exam 2 stages and phases

Question 1

what is the first stage of labor?

Answer 1

stage of dilation
begins with onset of labor (regular, painful uterine contractions that cause cervical dilation)
ends with complete dilation of the cervix
longest stage
length of time varies
divided into 2-3 phases (latent, active)

Question 2

what is the latent phase of labor?

Answer 2

beginning: onset of labor
dilation: 0-5 cm
timing of contractions: 2-30 M apart 30-45 sec
strength of contractions: mild
emotions: excited, talkative, confident, anxious, withdrawn
pain: mild
length of time: 10-14 H
show: scant amt. brownish discharge, mucous plug, pale pink mucous.

Question 3

what is the active phase of labor?

Answer 3

beginning: more active contractions
dilation: 6-10 cm
timing of contractions: 1.5-5 M apart, 60-90 seconds, regular
strength of contractions: moderate-strong
emotions: quite, concentrated
pain: moderate
length of time: 1 cm per H nulliparous/ 1.5 cm per H multiparous
show: pink to bloody, moderate to copious

Question 4

what is the nursing care for the 1st stage of labor?

Answer 4

assess pt
asses FHR
manage pain
emotional support
encourage or assist in position changes
assist with interventions
advocate for pt needs

Question 5

what is the 2nd stage of labor?

Answer 5

pushing
begins with full dilation (10cm)
ends with birth of infant
15 M to 4 H
varied emotions, burst of energy, exhaustion, excitement, fear
continuous support necessary

Question 6

what are the nursing interventions for the 2nd stage of labor?

Answer 6

coach for effective pushing
assist w/ positioning
offer reassurance and encouragement
prepare for delivery

Question 7

what is the 3rd stage of labor?

Answer 7

placenta
begins with the birth of the infant
ends with the birth of the placenta
5-10M, can be up to 30 M
maternal focus on infant, crying, relief
some discomfort when placenta expelled

Question 8

what are the nursing interventions for the 3rd stage of labor?

Answer 8

immediate infant care
assign APGAR
ID infant
admin uterotonics
emotional support
assist w/ interventions

Question 9

what is the 4th stage of labor?

Answer 9

recovery
begins with birth of placenta
1-4 H
uterus should be fully contracted
lochia rubra
perineal discomfort

Question 10

what are the nursing interventions for stage 4?

Answer 10

Assist with the “golden hour”
Assist with feeding
Admin baby meds
Assess BP, HR, and fundus every 15 M for the 1st 2 H

Assess fundus
- Check for tine by massaging (firm or boggy)
- Location in relationship to the umbilicus
- Document in cm or finger-breaths

Take temp every 4H 2 times then every 8H

Assess bladder
- Check for distension - Assist mom to void
- Cath if necessary
- Assess lochia: check for amount by looking at peri pad and linens

Assess perineum
- Turn pt on side, lift butt, have good lighting

Assess episiotomy or lacerations
- Place ice pack
- Assess for hemorrhoids