Nursing Actions Flashcards
Requirements for internal fetal monitoring device
ROM + at least 2 cm dilated
Nursing for decelerations
8-10 L/min O2 mask
Repositioning to side
Increase IV rate
Notify MD
Start planning for delivery
Also: amnioinfusion, stimulation (scratching head)
REMEMBER: POISON
Position
Oxytocin OFF
IV
Sterile vaginal exam
O2
Notify
For cord prolapse…
Call for help
Elevate presenting part off cord
Reposition to Trandelenburg or knee chest
Edu and emotional support
Call MD
Prepare for delivery - call charge, OR, NICU
Also: tocolytic agent terbutaline
REMEMBER: CORD
Call for help
Organize delivery
Relieve pressure
Deliver
For hypotension from epidural
Lateral position
Increase IV
O2 10 L mask
Notify MD and anesthesiologist
Monitor BP and FHR
IV vasopressor (ephedrine)
Nursing for epidural
Monitor VS and FHR
Pain assessments
Monitor bladder distention (straight cath?)
Encourage position changes
(Also make sure no iodine allergy)
Also: 1 L LR prior to prevent hypotension
“BURP” comfort measures for labor
Breathe
Urinate
Relax
Position
“BRAIN” thoughts when choosing methods for delivery
Benefits
Risks
Alternatives
Intuition
No, not now
“Caring” actions for mom
Hydrate (clear liquids)
Voiding
Bowel elimination
Ambulating
Positioning
Supportive, encouraging
Edu for sex postpartum
Safe when Lochia alba
Wait 6 weeks post CS
Dry vag due to low estrogen
Decrease intensity for 3 months to a year
Orgasm may stimulate let down reflex (milk squirting)
Timeframe for Rhogam
On week 28
Within 72 hours postpartum
Shots to give mom postpartum
MMR
Tdap
Flu
Rhogam
Action for PPH
Lower HOB
Massage fundus
Increase IV
Empty bladder
Administer oxytocic and prostaglandin drugs
Notify MD if severe
Nursing for hyperbilirubin
Monitor temp
Hydrate
Monitor stools
Sufficient feedings
Breastfeed in first hour of life
PUBS IUT is for…
Transfusing RBC into anemic fetus (possibly a side effect of the Rh antibodies in mom)
5 S’s to calm baby
Swaddle
Suck
Sway
Side or stomach lie
Shush and white nose
