Test #3 Flashcards
What items do you need to know at an Intrapartum assessment?
Weight
Medical Hx
OB history
Allergies- Meds and Food
Date of last period (Due Date)
Blood Type
Substance Abuse - Smoking, Drinking also
LABS:
H&H, RH Factor, Rubella Status, GBS Status, Platelets
What do you need to assess for during an intrapartum assessment?
Vital Signs
All body systems
Fetal HR
Basic UA for ketones, protein and glucose
Psychological Assessment (Support, anxiety, knowledge)
What is Dilation?
The opening of the Cervix
0-10
What is effacement?
Thinning of the cervix
100%=Completely thinned
What is station?
Where the fetal head is in relation to the mothers ischial spine
What are the premonitory signs of labor?
LIghtening:
Fetus descends into pelvic inlet
Braxton Hicks:
Irregular, intermittent contractions that occur during pregnancy. Causes more discomfort closer to onset of labor
Cervical changes:
Cervix begins to soften and weaken (ripening)
Bloody Show:
Loss of cervical mucous plug, causes blood-tinge discharge
Rupture of membranes
Sudden burst of energy:
Known as nesting, usually occurs 24-48 hours before start of labor
Loss of 1-3 lbs
Diarrhea, indigestion, nausea, vomitting may occur prior to onset of labor
After your water breaks, how long do you have before you need to deliver the fetus?
24 hours
What do we do during a Domestic Abuse Assessment?
All women should be screened for domestic violence. This should be completed when the pt is alone.
Has anyone close to you ever threatened to harm you?
Have you ever been hit, kicked, slapped or chocked by someone close to you?
Has anyone including your partner ever forced you to have sex?
Are you afraid of your partner or anyone else?
*Can contact authorities in regards to BABY!
What is Asthma?
A chronic disorder characterized by:
Smooth muscle spasms
Bronchial edema
Tenacious Mucous
What are some contributing factors to asthma?
Genetics
Environmental (Extrinsic) factors
Intrinsic factors
What are some assessments for asthma?
Wheezing
Tachypnea
Retractions
Nasal Flaring
Paroxysmal, irritative and non-productive cough
Prolonged expiratory phase
What are some daily medications for Asthma?
Long Acting Beta 2 Agonists
Inhaled corticosteroids
Methylzanthines
Mast cell inhibitors
Leukotriene Receptor Antagonist
What are some quick release medications for Asthma?
Short acting beta 2 agonists
Corticosteroids
Anticholinergic
What do we know about immune systems in babies under 3 months old?
They have lower infection rate due to protection of maternal antibodies
What do we know about infections in 3-6 month babies?
Infection rates soar
What do we know about infection in toddler/preschool kids?
They have a high incidence of infection but they decrease steadily
By age 5 what happens when pertaining to infections?
Less frequent infection rate
Some mycoplasma pneumonias
Strep infections increase
Nursing care on admission focuses on providing orientation to the unit and obtaining overall physical assessments of mother and fetus… What all do you assess?
Maternal vital signs and FHR
Any recent symptoms
Perform vaginal exam to determine cervical dilation and state of membranes
Determine frequency and intensity of contractions
Review systems such as respiratory, cardiac and neurological
Assess woman’s understanding of labor process and identification of woman’s support system
What information do you need to get during admission to develop a clinical pathway for four stages of labor?
Prenatal information
Current assessments
Expected teachings
Nursing care expected for each stage
Expected activity level
Proposed comfort measures
Elimination and nutritional needs
Level of family involvement
What do you need to get for the initial Intrapartum assessment?
Current Meds/Herbals
FULL head to toe going through all body systems
Psychosocial and Knowledge assessment
Why do you want to know what the top of the skull looks like?
You will see the suture lines
MAIN THING: Pay attention to the anterior fontanele.
-That is going to tell you the position when checking mom
What is the first phase of Stage 1?
Latent BEST time to do education
What is the second phase of Stage 1?
Active Dilation between 4-6cm
Baby moves to the pelvis
Anxiety rises as contractions get stronger
Doing a lot of reassuring to the mom
Physiological changes: Inc BP, O2 demand Inc, Mild respiratory acidosis at time of birth, Edema may occur, keep bladder empty bc it can empede baby coming down, Gastric volume remain inc, WBC inc during labor
What is the third phase of stage 1?
Transition
Contractions worse
Dilated 7-10
Body tremors, inc feelings of anxiety, irritability, eager to complete birth process, need support at bedside
All women should be screen for Domestic Abuse, THIS HAS TO BE DONE ALONE, what are some of the questions you would ask?
Has anyone close to you eer threatened to harm you?
Have you evern been hit, kicked, slapped or choked by someone close to you?
Has anyone including your partner ever forced you to have sex?
Are you afraid of your partner or anyone else?
During the psychosocial assessment what do you need to find out?
Use assessment techniques to meet laboring client’s needs for information and support
Know their support system:
-Father or support person-What do their caretaker activities involve?
Pain/Anxiety: Observe for rapid breathing, nervous tremors, clenching of teeth, thrashing, crying or increased pulse and respirations.
What are some factors associated with a positive birth experience?
Motivation for the pregnancy
Attendance at child birth education class
A sense of competence or mastering
Self cnfidence and self esteem
Positive relationship with male
Maintaining control duing labor
Trust in medical and nursing staff
What are some nursing care items in the Latent phase of labor?
Establish rappor with woman and support person
Discuss expectations of labor and delivery
Provide for privacy
Discuss individual expression of pain and discomfort
Discuss pain management options and patient preferences
What are some comfort measures in the active phase of labor?
Assist patient to reduce anxiety
- may need a paper bag if patients lips are tingling (Hypervent)
- Provide information and enhance coping skills
- Teach about what to expect during the labor process
Promote relaxation techniques
Give instructions to woman’s support person
Administer pharmacologic agents as ordered by physician or certified nurse-midwife
Assist with placement of epidural
What are some nursing care items for the second stage of labor?
Provide as much privacy as possible
Encourage woman and support person to decide who should be present at delivery
Provide praisea nd encouragent of progress
Help woman find effective pushing pattern
Support woman’s attempts to rest between pushes
What are some nursing care items for the 3rd and 4th stages of labor?
Encourage womand and support person to hold and look at infant as much as possible
Teach woman care to be performed after baby is delivered
Provide woman with food and fluids as allowed
ENJOY BABY!
What are some things to remember when dealing with an adolescent mother?
It is unique and she has developmental needs as well as physical needs that must be addressed
Very young adolescnet has fewer coping mechanisms and less experience to draw on than older laboring mothers
- Crucial to have support peson
- Adolescnets have high risk for pregnancy and labor complications
What is precipitous birth?
One that occurs rapidly
Less than 3 hours from start of labor to delivery
What are some nursing care items when dealing with precipitous birth?
Remember mother may fear what is going to happen and feel that everything is out of control
Mother needs to assume comfortable position
PRIORITY=Safe birth
Stay with mom
-Delegate someone to call PCP
What does the nurse need to do to deliver fetus if the PCP is not present due to it being a precipitous birth?
Nurse scrubs his or her hands if time permits
Use preset pack if no time for sterile table
When infants head crowns, mother should pant
Gentle pressure is applied against fetus head to prevent it from popping out rapidly
Perineum is supported and head is born between contractions
Pull mucal cord from around baby’s neck
When the shoulders are being delivered you want to put downward pressure on the 1st and upward pressure on the 2nd
DOCUMENT:
assessments, actions you took, time you contacted PCP and when they arrived, time started pushing, time of delivery, when membrane ruptured and when placenta came out
During active labor what do you want to check the urine for?
Ketones
Glucose
Protein
What happens to the GI during labor?
Gastric emptying time is prolonged
Acidity of gastric contents increase by ~2.5x
Risk of aspiration, especially when narcotics or anesthesia are used
What are some nursing care items that deal with Fluid and Electrolytes during labor?
Ice chips or sips of clear fluids are usually allowed during early labor
Clear fluids are:
Tea with honey and lemon, broths, apple juice
Other items:
Lollipops, hard candy, and popcicle
Maintain I&O
Fluids provide hydration and calories
Ensure frequent emptying of the bladder
Offer the bedpan every 2 hours and/or assist to bathroom
Patient may have physiologic diarrhea that occurs with labor
Be wary of infusing IV glucose:
This can lead to hypoglycemia in the newborn
Prolonged labor:
LR which minimizes acidosis and electrolyte imbalance
Active Phase:
Monitor degree of bladder fullness and make sure they empty bladder.
Prevent dehydration and bladder distention
What happens to the respiratory status during labor?
O2 deman increases at onset of labor because of contractions
Anxiety and pain from contractions increase=hyperventillation
fall in PaCO2 results in respiratory alkalosis
PUSHING: PaCO2 levels may rise alo with blood lactate levels and respiratory acidosis occurs
4th STAGE: acid base returns to normal levels by 24 hours
What are some diagnostics/labs during labor?
For prolonged labor or signs of dehydration:
Serum Electrolytes, CBC and Urine ketones
What can the RN do during labor?
Monitor
Evaluate
Teach
What can the LPN do during labor?
Monitor and report to RN any abnormal findings
Reinforce teaching
What can an aide do during labor?
Vital signs
Report patient complaints
Provide ice chips, popcicles, etc
what are some sources of pain during labor?
Emotional tension, anxiety and fear
Uterine contractions
Perineal and uterocervial traction
What is the main goal during intrapartum?
To have a happy, comfortable, safe labor and delivery resulting in a healthy breathing, alert newborn
What are some items that promote comfort or help control anxiety?
Pregressive relaxation
Touch Relaxation
Effleurage
Postiioning
Backrubs/Massage
Warm bath/Whirlpool tub
Birthing ball
Aromatherapy/Music therapy
Duala
Nurse’s Behavior
What is the goal of pharmacologic pain relief?
Provide maximum pain relief with minimum risk to mother and fetus
What impacts pain relief and acheiving min risk for pt and baby?
All systemic drugs used in labor for pain relief cross placental barrier by simple diffusion
Drug action in body depends on rate at which substance is metabolized by liver
Fetus has inadequate ability to metabolize analgesic agent
What does the laboring mother need to know prior to getting pharmacological pain relief?
Type of medication being administered
Route of administration
Expected side effects of medication
Implications for fetus or newborn
Safety measures needed (ie: stay in bed with rails up)
What are some narcotics given during labor?
Narcotics
Demerol
Morphine Sulfate
Stadol
Nubain
Barbiturates- Seconal, Nembutal
Narcotiv Antagonists - Narcan
What are some considerations with the timing of medications during labor?
After a complete assessment:
- Analgesic agent generally administered when cervical change has occurred
- Pain medication given too early may prolong labor and depress fetus
Drugs may cause fetal respiratory depression at birth if given too late in labor
Maternal and fetal vital signs must be stable before systemic drugs may be administered
Assess mother and fetus and evaluate contraction pattern before administering prescribed medications
What do you need to do before laboring mother gets an epidural?
Informed consent
Lab values
Platelet count-If less than 100 CANNOT do
if they have been on anticoagulant they must be off for 24 hours before
Give 1 Liter bolus of fluid:
Lactated Ringers or Normal Saline (So they don’t bottom out BP)
Get up and go to the bathroom b/c they won’t be able to afterwards
Make sure they are in the right position:
- Sittin on side of bed slouched over
- Knees up to chest position
Must have pulse ox on
How do you test if the epidural is in the right space?
Push epinephrine in and if the Heart rate increase they are in a vein and need to re do
What do you need to do after an epidural on a laboring mother?
Lay on back
Put pillow under right hip
Monitor BP every 3 min for 15 min then every 15 min
If BP decreaes bolus fluids, if that doesn’t work call anestesiologist
If it still doesn’t go up then administer 5-10mg of Ephedrine
What is continuous epidural analgesia?
Continuous medications are administered through epidural
Provides good analgesia
Produces less nausea and provides greater ability to cough
May produce breakthrough pain, sedation, respiratory depression
Itching and hypotension are side effects
What is a sign of a spinal fluid leak and what do you do?
SEVERE headache
Give caffeine and fluids
if it doesn’t get better do a blood patch:
A small amount of the patient’s blood is injected into the epidural space near the site of the original puncture; the resulting blood clot then “patches” the meningeal leak
What is a spinal block and why are they used?
Local anesthetic agen injected directly into spinal canal
Level of anestesia dependent upon level of administration
May be administered higher for cesarean birth or lower for vaginal birth
Onset of anesthesia is immediate
Wears off in 2-3 hours
What are some side effects of spinal block?
Maternal hypotension:
Can lead to fetal hypoxia, requiring frequent BP monitoring for health changes
Indwelling cUrinary catheter usually nee due to decreased bladde sensation and tone
Woman’s legs must be protected from injury for 8-12 hours after birth of baby due to decreased movement and sensation
What are some complications that can arise from spinal block or epidural?
Maternal hypotension from hypovolemia or effects of anesthesia:
-Treat with bolus of crystalloid IV fluid and notify anethetist
Bladder distention
Inability to push during second stage of labor
Severe headache with spinal anesthesia
Elevated temperature with epidural anesthesia
Possible neurologic damage
What is a Pudendal Block?
Local anesthesia injected directly into pudendal nerve which produces anesthesia to lower vagina, vulva and perineum
Only produces pain relief at end of labor
Has no effect on fetus or progress of labor
May cause hematoma, perforation of rectum, trauma to sciatic nerve
What is local infiltration?
Local anesthesia injected into perineum prior to episiotomy
Provides pain relief only for episiotomy incision
There is no effect on maternal or fetal vital signs
Requires large amounts of local anesthetic agents
What do you document when laboring mother gets anesthesia of any form?
Always assess pain using a scale and define the scale
Record when and how medicine was given
Record non-pharmacological pain management techniques
evaluate effectiveness of intervention using the pain scale
What are some nursing care items when dealing with general anesthesia?
Assess when mother ate or drank last
Administer prescribed premedication such as antacid
Place wedge under mother’s right hip to displace uteerus and preven vena cava compression
Provide oxygen prior to start of surgery
Ensure IV access is established
Assiste anesthesiologist by applying cricoid pressure (pic) during placement of endotracheal tube
What are some major complications with anesthesia?
Fetal Depression:
If mother receives general anesthesia, infant may have respiratory depression
Method not advocated when infant is considered high risk
Uterine relaxation:
Most general anesthetic agents cause some uterine relaxation
Vomiting
Aspiration:
Agents may also cause vomiting and aspiration
What are some assessment finding that make you suspect Hydramnios (Excess amniotic fluid)?
This is caused by the fetus makes too much urine or does not swallow enough, amniotic fluid builds up
Fundal height disproportionately large for dates
Difficulty palpating fetus and auscultating FHR
Tense, tight abdomen on inspection
Large spaces between fetus and uterine wall on ultrasound
What are some Maternal conditions associated with Hydramnios?
Diabetes
Rh Sensitization
Large Placenta
What are some fetal conditions associated with Hydramnios?
Hydrops fetalis:
serious condition in which abnormal amounts of fluid build up in two or more body areas of a fetus or newborn
Malformation of fetal swallowing
Neural tube defects
Anencephaly
Cardiac anomalies
Twins
What are some maternal implications of hydramnios?
Shortness of breath
Greatly increased cesarean rate
Uterine dysfunction
Abruptio Placentae
Postpartum Hemorrhage
Preterm labor
What are some fetal-neonatal implications of hydramnios?
Malformations
Preterm birth
increased mortality rate
prolapsed cord
Malpresentation
What are some assessment findings that make you suspect Oligohydramnios?
Fundal height small for datesFetus easily palpated and outlined
Ftus no ballottable
Variable Decelerations:
Because less water to cushion
Reduced AFI (Amniotic Fluid Index) on ultrasound
What are some conditions associated with Oligohydramnios?
Postmaturity
IUGR secondary to placental insufficiency
Major renal malformations:
- Renal Agenesis
- Dysplastic Kidneys
- lower urinary tract ostructive lesions
What are some implications of oligohydramnios?
Dysfunctional labr with slow progress
Fetal Deformation defects:
- Adhesions
- Skin and skeletal abnormalities
- Pulmonary hypoplasia
- Dysmorphic faces
- Shor ubilical cord
Umbilical cord compression
Head compression
What are some assessments of abruptio placentae?
Abdominal pain that doesn’t go away
Painful bleeding(May or may not see blood)
If internal bleed would see sign of shock:
decrease in blood pressure, rapid, weak, or absent pulse, irregular heart rate, confusion, cool, clammy skin, rapid and shallow breathing, anxiety, lightheadedness.
Fetus may have late decels
Decrease in variability (Move from tachycardia to brady)
Abdomen feels board like
Do you want to do a digital exam on a mother with placenta previa?
Also picture of placenta previa on answer card
NO NO NO NO NO
What are some conditions associated with Breech presentation?
Preterm birth
Placenta previa
Hydramnios
Multiple gestation
Uterine anomalies-IE. Bicornate uterus
Fetal Anomalies:
Anecephaly
Hydrocephaly
Most won’t be delivered vaginally
External Version: Turn baby in abdomen 36-38 weeks, if not successful then C-Section will be required
What are some conditions associated with Transverse Lie?
Grand multiparity with lax musculature
Preterm fetus
Abnormal uterus
Excessive amniotic fluid
Placenta previa
Contracted pelvis
High risk of prolapsed cord
Cesarean birth
What are some nursing care items for prolapsed cord?
Assess for nonreassuring fetal status
If a loop of cord is discovered, the examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head until provider arrives
Oxygen via face mask
Monitor FHR to determine if cord compression is adequately relieved
WOman assumes knee-chest position or bed is adjusted to Trendelenburg position
Transport to the operating room in this position
What is choanal Atresia, what would you see and do?
Blockage of the posterior side of the nose
Noisy respirations
Cyanosis at rest
Difficulty breathing during feeding
Interventions:
- Listen to brath sounds holding the mouth closed and 1 nostril
- Pass msall catheter through each side
- Hold spoon under to see if it fogs
- Call PCP
- Give O2 STAT
- Raise HOB
What is esophgeal atresia and assessments?
Congenital malformation which the esophagus terminates before it reaches the stomach and or a fistula is present that forms an unnatural connection between the esophagus and the trachea
Assessments:
- Vomiting
- Abdominal distention
- Failure to pass suction catheter
- Excessive oral secretions, coughing and choking
- Food comes out as soon as you feed
What is tracheosophagal fistula and what are some assessments?
Fistula at the connectionbetween the trachea and esophagus
Assessments:
- Coughing
- Apnea
- cyanosis
- Frothy Saliva
At risk of aspiration of stomach contents
Interventions:
Suctioning every 5 min
Assess family (Therapeutic responses & keep family in loop)
What is a diaphragmatic hernia?
Portion of the intestines is in the thoracic cavity through abnormal opening in the diaphragm
LIFE THREATENING
What is Meconium aspiration syndrome?
In utero the fetus is stressed and meconium is expelled
EPIGLOTTITIS MNEMONIC
CAPUT SUCCEEDAEUM MNEMONIC
EARLY AND LATE DECELERATIONS MNEMONIC
STAGES OF LABOR MNEMONICS
RESPIRATORY ACIDOSIS MNEMONIC
ANALGESIA VS ANESTHESIA MNEMONIC
ASTHMA MNEMONIC
ASTHMA MNEMONIC
RESPIRATORY DISTRESS SYNDROME MNEMONI
CYSTIC FIBROSIS MNEMONIC
HYPOXIA MNEMONIC
PITOCIN MNEMONIC
FETAL STATION MNEMONIC
FETAL STATION 2 MNEMONIC
APGAR MNEMONIC
FETAL HEART MONITOR MNEMONIC
VEAL CHOP MNEMONIC
LARYNGOTRACHEOBRONCHITIS MNEMONIC (LTB)
PLACENTA PREVIA AND ABRUPTIO
STAGES OF LABOR
