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NU314 OB > Nursing Managment for Labor/Birth > Flashcards

Nursing Managment for Labor/Birth Flashcards

1
Q

What should you assess for Maternal status?

A
  • Maternal vital signs
  • Review prenatal records
  • Vaginal exam
  • Evaluate pain
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2
Q

When can you not perform a vaginal exam on the mom?

A

When there is active bleeding

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3
Q

How often will a vaginal exam be performed?

A

every 4 hours

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4
Q

What is the purpose of performing a vaginal exam?

A

To assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status
And to gather info on presentation, position, station, degree of flexion, and presence of skull molding/swelling

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5
Q

What is used as lubricant for the initial vaginal exam?

A

water

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6
Q

How is the dilation and effacement assessed?

A

The width of the cervical opening determines dilation, and the length of the cervix assesses effacement

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7
Q

When the membranes rupture what should the priority focus be?

A

Assessing FHR first to identify deceleration which might indicate cord compression

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8
Q

What are signs of intrauterine infection?

A

maternal fever
fetal and maternal tachycardia
foul odor of vaginal discharge
increase in white blood cells

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9
Q

How is rupture of membranes confirmed?

A

Sample of fluid is taken via a nitrazine yellow dye swab to determine fluids pH

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10
Q

Is vaginal fluid acidic or alkaline?

A

Acidic

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11
Q

Is amniotic fluid acidic or alkaline?

A

Alkaline

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12
Q

What can cause a false-positive for a nitrazine test?

A

Women experiencing large amounts of bloody show

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13
Q

If the Nitrazine tets is inconclusive what other test may be performed to confirm rupture of membranes?

A

Fern test

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14
Q

What do the different levels of contractions feel like when palpating?

A

Mild-tip of nose
Moderate-like the chin
Strong- like the forehead

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15
Q

Leopold Maneuvers

A

method for determining the presentation, position, and lie of the fetus through the use of four specific steps

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16
Q

Maneuver 1

A

What fetal part (head or buttocks) is located in the fundus?

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17
Q

Maneuver 2

A

On which maternal side is the fetal back located

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18
Q

Where are fetal heart tones best auscultated?

A

On the back of the fetus

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19
Q

Maneuver 3

A

What is the presenting part?

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20
Q

Maneuver 4

A

Is the fetal head flexed and engaged in the pelvis?

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21
Q

When the membranes are ruptured what should the amniotic fluid look like?

A

Clear

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22
Q

Cloudy or foul smelling amniotic fluid indicates what?

A

Infection

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23
Q

What may green amniotic fluid indicate?

A

The fetus has passed meconium

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24
Q

What may cause the fetus to pass meconium before birth?

A 
Transient hypoxia
Prolonged pregnancy 
Cord compression
Intrauterine growth restriction 
Maternal hypertension/diabetes
Chorioamnionitis
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25
Q

When is the passage of meconium considered normal?

A

When fetus is in breech position

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26
Q

Analysis of FHR is one of the primary evaluation tools for what?

A

Determining fetal oxygen status directly

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27
Q

What are the guidelines for assessing FHR?

A
  • Initial 10-20 mins continuous FHR assessment on entry into labor/birth area
  • Prenatal/labor risk assessment
  • Intermittent auscultation q 30 mins for low risk and q 15 mins for high risk women during active labor
  • During second stage q 15 mins low risk and q 5 mins for high risk women during pushing stage
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28
Q

FHR Category I (Normal)

A

Does NOT require intervention

  • Baseline 110-160 bpm
  • variability moderate
  • present or absent accelerations
  • present or absent early decelerations
  • No late or variable decelerations
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29
Q

FHR Category II (Indeterminate)

A

Requires evaluation and continued surveillance

  • Fetal tachycardia >160 bpm present
  • Bradycardia < 110 bpm not accompanied by absent baseline variability
  • Absent baseline variability not accompanied by recurrent decelerations
  • Minimal or marked variability
  • Recurrent late decelerations
  • Prolonged decelerations > 2 mins but < 10
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30
Q

FHR Category III (Abnormal)

A

Requires intervention

  • Fetal bradycardia < 110 bpm
  • Recurrent late decelerations
  • Recurrent variable decelerations-declining or absent
  • Sinusoidal pattern
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31
Q

Baseline variability

A

irregular fluctuations in the baseline FHR, which is measured as the amplitude of the peak to trough in bpm

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32
Q

What is the most common cause of fetal death that could’ve been prevented?

A

Fetal Hypoxia

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33
Q

Continuous Electronic Fetal Monitoring

A

-Uses a machine to produce a continuous tracing of the FHR

Produce a graphic record of the FHR pattern

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34
Q

What are the primary objectives of Electronic Fetal Monitoring?

A
  • Provide info about fetal oxygenation and prevent fetal injury from impaired oxygenation
  • Detect FHR changes early before they are prolonged and profound
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35
Q

What is the criteria for using continuous Internal monitoring of FHR?

A
  • Ruptured membranes
  • Cervical dilation of at least 2 cm
  • Present fetal part low enough to allow placement of scalp electrode
  • Skilled practitioner available to insert
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36
Q

What are the 4 Categories of Baseline Variability?

A

Absent
Minimal
Moderate
Marked

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37
Q

Absent

A

fluctuation range undetectable

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38
Q

Minimal

A

Fluctuation range observed at < 5 bpm

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39
Q

Moderate (Normal)

A

fluctuation range from 6-25 bpm

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40
Q

Marked

A

Fluctuation range >25 bpm

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41
Q

What is the average FHR?

A

110-160 bpm

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42
Q

Fetal Bradycardia

A

occurs when FHR is below 110 bpm and lasts 10 minutes or longer

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43
Q

What may cause fetal bradycardia?

A 
Fetal hypoxia
Prolonged maternal hypoglycemia 
Fetal acidosis 
Analgesic drugs for mom
Anesthetic agents for mom
Maternal hypotension 
Fetal hypothermia 
Prolonged umbilical cord compression
Fetal congenital heart block
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44
Q

Fetal Tachycardia

A

baseline FHR > 160 bpm that lasts for 10 minutes or longer

45
Q

What can fetal tachycardia represent?

A

Early compensatory response to asphyxia

46
Q

What are other causes of fetal tachycardia?

A 
Fetal hypoxia
Maternal fever
Maternal dehydration
Amnionitis 
Drugs 
Maternal hyperthyroidism 
Maternal anxiety 
Fetal anemia 
Prematurity 
Fetal infection
Chronic hypoxemia 
Congenital anomalies 
Fetal heart failure/arrhythmias
47
Q

V C
E H
A O
L P

A

V-variability C-cord compression
E-early H-head compression
A-acceleration O-okay
L-late P-placental insufficiency

48
Q

What category would a Sinusoidal Pattern FHR be considered?

A

Category 3

49
Q

Sinusoidal Pattern

A

Smooth, sinewave-like undulating pattern
Cycle frequency of 3-5 bpm that persists > 20 mins
Severe hypoxia secondary to fetal anemia/hypovolemia

50
Q

Decelerations

A

transient fall in FHR caused by stimulation of the parasympathetic nervous system

51
Q

What are the classifications of decelerations?

A

Early
Late
Variable
Prolonged

52
Q

Early Decelerations

A

Characterized by a gradual decrease in FHR in which the lowest point occurs at the peak of the contraction
-Do NOT indicate fetal distress and do NOT require intervention

53
Q

Late Decelerations

A

decreases in FHR that occur after the peak of the contraction
-FHR does NOT return to baseline until well after contraction ends

54
Q

Variable Decelerations

A

decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions

55
Q

Variable decelerations are usually associated with what?

A

cord compression

56
Q

Prolonged Decelerations

A

abrupt FHR declines of at least 15 bpm that last longer than 2 minutes, but less than 10 minutes
-usually drops to < 90 bpm

57
Q

Pain is considered what type of experience?

A

universal experience

58
Q

What are some NON-pharmacological measures for pain management?

A
  • Continuous support
  • Hydrotherapy
  • Ambulation/position changes
  • Acupuncture/acupressure
  • Attention focusing/imagery
  • Therapeutic touch/massage/effleurage
  • Breathing techniques
59
Q

What non-pharmacological measure can be done during the first stage of labor to reduce its length?

A

walking and upright positions

60
Q

Effleurage

A

light, stroking superficial touch of the abdomen, in rhythm with breathing during contractions

61
Q

What pharmacological measures can help with pain?

A

Systemic analgesia
Regional/Local anesthesia
Neuraxial analgesia/anesthesia techniques

62
Q

Neuraxial analgesia/anesthesia techniques

A

use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space

  • does NOT interfere with progress of labor
  • allows woman to be active participant
63
Q

Systemic Analgesia

A

use of one or more drugs administered orally, intramuscularly, or intravenously; they become distributed through out the body via the circulatory system

64
Q

What type of drugs may be used for systemic analgesia?

A

Opioids
Ataractics/Antiemetics
Benzodiazepines

65
Q

Opioids

A

Moderate-Severe pain

  • butorphanol (Stadol)
  • Nalbuphine (Nubain)
  • Meperidine (Demerol)
  • Morphine
  • Fentanyl
66
Q

Antiemetics

A

Combo w/ opioids to reduce nausea, vomiting, and anxiety

  • Hydroxyzine (Vistaril)
  • Promethazine (Phenergan)
  • Prochlorperazine (Compazine)
67
Q

Benzodiazepines

A

Minor tranquilizing and sedative effects; or to stop seizures

  • Diazepam (Valium)
  • Midazolam (Versed)
  • Lorazepam (Ativan)
68
Q

Types of Regional Analgesia/Anesthesia

A
  • Epidural block
  • Combined spinal-epidural block (walking epidural)
  • Patient controlled epidural
  • Local infiltration
  • Pudendal block
  • Intrathecal (spinal) analgesia/anesthesia
69
Q

Epidural Block

A

continuous infusion or intermittent injection; usually started when dilation > 5 cm

70
Q

Combined Spinal-Epidural Block

A

“Walking Epidural”

inserting epidural needle into the epidural space and inserting small needle into subarachnoid space

71
Q

Patient Controlled Epidural

A

use of indwelling epidural catheter with an infusion of medication and a programmed pump that allows the woman to control dosing

72
Q

Local Infiltration

A

injection of local anesthetic into the superficial perineal nerves to numb perineal area
-Before performing episiotomy

73
Q

Pudendal Nerve Block

A

injection of local anesthetic into pudendal nerves near ischial spine
-second stage of labor, episiotomy, operative vaginal birth

74
Q

Intrathecal (spinal) Analgesia/Anesthesia

A

injection with or without opioids into the subarachnoid space to provide pain relief
-elective and emergent cesarean births

75
Q

What is general anesthesia typically reserved for?

A

Emergency cesarean births or woman with contraindications of use of regional anesthesia

76
Q

How can General Anesthesia be administered?

A

IV injection, inhalation, or both

77
Q

What is the common process for general anesthesia?

A
  • First thiopental IV to produce unconsciousness
  • Next muscle relaxant
  • Intubation, followed by nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia
78
Q

First Stage of Labor: Phone Assessment

A
  • Estimated date of birth
  • Fetal movement frequency
  • Other premonitory signs of labor
  • Parity, gravida, and previous childbirth experiences
  • Time frame in previous labors
  • Characteristics of contractions
  • Bloody show/membrane status
  • Presence of support
79
Q

What general measures will be taken during the first stage of labor?

A
  • Admission history
  • Results of routine lab tests and any special tests
  • Ask about childbirth plan
  • Complete physical assessment
  • Initial contact by phone or in person
80
Q

Maternal Physical Assessment upon admission

A

-Vitals, heart/lung sounds, height/weight
-Fundal height measurement
-Uterine activity: contraction frequency, duration, and intensity
-Status of membranes
-Cervical dilation/effacement
FHR, position, station
-Pain level

81
Q

What lab tests are typically done upon admission in the first stage?

A
  • Urinalysis
  • CBC
  • Syphilis screen, HbsAg screen, GBS, HIV, possible drug screen if not included in prenatal history
  • Psychological status
82
Q

How often is the moms temperature taken during the first stage of labor?

83
Q

How often is the moms temperature taken after ROM?

84
Q

How often are BP, pulse, and respirations taken during the latent phase of labor?

A

every hour

85
Q

How often are BP, pulse, and respirations taken during the active and transition phases of labor?

A

q 30 minutes

86
Q

How often are uterine contractions monitored during the latent phase?

A

q 30-60 minutes

87
Q

How often are uterine contractions monitored during the active phase?

A

15-30 minutes

88
Q

How often are uterine contractions measured during the transition phase?

A

q 15 minutes

89
Q

How often should the FHR be assessed during the latent phase?

A

q 30-60 minutes

90
Q

How often should FHR be assessed during active phase?

A

q 15-30 minutes

91
Q

You should also assess the FHR before doing what?

A

ambulation
before any procedure
before administering analgesia or anesthesia to mom

92
Q

First Degree Laceration

A

extends through the skin

93
Q

Second Degree Laceration

A

extends through the muscles of the perineal body

94
Q

Third Degree Laceration

A

Continues through the anal sphincter muscle

95
Q

Fourth Degree Laceration

A

through the anal sphincter and the anterior rectal wall

96
Q

Nursing Interventions Second Stage during Labor

A
  • support woman and partner in active decision making
  • support involuntary bearing-down efforts
  • provide instructions, assistance, and pain relief
  • Maternal positions to enhance descent and reduce pain
  • prepare for assisting with delivery
97
Q

Nursing Interventions with Birth

A
  • Cleansing of perineal/vulva area
  • Assisting w/ birth, suctioning newborn, umbilical cord clamping
  • Providing immediate care of newborn
98
Q

What are the 5 parameters of an APGAR score?

A
  • heart rate
  • respiratory effort
  • muscle tone
  • response to stimulus
  • color
99
Q

How are the parameters of the APGAR score arranged?

A

From most important (HR) to least important (color)

100
Q

What is considered immediate care for the newborn?

A

Drying
APGAR score
Identification

101
Q

Assessment during Third Stage of Labor

A
  • Monitoring placental seperation
  • Examining placental and fetal membranes
  • Assessing for perineal trauma
  • Inspecting condition of episiotomy
  • Assess for perineal lacerations
102
Q

Nursing Interventions during Third Stage

A
  • Instructing when to push when signs of separation are apparent
  • Giving oxytocin if ordered
  • providing warmth
  • ice to perineum if episiotomy performed
  • monitor mom’s physical status
  • record birth statistics
  • document birth in birth book
103
Q

What does assessment during the Fourth Stage involve?

A 
Vital signs
Fundus
Perineal area
Comfort level
Lochia
Bladder status
104
Q

During the first hour after birth how often are vitals taken?

A

q 15 minutes then q 30 minutes for the next hour if needed

105
Q

A decrease in the mom’s blood pressure after birth may indicate what?

A

Uterine hemorrhage

106
Q

An increase in mom’s blood pressure after birth may indicate what?

A

Preeclampsia

107
Q

How often should fundal height, position, and firmness be assessed after birth?

A

q 15 minutes during the first hour

108
Q

Nursing Interventions Fourth Stage

A
  • Support and info
  • Fundal checks; perineal care and hygiene
  • Bladder status and voiding
  • Comfort measures
  • Parent-newborn attachment
  • Teaching

NU314 OB (21 decks)

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