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Nursing Semester 2 > Toni - Week 3 - Exam 2 > Flashcards

Toni - Week 3 - Exam 2 Flashcards

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1
Q

what are the 6 premonitory signs that indicate labor is near?

A

lightening, bloody show, cervical ripening, stronger braxton hicks, energy burst, and spontaneous rupture of membranes (SROM)

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2
Q

T/F: premonitory signs mean that labor is near or that it will occur in a set time frame.

A

FALSE. doesn’t necessarily mean labor

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3
Q

how is lightening defined?

A

occurs mostly with first time mothers; “baby has dropped” - mothers notice they can take a deep breath again

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4
Q

how is bloody show defined?

A

little capillaries break and vaginal mucus mixes with blood

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5
Q

how is cervical ripening described?

A

cervix feels as hard as your forehead/nose then softens to your lips

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6
Q

Stronger Braxton Hicks contractions can ___ the mother

A

confuse

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7
Q

what occurs during the sudden energy burst?

A

very common; women begin nesting, cleaning, folding baby clothes

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8
Q

how is the SROM described?

A

amniotic fluid bag ruptures, water has broken

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9
Q

what is the concern when bag membranes have ruptured?

A

the sterile environment has been open; bacteria migration is open;

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10
Q

what do we recommend when bag membranes have ruptured?

A

we recommend the mother comes into the hospital; she can put on a pad and we can test for amniotic fluids; we can do a sterile speculum we should start the clock b/c labor can start within 18 hrs

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11
Q

what is the definition of true labor? how many stages?

A

when contractions increasingly regular, longer, stronger, and more frequent - at least 40 - 45 second contractions; 4 stages

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12
Q

when is the first stage of labor?

A

onset of labor to complete dilation; contractions are closer together; progressive effacement and dilation; 10 cm or no cervix left

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13
Q

when is the second stage of labor?

A

complete dilation to birth

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14
Q

when is the third stage of labor?

A

birth to expulsion of the placenta - hemodynamic change - no more than 30 min or less

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15
Q

when is the fourth stage of labor?

A

first few hours after birth

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16
Q

when does a nurse use leopold’s maneuvers?

A

routinely when preparing fetal monitoring

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17
Q

what does the first maneuver consist of?

A

assess part of the fetus in the upper fundus

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18
Q

what does the second maneuver consist of?

A

assess location of the fetal back

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19
Q

what does the third maneuver consist of?

A

identifying presenting part

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20
Q

what does the fourth maneuver consist of?``

A

determine descent of presenting part - fetal attitude → feel both sides until hitting cephalic prominence

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21
Q

who performs the fourth leopold maneuver?

A

Only done by midwife or MD

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22
Q

what are the two ways to monitor fetal heart rate?

A

external FHR monitoring and internal FHR monitoring

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23
Q

what does external fetal monitoring consist of?

A

ultrasound is placed over fetal back - external on mother’s belly

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24
Q

what 3 things can interfere with external fetal monitoring?

A

maternal obesity, excessive fetal or maternal movement, and fetus in OP position (baby’s back faces back)

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25
Q

what does internal fetal monitoring consist of?

A

a fetal scalp electrode is attached to presenting part of fetus

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26
Q

who can perform an internal fetal monitoring test?

A

a nurse that has passed a competency test to do so

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27
Q

what is the risk of internal fetal monitoring?

A

it acts as another avenue for infection

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28
Q

what are the 2 necessary criteria in order for a woman to be eligible for internal fetal monitoring?

A

woman must be dilated to at least 2 cm + have ruptured membranes

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29
Q

T/F A nurse can rupture membranes.

A

FALSE!! We have to call an MD to rupture membranes.

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30
Q

what are the two ways to monitor uterine contractions?

A

external UC monitoring and internal UC monitoring

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31
Q

what does external UC monitoring consist of?

A

a tocodynamometer is place on woman’s fundus, which measures frequency and durationg of uterine contraction

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32
Q

T/F the tocodynamometer also measures intensity of a UC.

A

FALSE - only frequency and duration

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33
Q

what 2 things can interfere with external UC monitoring?

A

maternal obesity and excessive maternal movement

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34
Q

what does internal UC monitoring consist of?

A

intrauterine pressure catheter inserted through cervix into uterus pocket of fluid, measuring UC intensity

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35
Q

what are the 2 necessary criteria in order for a woman to be eligible for internal UC monitoring?

A

woman must be dilated to at least 2 cm + have ruptured membranes

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36
Q

Define “fetal heart rate”

A

the average FHR during a 10 minute period

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37
Q

what is the baseline for FHR?

A

normal baseline is 110-160

38
Q

what are the perimeters for fetal bradycardia?

A

below 110 for 10 minutes or more

39
Q

what are the 4 possible causes for fetal bradycardia?

A

maternal hypotension, fetal hypoxia/acidosis, epidural, and/or analgesic drugs

40
Q

what are the perimeters for fetal tachycardia?

A

HR above 160 for 10 minutes or more

41
Q

what are the 3 possible causes for fetal tachycardia?

A

maternal fever, fetal hypoxia (although often bradycardia), stimulant drugs (cocaine, amphetamine)

42
Q

what does moderate fluctuation of FHR indicate?

A

normal; indicates fetal well-oxygenated; responding to environment

43
Q

what does absent/minimal fluctuation of FHR indicate?

A

indicates possible acidosis and uteroplacental insufficiency (placenta/uterus not supplying uterus with what it needs); line is smooth = not good; not responding to environment; scary

44
Q

what does marked (increased) fluctuation of FHR indicate?

A

It is uncommon, may be benign or indicate hypoxia

45
Q

what are periodic fetal heart rate changes?

A

temporary recurrent changes in FHR baseline occurring in relation to uterine contractions.

46
Q

how many different fetal heart rate changes are there? what are they?

A

4; accelerations, early decelerations, late decelerations, and variable decelerations

47
Q

how are accelerations defined?

A

an increase above FHR baseline of at least 15 bpm for at least 15 seconds

48
Q

what do accelerations indicate?

A

fetal well-being

49
Q

what NI should occur with accelerations?

A

none; document.

50
Q

how are early decelerations defined?

A

FHR deceleration begins and ends with UC; inversely mirrors contraction.

51
Q

what do early decelerations indicate?

A

they are benign; caused by fetal head compression; may occur during pushing

52
Q

what NI should occur with early decelerations?

A

none; not concerning

53
Q

how are late decelerations defined?

A

begins after UC starts and return to baseline after UC ends; lowest point (nadir) occurs with the peak of UC

54
Q

what do late decelerations indicate?

A

ominous sign of fetal hypoxia associated with uteroplacental insufficiency

55
Q

what NI should occur with late decelerations?

A

oxygenate, rotate, hydrate (↑ IV rate; start IV), stop oxytocin if infusing

56
Q

how are variable decelerations defined?

A

abrupt FHR deceleration with abrupt return to baseline; variable in shape (U,V,W)

57
Q

what do variable decelerations indicate?

A

associated with umbilical cord compression; possibly when amniotic fluid has ruptured

58
Q

what NI should occur with variable decelerations?

A

oxygenate, & rotate; stop oxytocin; amnioinfusion; vaginal exam to check for possible cord prolapse (cord b/t head and pelvis)

59
Q

who can perform an amnioinfusion?

A

the health care provider in house

60
Q

what are the 3 categories in the three-tier fetal HR interpretation?

A

normal. indeterminate, and abnormal

61
Q

define category I normal heart rate interpretation?

A

predicts normal fetal acid-based status; no interventions

62
Q

what is an example of category I: normal interpretation?

A

baseline FHR 110-160, moderate variability; presence or absence of accelerations or early decelerations

63
Q

define a category II: indeterminate interpretation?

A

not predictive of abnormal fetal acid-base status; requires continued surveillance and reevaluation

64
Q

what is an example of category II: indeterminate interpretation?

A

tachycardia, bradycardia w/o absent variability

65
Q

define category III: abnormal interpretation?

A

abnormal fetal acid- base statusl; requires intervention

66
Q

what is an example of category III: abnormal interpretation?

A

absent variability with recurrent late decelerations

67
Q

what are 15 nonpharmacologic comfort measures that can be taken during labor?

A
  • clean room
  • soft lighting
  • comfortable temperature
  • mom clean and dry (BM, pads)
  • mouth care - ice chips
  • empty bladder (full bladder can impede head from coming)
  • position changes (improves everything)
  • minimize distractions
  • hydrotherapy
  • hot and cold towels (timed with UC)
  • imagery (visualization)
  • focal point (can be partner)
  • breathing techniques
  • massage
  • acupressure (we can’t do this)
68
Q

what is the systematic labor analgesia?

A

IV opioids, like fentanyl (short duration); have to be careful of timing; newborn respiratory drive effected; couple of hours before delivery

69
Q

what are the advantages of systematic labor analgesia?

A

rapid onset; short duration

70
Q

systematic labor analgesia may cause which 3 disadvantages?

A

↓ FHR variability, ↓ UC frequency and intensity (slows down labor), and newborn respiratory depression

71
Q

what occurs when systematic labor analgesia is in the baby’s system when he/she is born?

A

the baby might not want to breath; we can give Narcan to the baby to reverse the effects

72
Q

what is epidural analgesia?

A

local anesthetic and opioid injected into the epidural space

73
Q

what is the advantage of epidural analgesia?

A

it provides excellent pain relief

74
Q

what are the 4 disadvantages of epidural analgesia?

A

may cause:

  • maternal hypotension/fetal distress
  • motor loss
  • urinary retention; usually cath within 30 minutes
  • prolonged 2nd stage (may not have the secondary powers to push)
75
Q

what are the 4 nursing responsibilities when it comes to epidurals?

A
  • administer ordered IV fluid bolus before procedure d/t hypotension
  • assist with maternal positioning during and after placement
  • frequent maternal and fetal assessment
  • insert foley if unable to void
76
Q

T/F: with an epidural, the mother then becomes a high risk patient.

A

TRUE

77
Q

what is the criteria for a epidural?

A

the mother must be at least 4 cm dilated.

78
Q

define cardinal movements of labor.

A

changes in position of the fetus during labor to allow the smallest diameter to fit through the pelvis.

79
Q

what are the 7 different cardinal movements?

A

descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion

80
Q

define an episiotomy.

A

a surgical incision into perineum to enlarge vaginal opening.

81
Q

what are the two different styles of episiotomies?

A

midline incision and mediolateral incision

82
Q

what are the advantages of a midline episiotomy?

A

muscle fibers split lengthwise, allows faster healing and less pain

83
Q

what is the disadvantages of a midline episiotomy?

A

can extend into 3rd or 4th degree lacerations; impairs the integrity of the perineum

84
Q

T/F those that have an episiotomy that have torn all the way to the rectum cannot have suppositories

A

TRUE

85
Q

what are the advantages of a mediolateral episiotomy?

A

larger incision possible; avoids rectal structures

86
Q

what are the disadvantages of a mediolateral episiotomy?

A

cuts across muscle fibers; more pain and slower healing

87
Q

what are the two definitions of “crowning”?

A
  1. when the top of the fetal head no longer recedes during contractions
  2. widest part of baby’s head has passed through perineum
    “burning feeling”
88
Q

what is the 3rd stage of labor?

A

the discharge of the placenta

89
Q

how long does the 3rd stage of labor take?

A

20-30 minutes

90
Q

T/F the blood vessels of the uterus begin to seep and helps the placenta fall

A

TRUE

91
Q

what are newborn security measures?

A
  • mom, baby, and support person have bracelets on

- baby has 2 bracelets on (ankle/wrist)

Nursing Semester 2 (21 decks)

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