Intrapartum Nursing Assessment

Question 1

What’s included in the initial intrapartum assessment?

Answer 1

Vital signs

Fetal heart rate (FHR)

Contractions

Review prenatal records

Gather additional health history as needed

Identify abnormal symptoms

Question 2

What are some abnormal symptoms when doing an intrapartum assessment?

Answer 2

Vaginal bleeding

Acute abdominal pain

Temperature greater than 100.4 F

Premature labor

Premature rupture of membranes

Hypertension

Non-reassuring FHR pattern

Question 3

Normal blood pressure?

Answer 3

Less than 120/80

Systolic should not rise more than 30 over early pregnancy baseline

Diastolic should not rise more than 15 over early pregnancy baseline

Question 4

Normal pulse, respirations and temperature

Answer 4

Pulse: 60-100 bpm

RR: 12-20

Temp: 36.2-37.6 (98-99.6 F)

Question 5

Normal fetal heart rate?

Answer 5

110-160 / min

Question 6

Normal weight gain?

Answer 6

25-35 pounds

Question 7

Fundus level at 40 weeks gestation?

Answer 7

At the level of the xiphoid process

Question 8

Assessment of the lungs?

Answer 8

Lungs clear with no adventitious sounds

Minimal dependent edema

Question 9

What type of blood work should we note?

Answer 9

Note blood type and RH factor, because RH negative moms need special treatment

Hemoglobin- 12-16

Hematocrit- 38-47%

Platelets- 150,000- 400,000

Screenings should be negative for syphilis, hep B, HIV

Question 10

Urine screenings should be negative for?

Answer 10

Glucose

Ketones

Proteins

Red or white blood cells

Question 11

How do we evaluate labor progress?

Answer 11

Uterine contractions

Cervical effacement

Cervical dilation

Fetal station

Membrane status

Question 12

How do we assess uterine contractions?

Answer 12

Regular? Increasing in frequency, duration, and intensity?

• measured by palpating at the funds with your fingertips (mild/moderate/strong)
• Can be monitored electronically with the toco held in place by an elastic belt
• can also be monitored by an intrauterine pressure catheter

Question 13

How to assess membrane status

Answer 13

May rupture before or during labor

-Most reliable method is visualization of amniotic fluid leaking from cervix

Nitrazine test tape which changes colour when exposed to amniotic fluid

Ferning on glass slide older method for assessment of ROM

Question 14

How often do you document FHR for a low risk pregnancy

Answer 14

Every 30 minutes during the first stage of labour and every 15 mins during the second stage

Question 15

Low risk pregnancy is defined as?

Answer 15

No pregnancy risk factors

No meconium stained fluid

Labour without augmentation or induction

Normal labour patterns

Question 16

How often do you document FHR for high risk mom and baby?

Answer 16

We want to initiate continuous electronic monitoring and additionally, document every 15 mins during the first stage, and every 5 mins during the second stage.

Question 17

What is Leopold maneuvers?

Answer 17

Systematic way to assess the position of the fetus within the abdomen

Question 18

What are the steps for the leopold maneuvers?

Answer 18

First, palpate top of abdomen. A baby’s head will feel more firm, hard and round than a babys bottom.

Second, palpate both sides of abdomen to determine location of babies back. It should feel firm and smooth.

Third, palpate fetal part just above symphysis pubis, should confirm findings of first step

Fourth, facing mother’s feet run hands along sides of abdomen to determine if head is flex or extended. With a flexed head the first cephalic prominence will be opposite the back.

Question 19

What is fetal tachycardia? And what causes it?

Answer 19

> 160 bpm over a 10 min period

Maternal fever, dehydration, medication, as well as fetal prematurity, anemia, hypoxia

Question 20

What is fetal bradycardia causes it?

Answer 20

< 110 over 10 mins

Maternal hypotension, fetal head or cord compression as well as fetal hypoxia