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
Fetal lie (relation of fetal spine to maternal spine):
- longitudinal (vertical)
- ?
- ? - transverse (horizontal)
- ?
Longitudinal (vertical) – both spines are vertical
- Cephalic - Head down
- Breech – butt down
Transverse (horizontal) – moms spine is vertical, baby’s spine is horizontal
- Shoulder position
2 external fetal monitors
2 internal fetal monitors
fetal scalp electrode (FSE), ultrasound, tocodynamometer, and intrauterine pressure catheter (IUPC)
ultrasound and tocodynamometer
fetal scalp electrode (FSE) and intrauterine pressure catheter (IUPC)
Nursing interventions for non-reassuring patterns?
UNCOIL
UN – undo what is causing problem
C – change position
O – oxytocin off, oxygen on (non-rebreather face mask)
I – IV fluid bolus
L – lower head of bed
which FHR pattern is this?
- Not good
- Probably indicating fetal acidosis
- a specific abnormal waveform pattern on the FHR tracing, no acceleration/deceleration fluctuations
sinusoidal pattern
are these T/F of the 3rd stage:
- should be 30 mins or less (risk of hemorrhage and placenta retention if longer)
- Pitocin/oxytocin IV bolus infusion begun after delivery of placenta to decrease blood loss
- Fundal massage to see if cervix continues to be firm
- Any perineal tears or lacerations are repaired
- placenta is expelled
- baby is birthed
all is true
except
baby is birthed in 2nd stage
when presenting fetal part reaches 0 station
- Engagement –
which stage of labor
- begins after delivery of placenta
- ends 4 hours after postpartum
4th stage
baseline FHR
- _________ BPM
- Must be observed for ____ mins
baseline FHR
- 110-160 BPM
- Must be observed for 10 mins
- Cone shaped head is expected – molding of fetal head is common in child birth and usually improves in _______ hours
- Fetal skull bones are united by ______________ sutures
- Cone shaped head is expected – molding of fetal head is common in child birth and usually improves in 24 hours
- Fetal skull bones are united by membranous sutures
pelvis type - platypelloid, gynecoid, android, anthropoid
_________ – most common, circle shape and best for vaginal delivery
____________ – heart shape
____________ – oval shape
____________– flat shape, most likely c/s delivery
- Gynecoid – most common, circle shape and best for vaginal delivery
- Android – heart shape
- Anthropoid – oval shape
- Platypelloid – flat shape, most likely c/s delivery
nurse can do this to check fetal position
(a series of four steps used in obstetrics to assess the position, presentation, and lie of a fetus inside the woman’s uterus by palpating her abdomen with both hands)
leopolds maneuver
Nursing interventions: _____ stage, ________ phase
- Palpate contractions Q 15 mins or continuous fetal monitoring
- SVE – dilation, effacement, station, fetal position
- FHR Q 15-30 mins
- Vitals Q 15-30 mins
- Assist with breathing
- Keep woman from pushing until fully dilated
1st stage, transition phase
Nursing interventions: _____ stage
-Vitals Q 15 mins (1 hour)
-Temp Q 1 hour
-IV fluids with Pitocin/oxytocin
-Palpate fundus Q 15 mins (1 hour)
- Firm or boggy?
- Increased bleeding?
-VB
-Assess and care for Perineum
-Assess need to void
-Encourage kangaroo care and bonding
-Assist with infant feeding
-Breast or formula
-Check correct instrument/sponge count
4th stage (before transferring her to mother/baby)
- Fetal _______ – relation of fetal spine to maternal spine
- Fetal lie – relation of fetal spine to maternal spine
are all accelerations good?
are accelerations periodic, episodic, or both?
yes
both
which phase is woman dilated
0-3 cm
4-7 cm
8-10 cm
1st stage, latent phase
1st stage, active phase
1st stage, transition phase
which type of deceleration? early, late, prolonged, variable
- Not too concerned
- intervention – none, maybe SVE
- Cause – head compression
- Shape – gradual, Mirrors contraction
- Onset – before peak of contraction
early decel
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)
- Cool clothes
- Reassurance
- Assist into pushing position and with pushing
2nd stage
true or false labor
- contractions are irregular
- no change in duration or intensity
- discomfort may be in abdomen
false
station
Above ischial spines, floating, not engaged = ___________
Above ischial spines – (ballotable – floating, not engaged)
which stage of labor
- begins after birth of baby
- ends delivery of placenta (placenta is expelled in this stage)
3rd stage
FHR variability - marked, minimal, absent and moderate
________ = bad
No variability in FHR
___________ = not good
Less than 5 BPM variability in FHR
Try to stimulate fetus
Is it due to mom’s pain meds?
___________ = expected
Variability in FHR is between 6 – 25 BPM
__________ = not good
Variability in FHR is greater than 25BPM
absent
minimal
moderate
marked
5 p’s
passage
passanger
position
power
psyche
which P is - Station, engagement
passage
passanger
position
power
psyche
Position
Nursing interventions: acceleration
UNCOIL or perform SVE?
trick question: neither! ALL accelerations are good
power: primary forces vs secondary forces
- ___________ forces – abdominal muscles used in pushing (bearing down)
- ___________ forces – uterine muscular contractions (until 100% dilation)
- secondary forces – abdominal muscles used in pushing (bearing down)
- Primary forces – uterine muscular contractions (until 100% dilation)
Nursing interventions: early deceleration
perform SVE first or turn client first?
Remember with early deceleration were Not too concerned and interventions – none, maybe SVE
- perform SVE – b/c were thinking the baby’s head is becoming more compressed as it moves further down the canal preparing for labor
- Turn client
which ROM test looks like a crystalized snow flake under the microscope when positive?
- Ferning test
- Nitrazine paper
- Amnisure test
- Ferning test
If the deceleration lasts longer than 10 mins is it considered a prolonged deceleration or a change in FHR baseline?
If the deceleration lasts longer than 10 mins = baseline change in FHR
> 32 weeks gestation = 15x15
- Must be 15 BPM above baseline
- For 15 seconds at least
<32 weeks gestation = 10x10
- Must be 10 BPM above baseline
- For 10 secs at least
is this the rule for deceleration or acceleration?
accelerations
which ROM test turns yellow if negative and blue if positive?
- Ferning test
- Nitrazine paper
- Amnisure test
- Nitrazine paper
Labs done upon admission:
-Blood type
-Rh factor
-Type and screen
-___________ status – immune, non-immune, equivocal
-____________
- Positive = start antibiotics (_________)
- If allergic = clindamycin
- Labs
- Blood type
- Rh factor
- Type and screen
- Rubella status – immune, non-immune, equivocal
- Group B strep (GBS)
- Positive = start antibiotics (penicillin)
- If allergic = clindamycin
what are the 2 methods of monitoring FHR
what are the 2 methods of monitoring contractions
fetal scalp electrode (FSE), ultrasound, tocodynamometer, and intrauterine pressure catheter (IUPC)
ultrasound and fetal scalp electrode (FSE)
tocodynamometer and Intrauterine pressure catheter (IUPC)
are these fetal monitor patterns reassuring or non-reassuring?
- persistent and severe variable decelerations
- late decelerations
- prolonged decelerations
- absent variability
- accelerations
- sinusoidal pattern
- severe and marked bradycardia
- prolonged tachycardia
-non
-non
-non
-non
-reassuring
-non
-non
-non
which P is - Primary and secondary
passage
passanger
position
power
psyche
power
time is important for ROM bc longer than ____ hours ROM increases likelihood of infection
18
Total duration of labor usually shorter for multipara or nullipara?
multipara
which of these should would apply if the nurse is caring for a client with non-reassuring patterns?
undo what is causing the problem
turn from right side to left side
turn off oxytocin drip
give non-rebreather face mask
IV fluid bolus
raise head of bed
perform SVE
Notify MD/midwife and document
Tocolytics - if contracting
If uncorrectable – prepare for immediate delivery
all are good except LOWER HOB
UN – undo what is causing problem
C – change position
O – oxytocin off, oxygen on (non-rebreather face mask)
I – IV fluid bolus
L – lower head of bed
Notify MD/midwife and document
Tocolytics - if contacting
If uncorrectable – prepare for immediate delivery
- Fetal __________ – relation of the fetal parts to one another
- Fetal attitude – relation of the fetal parts to one another
Fetal tachycardia
FHR greater than _____ BPM
Not good
Suspect infection, take mom’s temp
160
6/80/-1
which stage of labor?
is fetus engaged?
6/80/-1
6 cm dilated = 1st stage, active phase
80% effaced
-1 station
no
which ROM test shows 2 lines if positive and 1 line if negative?
- Ferning test
- Nitrazine paper
- Amnisure test
- Amnisure test
which type of deceleration? early, late, prolonged, variable
- Not good
- Intervention – investigate why (mom high/low BP, bleeding), UNCOIL
- Cause – uteroplacental insufficiency (UPI)
- Shape – mirrors contraction
- Onset – after peak of contraction
late decel
true or false labor
- contractions are at regular intervals – 5 mins apart and stronger every hour
- intervals between contractions slowly shorten
- contractions increase in duration and intensity
true
Nursing interventions: ______ stage, _______ phase
- Anticipatory info and support
- Encourage ambulation
- Ice chips/fluids
- Vitals Q 1 hour
- Temp Q 4 hour
- Temp Q 2 hour if ROM
- FHR intermittent Q 30-60 mins
1st stage, latent phase
signs of placental separation (placenta is about to be delivered):
- globular uterus lowers/rises in abdomen?
- gush or trickle of blood/fluid from vagina?
- increased protrusion of umbilical cord (gets longer/shorter out of vagina)?
- globular uterus rises in abdomen
- gush or trickle of blood from vagina
- increased protrusion of umbilical cord (gets longer out of vagina)
Nursing interventions: _____ stage
Newborn care
- Provide new born care
- Stimulation and warmth
- Vital signs
- APGAR score
- ID
- Physical assessment
- Facilitate attachment encourage kangaroo care
Maternal care
- Monitor for delivery of placenta
- Document time of delivery and intactness
3rd stage
__________ beginning of contraction 1 to beginning of contraction 2
____________ beginning of contraction 1 to end of contraction 1
_____________ how strong
intensity, duration, frequency
- frequency – beginning of contraction 1 to beginning of contraction 2
- duration – beginning of contraction 1 to end of contraction 1
- intensity – how strong
Premonitory signs of impending labor (Body is getting ready, could still be up to 2 weeks out):
- ____________ – fetus settles/drops into pelvis (mom can breathe easier with pressure off lungs)
- Braxton hicks contractions – regular or irregular?
- Cervical changes?
- Bloody show/expulsion of mucus plug ?
- SROM or AROM?
- Sudden burst of energy – ____________
- Weight gain or loss?
- GI upset ?
- Lightening – fetus settles/drops into pelvis (mom can breathe easier with pressure off lungs)
- Braxton hicks contractions – irregular
- Cervical changes
- Bloody show/expulsion of mucus plug
- SROM
- Sudden burst of energy – nesting
- Weight loss – 1-3 lbs
- GI upset
Nursing interventions: ______ stage
- SVE to assess fetal descent
- FHR Q 5-15 mins
- Vital signs Q 30 mins
- Support and info
- Assist with pushing and MD with birth
2nd stage
which stage of labor
- begins with Full dilation and effacement
- ends with birth of baby
2nd stage
(pushing stage)
which type of deceleration? early, late, prolonged, variable
- Not good
- Deceleration lasts 2 mins or longer, but less than 10 mins
prolonged decel
which 2 require ROM
which 2 do not require ROM
fetal scalp electrode (FSE), ultrasound, tocodynamometer, and intrauterine pressure catheter (IUPC)
fetal scalp electrode (FSE) and intrauterine pressure catheter (IUPC)
ultrasound and tocodynamometer
FHR variability is the best indicator of fetal ________
oxygen
which P is - pelvis, cervix
passage
passanger
position
power
psyche
passage
periodic vs episodic
________ – not associated with uterine contractions
_________– associated with uterine contractions
Episodic – not associated with uterine contractions
Periodic – associated with uterine contractions
____________ – meaty, bloody side, maternal side
___________ – fetal side
dirty duncan vs shiny shultz
dirty Duncan – meaty, bloody side, maternal side
shiny shultz – fetal side
Discharge care to postpartum care
- ______ vitals
- _______ bleeding
- ________ bladder
- ________ fundus
- Report of _____________ from any anesthetic agent received during birth
- Admission of baby with mother to postpartum unit (or newborn nursery) – and ____________ for matching
Discharge care to postpartum care
- Stable vitals
- Stable bleeding
- Undistended bladder
- Firm fundus
- Report of returned sensations from any anesthetic agent received during birth
- Admission of baby with mother to postpartum unit (or newborn nursery) – and read bracelets for matching
Nursing interventions for non-reassuring patterns
UN –
C –
O –
I –
L –
UN – undo what is causing problem
C – change position
O – oxytocin off, oxygen on (non-rebreather face mask)
I – IV fluid bolus
L – lower head of bed
Fontenelles/sutures
- Anterior – closes by _____ months
- Posterior – closes by _____ months
- Anterior – closes by 18 months
- Posterior – closes by 2 months
Standard maternal assessment for a healthy mom in the 4th stage of labor following a vaginal delivery:
-Vaginal bleeding
-Vital signs
-Bladder assessment
-Fundal (uterine) assessment - how should uterus feel?
-Perineal assessment
-Vaginal bleeding
-Vital signs
-Bladder assessment
-Fundal (uterine) assessment
- It should be firm
- A soft and relaxed (boggy) uterus is concerning
-Perineal assessment
psychological readjustment of the _______ stage of labor:
-thirsty and hungry
-shaking – 1-2 hours after birth, CNS response after the strenuous work of labor stops
-Fluid and heat loss (warm blankets)
-Bladder often hypotonic – bladder muscles loss ability to contract properly
-Uterus should remain contracted - Midline of abdomen, Between symphysis pubis and umbilicus
4th stage
benefits of kangaroo care: T/F
- helps regulate mom’s temp and HR
- stimulates production of breastmilk
- promotes attachment
- regulates maternal oxytocin release
- helps regulate baby’s temp and HR
- stimulates production of breastmilk
- promotes attachment
- increases maternal oxytocin release
Nursing interventions: ______ stage, ______ phase
- Palpate contractions Q 15-30 mins or continuous fetal monitoring
- SVE – dilation, effacement, station, fetal position
- Void Q 1-2 hours
- IV fluid infusion
- FHR Q 15-30 mins
- Vitals Q 15-30 mins
- ROM – COAT and FHR
- Change position and pads often
1st stage, active phase
Abnormalities potentially affecting process of labor
____________– too small
_____________ – malpresentation
_____________ – posterior (occiput posterior)
______________– inadequate (contractions/pushing)
_______________ – intense fear, anxiety, poor support system, exhaustion
passanger
psyche
power
position
passage
Passageway – too small
Passenger – malpresentation
Position – posterior (occiput posterior)
Powers – inadequate (contractions/pushing)
Psychological factors – intense fear, anxiety, poor support system, exhaustion
fetal presentation is cephalic (head down):
match term with definition
- Suboccipitobregmatic diameter
- Occipitofrontal diameter
- Occipitomental diameter
- Submentobregmatic diameter
__________________ - around forehead is touching the ischial spines
___________________- top of head and underneath chin are touching the ischial spines
____________________- back of head and chin are touching the ischial spines
___________________- crown of head is touching the ischial spines
- Suboccipitobregmatic diameter – crown of head is touching the ischial spines
- Occipitofrontal diameter – around forehead is touching the ischial spines
- Occipitomental diameter – back of head and chin are touching the ischial spines
- Submentobregmatic diameter – top of head and underneath chin are touching the ischial spines
fetal presentation is Breech (butt down):
______________(pike position) legs straight, folded in half at hips
______________(cannonball position) knees bent, folded in half at hips
________________one or both hips are straight and foot is presenting part
frank breech
footling breech
complete breech
- Frank breech – (pike position) legs straight, folded in half at hips
- Complete breech – (cannonball position) knees bent, folded in half at hips
- Footling breech – one or both hips are straight and foot is presenting part
fetal presentation:
- _______ - head down
- _________ - butt down
- ________ - horizontal
- cephalic - head down
- breech - butt down
- shoulder - horizontal
are these the goal/purpose of admission or discharge?
- Greet, establish rapport
- Orient to room, facilities, equipment
- Informed consent – if laboring or suspect delivery
- Notify physician/CNM
admission
category ___ – normal
category ___ – indeterminate
category ___ – abnormal (baby probably needs to be delivered asap)
1
2
3
station
-5 to -1 =
0 =
+1 to +5 =
Above ischial spines – (ballotable – floating, not engaged) —-
engaged = 0
below ischial spines ++++
Nursing interventions: late deceleration
UNCOIL or perform SVE?
UNCOIL
true or false labor
- no cervical changes (dilation and effacement)
- rest, walking, warm tub bath, etc. help lessen contractions
false
which part of the labor assessment checks the following:
- fetal presentation – cephalic, breech, transverse
- cervix – posterior, midposition, anterior
- dilation – 0-10 cm
- effacement – 0-100% thick to thin
- station -5 0 +5
sterile vaginal exam (SVE)
cervix dilation
cervix effacement
0-100%
0-10 cm
cervix dilation 0-10 cm
cervix effacement 0-100%
3 skull measurements-
- _____________ diameter (head measurement side to side) – largest transverse diameter of the fetal skull
- ________ diameter (head measurement front to back)
- _____________ - distance around the widest part of the baby’s head.
OFD occipito frontal diameter, BPD biparietal diameter, head circumference
- BPD biparietal diameter (head measurement side to side) – largest transverse diameter of the fetal skull
- OFD occipito frontal diameter (head measurement front to back)
- HC head circumference
what 3 parts make up the 3 letters in the fetal positions?
_ _ _
1st letter = is the fetal present part closest to moms right pelvis or left pelvis? (R,L)
2nd letter = what is the presenting fetal part? (O, M, S, A)
3rd letter = is the fetal presenting part closer to moms anterior or posterior side or is it transverse? (A, P, T)
fetal positions: ROA
what does R stand for?
fetal positions: LOP
what does L stand for?
1st letter = is the fetal present part closest to moms right pelvis or left pelvis? (R,L)
fetal positions: ROA
what does O stand for?
fetal positions: LMA
what does M stand for?
fetal positions: LSA
what does S stand for?
fetal positions: RAP
what does A stand for?
2nd letter = what is the presenting fetal part? (O, M, S, A)
- Occiput – back of head
- Mentum – chin
- Sacrum – butt
- Acromion process – scapula/shoulder
fetal positions: ROA
what does A stand for?
fetal positions: LOP
what does P stand for?
fetal positions: LOT
what does T stand for?
3rd letter = is the fetal presenting part closer to moms anterior or posterior side or is it transverse? (A, P, T)
fetal position ?
which quadrant would fetal heart beat be found?
ROA
LRQ
fetal position?
which quadrant would fetal heart beat be found?
ROP
LRQ
fetal positions (2)?
which quadrant would fetal heart beat be found?
LOA, LOT
LLQ
fetal positions (2)?
which quadrant would fetal heart beat be found?
LSA, LSP
ULQ
fetal positions (2)?
which quadrant would fetal heart beat be found?
RMP, LMA
LLQ, RLQ
