T2 - Nursing Care of Family (Josh) Flashcards
When does lightening occur?
2-3 wks before onset of labor
Signs of impending labor?
Lightening
Braxton Hicks
Ripening of cervix
Expulsion of mucous plug
Bloody show
Energy Surge
Which type of contractions are felt in the back and above the umbilicus?
False UC
***true start in back and radiate to lower abdomen
Palpating UC:
- Mild =
- Moderate =
- Strong =
Mild = nose
Moderate = chin
Strong = forehead
If there is no Resting Tone, what should we do?
Stop Pitocin
Increase Fluids
Give Terbutaline
***resting tone is important b/c it is time when placenta perfuses
What three questions does Leopold’s Maneuvers answer?
1) What fetal part is in the fundus?
2) Where is the fetal back located?
3) What is presenting fetal part?
After ROM or membranes, how often should we measure TEMP?
q 1-2 hr
What is the risk for membranes ruptured longer than 24 hrs?
infection
***prophylactic antibiotics
Abnormal AF:
What does Greenish Brown Color indicate?
meconium
Abnormal AF:
What does Yellow, Stained color indicate?
breech presentation (sign of pressure on fetal abdomine during descent)
Abnormal AF:
What does Port Wine color indicate?
bleeding, possible abruption, premature separation of placenta
Abnormal AF:
What does thick, cloudy, foul odor indicate?
intrauterine infection
What color would normal AF look?
pale or straw colored
- with flecks of vernix caseosa, lanugo, and scalp hair
When does First Stage begin?
End?
onset of regular UC
100% effaced and 10 cm
How often are vitals taken during Latent Phase of First Stage?
q 1 hr
***Temp q4hr if membranes intact and q 1-2 hr after ROM
During Latent Phase, how often are UC?
q 30 mins for low risk
q 15 mins for high risk
How often should VS be taken during Active Phase of First Stage?
q 30 mins for low risk
q 15 mins for high risk
When can the epidural be given?
when UC pattern is established and cervis is 5 cm
Why should we encourage voiding?
full bladder can impede labor progress and result in trauma to bladder
During Active Phase, what is the frequency of UC?
q 2-3 mins
***duration is 45-90 secs
What is fetal station during Transition phase?
+2 to +3
Nursing Care during Transition Phase?
Assist w/ breathing
Encourage to rest b/t UC
Encourage voiding
What is the only CERTAIN sign that the Second Stage of Labor has began?
inability to feel the cervix during vaginal exam (indicating it is completely dilated and effaced)
How long should duration of each UC be during Second Stage?
90 secs max w/ at least 30 secs of rest for perfusion
What symptoms should alert us to Maternal Alkalosis?
hyperventilation
syncope
vertigo
***breathe in cupped hands
What is Crowning?
perineum bulges and thins as fetal presenting part presses downward onto perneum
***head should stay, not slide back in
How is an Epesiotomy measured?
How is a Laseration measured?
location: midline, right, left
degrees: 1st - 4th
Perineal Lacerations:
1st Degree =
2nd Degree =
3rd Degree =
4th Degree =
1st Degree = epidermis
2nd Degree = epidermis and muscle
3rd Degree = extends into rectal sphincter
4th Degree = extends through rectal mucosa
Should we pull on cord?
no, let it come to you
What should we administer post delivery?
Pitocin
- causes uterus to clamp down to expel everything out
What is normal FHR?
110-160
What is normal Fetal Resp?
30 - 60
What is normal Fetal Temp?
97.7
What is measured w/ APGAR?
Appearance Pulse Grimace/Cry Activity (Tone/Motion) Respirations (good, strong cry)
At 1 minute, should a baby get an APGAR of 10?
no, because they will not be totally pink due to blood flow to outer extremities
APGAR Score:
Appearace
Blue/Pale = 0
Body Pink/Extremities Blue = 1
Completely Pink = 2
APGAR Score:
Pulse
Absent = 0
100 = 2
APGAR Score:
Grimace
No Response = 0
Grimace = 1
Cry = 2
APGAR Score:
Activity
Flaccid = 0
Some flexion of extremities = 1
Well Flexed = 2
APGAR Score:
Respirations
Absent = 0
Slow, weak cry = 1
Good cry = 2
During Recovery Stage, which time is most critical regarding hemorrhage?
1st hr
***Monitor q 15 mins
Where should the Fundus be during Recovery Stage
firm, midline, and halfway b/t umbilicus and symphysis pubis
What should Lochia look like during Recovery Stage?
rubra (bright red) w/ NO large clots
What does REEDA stand for in regards to the Recovery Stage?
Redness Edema Ecchymosis Discharge Approximation
***Used to evaluate the perineum
During Latent Phase of Stage 1, what is best place for mom to be?
home
***stay home as long as possible
Which type of pushing should be avoided?
closed-glottis pushing
***inhibits O2 transport to fetus
