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MATERNAL AND CHILD NURSING > Module 05: Care of Mother and Fetus During Intrapartal Period (Part 02) > Flashcards

Module 05: Care of Mother and Fetus During Intrapartal Period (Part 02) Flashcards

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1
Q

This is defined as the coordinated sequence of events wherein involuntary uterine contraction causes progressive effacement and dilation.

A

Labor or Eutocia

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2
Q

Labor or Eutocia is also characterized as what?

A

The voluntary bearing down efforts that allows the expulsion of the fetus.

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3
Q

This is the actual expulsion of the products of conception, which occurs during the second stage of pregnancy.

A

Delivery (Shortest stage of labor)

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4
Q

Under the birth according to gestational age, this pertains to the birth of the fetus, where it is less than 37 weeks.

A

Preterm

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5
Q

Under the birth according to gestational age, this pertains to the birth of the fetus, where it is within 37 to 42 weeks or 2 weeks before or after the Expected Date of Delivery.

A

Term or Normal

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6
Q

Under the birth according to gestational age, this pertains to the birth of the fetus, where it is beyond 42 weeks.

A

Post Term

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7
Q

What is the expected hours of pregnancy of a primipara (first pregnancy) woman?

A

14 to 20 hours

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8
Q

What is the expected hours of pregnancy of a multipara woman?

A

8 to 14 hours

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9
Q

These are characterized to begin several weeks prior to labor and is encouraged to be taught to all pregnant women.

A

Impending Signs of Labor

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10
Q

What are the different impending signs of labor?

A

(A) Lightening
(B) Engagement
(C) Increased Braxton-Hicks Contraction
(D) Ripening of the cervix
(E) Sudden burst of energy of the mother
(F) Allowable Weight Loss

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11
Q

This occurs when the fetus settles or descends into the pelvic inlet. This occurs 10 to 14 days before the onset of labor among primipara women.

A

Lightening

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12
Q

What are the results of lightening?

A

(A) Increase in urinary frequency.
(B) Relief of dyspnea; abdominal tightness and diaphragmatic pressure.
(C) Shooting leg pain due to pressure on sciatic nerve.

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13
Q

What happens during the mother’s 36th week of pregnancy in terms of lightening?

A

During the 36th week of pregnancy, a pregnant mother has difficulty in breathing due to the pressure on her diaphragm. Lightening brings relief to the mother because the pressure to the diaphragm is removed.

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14
Q

This impending sign of labor pertains to the settling of the presenting part into the pelvic inlet, wherein the landmark of this is the ischial spine.

A

Engagement (Station 0)

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15
Q

This impending sign of labor pertains to the increased frequency of contraction. This produces gnawing pain in the abdomen and groin.

A

Increased Braxton Hicks Contractions

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16
Q

What should be asked of the mother when she is experiencing increased Braxton Hicks Contractions?

A

Mother may be asked to return home if not yet true labor.

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17
Q

What should the nurse do when the mother is experiencing increased Braxton Hicks Contractions?

A

The registered nurse should show sympathetic support and explain labor contractions.

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18
Q

This impending sign of labor occur when the cervix becomes butter soft. The internal sign is felt only during a pelvic exam.

A

Ripening of the Cervix

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19
Q

The ripening of the cervix is felt only through what?

A

A pelvic exam

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20
Q

This impending sign of labor occurs due to the increase in epinephrine initiated by decreased progesterone produced by the placenta.

A

Sudden Burst of Energy

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21
Q

This hormone is characterized to prepare the mother’s body for labor work.

A

Epinephrine (Nesting instinct; preparing for the baby)

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22
Q

What should the nurse do when the mother is experiencing a sudden burst of energy?

A

The registered nurse should let the mother save her energy as fatigue can affect the type of analgesia needed and let her rest in preparation for labor.

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23
Q

This is characterized as painless labor.

A

Twilight

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24
Q

This impending sign of labor occurs when the mother gains about 2 to 3 lbs or one kilogram 2 to 3 days before the onset of labor.

A

Allowable Weight Loss (Related to the changes of estrogen and progesterone levels)

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25
Q

What are the three (3) other signs of impending labor?

A

(A) Increase vaginal mucus discharge
(B) Fetal movement is less active
(C) Episodes of false labor

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26
Q

This impending sign of labor occurs where there is whitish discharges excreted by the mother to prepare the birth canal for delivery. This is also important to prevent infection.

A

Increased Vaginal Mucus Discharge

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27
Q

Why is there less active fetal movement during impending labor?

A

Because of engagement.

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28
Q

How many is the normal fetal movement count?

A

200 kicks per 24 hours, 10 kicks per one hour

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29
Q

What makes false labor different from true labor?

A

(A) Frequency of Contractions: Begin and remain irregular
(B) Intensity of Contractions: No increase
(C) Pain relief: Often disappear with ambulation and sleep
(D) Pain location: Felt first abdominally and remain confined to the abdomen and groin
(E) Cervical changes: Do not achieve cervical dilatation

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30
Q

What makes true labor different from false labor?

A

(A) Frequency of Contractions: Begin irregularly but become regular and predictable
(B) Intensity of Contractions: Increases
(C) Pain relief: Continue no matter what the woman’s level of activity
(D) Pain location: Felt first in lower back and sweep around to the abdomen in a wave
(E) Cervical changes: Achieves cervical dilatation

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31
Q

These signs are characterized to be felt a few hours prior to labor. All pregnant women must be aware of these signs.

A

Signs and Symptoms of Onset of Labor

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32
Q

This sign and symptom of onset of labor pertains to the expulsion of the mucus plug (operculum) due to the softening of the cervix plus blood from the ruptured capillaries due to the pressure from the fetus.

A

Bloody Show

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33
Q

What color is the discharge when the mother is experiencing bloody show?

A

Pink or brown tinged discharge

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34
Q

This sign and symptom of onset of labor is characterized as the surest sign that labor has begun its uterine contractions.

A

True Labor Contractions

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35
Q

What should the nurse do when the mother is experiencing true labor contractions?

A

The registered nurse should remind the mother to do breathing exercises to reduce anxiety and pain.

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36
Q

This sign and symptom of onset of labor pertains to the sudden gush of amniotic fluid from the vagina. This may occur before and after labor (occurs within 24 hours).

A

Spontaneous Rupture of Membrane (SROM)

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37
Q

What should the nurse observe when the mother is experiencing Spontaneous Rupture of Membrane (SROM)?

A

Aseptic technique (less manipulation through internal exam)

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38
Q

What are the risks associated with Spontaneous Rupture of Membrane (SROM)?

A

(A) Intrauterine Infection
(B) Prolapsed of Umbilical Cord
Cuts off oxygen supply to fetus

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39
Q

What are the nursing interventions to be executed during Spontaneous Rupture of Membrane (SROM)?

A

(A) Check fetal heart rate (FHR) every one minute
(B) Check temperature every two hours
(C) Position: Prone in knee chest position

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40
Q

What should the nurse report when the mother is experiencing Spontaneous Rupture of Membrane (SROM)?

A

(A) Strong or foul odor: Infection
(B) Meconium- stained: Possible fetal anoxia (vertex)
(C) Wine colored: Premature separation of placenta

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41
Q

When does Spontaneous Rupture of Membrane (SROM) usually occur?

A

it ruptures six (6) hours prior to labor. When it ruptures, less internal examination should be executed to prevent infection. The nurse should also practice aseptic technique.

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42
Q

What are the possible diagnostic procedures for (amniotic fluid or urine) Spontaneous Rupture of Membrane (SROM)?

A

(A) Alkaline Test (nitrazine paper)
(B) Fern Test

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43
Q

Under this test for amniotic fluid, the dried amniotic fluid and mucus looks like crystallized ferns by microscopic exam.

A

Fern Test

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44
Q

This is known as the thinning and shortening of the cervix. This is measured in percentages wherein 100% denotes full _________.

A

Effacement

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44
Q

Under effacement,70% to 80% of the thinning and shortening of the cervix would resemble the feeling of what?

A

Between the thumb and the index finger

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45
Q

Under effacement,90% to 100% of the thinning and shortening of the cervix would resemble the feeling of what?

A

Gloves

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46
Q

This is known as the widening of the external cervical os.

A

Dilation (0 to 10 cm wherein 10cm pertains fully dilated)

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47
Q

What are the different causes of labor pain?

A

(A) Uterine Contractions.
(B) Hypoxia in myometrium and adjacent tissues which may cause oxygen deficit ( decreased O2 causes increased pain receptors).
(C) Cervical stretching and dilation.
(D) Stretching support during contraction and expulsion efforts.
(E) Compression of nerve ganglia in cervix and lower uterus by tightly interlocking muscle bundles.
(F) Emotional tension due to fear.
(E) Pressure of presenting parts on bladder, bowel pelvic structures.

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48
Q

Under the process of assessment, labor pain is manifested through what?

A

(A) Facial tension
(B) Flushing or pallor
(C) Hand clenched in a fist
(D) Increased PR and BP
(E) Difficulty with ability to reason clearly
(F) Increased duration and strength of contractions
(G) Decreased interval between contractions

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49
Q

How long does it take to dilate 1 cm in early labor?

A

1 cm dilates in about 1.2 hours on average in early labor.

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50
Q

What happens during the transition phase?

A

The cervix dilates from 7 to 10 cm, typically in 1-2 minutes intervals of contractions, indicating the end of labor.

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51
Q

What signals the pushing stage?

A

At 10 cm dilation, the cervix is fully open, and the mother will experience strong urges to push.

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52
Q

How frequent are contractions at full dilation (9-10 cm)?

A

Contractions occur every 1-2 minutes as the cervix is fully dilated and ready for pushing.

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53
Q

Under diagnosis, this depends on the subjective and objective data gathered. What are the different types of nursing diagnosis for labor pains?

A

(A) Pain related to labor contractions
(B) Anxiety related to process of labor and birth
(C) Health-seeking behaviors related to management of discomfort of labor
(D) Situational low self-esteem related to inability to use prepared childbirth method

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54
Q

What are the different types of nursing interventions for labor pain?

A

(A) Breathing Techniques
(B) Bathing (for comfort)
(C) Massage (for comfort)
(D) Focusing and imagery
(E) Biofeedback
(F) Yoga
(G) Aromatherapy and Essential Oils
(H) Herbal Preparations
(I) Prayer

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55
Q

What are the three (3) phases of labor contractions?

A

(A) Increment or crescendo
(B) Acme
(C) Decrement of Decrescendo

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56
Q

Under this phase of labor contractions, the contraction starts at the fundal area and increases in intensity from the beginning of the contraction until it peaks.

A

Increment or crescendo

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57
Q

This phase of contraction is known as the height or peak of the contraction, where the contraction is felt strongest at the sides of the abdomen.

A

Acme

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58
Q

Under this phase of labor contractions, the contraction decreases, starting from the height of the contraction until it fades, ending at the lower portion of the uterus.

A

Decrement of decrescendo

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59
Q

Under acme, the contraction is felt strongest at what?

A

At the sides of the abdomen.

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60
Q

What are the different characteristics of labor contractions?

A

(A) Duration
(B) Frequency
(C) Interval or Rest
(D) Strength

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61
Q

This is known as the time from the beginning (increment) to the end (decrement) of the same or single contraction.

A

Duration

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62
Q

This is known as the time from the beginning of one increment to the beginning of the next contraction.

A

Frequency

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63
Q

This is known as the rest period between contractions, from the end of decrement to the beginning of increment of the next contraction.

A

Interval or Rest (It’s the best time to check Fetal Heart Tones (FHT) and maternal blood pressure (BP).)

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64
Q

This is evaluated by palpating the abdomen during the peak of the contraction using light finger pressure.

A

Strength

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65
Q

Explain the first stage of labor or the dilating stage.

A

The First Stage is from true contractions to full cervical dilation (10 cm). It’s the longest stage, lasting 14-20 hours for first-time mothers and 8-18 hours for experienced mothers.

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66
Q

Explain the second stage of labor or the expulsion stage.

A

The Second Stage is from full cervical dilation to the delivery of the fetus. It is the shortest stage of labor.

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67
Q

Explain the third stage of labor or the placental stage.

A

The Third Stage is from the delivery of the fetus to the delivery of the placenta.

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68
Q

Explain the fourth stage of labor or the immediate recovery.

A

The Fourth Stage is the recovery period, from the delivery of the placenta to 1-4 hours after delivery.

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69
Q

What is the duration of the first stage of labor in nullipara and multipara women?

A

(A) Nullipara: 12-18 hours
(B) Multipara: 8-9 hours

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70
Q

What are the three phases of the first stage of labor (LAT)?

A

(A) Latent Phase
(B) Active Phase (typically 6 hours; if it lasts less than 6 hours, it is precipitous labor)
(C) Transitional Phase

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71
Q

When can a pregnant patient be sent home or admitted to the hospital based on cervical dilation?

A

(A) 0-3 cm: The patient can go home.
(B) 4-7 cm: The patient is admitted to the hospital.
(C) 8-10 cm: The patient goes to the labor or delivery room.

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72
Q

What key information should be reviewed about the client’s obstetric history?

A

(A) Age and Estimated Date of Confinement (EDC)
(B) GTPAL (Gravida, Term, Preterm, Abortions, Living children)
(C) Lab tests and types of requested analgesia/anesthesia
(D) Other pregnancy-related problems and past/current management

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73
Q

What are the important details to include in the client profile?

A

(A) Name, age, physician, allergies, blood type
(B) Preparation for childbirth
(C) Support persons
(D) Cultural influences
(E) Plan for newborn care (e.g., feeding method, pediatrician)

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74
Q

What important notes should be included from the general history?

A

Gynecological and obstetric questions only; focus on key points for the current pregnancy.

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75
Q

How can you differentiate true labor from false labor?

A

True labor involves progressive effacement, dilation, and station. It can be confirmed by contraction palpation, electrical monitoring, and vaginal exams.

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76
Q

How are contractions assessed during the first stage of labor?

A

Contractions are evaluated through palpation and electrical monitoring.

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77
Q

How are effacement, dilation, and station assessed?

A

Through a vaginal exam.

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78
Q

This practice aims to check the presentation and position of the fetus.

A

Leopold’s Maneuver

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79
Q

What should be checked regarding the membranes?

A

Determine if the membranes have ruptured and check for a prolapsed or intact cord.

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80
Q

How often should maternal vital signs be taken during labor?

A

(A) Latent phase: Every 1 hour
(B) Active phase: Every 30 minutes
(C) Transitional phase: Every 15 minutes
Note: Take BP between contractions, as BP increases during contractions.

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81
Q

How often should maternal temperature be taken during labor?

A

(A) If membranes are intact: Every 4 hours
(B) If membranes are ruptured: Every 2 hours

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82
Q

How and when should Fetal Heart Tones (FHT) be monitored?

A

(A) Use ultrasound (UTZ) or electronic monitor (Doppler).
(B) Take FHR between contractions (FHR decreases during contractions).

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83
Q

What is the normal fetal heart tone (FHT)?

A

Normal FHT: 120-160 bpm with average variability, no late/variable decelerations, and early decelerations may be present.

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84
Q

What should be assessed regarding the mother’s psychological response to labor?

A

Observe the mother’s emotional and psychological response as labor begins and progresses.

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85
Q

This fetal monitor is used to assess the frequency, duration and strength of contractions. This has its risks for infection and is characterized to limit movement

A

Internal Fetal Monitor (Used only for high risk labor)

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86
Q

This fetal monitor is used to assess the frequency and duration of contraction. This is characterized to be less reliable than internal monitoring.

A

External Fetal Monitor (Used in early labor with 0 cm dilation)

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87
Q

What are the indications for fetal heart monitoring?

A

(A) Decreased fetal movement
(B) Abnormalities in FHR
(C) Passage of meconium
(D) Abnormal fetal position (breech)
(E) Premature and postmature pregnancies
(F) Maternal complications (PIH, DM, fever)
(G) Oxytocin augmentation or induction
(H) Bleeding

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88
Q

How is time measured on a Cardiotocography (CTG)?

A

6 boxes = 1 minute (1 box = 10 seconds)

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89
Q

Under Cardiotocography (CTG) Monitoring, what do the upper and lower portions represent?

A

(A) Upper portion: Records fetal heart rate
(B) Lower portion: Records uterine contractions

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90
Q

What happens to FHT during contractions?

A

When there is a contraction, the FHT decreases (mirror image: increasing contractions, decreasing FHT). There may be 2 contractions in 1 minute.

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91
Q

What are the three key parameters to assess when evaluating FHR patterns?

A

(A) Baseline rate
(B) Variability in the baseline rate (long-term and short-term)
(C) Periodic changes in the rate (acceleration, early/late deceleration, variable deceleration)

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92
Q

What is the normal range for baseline fetal heart rate (FHR)?

A

Normal baseline FHR is between 120-160 bpm (or 110-160 bpm).

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93
Q

This type of variability in Fetal Heart Rate (FHR) pertains to beat to beat changes in FHR.

A

Short-term variability

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94
Q

This type of variability in Fetal Heart Rate (FHR) pertains to rhythmic fluctuations in FHR over time.

A

Long-term variability

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95
Q

What are the types of periodic changes in FHR?

A

(A) Acceleration: Temporary increase in FHR
(B) Early deceleration: Decrease in FHR mirroring contractions, normal
(C) Late deceleration: Decrease in FHR after contraction, a sign of fetal distress
(D) Variable deceleration: Abrupt drop in FHR, often due to cord compression

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96
Q

What is the normal baseline fetal heart rate (FHR) for a full-term fetus?

A

Normal baseline FHR is 120-160 bpm.

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97
Q

What are the characteristics of a reassuring FHR pattern?

A

(A) Baseline FHR: 120-160 bpm
(B) Preserved beat-to-beat and long-term variability
(C) Accelerations last 15+ seconds above baseline and peak at 15+ bpm.

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98
Q

This condition pertains to a fetal heart rate (FHR) greater than 160 bpm lasting for more than 10 minutes.

A

Tachycardia

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99
Q

What are the common causes of fetal tachycardia?

A

(A) Early late hypoxia
(B) Maternal fever
(C) Amnionitis
(D) Parasympatholytic drugs (e.g., atropine)

100
Q

When is fetal tachycardia not serious?

A

Not serious if due to maternal fever.

101
Q

When is fetal tachycardia perceived as serious?

A

Serious if associated with late decelerations, severe variable decelerations, or absence of variability.

102
Q

What are the nursing interventions for fetal tachycardia?

A

(A) Administer antipyretics or cooling measures to reduce fever
(B) Provide oxygen at 10-12 L/min via face mask

103
Q

This condition pertains to a fetal heart rate 9FHR) less than 120 bpm lasting for more than 10 minutes.

A

Bradycardia

104
Q

What are the common causes of fetal bradycardia?

A

(A) Late fetal hypoxia
(B) Maternal hypotension
(C) Prolonged umbilical cord compression
(D) Beta-adrenergic blocking drugs (e.g., anesthesia, propranolol)

105
Q

When is fetal bradycardia not perceived or considered as distress?

A

Fetal bradycardia is not considered distress if there is good variability, no periodic changes, and FHR is above 80 bpm.

106
Q

When is fetal bradycardia considered as distress or serious?

A

Serious if due to hypoxia and with loss of variability and late decelerations.

107
Q

What are the nursing interventions for fetal bradycardia?

A

(A) Provide oxygen at 10-12 L/min
(B) Place the mother in a lateral position to prevent compression of the inferior vena cava

108
Q

What is the must-know FHR baseline range?

A

FHR baseline is 110-160 bpm.

109
Q

What should be done if FHR is 80 bpm and the mother is on anesthesia?

A

No management is needed if the mother is on anesthesia, but if not, this indicates a complication and should be reported immediately.

110
Q

This type of variability refers to beat to beat changes in FHR (from one beat to another).

A

Short-term variability

111
Q

This is the normal irregularity of the cardiac rhythm, influenced by the parasympathetic and sympathetic nervous systems.

A

FHR variability

112
Q

This type of variability refers to fluctuations in FHR that occur in 3-5 cycles per minute.

A

Long term variability

113
Q

What are the characteristics of good variability?

A

Good variability includes cyclic fluctuations and beat-to-beat changes in the baseline FHR.

114
Q

This type of variability indicates CNS depression in the fetus.

A

Loss of Variability

115
Q

What causes increased variability in FHR?

A

Increased variability may result from fetal stimulation due to contractions, palpation, or fetal/maternal activity.

116
Q

What causes decreased variability in FHR?

A

Decreased variability may result from CNS depressants, hypoxia, or fetal sleep cycles.

117
Q

These are accelerations or decelerations from the baseline that return to baseline. They occur in response to uterine contractions and fetal movements.

A

Periodic Changes

118
Q

Under periodic changes, this is known as the transitory increase above the baseline, caused by fetal movement or stimuli such as uterine contractions.

A

FHR Acceleration

119
Q

What nursing intervention is needed for FHR acceleration?

A

No intervention is needed; it indicates fetal well-being.

120
Q

What causes early deceleration in FHR?

A

Early deceleration is caused by fetal head compression during contractions or pressure on the cervix.

121
Q

Under periodic changes, this is known as the fall of the FHR from normal and this is often considered as a reassuring pattern.

A

Early deceleration

122
Q

What nursing intervention is needed for early deceleration?

A

No intervention is needed, as it is considered a reassuring pattern.

123
Q

What does the shape of early deceleration look like on the monitor?

A

(A) It has a uniform shape that inversely mirrors the uterine contraction, starting and ending with the contraction.
(B) The onset and the return of the declaration coincides with the start and the end of the contraction
(C) Through of deceleration coincides with peak of compression

124
Q

Under periodic changes, this is known as the fall of FHR below baseline in late contraction.

A

Late Deceleration

125
Q

What causes late deceleration in FHR?

A

Late deceleration is caused by uteroplacental insufficiency due to factors like oxytocin augmentation, supine hypotension, or epidural/spinal anesthesia.

126
Q

What nursing interventions should be done for late deceleration?

A

During fetal distress:
(A) Assist mother to left lateral position
(B) Elevate legs
(C) Increase IV rate to treat hypotension
(D) Administer oxygen
(E) Discontinue oxytocin

127
Q

What does the shape of late deceleration look like on the monitor?

A

It has a smooth shape, inversely mirrors the contraction, but occurs late in the contraction.

128
Q

When does deceleration start?

A

They start after the contraction and begins and persists after the contraction ends.

128
Q

This is known as the decrease in fetal heart rate (FHR) that is variable in duration, intensity, and timing relative to contractions.

A

Variable Deceleration (80-90 % of deceleration)

129
Q

Variable Deceleration is due to what?

A

Due to umbilical cord compression

130
Q

What are the nursing interventions for variable decelerations?

A

(A) Change maternal position
(B) Stop oxytocin
(C) Administer oxygen
(D) Suspect prolapse cord

131
Q

What does the shape of variable decelerations look like on the monitor?

A

Variable decelerations vary in onset, occurrence, and waveform, showing variable shapes relative to contractions.

132
Q

What are the different concerning characteristics od variable decelerations?

A

(A) Last >60 seconds
(B) Biphasic shape
(C) No Shouldering
(D) Reduce berlin variability within deceleration
(E) Failure to return to baseline

133
Q

These are variable in duration, intensity, and timing. Acceleration - deceleration-acceleration is due to compression and decompression of cont.

A

Variable Decelerations

134
Q

This diagnostic test may be done when fetal distress is present and additional information is needed.

A

Fetal Blood Sampling

135
Q

How is fetal blood sampling done?

A

The physician places an endoscope against fetal presenting part and the blood sample is obtained from the fetal scalp.

136
Q

What are the normal results from fetal blood sampling?

A

Normal: pH = 7.25 or higher

137
Q

What are the abnormal results from fetal blood sampling?

A

(A) Preacidotic : pH = 7.20 - 7.24
(B) Acidotic: pH <7.20 : means fetal distress (hypoxia)

138
Q

How should planning be executed in the first stage of labor?

A

(A) Provide safe and effective environment
(1) Orient couple to surroundings
(2) Promote physical safety

(B) Promote psychological integrity
(1) Promote maternal fetal well being during birth process
(2) Provide support and counseling to laboring couple

(C) Provide health promotion/maintenance
(1) Promote independence of self-care activities
(2) Encourage breathing exercises

139
Q

How does the woman typically respond during the latent phase of labor?

A

The woman may feel apprehensive, excited, can communicate, and will seek information.

140
Q

What nursing interventions or nursing support are recommended during the latent phase of labor?

A

(A) Encourage the mother to bathe
(B) Prepare the vulva (no shaving)
(C) Administer enema (optional in some hospitals)
(D) Provide ice chips (NPO to prevent aspiration)
(E) Establish an IV line
(F) Establish rapport with the patient

141
Q

What is the NPO recommendation before a cesarean (CS) delivery?

A

Do not give food for 6-8 hours prior to the procedure.

142
Q

Is the pregnant woman encouraged to eat during normal delivery (EINC)?

A

YES

143
Q

What are the reasons for administering an enema during labor?

A

(A) Prevents infection for both mother and fetus
(B) Helps increase uterine contractions
(C) Prevents postpartum discomfort
(D) Facilitates the descent of the fetus into the birth canal

144
Q

What are the contraindications for administering an enema during labor?

A

(A) Malpresentation and position
(B) Vaginal bleeding
(C) Ruptured bag of water
(D) Crowning

145
Q

What should the nurse do for the family during the latent phase of labor?

A

(A) Orient the family to the room, equipment, and procedures
(B) Assess the family’s information base and learning needs
(C) Be available for health teaching (e.g., chest breathing)
(D) Keep couple informed of progress
(E) Assist in frequent changes of position (Left lateral prevents “supine hypotension” or “supine vena cava syndrome”)
(F) Encourage to void every 2-3 hours
(G) Encourage ambulation to shorten 1st stage of labor
(H) Monitor labor signs of fetal distress

146
Q

What maternal position should be encouraged during labor to prevent supine hypotension?

A

Encourage the left lateral position to prevent supine hypotension or supine vena cava syndrome.

147
Q

How often should the pregnant woman void during labor?

A

Encourage the pregnant woman to void every 2-3 hours.

148
Q

What is the benefit of ambulation during the first stage of labor?

A

Ambulation helps to shorten the first stage of labor.

148
Q

During this stage, the woman may experience fears of losing control, fatigue, difficulty following directions, and becomes more dependent.

A

Active Phase

149
Q

What nursing support is recommended during the active phase of labor?

A

(A) Encourage the woman to maintain breathing patterns
(B) Provide a quiet environment and reassurance
(C) Promote comfort (e.g., backrubs, cool cloth on the forehead)
(D) Provide ice chips and ointment for dry lips
(E) Prepare and ready medications
(F) Monitor vital signs and progress of labor FHR

150
Q

During this stage, the woman responds with severe pain; vague in communication; and hyperesthesia (hypersensitivity of the other to touch).

A

Transitional Phase

151
Q

What nursing support is recommended during the transitional phase of labor?

A

(A) Encourage the woman to maintain breathing patterns
(B) Provide a quiet environment to reduce external stimuli
(C) Offer reassurance and praise
(D) Promote comfort: backrubs, cool cloth on forehead
(E) Provide ice chips, ointment for dry lips
(F) Encourage to void every 2 hours (to prevent bladder rupture)

152
Q

What is the nurse’s role during evaluation in the transitional phase?

A

To help the expectant couple understand and practice safety measures.

153
Q

These are used to promote relaxation by distracting the mother from her from intense contraction sensations and to provide adequate oxygenation.

A

Breathing Techniques

154
Q

How are breathing techniques excuted?

A

(A) Breathing is done only during contractions
(B) Rest and sleep between contractions is important
(C) Instruct the laboring woman to do the ff:
(1) Assume a comfortable position
(2) Try to maintain a relaxed state throughout the contraction
(3) Close her eyes
(4) Concentrate on a focal point

155
Q

This essential breathing technique is executed by inhaling through the nose, exhale through pursed lips.

A

Cleansing Breath

156
Q

This essential breathing technique is executed by taking in 8 to 10 breaths per minuted. This is often used for early and milder contractions.

A

Slow chest breathing (1st stage of labor)

157
Q

This essential breathing technique is executed by taking in 16 to 20 breaths per minuted. This is often used for increasing frequency and intensity of contractions.

A

Rapid chest breathing (1st stage of labor)

158
Q

This essential breathing technique is executed as contractions grow more frequent and intense.

A

Shallow chest breathing (1st stage of labor)

159
Q

When should breathing be performed during labor?

A

Breathing should be done only during contractions, with rest and sleep between contractions.

160
Q

This occurs when dilation falters during the active phase despite regular contractions.

A

Failure to progress

161
Q

What are the common complications of labor?

A

(A) Premature rupture
(B) Failure to progress
(C) Pelvic size
(D) Position of the baby
(E) Past Cesarean (CS) (consider VBAC if with low transverse incision)

162
Q

Failure to progress may be addressed by: (These methods are used to reestablish labor when there’s failure to progress)

A

(A) Amniotomy
(B) Induction of labor (using oxytocin drip or prostaglandin E2 gel - vaginal suppository)

163
Q

What is the normal dilation rate during active labor?

A

Dilation typically progresses at 1.2 to 1.5 cm per hour during active labor.

164
Q

What are the danger signs for the mother during labor?

A

(A) Rising or falling blood pressure
(B) Abnormal pulse
(C) Inadequate contractions
(D) Increased apprehension
(E) Abnormal lower abdominal contou

164
Q

What are the danger signs for the fetus during labor?

A

(A) High or low fetal heart rate
(B) Meconium staining
(C) Hyperactivity
(D) Fetal acidosis

165
Q

What is a common diagnosis for a woman in the first stage of labor related to emotions?

A

Powerlessness related to the duration of labor.

166
Q

What is the desired outcome for a woman feeling powerless during labor?

A

The client voices she feels in control of happenings and expresses preferences for positions and techniques to control pain.

167
Q

What risk is associated with breathing exercises during labor?

A

Risk for ineffective breathing pattern related to improper breathing techniques.

168
Q

How can a nurse help empower a laboring mother?

A

(A) Respect contraction time
(B) Promote changes in position
(C) Help with fetal alignment
(D) Encourage voiding and provide bladder care
(E) Help empower laboring mother

169
Q

What risk is associated with breathing exercises during labor?

A

Risk for ineffective breathing pattern related to improper breathing techniques.

170
Q

What is the desired outcome for a woman with risk for ineffective breathing pattern?

A

Clients respiratory rate returns to normal after contraction, no reports of light-headedness.

171
Q

This is often prevented to avoid respiratory alkalosis from excessive loss of carbon dioxide.

A

Hyperventilation (Tip: Inhale deeply, and push with breath)

172
Q

The outcome evaluation for this condition is that the client will state she feels in control with situation, she and support person express confidence in their ability to weather this extraordinary event in their life.

A

Anxiety Related to Stress of Labor

173
Q

How can you manage a laboring woman’s anxiety during labor?

A

(A) Offer emotional support
(B) Respect and promote the role of the support person
(C) Support the woman’s pain management needs

174
Q

What is a diagnosis related to hydration during labor?

A

Risk for fluid volume deficit related to prolonged lack of intake and diaphoresis during labor.

175
Q

What is the expected outcome for fluid volume management during labor?

A

The client drinks at least one glass of beverage every hour, states she does not feel thirsty, and voids 30 ml/hr every 2-4 hours.

176
Q

What management strategies can help maintain hydration during labor?

A

(A) Offer ice chips, popsicles, or lollipops
(B) Provide isotonic sports drinks if needed to prevent secondary uterine inertia.

177
Q

This is when the fetal head enters and remains in the pelvic inlet.

A

Engagement

178
Q

What forces help in the descent of the fetus during labor?

A

(A) Pressure of amniotic fluid
(B) Direct pressure of the fundus on the breech
(C) Contractions of abdominal muscles
(D) Extension and straightening of the fetal body

179
Q

This is known as the downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. The rate is greatest during the second stage of labor.

A

Descent

180
Q

When does the descent occur among primagravidas?

A

Before the onset of labor.

181
Q

When does the descent occur among multiparas?

A

The descent may not occur until labor is advanced.

182
Q

This occurs due to resistance to descent, and it increases as the fetus moves through the birth canal, usually complete by the time the presenting part reaches the pelvic floor.

A

Flexion

183
Q

This aligns the fetal head with the pelvic outlet, facilitating a smoother passage through the birth canal.

A

Internal Rotation

184
Q

This occurs as the fetal head moves downward, due to uterine contractions and resistance from the pelvic floor and moving out of the birth canal.

A

Extension ( The anterior wall of the pelvis is 4-5 cm deep)

185
Q

Under this, as the shoulders rotate to the AP diameter of the pelvis, the head further rotates until the sagittal suture is transverse again. Thus, the shoulders accommodate to the widest diameter of the outlet for birth, just as the fetal head did.

A

External Rotation

186
Q

This is known as the delivery of the shoulders. During this, the shoulder of the fetus enter the pelvis obliquely and remain oblique when the head rotates to the antero-posterior diameter through internal rotation.

A

Restitution (When the shoulder is delivered, pull upwards)

187
Q

During this, usually the anterior shoulder is born first, followed by the posterior shoulder; the rest of the body is quickly extruded.

A

Expulsion

188
Q

Under this process, cover the anus with sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the to control the emerging head.

A

Ritgen’s Maneuver

189
Q

What should the nursing do during the first principle in the care of the newborn?

A

To establish and maintain patent airway. The head should be delivered in between contractions. (Insert two fingers into the vagina so as to feel for the presence of a cord looped around the neck (nuchal cord).

190
Q

What should be assessed during the second stage of labor?

A

(A) Maternal vital signs
(B) Fetal status
(C) Labor progress
(D) Psychological and cultural

191
Q

When should a newborn be suctioned immediately?

A

Only when needed, such as in the presence of meconium staining.

192
Q

How should a newborn be stimulated to cry?

A

By rubbing the back, not slapping the feet or buttocks.

193
Q

How much of the umbilical cord should be left after clamping?

A

Leave at least 1 cm to allow for re-clamping in case the clamp detaches.

193
Q

What should you do if there are no contractions?

A

Do not let the mother push; wait for another contraction.

194
Q

How should the fetus’s status be monitored during labor?

A

Assess fetal heart rate and wellbeing.

195
Q

What is the expected rate of cervical dilation for a primigravida?

A

1 cm per hour.

196
Q

What is the expected rate of cervical dilation for a multigravida?

A

1.5 cm per hour.

197
Q

What fetal station should the fetus be at by the end of the first stage of labor?

A

+2 station.

198
Q

What are the characteristics of uterine contractions in active labor?

A

Occur every 2-3 minutes, last 60-75 seconds, and are strong in intensity.

199
Q

What happens to the amount of bloody show during labor?

A

The amount increases.

200
Q

What is the normal blood loss during labor, and when is bleeding a concern?

A

Normal blood loss is around 200-300 cc; more than 500 cc indicates bleeding.

201
Q

When might the mother feel the urge to bear down?

A

As labor progresses, especially when fully dilated.

202
Q

What psychological behaviors might a woman in labor show?

A

Intense concentration on pushing efforts, eagerness to participate, or difficulty coping.

203
Q

How should the nurse execute planning during the second stage of labor?

A

(A) Manage patient’s discomfort in labor with non- pharmacologic methods.
(B) Identifies relief measures if needed.
(C) States labor and birth were positive experience for the mother.

204
Q

How should the nurse execute implementation during the second stage of labor?

A

(A) Continue assessments of maternal vital signs and contractions every 5 mins
(B) Assist laboring woman into a position that promotes comfort
(C) Assist/coach in pushing effort

(D) Observe for signs of approaching birth:
(1) Perineal bulging
(2) Visualization of the visual head

(E) Complete perineal cleansing and perineal scrub
(1) Use warmed antiseptic (cold causes cramping) and front to back motion

(F) Provide comfort measures
(1) Offer ice chips to moisten mouth
(2) Place cool cloth on forehead
(3) Support woman’s body /extremities during pushing

(G) Provide assistance to the physician or midwife during delivery
(1) Milk the cord towards the baby
(2) Double clamp the cord and cut when cord pulsation disappear (3 mins max)
(3) Clear mouth and nose with bulb syringe (if needed; meconium stain)
(4) Attend to safety and comfort of the newborn

205
Q

Why is the lithotomy position no longer the major position in labor?

A

It can cause intense pelvic congestion if held for too long.

205
Q

How should the legs be positioned in the lithotomy position?

A

Raise both legs simultaneously to padded stirrups at equal height (stirrups).

206
Q

What can happen if a laboring woman remains in the lithotomy position for 1 hour?

A

Intense pelvic congestion.

207
Q

What precaution should be taken when the woman is in the lithotomy position?

A

Ensure someone is at the foot of the bed to catch the fetus.

208
Q

What is the benefit of the side-lying position during labor?

A

It helps prevent pressure on the vena cava.

209
Q

Describe the dorsal recumbent position.

A

The woman is on her back with knees flexed.

210
Q

It is a surgical incision of the perineum to prevent tearing and relieve pressure on the fetal head during birth.

A

Episiotomy (it releases pressure on the fetal head with birth)

211
Q

What instrument is used for performing an episiotomy?

A

Blunt-tipped scissors

212
Q

Why is a firm surface and side support necessary during an episiotomy?

A

To ensure stability and precision during the procedure.

213
Q

This process is known as the suturing and repair of the perineal incision made during an episiotomy, typically done during contractions.

A

Episiorrhaphy

214
Q

This is an incision made in the midline of the perineum.

A

Midline episiotomy

215
Q

This is an incision begun at the midline but directed laterally away from the rectum, which reduces the risk of rectal mucosal tears.

A

Mediolateral Episiotomy

216
Q

What does anesthesia mean?

A

The loss of sensation.

217
Q

This is a state of controlled unconsciousness where you feel nothing, often achieved by injecting medications into a vein or breathing anesthetic gases.

A

General Anesthesia (medications are injected into a vein, or anesthetic gases may be breathed into the lung)

218
Q

What does general anesthesia produce?

A

Unconsciousness

219
Q

The specialized use of local anesthetics to numb a part of the body by injecting drugs near nerve bundles, allowing the patient to stay conscious but pain-free.

A

Regional Anesthesia (Local anesthetic drugs are injected near to the bundles of nerves which carry signals from that area of the body to the brain)

220
Q

What are examples of regional anesthesia?

A

Spinal and epidural blocks.

221
Q

It numbs a small part of the body using injections, drops, sprays, or ointments, allowing the patient to stay conscious but pain-free.

A

Local Anesthesia

222
Q

This may be used before or during anesthesia to produce a “sleepy-like” state, offering additional comfort.

A

Sedation medication

223
Q

What is the difference between anesthesia and sedation during surgery?

A

Anesthesia prevents you from feeling pain, while sedation makes you drowsy and mentally relaxed during the procedure.

224
Q

Where is the epidural injection site?

A

The space at L3-L4, and a catheter may be left in place for continuous delivery.

225
Q

When is an epidural typically administered during labor?

A

During the 1st stage of labor after 5-6 cm dilation, and it may also be given during the 2nd stage.

226
Q

Can the epidural be repeated during labor?

A

Yes, repeated doses may be administered as needed.

227
Q

What are the characteristics of regional anesthesia?

A

(A) May cause hypotension
(B) Relieves pain from contractions and numbs vagina and perineum
(C) Not cause headache (dura is pentrated)

228
Q

What are the different nursing considerations for regional anesthesia?

A

(A) Monitor BP
(B) Side lying position
(C) IV fluids increase with hypotension
(D) Provide support during the block

229
Q

Where is the spinal injection site?

A

In the subarachnoid space at L3-L5.

230
Q

When is spinal anesthesia typically administered?

A

Just before the birth of the baby.

231
Q

What are the characteristics of spinal anesthesia?

A

(A) May cause hypotension.
(B) Relieves pain from contractions and numbs the vagina, perineum, and lower extremities.
(C) May cause postpartum headache.

232
Q

What are the nursing considerations for spinal anesthesia?

A

(A) Monitor BP.
(B) Place a rolled blanket under the right hip to displace the uterus from the vena cava.
(C) Increase IV fluids if hypotension occurs.
(D) Provide support during the block.

233
Q

Where is the pudendal block injection site?

A

Into the pudendal nerve through the transvaginal route.

234
Q

When is the pudendal block administered?

A

Just before the birth of the baby.

235
Q

What are the characteristics of a pudendal block?

A

(A) Relieves perineal discomfort.
(B) Numbs the area for episiotomy.

236
Q

What should the nurse do during a pudendal block?

A

Provide support during the block.

237
Q

This is characterized as the delivery of the baby through the vagina.

A

Normal Spontaneous Delivery (NSD)

238
Q

This is characterized as the delivery of the baby through an abdominal and uterine incision.

A

Caesarean Birth

239
Q

What are some common indications for caesarean birth?

A

(A) Fetal distress.
(B) Breech position.
(C) Dystocia.
(D) Cephalopelvic disproportion (CPD) –
pelvic inlet is not appropriate for
delivery of the head of the baby
(E) Prior cesarean surgery
(F) Cord prolapse
(G) Abruptio Placenta

240
Q

What are common complications of caesarean delivery?

A

(A) Infections
(B) Hemorrhage
(C) Blood clots
(D) Surgical injury to the bladder or intestines
(F) Surgical injury to the fetus

241
Q

What are obstetrical forceps used for during delivery?

A

Obstetrical forceps are double-bladed instruments designed to grasp the fetal head.

242
Q

When is a forceps delivery performed?

A

(A) To hasten delivery when the mother’s life is threatened.
(B) To shorten the 2nd stage of labor.
(C) To intervene when regional or general anesthesia has affected the woman’s ability to push.

MATERNAL AND CHILD NURSING (17 decks)

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