as though mother is not interested in baby, but this stage is normal
What happens during taking-hold? How long does it last?
Taking hold last up to several weeks, but does depend on family unit and mother. This is when the mother is questioning everything and wants to learn as much as she can, best time for postpartum teaching
What happens during Letting do?
Mother has learned how to integrate her baby into her life
What are the 6 lamaze birth practices?
1- let labor happen naturally
2- avoid any unnecessary medical interventions
3- try to avoid delivery on your back
4-bring someone with you who will be continuous support
5- walk and move around
6- keep baby with you
during which stage does the mother become exhausted, and many times fall asleep and have red cheeks
Transitional phase
What is a common phrase used by mothers when their baby has thrush?
“it feels like broken glass”
During the golden hour, what is the nurses role?
Vitals Q15mins
Fundal checks and massage
Lochia checks- hemorrhage
What are the three stages of breast-milk?
colostrum, fore-milk, hind-milk
What are the 4 main reasons for labor pain?
1- stretching of cervix and perineum 2- movement of ligaments 3- build up of lactic acid 4- Pulling apart of pelvis (keep in mind emotional responses)
What are the 3 levels of pain management?
1- non-pharm
2- systemic
3- epidural
What are some examples of non- pharm pain management ?
movement, counter pressure, music, meditation, massage, shower, bath
What is used for systemic pain management ?
IV meds, dulls pain but does not remove it. Mother becomes a falls risk.
Does pass to baby.
What are the 4 Ps of Labor?
Passenger- fetus
Powers- contractions
Pelvis
Psyche- mother
What are the 4 Ps of preventable practice?
Physical environment
Permission
Practices
People
When would a pudendal block be used?
Episiotomy or laceration
What are the contraindications for an epidural?
Is it too late? Spine abnormalities anticuagulation therapy known infection Existing hypovolemia
The nurses role before an epidural is…?
Get baseline vitals of mom and baby Vitals Q5 mins & BP/pulse/ O2 Should already have a IV in place IV fluids Contact anesthesia Help position her *have partner leave or sit down*
During an epidural the nurses role is to…?
Vitals Q1min
look for signs of nausea, vomiting= can be secondary to hypotension
Be a support for mom
after an epidural the nurses role is to?
EFM and Vitals on mom
Make sure mom is numb, and continues to be numb
Document all responses
Foley cath
What is a post- spinal headache?
Starts several hours after may get worse with movement- orthostatic may include neck and shoulders check vitals loss of CSF through puncture
What do you do if your patient has a post-spinal headache?
Best rest Vitals Hydrate oral caffeine- or IV in some cases oral analgesics
Pre-OP c-section, What is the RN’s job?
ID patient IV in place IV antibiotics Vitals Include one family member for teachings call neonatal provider and pediatrician call anesthesia GO WITH HER Secure chart
During C-section, the RN does these
MONITOR NEVER leave make sure IV antibiotics are hung Foley cath if not already done Document all events Get supplies Prepare baby warmer Plug in cauterizing device
The RN’s role post-op c-section is…?
Vitals Q15mins FHT Lochia monitoring IV patency Pitocin meds Ice for perineum or incision Blankets for warmth Assist with breastfeeding DOCUMENT I&O
During Latent phase, how often do you check FHT?
Q1hr
During Active phase, how often do you check FHT?
Q30 mins
During 2nd stage, how often do you check FHT?
Q15mins for low risk
Always asses FHT after these events
Vaginal exam ROM Foley bulb for cervical ripening Med admin Fetal stimulation
When there are Variable decels, what do you do?
1 re-position 2 cut pit 3 O2 4 Lactated ringers 5 notify DR
When there are Late decels, what do you do?
1 Re-position 2 Bolus LR 3 cut pit 4 O2 5 Call DR
What is the 3 part nursing diagnosis statement?
1- Problem “patient at risk for ______
2-Etiology “Related to _____
3-Defining Characteristics “As evident by ____
What are the 4 Ts of Hemorrhage ?
Tone- uterine
Tissue- Retained placenta
Trauma- lacerations, rupture
cloTTing- Coagulopathy
What is wound dehiscence ?
Gap in sutures
What can cause Metritis?
c-section
PROM
Scalp electrodes
What are the symptoms of Metritis?
chills Fever 101-104 abd/ uterine pain 30% increase in WBC Malaise
What are the interventions for Metritis?
CBC Cultures Hygiene IV antibiotics Antipyretics Drain abscess
What is paralytic Ileus?
Bowel blockage/ slowing
- is a post op complication- check for bowel sounds
- may be hard and distended
- pain, nausea, vomitting
