Nursing Care During Stages of Labor Ch. 14 ATI

Question 1

First stage of labor characteristics and two phases

Answer 1

Beginning of dilation and contractions. Starts as irregular. Progresses to regular. Starts at 0 cm and progresses to 10 + fully effaced. Latent and active.

Question 2

Second stage of labor characteristics and two phases

Answer 2

Full cervical dilation and complete effacement at start. Latent is period of rest and relative calm while the fetus descends passively. Active is the pushing and giving birth.

Question 3

Third stage of labor characteristics and what to assess

Answer 3

Placental delivery. Assess for signs of separation and overall health of placenta

Question 4

Fourth stage of labor characteristics and what to assess

Answer 4

Afterbirth, recovery for 2 hours. Monitor vitals of mom + baby

Question 5

Stage 1 perineal laceration

Answer 5

Skin but no muscle

Question 6

Stage 2 perineal laceration

Answer 6

Skin and muscle but not anal sphincter

Question 7

Stage 3 perineal laceration

Answer 7

Skin, muscle, perineum, external anal sphincter

Question 8

Stage 4 perineal laceration

Answer 8

Everything including anterior rectal wall

Question 9

What indicates crowning is occuring

Answer 9

Vagina will bulge as baby’s head starts to appear.

Question 10

What is the single most important indicator of labor progression

Answer 10

Cervical dilation

Question 11

What do you need to monitor upon patient arrival?

Answer 11

Labs, vitals, FHR, status of amniotic membranes

Question 12

When should you avoid vaginal examinations

Answer 12

If vaginal bleeding is present until placenta previa or abruptio placenta is ruled out

Question 13

What color should nitrazine paper turn and what is the pH

Answer 13

Blue, 6.5 - 7.5

Question 14

Why should patients void frequently even if they don’t have an urge

Answer 14

Distended bladder reduces pelvic space needed for birth