T2 - Nursing Care of Family (Josh)

Question 1

When does lightening occur?

Answer 1

2-3 wks before onset of labor

Question 2

Signs of impending labor?

Answer 2

Lightening

Braxton Hicks

Ripening of cervix

Expulsion of mucous plug

Bloody show

Energy Surge

Question 3

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

Answer 3

False UC

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

Question 4

Palpating UC:

• Mild =
• Moderate =
• Strong =

Answer 4

Mild = nose

Moderate = chin

Strong = forehead

Question 5

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

Answer 5

Stop Pitocin

Increase Fluids

Give Terbutaline

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

Question 6

What three questions does Leopold’s Maneuvers answer?

Answer 6

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

Question 7

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

Answer 7

q 1-2 hr

Question 8

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

Answer 8

infection

***prophylactic antibiotics

Question 9

Abnormal AF:

What does Greenish Brown Color indicate?

Answer 9

meconium

Question 10

Abnormal AF:

What does Yellow, Stained color indicate?

Answer 10

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

Question 11

Abnormal AF:

What does Port Wine color indicate?

Answer 11

bleeding, possible abruption, premature separation of placenta

Question 12

Abnormal AF:

What does thick, cloudy, foul odor indicate?

Answer 12

intrauterine infection

Question 13

What color would normal AF look?

Answer 13

pale or straw colored

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

Question 14

When does First Stage begin?

End?

Answer 14

onset of regular UC

100% effaced and 10 cm

Question 15

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

Answer 15

q 1 hr

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

Question 16

During Latent Phase, how often are UC?

Answer 16

q 30 mins for low risk

q 15 mins for high risk

Question 17

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

Answer 17

q 30 mins for low risk

q 15 mins for high risk

Question 18

When can the epidural be given?

Answer 18

when UC pattern is established and cervis is 5 cm

Question 19

Why should we encourage voiding?

Answer 19

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

Question 20

During Active Phase, what is the frequency of UC?

Answer 20

q 2-3 mins

***duration is 45-90 secs

Question 21

What is fetal station during Transition phase?

Answer 21

+2 to +3

Question 22

Nursing Care during Transition Phase?

Answer 22

Assist w/ breathing

Encourage to rest b/t UC

Encourage voiding

Question 23

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

Answer 23

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

Question 24

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

Answer 24

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

Question 25

What symptoms should alert us to Maternal Alkalosis?

Answer 25

hyperventilation syncope vertigo ***breathe in cupped hands

Question 26

What is Crowning?

Answer 26

perineum bulges and thins as fetal presenting part presses downward onto perneum ***head should stay, not slide back in

Question 27

How is an Epesiotomy measured? How is a Laseration measured?

Answer 27

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

Question 28

Perineal Lacerations: 1st Degree = 2nd Degree = 3rd Degree = 4th Degree =

Answer 28

1st Degree = epidermis 2nd Degree = epidermis and muscle 3rd Degree = extends into rectal sphincter 4th Degree = extends through rectal mucosa

Question 29

Should we pull on cord?

Answer 29

no, let it come to you

Question 30

What should we administer post delivery?

Answer 30

Pitocin - causes uterus to clamp down to expel everything out

Question 31

What is normal FHR?

Answer 31

110-160

Question 32

What is normal Fetal Resp?

Answer 32

30 - 60

Question 33

What is normal Fetal Temp?

Answer 33

97.7

Question 34

What is measured w/ APGAR?

Answer 34

``` Appearance Pulse Grimace/Cry Activity (Tone/Motion) Respirations (good, strong cry) ```

Question 35

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

Answer 35

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

Question 36

APGAR Score: Appearace

Answer 36

Blue/Pale = 0 Body Pink/Extremities Blue = 1 Completely Pink = 2

Question 37

APGAR Score: Pulse

Answer 37

Absent = 0 100 = 2

Question 38

APGAR Score: Grimace

Answer 38

No Response = 0 Grimace = 1 Cry = 2

Question 39

APGAR Score: Activity

Answer 39

Flaccid = 0 Some flexion of extremities = 1 Well Flexed = 2

Question 40

APGAR Score: Respirations

Answer 40

Absent = 0 Slow, weak cry = 1 Good cry = 2

Question 41

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

Answer 41

1st hr ***Monitor q 15 mins

Question 42

Where should the Fundus be during Recovery Stage

Answer 42

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

Question 43

What should Lochia look like during Recovery Stage?

Answer 43

rubra (bright red) w/ NO large clots

Question 44

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

Answer 44

``` Redness Edema Ecchymosis Discharge Approximation ``` ***Used to evaluate the perineum

Question 45

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

Answer 45

home ***stay home as long as possible

Question 46

Which type of pushing should be avoided?

Answer 46

closed-glottis pushing ***inhibits O2 transport to fetus