OB ATI: Chapter 14 – Nursing Care During Stages of Labor – Flashcards

☐ Conduct an admission history, review of antepartum care, and review of the birth plan. ☐ Obtain laboratory reports. ☐ Monitor baseline fetal heart tones and uterine contraction patterns for 20 to 30 min. ☐ Obtain maternal vital signs. ☐ Check the status of the amniotic membranes. ◯ Perform maternal and fetal assessments continuously throughout the labor process and immediately after birth. ◯ Avoid vaginal examinations in the presence of vaginal bleeding or until placenta previa or placenta abruptio is ruled out. If necessary, vaginal examinations should be done by the provider. ◯ Cervical dilation is the single most important indicator of the progress of labor. ◯ The progress of labor is affected by fetal lie, presentation, attitude, and fetal size in relationship to the mother's pelvis. ◯ The frequency, duration, and strength (intensity) of the uterine contractions cause fetal descent and cervical dilation.

◯ Leopold maneuvers performed ◯ Perform a vaginal examination as indicated (if no evidence of progress) to allow the examiner to assess whether client is in true labor and whether membranes have ruptured. ■ Encourage the client to take slow, deep breaths prior to the vaginal exam. ■ Monitor the cervical dilation and effacement. ■ Monitor the station and fetal presentation. ■ Prepare for an impending delivery as the presenting part moves into positive stations and begins to push against the pelvic floor (crowning).

■ When there is suspected rupture of membranes, the nurse should first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid. ■ Verify presence of alkaline amniotic fluid using nitrazine paper (turns blue, pH 6.5 to 7.5). ■ A sample of the fluid may be obtained and viewed on a slide under a microscope. Amniotic fluid will exhibit a frondlike ferning pattern. Assess the amniotic fluid for color and odor: clear, straw color, and free of odor. Abnormal findings include the presence of meconium, abnormal color (yellow or port wine), a foul odor.

prevent bladder distention, which can impede fetal descent through the birth canal and cause trauma to the bladder. ■ Clients may not feel the urge to void secondary to the labor process or anesthesia. ■ Encourage the client to void frequently.

4 hr (every 1 to 2 hr if membranes have ruptured)

◯ Provide teaching to the client and her partner about what to expect during labor and on implementing relaxation measures: breathing (deep cleansing breaths help divert focus away from contractions), effleurage (gentle circular stroking of the abdomen in rhythm with breathing during contractions), diversional activities (distraction, concentration on a focal point, or imagery). ◯ Encourage upright positions, application of warm/cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort. ◯ Encourage voiding every 2 hr. ■ During first stage, active phase of labor ☐ Provide client/fetal monitoring. ☐ Encourage frequent position changes. ☐ Encourage voiding at least every 2 hr. ☐ Encourage deep cleansing breaths before and after modified paced breathing. ☐ Encourage relaxation. ☐ Provide nonpharmacological comfort measures. ☐ Provide pharmacological pain relief as prescribed. ■ During first stage, transition phase of labor ☐ Continue to encourage voiding every 2 hr. ☐ Continue to monitor and support the client and fetus. ☐ Encourage a rapid pant-pant-blow breathing pattern if the client has not learned a particular breathing pattern. ☐ Discourage pushing efforts until the cervix is fully dilated. ☐ Listen for client statements expressing the need to have a bowel movement. This sensation is a sign of complete dilation and fetal descent. ☐ Prepare the client for the birth. ☐ Observe for perineal bulging or crowning (appearance of the fetal head at the perineum). ☐ Encourage the client to begin bearing down with contractions once the cervix is fully dilated.

◯ Blood pressure, pulse, and respiration measurements every 5 to 30 min ◯ Uterine contractions ◯ Pushing efforts by client ◯ Increase in bloody show ◯ FHR every 15 min and immediately following birth ◯ Assessment for perineal lacerations, which usually occur as the fetal head is expulsed. Perineal lacerations are defined in terms of depth. ■ First degree - Laceration extends through the skin of the perineum and does not involve the muscles. ■ Second degree - Laceration extends through the skin and muscles into the perineum. ■ Third degree - Laceration extends through the skin, muscles, perineum, and anal sphincter muscle. ■ Fourth degree - Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall.

◯ Continue to monitor the client/fetus. ◯ Assist in positioning the client for effective pushing. ◯ Assist in partner involvement with pushing efforts and in encouraging bearing down efforts during contractions. ◯ Promote rest between contractions. ◯ Provide comfort measures such as cold compresses. ◯ Cleanse the client's perineum as needed if fecal material is expelled during pushing. ◯ Prepare for episiotomy, if needed. ◯ Provide feedback on labor progress to the client. ◯ Prepare for care of neonate. A nurse trained in neonatal resuscitation should be present at delivery. ■ Check oxygen flow and tank on warmer. ■ Preheat radiant warmer. ■ Lay out newborn stethoscope and bulb syringe. ■ Have resuscitation equipment in working order (resuscitation bag, laryngoscope) and emergency medications available. ■ Check suction apparatus.

◯ Blood pressure, pulse, and respiration measurements every 15 min ◯ Signs of placental separation from the uterus as indicated by ■ Fundus firmly contracting ■ Swift gush of dark blood from introitus ■ Umbilical cord appears to lengthen as placenta descends ■ Vaginal fullness on exam ◯ Assignment of 1 and 5 min Apgar scores to the neonate

◯ Instruct the client to push once signs of placental separation are indicated. ◯ Promote baby-friendly activities between the family and the newborn, which facilitates the release of endogenous maternal oxytocin. ◯ Administer analgesics as prescribed. ◯ Administer oxytocics once the placenta is expulsed to stimulate the uterus to contract and thus prevent hemorrhage. ◯ Gently cleanse the perineal area with warm water or 0.9% sodium chloride, and apply a perineal pad or ice pack to the perineum.

◯ Maternal vital signs ◯ Fundus ◯ Lochia ◯ Urinary output ◯ Baby-friendly activities of the family

◯ Assess maternal vital signs every 15 min for the first hour and then according to facility protocol. ◯ Assess fundus and lochia every 15 min for the first hour and then according to facility protocol. ◯ Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and to prevent hemorrhage. ◯ Encourage voiding to prevent bladder distention. ◯ Promote an opportunity for parental-newborn bonding.

C

A, D, E

B

D

D