L&B 7b/Fourth stage of Labor/Nursing Interventions

Question 1

Fourth stage of labor OUTLINE

Placental exam
Inspection and clamping of the cord "AVA"
Assessment of episiotomy "REEDA"
Lochia
Maternal infant bonding

Answer 1

Fourth stage of labor OUTLINE

Placental exam
Inspection and clamping of the cord "AVA"
Assessment of episiotomy "REEDA"
Lochia
Maternal infant bonding

Question 2

Fourth stage of labor: Inspection and clamping of the cord

1) Delayed
2) Before applying the cord clamp examine

Answer 2

1) Delayed cord clamping is associated with positive outcome and is the preferred approach

(London 416)

Question 3

Fourth stage of labor: Inspection and clamping of the cord 1) Before applying the cord clamp examine for ?

2) Document ?
3) Cord is clamped where? (distance)
4) Avoid clamping?
5) Hollister clamp removed when?

Answer 3

1) Cut end of cord for two arteries and one vein (largest vessel) AVA
2) Record number of vessels on the birth and newborn records
3) Cord is clamped appx .5 to 1 inch from abd
4) abd skin must not be clamped
5) Hollister clamp is removed in the nursery about 24 hrs after the cord has dried

(London 416)

Question 4

Fourth stage of labor/Assessment/Lochia Rubra

1) What is it?
2) Color
3) A soak perineal pad contains appx how much blood?

Answer 4

1) Bloody vaginal discharge presents shortly after birth/placenta delivery
2) Bright Red with or without clots
3) 100 mL of blood

Question 5

Fourth stage of labor/Assessment/Lochia Rubra

1) If perineal pad becomes soaked in a ___?___min period or blood pooling under buttock ___?___

Answer 5

1) 15 mins

2) Monitor closely

Question 6

Fourth stage of labor/Assessment/Uterus

If fundus rises and displaces to the right consider two factors:

Answer 6

1) As the uterus rises, the uterine contractions become less effective and increased bleeding may occur
2) The most common cause of uterine displacement is bladder distention

(London 420)

Question 7

Fourth stage of labor/Assessment/Bladder

1) Palpate to determine?
2) Reasons bladder may be full and cannot void

Answer 7

1) Distended?
2) IV, uteroplacental circulation, loss of sensation due to trauma to bladder and urethra, regional anesthesia

(London 420)

Question 8

Fourth stage of labor/Assessment/Episiotomy & Perineum

1) Inspect for (2)
2) Relief measure

Answer 8

1) Edema and hematoma formation

2) Ice pack

Question 9

Fourth stage of labor/Assessment/Episiotomy & Perineum

REEDA

Answer 9

Redness
Edema
Ecchymosis
Drainage
Approximation

Question 10

Fourth stage of labor/Assessment/Fundus

1) After childbirth why is it critical that the uterine fundus stay well contracted?
2) Palpate fundus frequently for the next,,,,?
3) Fundus located?
4) Palpate fundus but do not massage it unless
5) What does bobby uterus indicate?

Answer 10

1) To clamp off uterine blood vessels at the placental site and prevent hemorrhaging
2) 4 hours to ensure that it remains firmly contracted
3) Midline at or below umbilicus
4) it is soft (boggy)
5) Pooling of blood within uterus causing clots

Question 11

Fourth stage of labor/Assessment/During the recovery period monitor VS

1) BP every 5-15 mins
2) HR
3) A rise in BP may be in response/caused (2)
4) A lowered blood pressure and rising pulse may indicate?

Answer 11

1) should return to prelabor level
2) slightly lower than it was during labor
3) Oxytocic or preeclampsia
4) Blood loss

Question 12

Fourth stage of labor/Assessment/During the recovery period monitor VS (cont)
1) Temperature

Answer 12

1) Often tremors offer heated blanket