week 3 Flashcards
3 phases within 1st stage of labor
latent
active
transition
if the fetus is tachycardic what should the nurse suspect and whats one of the first things the nurse should do?
Suspect infection
take mom’s temp
which one does not give intensity of contraction or resting tone between contractions, so nurse must palpate uterus to assess?
tocodynamometer or IUPC
tocodynamometer
6 cm/100%/0
which stage of labor?
is fetus engaged?
6 cm dilated = 1st stage, active phase
100% effaced
0 station = baby is engaged
Mechanisms of labor:
____ – widest part of presenting part enters pelvis
____– head moves down in pelvis
____ – fetus tucks chin into chest
____ – fetus turns to face spine (OA)
____ – head extends for delivery under pubic bone
____ - head rotates to OT position and shoulders align vertically with mom’s pelvis
____ – anterior shoulder delivers, then posterior shoulder, then rest of baby
Extension, Descent, Flexion, Internal rotation, External rotation, Engagement, Expulsion
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion
which one is false labor
- discomfort begins in back and radiates to abdomen – maybe
- cervical changes (dilatation and effacement) are progressive
- contractions do not decrease with rest, walking, warm tub bath, etc.
- contractions are irregular
- contractions are irregular
Fetal lie (relation of fetal spine to maternal spine): transverse, longitudinal
- ____________ (vertical)
- _____________ (horizontal)
- longitudinal (vertical) – both spines are vertical
- transverse (horizontal) - moms spine is vertical, baby’s spine is horizontal
Nursing care during the 1st stage, transition phase includes encourage client to change positions - T/F
true
which stage of labor does this describe
Active descent phase (pushing)
Strong contractions
Ferguson reflex activated (bear down)
2nd stage
which type of deceleration? early, late, prolonged, variable
- Intervention - Investigate why, maybe UNCOIL
- Cause - Umbilical cord compression
- Shape – sharp, abrupt
- Onset – not related to contractions
variable decel
which P is - Fetal head, attitude, lie, presentation
passenger
_____________ – relationship of the presenting part to the ischial spines
- Station
which one is false labor
- rest, walking, warm tub bath, etc. help lessen contractions
- contractions are at regular intervals – 5 mins apart and stronger every hour
- intervals between contractions slowly shorten
- contractions increase in duration and intensity
- rest, walking, warm tub bath, etc. help lessen contractions
associated with which force - primary vs secondary
Contraction phases
- increment (increasing)
- acme (peak)
- decrement (decreasing)
described with
- frequency
- duration
- intensity
primary – uterine muscular contractions (until 100% dilation)
secondary is just bearing down with abdominal muscles
Comfort measures: ______ stage
- Heated blanker
- Food/fluid
- Ice pack to perineum
- Pain med
- Rest
4th stage
which stage
- Begins with onset of true labor
- Ends when cervix is 10 cm (fully dilated)
1st, 2nd, 3rd, 4th
1st - longest phase
T/F
involuntary contractions are a sign indicating labor is beginning
true
fetal ___________ - the part of the fetus that is positioned to enter the birth canal first during delivery.
- Fetal presentation
Fetal bradycardia
FHR less than _____ BPM
Not good
O2 is low
110
which of these would be a bad sign in a client post birth:
- Hypotension
- Tachycardia
- Uterine atony - uterus fail to contract
- Excessive bleeding
- Hematoma
all
Comfort measures: ________ stage
- Clear fluids/ice chips
- Ambulation
- Hydrotherapy – birthing tub
- Perineal care
- Relaxation between contractions
- Distraction
- Effleurage – massage circle movements with palms on belly
- Firm pressure on back or sacrum
- Visualization
- Controlled breathing
- Position changes – includes birthing ball, peanut ball (good for epidural pt)
1st stage, all phases
what are these testing for?
- Ferning test
- Nitrazine paper
- Amnisure test
ROM
true or false labor
- discomfort begins in back and radiates to abdomen – maybe
- cervical changes (dilatation and effacement) are progressive
- contractions do not decrease with rest, walking, warm tub bath, etc.
true
which P is - Emotions, energy, support
passage
passanger
position
power
psyche
psyche