Week 2 Material Flashcards
Stage 1 of labor: Latent (Early)
-Longest stage
-Cervix dilates 0-3 cm
-Intensity: mild
-contractions:15-30 minutes
Stage 1: Active Phase
-Cervix Dilates 4-7 cm
-Intensity: Moderate
-Contractions: 3-5 Minutes (30-60 sec)
Stage 1: Transition
-Cervix Dilates: 8-10 cm
-Intensity: Strong
-Contractions: 2-3 minutes (60-90 sec)
Acronym “LAT”
Labor Actively Transitioning
Stage 1 Interventions
-Comfort-warm shower, massage, epidural
-fluids/ ice chips
-quiet environment
-voiding every 1-2 hours
-Encourage participations in care/ keep informed
-Instruct partner in effleurage (light stroking of abd.)
-Enc. effective breathing pattern/ rest between contractions
Stage 2:The baby is delivered
-Starts when the cervix is fully dilated/ effaced
-ends when the baby is delivered
-pushing
Stage 2-nurse interventions
Ice chips/ointment for dry lips
-Praise/ encouragement to mom
-Monitor uterine contractions/ moms V.S.
-Maintain Privacy/encourage rest between contractions
-Enc. effective breathing
-Monitor for signs of birth (perineal bulging/ visualization of head)
Stage 3- The Placenta is Delivered
-5-30 minute=delivered placenta
-Signs of delivery=
+lengthening umbilical cord
+gush of blood
+uterus changes from oval to globular shape
Stage 3-Interventions
-Assess mom’s V.S.
-Uterine Status (fundal rubs)
-Provide warmth to mother
-Promote parental-neonatal attachment
-Examine placenta &verify it is intact, should have 2 arteries and 1 vein
Stage 4:Recovery
-First 1-4 hours after delivery of placenta
Stage 4-Interventions
-Assess fundus
-Continue to monitor temps/ V.S. for infection
-Administer IV fluids
-Monitor lochia discharge (moderate/red)
-Monitor RR depression, vomiting, aspiration if general anesthesia was used
-Watch for postpartum complication (postpartum hemorrhage)
Stage 4: Expected VS. Unexpected
Expected: firm/ at midline
Unexpected: soft, boggy, displaced
Medication: Terbutaline (Brethine)
*beta-2 adrenergic agent
*stop/prevent preterm labor by relaxing uterus, slowing down contractions
*IV, SQ
*AE=tachycardia, palpations, SOB pulmonary edema
*given during stressful time, therefore, AE can increase mom’s anxiety
*Education: what to expect, changes in vital signs
Why are antepartal test done?
-Assess baby in wound
-women that high risk
Biophysical risk factors (high risk)
*genetic, nutritional,medical, obstetrical
Psychosocial Risk factors (high risk)
*Psychosocialfactors—maternal behaviors orlifestyle that have a negative effect on mom orfetus(smoking, caffeine use, alcohol/drug use,psychological status).
Sociodemographic risk factors (high risk)
*Sociodemographicfactors—(access to care,age, parity, marital status, income, ethnicity).
Environmental Risk Factors (High Risk)
*Environmentalfactors-(chemicals radiation,pollutants).
Nurse’s Role in Antepartal Tests
Many women having antenatal tests are at high risk forfetal and maternal complications and are anxious andvulnerable.
-inform, comfort, reassure, psychosocial support, document, establish trust
Antepartal Diagnostic Tests
-Amniocentesis
-Chorionic Villi Sampling
-Magnetic Resonance Imaging (MRI)
-Percutaneous Umbilical Blood Sampling
-Ultrasonography
Ultrasound-How/ Nurse Action
-High frequency waves produce an internal image.
-Interpretation of results
Normal findings include: fetus appropriate gestational age size, viability, position and functional capabilities.
Standard US
fetal presentation and number, amniotic fluid volume, cardiac activity, placental position, fetal biometry (gestational age measurements).
Limited Examination
performed when a specific question needs to be investigated.Ex. in labor, baby is head down
Special Examination
more intense than a standard US, performed when there is an increased risk of an anomaly based on the history, lab results, or the results are limited from standard US.(not routine)