UNIT 2 (SKILLS) NURSING CARE MANAGEMENTLABOR, DELIVERY AND POST PARTUM

Question 1

NURSING DIAGNOSIS

Answer 1

1. Pain-related to labor contractions
2. Anxiety-related to the process of labor and birth
3. Health-seeking behaviors related to the management of discomfort of labor.

Question 2

OUTCOME IDENTIFICATION

Answer 2

• be sure to be realistic. Do not project a definite time of labor to be completed. Since one patient may be different to other..
  -fears and anxiety of the womans in labor can be alleviated.

Question 3

IMPLEMENTATION

Answer 3

• proper coordination of care among healthcare providers and planning with the woman and her support person.
  -provide an interpreter if not proficient in English.
  -providing back rubbed or having her handled might provide caring measure.

Question 4

OUTCOME EVALUATION

Answer 4

1. the client states that the pain during labor was tolerable, because of her advanced preparation.
2. the client verbalizes that her need for additional comfort measures was met.
3. Client and family members state that the labor and birth experience was positive growth experience for them, both individually and as a family.

Question 5

INITIAL INTERVIEW AND PHYSICAL EXAMINATION

Answer 5

1. EDD, frequency, duration, and intensity of contractions
2. Amount and character of the show
3. Whether rupture of membranes has occurred.
4. Time the woman last ate.
5. any known drug allergies.
6. Past pregnancy and previous pregnancy history.
7. Her birth plan or what individualized measures she has planned, such as no anelgesia or who will cut the umbilical cord
8. Vital signs (assessed between contractions)
9. Contractions (frequency, durtion, and intensity)
10. Her preparedness and readiness for labor.

Question 6

-is when uterus start to contract then relax. These contractions help to thin and open the cervix.
-EFFACEMENT
-DILATION

Answer 6

FIRST STAGE

Question 7

LATENT DURATION

Answer 7

30-45 secs.

Question 8

LATENT FREQUENCY

Answer 8

5-30 minutes

Question 9

LATENT INTENSITY

Answer 9

Mild to moderate pain

Question 10

LATENT DILATION

Answer 10

1-4 cm

Question 11

LATENT BEHAVIOR OF THE MOTHER

Answer 11

Excited and nervous

Question 12

ACTIVE DURATION

Answer 12

45-60 secs.

Question 13

ACTIVE FREQUENCY

Answer 13

3-5 MINUTES

Question 14

ACTIVE INTENSITY

Answer 14

Moderate to strong contractions

Question 15

ACTIVE DILATION

Answer 15

4-7 cm

Question 16

ACTIVE BEHAVIOR OF THE MOTHER

Answer 16

Serious, in pain and anxious

Question 17

TRANSITION DURATION

Answer 17

8-10CM

Question 18

TRANSITION FREQUENCYH

Answer 18

2-3 minutes

Question 19

TRANSITION INTENSITY

Answer 19

Most intense/ painful

Question 20

TRANSITION DILATION

Answer 20

8-10 cm

Question 21

TRANSITION BEHAVIOR OF THE MOTHER

Answer 21

Concentrating, irritated, in severe pain, nauseous, shivering etc.

Question 22

• is the period from full dilatation and cervical effacement to the infant; with uncomplicated birth.

Answer 22

SECOND STAGE

Question 23

NURSING INTERVENTION FOR SECOND STAGE OF LABOR

Answer 23

teach mom how to push, exhale when pushing and position patient (high fowlers or lithotomy)

Question 24

-starts with full delivery of the baby and ends with full delivery of the placenta.

Answer 24

THIRD STAGE OF LABOR

Question 25

NURSING INTERVENTION FOR THIRD STAGE OF LABOR

Answer 25

Monitor vs of the mother and baby. Administer oxytocin as prescribed.

Question 26

INDICATIONS THAT PLACENTA HAS LOOSENED AND READY TO DELIVER

Answer 26

1. Lengthening of the umbilical cord.
2. The sudden gush of vaginal blood
3. Change in the shape of the uterus
4. Firm contraction of the uterus
5. Appearance of the placenta at the vaginal opening.

Question 27

REMEMBER “SHINY SCHULTZ” “ this is shiny” side from the baby. Shiny and new which is the baby. This past come out first.

Answer 27

SCHULTZ MECHANISM