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Maternal-Newborn (Josh) > T2 - Nursing Care of Family (Josh) > Flashcards

T2 - Nursing Care of Family (Josh) Flashcards

1
Q

When does lightening occur?

A

2-3 wks before onset of labor

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2
Q

Signs of impending labor?

A

Lightening

Braxton Hicks

Ripening of cervix

Expulsion of mucous plug

Bloody show

Energy Surge

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3
Q

Which type of contractions are felt in the back and above the umbilicus?

A

False UC

***true start in back and radiate to lower abdomen

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4
Q

Palpating UC:

  • Mild =
  • Moderate =
  • Strong =
A

Mild = nose

Moderate = chin

Strong = forehead

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5
Q

If there is no Resting Tone, what should we do?

A

Stop Pitocin

Increase Fluids

Give Terbutaline

***resting tone is important b/c it is time when placenta perfuses

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6
Q

What three questions does Leopold’s Maneuvers answer?

A

1) What fetal part is in the fundus?
2) Where is the fetal back located?
3) What is presenting fetal part?

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7
Q

After ROM or membranes, how often should we measure TEMP?

A

q 1-2 hr

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8
Q

What is the risk for membranes ruptured longer than 24 hrs?

A

infection

***prophylactic antibiotics

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9
Q

Abnormal AF:

What does Greenish Brown Color indicate?

A

meconium

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10
Q

Abnormal AF:

What does Yellow, Stained color indicate?

A

breech presentation (sign of pressure on fetal abdomine during descent)

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11
Q

Abnormal AF:

What does Port Wine color indicate?

A

bleeding, possible abruption, premature separation of placenta

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12
Q

Abnormal AF:

What does thick, cloudy, foul odor indicate?

A

intrauterine infection

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13
Q

What color would normal AF look?

A

pale or straw colored

  • with flecks of vernix caseosa, lanugo, and scalp hair
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14
Q

When does First Stage begin?

End?

A

onset of regular UC

100% effaced and 10 cm

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15
Q

How often are vitals taken during Latent Phase of First Stage?

A

q 1 hr

***Temp q4hr if membranes intact and q 1-2 hr after ROM

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16
Q

During Latent Phase, how often are UC?

A

q 30 mins for low risk

q 15 mins for high risk

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17
Q

How often should VS be taken during Active Phase of First Stage?

A

q 30 mins for low risk

q 15 mins for high risk

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18
Q

When can the epidural be given?

A

when UC pattern is established and cervis is 5 cm

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19
Q

Why should we encourage voiding?

A

full bladder can impede labor progress and result in trauma to bladder

20
Q

During Active Phase, what is the frequency of UC?

A

q 2-3 mins

***duration is 45-90 secs

21
Q

What is fetal station during Transition phase?

A

+2 to +3

22
Q

Nursing Care during Transition Phase?

A

Assist w/ breathing

Encourage to rest b/t UC

Encourage voiding

23
Q

What is the only CERTAIN sign that the Second Stage of Labor has began?

A

inability to feel the cervix during vaginal exam (indicating it is completely dilated and effaced)

24
Q

How long should duration of each UC be during Second Stage?

A

90 secs max w/ at least 30 secs of rest for perfusion

25
Q

What symptoms should alert us to Maternal Alkalosis?

A

hyperventilation

syncope

vertigo

***breathe in cupped hands

26
Q

What is Crowning?

A

perineum bulges and thins as fetal presenting part presses downward onto perneum

***head should stay, not slide back in

27
Q

How is an Epesiotomy measured?

How is a Laseration measured?

A

location: midline, right, left
degrees: 1st - 4th

28
Q

Perineal Lacerations:

1st Degree =
2nd Degree =
3rd Degree =
4th Degree =

A

1st Degree = epidermis

2nd Degree = epidermis and muscle

3rd Degree = extends into rectal sphincter

4th Degree = extends through rectal mucosa

29
Q

Should we pull on cord?

A

no, let it come to you

30
Q

What should we administer post delivery?

A

Pitocin

  • causes uterus to clamp down to expel everything out
31
Q

What is normal FHR?

A

110-160

32
Q

What is normal Fetal Resp?

A

30 - 60

33
Q

What is normal Fetal Temp?

A

97.7

34
Q

What is measured w/ APGAR?

A 
Appearance
Pulse
Grimace/Cry
Activity (Tone/Motion)
Respirations (good, strong cry)
35
Q

At 1 minute, should a baby get an APGAR of 10?

A

no, because they will not be totally pink due to blood flow to outer extremities

36
Q

APGAR Score:

Appearace

A

Blue/Pale = 0

Body Pink/Extremities Blue = 1

Completely Pink = 2

37
Q

APGAR Score:

Pulse

A

Absent = 0

100 = 2

38
Q

APGAR Score:

Grimace

A

No Response = 0

Grimace = 1

Cry = 2

39
Q

APGAR Score:

Activity

A

Flaccid = 0

Some flexion of extremities = 1

Well Flexed = 2

40
Q

APGAR Score:

Respirations

A

Absent = 0

Slow, weak cry = 1

Good cry = 2

41
Q

During Recovery Stage, which time is most critical regarding hemorrhage?

A

1st hr

***Monitor q 15 mins

42
Q

Where should the Fundus be during Recovery Stage

A

firm, midline, and halfway b/t umbilicus and symphysis pubis

43
Q

What should Lochia look like during Recovery Stage?

A

rubra (bright red) w/ NO large clots

44
Q

What does REEDA stand for in regards to the Recovery Stage?

A 
Redness
Edema
Ecchymosis
Discharge
Approximation

***Used to evaluate the perineum

45
Q

During Latent Phase of Stage 1, what is best place for mom to be?

A

home

***stay home as long as possible

46
Q

Which type of pushing should be avoided?

A

closed-glottis pushing

***inhibits O2 transport to fetus

Maternal-Newborn (Josh) (29 decks)

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