5. First Stage Assessments

why ask the estimated date of birth during a labor phone assessment?

to determine gestational age and whether possible labor is preterm or term

things to ask in a phone assessment

• estimated due date

• fetal movement + frequency

• premonitory signs of labor

• parity, gravida, previous birth experiences

• time frame in previous labors

• characteristics of contractions

• bloody show and membrane status

• presence of supportive adult in household or if solo

what should the nurse advise when a patient reports signs of preterm labor?

prompt in-person evaluation

what should a patient do if she thinks her membranes have ruptured?

contact the maternity provider and come in for evaluation

• do not wait for stronger contractions

what should the nurse do when admitting a patient in labor?

• obtain the admission history

• review routine and special test results

• ask about the childbirth plan

• complete a physical assessment

what is a childbirth plan?

the patient’s documented preferences for labor and birth, including what she wants and does not want

order of admissions assessment

1. maternal health history

2. physical assessment: body systems, vitals, heart and lung sounds, height and weight

3. pregnancy assessment

4. fetal assessment

5. labs

6. psychological status

parts of pregnancy assessment on admission

• fundal height measurement

• uterine activity (contractions)

• status of membranes (intact/ruptured)

• cervical dilation

• degree of effacement

• FHR, position, station

• pain level (always)

what is fundal height?

the distance (cm) from the symphysis pubis to the top of the uterus

• helps assess fetal growth and whether size is consistent with gestational age

x

contraction frequency, duration, and intensity;membrane status;cervical dilation and effacement

what fetal findings should the nurse assess on admission?

• fetal heart rate baseline

• variability, accelerations, and decelerations

• fetal position & station

labs taken on admission

• urinalysis, CBC

• syhpilis screening. HIV (w/ consent), GBS, hepatitis B surface antigen (HBsAg)

• possible drug screening if not in prenatal hx

what findings are checked in the urine during labor admission?

protein, ketones, nitrites (UTI), glucose

what should the nurse assess about the patient’s psychological status during labor?

anxiety, emotional support, and ability to cope

why assess the patient’s knowledge, experience, and expectations during labor?

to tailor explanations, support, and care to her needs

what should the nurse assess about amniotic fluid during labor?

color, odor, amount

• clear fluid is expected

• blood, meconium, or a foul odor requires evaluation

tests for ruptured membranes

• fern test

• nitrazine papers

what can cause a false-positive nitrazine result?

blood contamination

• interpret the result with the other findings