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ATI birth process
exam 2 material
| Question | Answer |
|---|---|
| An intrapartum nurse should care for three clients during each labor and delivery | fetus, mother, family unit |
| Physiologic changes that preceed labor: | backache, lightening, weight loss, contactions, bloody show, energy burst, rupture of membrances |
| bloody show | a brownish, or blood tinged mucus discharge caused by expulsion of the cervical plug resulting in the onset of cervial dialtion and effacement |
| Weight loss that preceeds labor: | 1-3 lbs |
| Rupture of membranes | labor usually occurs w/in 24 hours of the rupture, prolonged rupture greater than 24 hrs before delivery may lead to infection, a nurse should immediately assess FHR for abrupt decelerations, |
| Amniotic fluid should be | pale to straw color, not foul smelling, watery and clear, 500 and 1200 ml, and turn nitrazine paper blue 6.5 to 7.5 ph. |
| What are the 5 Ps defining labor | passenger, passageway, powers, position, psychologic response |
| lie | the relationship of the maternal longitudinal axis to the fetal longitudinal axis |
| Transverse lie | fetal long axis is horizontal and forms a right angle to the maternal axis nd will not accomadate birth vaginally |
| parallel or longitudinal lie | fetal long axis is parallel to maternal long axis either a cephalic or breech presentation. |
| Attitude | relationship of fetal body parts to one another |
| fetal flexion | chin flexed to chest, extremities flexed into torso |
| fetal extension | chin extended away from chest, extremities extended |
| Presentation | the part of the fetus that is entering the pelvic inlet first, it can be the back of the head, chin shoulder or breech. |
| occiput | head |
| mentum | chin |
| breech | sacrum or feet |
| fetopelvic or fetal position | the relationship of the presenting part of the fetus, preferably the occiput, in reference toits directional position as it relates to one of the four maternal pelvic quadrants. It is labeled with three letters. |
| First letter of fetopelvic position | references either the right of left side of the maternal pelvis |
| the second letter references of fetopelvic position | presenting part of the fetus, either occiput O, sacrum S, mentum M, or scapula |
| The third letter of fetopelvic position references | either anterior A posterior P or transverse part of the maternal pelvis |
| If you have a ROA, then | right quadrant, occiput presenting anteriorally |
| Station | measurement of fetal descent in centimeters with station 0 being the imaginary line at the level of the ischial spines. Minus stations are superior and plus stations are inferior to the ischial spines |
| Passageway | the birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and intoitus (vaginal opening) |
| Powers | uterine contractions cause effacement and dilation of the cervix, and descent of the fetus |
| Position | of the woman who is in labor. The client should engage in frequent positions changes during labor to increase comfort, relieve fatigue, and promote circulation. |
| Gravity can | aid in the fetal descent in upright, sitting kneeling an squatting positions |
| Physiological response | maternal strss, tension, and anxiety can produce physilogical changes that impair the progress of labor |
| Preporcedure of labor includes: | leopold maneuvers, tocotransducer, EFM, urinalisis, blood tests, client education |
| Leopold manuevers | abdominal palpations of the number of fetuses, the fetal presenting part, and probable location where fetal heart tones may be best auscultated on the woman's abdomen. |
| esternal electronic monitoring (tocotransducer) | seperate transducer applied to the maternal abdomen over the fundus that measures uterine activity. displays contractions, applied by nurse, may be adjusted for maternal movement |
| External Fetal Monitoring EFM | applied to the abdomen of the client to asssess FHR patterns during labor and birth |
| Laboratory analysis includes | blood and urine tests |
| urinalysis | clean catch urine samples, determines hydration, nutrional status, proteinuria, UTIs and beta strep cultures |
| Blood tests include | HCT and ABO and Rh factor |
| intraproceedure from labor and birth process | assess maternal vital signs, FHR, uterine contractions via palpation or monitoring, insert a solid water filled intrauterine pressure catheter to determine pressure |
| Once membranes are ruptured check maternal temp every | 1-2 hrs |
| check contractions for | intensity, duration and frequency |
| a prolonged contraction duration or too frequent contractions without sufficient time for uterine relacation in between can | reduce blood flow to the placenta and lead to fetal hypoxia and decreased FHR |
| cervical dilation | stretching of the cervical os adequate to allow fetal passage and effacement |
| vaginal examination consists of | cervical dilation, descent of the fetus, fetal position, presenting part and lie and membranes intact or not |
| True labor S/S | contractions become regular, stronger, last longer and are more frequent, felt in lower back radiating to the abdomen, walking can increase constraction intensity, continue despite comfort measures, progressive change in dilation and effacment... |
| False labor S/S | painless, irregular, decrease in frequency, duration, and intensity, with walking or position changes, felt in lower back or abdomen above umbilicus, often stop with sleep or comfort measures such as hydration or peeing, no significant change indilation. |
| engagement | occurs when the presenting part usually biparietal (largest) passes the pelvic inlet |
| descent | the progress of the presenting part |
| flexion | when the fetal head meets resistance of the cervix , pelvic wall or pelvic floor. the head flexes bringing the chin closeto the chest pesenting a smaller diameter to pas through the pelvis |
| internal rotation | the fetal occiput ideally rotates to a lateral anterior position as it progresses from the ischial spines to the lower pelcis in a corkscrew motion to pass through pelvis |
| extension | the fetal occiput passes under the symphysis pubis and then the head is deflected anteriorly and is born by extension of the chin away from the fetal chest |
| Restitution and external rotation | after the head is born, it rotates to the position it occupied as it entered the pelvic inlet in alighment with the fetal body and completes a quarter turn to face transverse as the anterior shoulder passes under symphysis |
| expulsion | after birth of the head and shoulder the trunk of the neonate is born by flexing it toward the symphysis pubis |
| stages of labor | first second third and fourth |
| first stage consists of | latent phase, active and transition |
| latent phase | some dilation and effacment, cervix is 0 cm to 3cm, irregular and mild to mod contractions, frequency is 5-30 min for a duration of 30-45 seconds |
| active phase | cervix 4-7 cm, rapid dilation and effacement, some fetal descent, feelings of helplessness, anxiety, mod- strong contractions 3- 5 minutes and lasting 40-70 seconds |
| trasition phase | cervix 8-10 cm, N/V and feelings of not being able to continue, strong to very strong contactions 2-3 minutes for 45-90 seconds |
| second stage | birth, full dilation, intense contractions 1-2 minutes |
| third stage | delivery of placenta |
| Schultze | shiny part first in delivery of placenta |
| Duncan | dull part first in the delivery of placenta |
| fourth stage | achievement of vital sign homeostasis |
| Nursing assessments in the fourth stage | maternal vital signs, fudus, lochia, perineum, urinary output, maternal and newborn bonding activities |
| during the first hour the nurse will assess vitals, fundus and lochia every | 15 minutes and then according to facility protocl |
| When can an epidural be administered | first active stage |
| when can a spinal block be administered | second stage |
| to counteract the pain in the lower back you can | apply sacral counterpressure |
| sacral counterpressure | consistent pressure applied by the support person using the heel of the hand or fist against the client's sacral area |
| A normal fetal hear rate is | 110-160 /min |
| each uterine contraction is comprised of | increment, acme, decrement |
| increment is | the begining of the contraction as intensity is increasing |
| acme | the peak intensity of the contraction |
| decrement | the decline of the contracion intensity as the contraction is ending |
| fetal bradycardia (<110 for more than 10 minutes)can be caused by | uteroplacental insufficiency, cord prolapse, congenital heart block, anesthetic meds, maternal hypotension |
| nursing interventions for fetal bradycardia <110 for more than 10 minutes | discontinue pitocin, side lying position, administer o2, start an IV line, administer tocolytic meds as prescribed, stimulate fetal scalp, notify provider |
| fetal tachycardia >160 for 10 min or more can be caused by | maternal infection, fetal anemia, Fetal HF or dysrythmias, maternal use of cocaine or dehydration |
| fetal tachycardia interventions | administer pyretics, o2, bolus of IV fluids |
| Decrease or loss of FHR caused by | meds that depress CNS, fetal hypoxia, fetal sleep cycle, congenital abnormalities |
| decrease or loss of FHR actions by nurse | stimulate fetal scalp, assist primary care provider with application of calp electrode or fetal pH blood sampling, porision client in the left lateral position |
| Early decelerations | comproseeion of the fetal head in contraction |
| late decelerations | uteroplacental insufficiency causing inadequate fetal oxygentation |
| Early deceleration interventions | no action required |
| variable decelerations | unbilical cord compression, short cord, prolapsed cord, nuchal cord |
| actions in variable decelerations | change the clients position, discontinue osytocin, admin O2 mask, perform assist with a vaginal examination, assist with amnioinfusin if ordered |
Created by:
Hoopster