Term
| List Five prodromal signs of labor the nurse might teach the client |
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Definition
| Lightening, braxton hicks contraction, increased bloody show, loss of mucous plug, burst of energy, and nesting behaviors |
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Term
| How is true labor discriminated from false labor? |
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Definition
True labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back and cervical changes!
False Labor: Irregular rhythm, abdominal pain(not in back)that decreases with ambulation |
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Term
| State two ways to determine whether the membranes have truly ruptured? |
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Definition
| Nitrazine testing: paper turns dark blue or black; Demonstration of fluid ferning under microscope |
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Term
| Are psychoprophylactic breathing tech. prescribed for use according to the stage and phase of labor? |
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Definition
| No. Clients should use theses tech. according to their discomfort level and should change techn. when one is no longer working for relaxation. |
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Term
| Identify two reasons to withhold anesthesia and analgesia until the midactive phase of stage 1 labor. |
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Definition
| If analgesia and anesthesia are given too early, they can retard labor; if given too late, they can cause fetal distress |
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Term
| Hyperventilation often occurs in the laboring client. What results from hyperventilation, and what actions should the nurse take to relieve the condition? |
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Definition
| Respiratory alkalosis occurs; it is caused by blowing off CO2 and is relieved by breathing into a paper bag or cupped hands |
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Term
| Describe the maternal changes that characterize the transition phase of labor |
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Definition
| Irritability and unwillingness to be touched, but does not want to be left alone; Nausea Vomiting and hiccupping |
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Term
| When should a laboring client be examined vaginally? |
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Definition
| Vaginal exams should be done prior to analgesia and anesthesia to rule out cord prolapse, to determine labor progress if it is questioned, and to determine when pushing can begin |
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Term
| Define cervical effacement |
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Definition
| The taking up of the lower cervical segment into the upper segment; the shortening of the cervix expressed in percentages from 0 to 100% or complete effacement |
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Term
| Where is the fetal heart rate best heard? |
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Definition
| Through the fetal back in vertex; OA positions |
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Term
| Normal Fetal HR during labor is? |
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Definition
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Term
Normal Maternal BP during labor is?
Normale maternal pulse during labor is?
Normal Maternal Temperature during labor is? |
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Definition
| less than 140/90; less than 100 bpm; less than 100.4*F |
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Term
| List four nursing actions for the second stage of labor |
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Definition
| Make sure cervix is completely dilated before pushing is allowed. Assess FHR with each contraction. Teach woman to hold breath for no longer than 10 secs. Teach pushing Technique. |
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Term
| List three signs of placental separation |
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Definition
| Gush of blood, lengthening of cord, and Globular shape of uterus |
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Term
| When should the postpartum dosage of pitocin be admin? why is it admin? |
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Definition
| Give immediately after placenta is delivered to prevent postpartum hemorrhage and atony |
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Term
| State one contraindication to the use of ergot drugs (Methergine). |
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Definition
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Term
| State five symptoms of respiratory distress in the newborn. |
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Definition
| Tachypnea, dusky color, flaring nares, retractions, and grunting |
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Term
| If meconium was passed in utero, what action must the nurse take in the delivery room? |
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Definition
| arrange for immediate endotracheal tube observation to determine the presence of meconium below the vocal cords (prevents pneumonitis and meconium aspiration syndrome) |
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Term
| What is considered a good Apgar score? |
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Definition
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Term
| What is the purpose of eye prophylaxis in the newborn? |
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Definition
| To prevent ophthalmia neonatrum; which results from exposure to gonorrhea in the vagina |
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Term
| What is the danger associated with regional block? |
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Definition
| Hypotension resulting from vasodilation below the block, which pools blood in the periphery, reducing venous return |
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Term
| What is the major cause of maternal death when general anesthesia is admin? |
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Definition
| Aspiration of Gastric contents |
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Term
| Why are PO meds avoided during labor? |
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Definition
| Gastric activity slows or stops in labor, decreasing absorption from PO route; it may cause vomiting |
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Term
| State the best way to admin IV drugs during labor? |
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Definition
| At beginning of contraction, push a little medication in while uterine blood vessels are constricted, thereby reducing dose to fetus |
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Term
| When is it dangerous to admin butorphanol (Stadol), an agonist/antagonist narcotic? |
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Definition
| When the client is an undiagnosed drug abuser of narcotics, it can cause immediate withdrawal symptoms |
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Term
| Hypotension commonly occurs after the laboring client receives a regional block. What is one of the first signs the nurse might observe? |
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Definition
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Term
| State three actions the nurse should take when hypotension occurs in a laboring client? |
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Definition
| Turn client to Left side; Admin 02 by mask at 10L/min; Increase spped of intravenous infusion (if it does not contain medicine) |
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Term
| The fourth state is defined as: |
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Definition
| The first 1 to 4 hours after delivery of the placenta |
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Term
| What actions can the nurse take to assist in preventing postpartum hemorrhage? |
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Definition
| Massage the fundus (gently) and keep the bladder emptied |
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Term
| To promote comfort, what nursing interventions are used for a third-degree episiotomy, which extends into the anal sphincter? |
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Definition
| Ice pack, witch hazel compresses; and no rectal manipulation |
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Term
| What nursing interventions are used to enhance maternal-infant bonding during the fourth stage of labor? |
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Definition
| Withhold eye prophylaxis for up to 2 hours, perform newborn admission and routine procedures in room with parents. encourage early initiation of breastfeeding. Darken room to encourage newborn to open eyes |
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Term
| List three nursing interventions to ease the discomfort of afterpains. |
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Definition
| Keep bladder empty. Provide warm Blanket for abdomen. Admin analgesics prescribed by HCP |
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Term
| List the symptoms of a full bladder that might occur in the fourth stage of labor |
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Definition
| Fundus above umbilicus; dextroverted (to the right side of abdomen); increased bleeding (uterine atony) |
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Term
| What action should the nurse take first when a soft, boddy uterus is palpated? |
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Definition
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Term
| What are the symptoms of hypovelmic shock? |
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Definition
| Pallor, Clammy skin, tachycardia, lightheadedness, hypotension |
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Term
| How often should the nurse check the fundus during the fourth stage of labor? |
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Definition
| Every 15 minutes for 1 hour; every 30 mins for 2 hours if normal |
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