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Maternal Newborn - Cher > Test 2 - Nursing Care during delivery PPT > Flashcards

Test 2 - Nursing Care during delivery PPT Flashcards

1
Q

If the fetus is at the ischial spines what station is that?

A

zero

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2
Q

If the fetus is not past pelvic bone and ballottement occurs what station is that?

A

-3

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3
Q

If the fetus is engaged and ballottement does not occur what station is that?

A

+3

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4
Q

Term for the degree of descent presenting above of below the ischial spines?

A

Fetal Station

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5
Q

When the head is no longer moving in and out when the mom is pushing is is considered: ________

A

Engaged

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6
Q

3 descriptors of Lochia:

A

Rubra
Serosa
Alba

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7
Q

The type of lochia seen immediately after birth and for about 3 days following?

A

Rubra

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8
Q

The type of lochia that becomes pink or brown after 3-4 days?

A

Serosa

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9
Q

The type of lochia 10-14 days after birth when the drainage becomes yellow to white?

A

Alba

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10
Q

When does “lightening” occur?

A

2-3 weeks before onset of labor

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11
Q 
-Uterine contractions:
feels like tip of nose
-Uterine contractions:
feels like chin
-Uterine contractions:
 feels like forehead
A

Mild
Moderate
Strong

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12
Q

What do you do if you do not have a resting tone between contractions?

A

Stop Pitocin

Give Fluids

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13
Q

Explain Leopold’s Maneuver Box 19-5 pg 441

A
  1. palpate fundus (fetal part) 2. determine fetal back
  2. fetal presenting part
  3. cephalic prominence, ID attitude of head
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14
Q

nitrazine test:

If there is fluid to be found the strip will turn:
If only urine, the strip will turn:

A

used to detect the presence of amniotic fluid in vaginal secretions.
Blue

Yellow

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15
Q

With ROM immediately check ____ for ___?

A

FHR

change in variability

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16
Q

The longer the membranes are ruptured, the greater risk for____?

A

Infection!

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17
Q

After rupture of membranes temp is checked q ___ hours

A

2

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18
Q

If membranes are ruptured what is woman given after 24 hours?

A

prophylactic antibiotics

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19
Q

What do we do less of after rupture of membranes?

A

Sterile vag exam

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20
Q

What is the word for artificial rupture of membranes?

A

amniotomy

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21
Q

Normal amniotic fluid looks like:

A 
Pale
straw colored
flecks of vernix caseosa
Scalp hair
Characteristic Odor
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22
Q

Amniotic fluid that is another color means:
Green/brown:
Dark yellow stained:
Port Wine Color:

Thick, cloudy, foul odor:

A
  • Meconium
  • infection
  • Bleeding, possible abruption, premature separation of the placenta

-infection

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23
Q

Begins with onset of regular uterine contractions cervical effacement and dilation
Ends with cervix 100% effaced and dilated to 10 cm.

A

First Stage of Labor

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24
Q

Three Phases of first stage of labor:

A

Latent phase: up to 3 cm of dilation
Active phase: 4 to 7 cm of dilation
Transition phase: 8 to 10 cm of dilation

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25
Q 
Nursing care in latent phase of first stage of labor =
BP/HR/RR:
Temp: 
UC:
FHR
A
  • BP/HR/RR q 1 h
  • Temp q 4h, q 1-2 h after ROM
  • q 30 min (low) q 15 min (hi)
  • FHR sontinuous or q 1 h low risk
26
Q

Word for gentle stroking of abdomen by pregnant mom:

A

effleurrage

27
Q 
Nursing care in active phase of first stage of labor =
BP/HR/RR:
Temp: 
UC:
FHR
A

q 30 min
q 30 min
If regular epidural allowed

28
Q 
Transition phase of labor:
Cervix:
UC freq:
UC dur:
UC intensity:
Station:
Urge to:
A 
8-10
q2-3  min
45-90 sec
strong
\+2 - +3
push
29
Q

Nursing care in transition phase of first stage of labor Assist with:

Encourage not to:

A

Breathing, voiding, informing and stay with client

Push yet

30
Q

Only certain sign that the second stage of labor has begun is the inability to feel the ________ during vaginal examination, indicating that it is completely ______ and ________.

A

cervix
dilated
effaced

31
Q

3 phases of second stage of labor:

A

Latent
Descent
Transition

32
Q

Which phase of stage 2 is this:

Calm with passive descent of baby through birth canal (laboring down)

A

Latent

33
Q

Which phase of stage 2 is this:

Active pushing and urges to bear down (Ferguson reflex )

A

Descent

34
Q

Which phase of stage 2 is this:

Presenting part is on perineum, and bearing-down efforts effective for promoting birth

A

Transition

35
Q

Nursing actions during second stage of labor:

A
  • Position for pushing efforts widen
  • Assess FHR with each UC
  • Assess UC for duration/ relaxation phase (at least 30 seconds)
  • Administer any meds during UC so amount to fetus minimized
  • Monitor VS p maintenance dose of analgesic
36
Q

If there is a hypotensive episode after analgesia what do we do:

A
  • Turn off Pitocin (if infusing)
  • Increase Primary IV fluids
  • O2 by Mask
  • Elevate client’s legs slightly (10-20*)
  • Turn client to lateral position
  • Notify physician and/or anesthesia personnel
  • Be prepared: ephedrine may be ordered
  • Remain with client
37
Q

What do you do for maternal hyperventilation?

A
  1. Teach cupped hands breathing or breath into paper bag or slow open glottis breathing
  2. Demonstrate breathing for several UC to establish rate/rhythm
38
Q

When the widest part of the baby’s head distends the vulva just before birth it is called:

A

crowning

39
Q

Term for vagina that has been cut through the rectal wall.

A

episiproc

40
Q

Laceration that affects the epidermis:

A

1st degree

41
Q

Laceration that affects the epidermis and muscle

A

2nd degree

42
Q

Laceration that Extends into rectal sphincter

A

3rd degree

43
Q

Laceration that extends through rectal mucosa

A

4th degree

44
Q

A perineal incision to enlarge the vagina:

A

Episiotomy

45
Q

Type of episiotomy that is 1-2 cm incision straight from vagina toward the rectum

Type of episiotomy that is
4-5 cm. incision left or right

A

Midline

Mediolateral

46
Q

What happens in the 3rd stage of labor?

A
  1. Placental separation and expulsion
  2. Fundus firmly contracting
  3. Change in shape of uterus to globular
  4. Gush of dark blood from introitus
  5. Apparent lengthening of umbilical cord
47
Q

Fetal Assessment:

Pulse –_____ to ____ (may be irregular)
Respirations – ___ to ___
Temp - > ___._
Umbilical Cord – ___ vessels

A

110 - 160
30-60
97.7
3

48
Q

What does APGAR stand for?

A 
Appearance
Pulse
Grimace
Activity
Respirations
49
Q

What is stage 4?

A

Recovery

50
Q

Nursing care during stage 4:

Monitor q 15 minutes first hour past birth:

A 
Fundus 
Lochia 
Perineum 
PAR record
Breastfeeding and Bonding
51
Q

Where should fundus be after birth? How should it feel?

A

Firm, midline and halfway between umbilicus and symphysis pubis

52
Q

What should lochia be after birth?

A

color rubra; No large clots

53
Q

How do we assess perimeum after birth?

A

REEDA system

54
Q

What is monitored as a part of PAR?

A

activity, respirations, blood pressure, LOC, color (Mother)

O2 sats if had general anesthesia

55
Q

What could you do if you were in a situation outside a hospital with an emergency birth and needed to get the uterus to contract after the birth?

A

Stimulate nipple

56
Q

Nurse assumes legal responsibility for:
Assessing -
Keeping -

FHR and pattern
fetal response to

A
  • progress of labor
  • primary health care provider informed about progress in labor and deviations from expected findings
  • stress of labor
57
Q

_______-______ amniotic fluid may be indicative of fetal distress associated with hypoxia

A

Meconium stained

58
Q

Assessment of laboring woman’s urinary output and bladder is critical to ensure _______ of labor and to prevent ______to bladder

A
  • progress

- injury

59
Q

When responding to rhythmic nature of second stage of labor, woman normally:

A
  • Changes body positions
  • Bears down spontaneously
  • Vocalizes (open-glottis pushing) when she perceives urge to push (Ferguson reflex)
60
Q

Closed glottis pushing should be avoided because:

A

oxygen transport to fetus will be inhibited

Maternal Newborn - Cher (6 decks)

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