HESI p. 216-223 Intrapartum nursing care | 41 Expert curated questions and answers | verified for accuracy | 100% accuracy | Pass Guarantee

first stage of labor

from the beginning of regular contractions or ROM to 10 cm of dilatation and 100% effacement.

second stage of labor

10 cm to delivery of the fetus.

third stage of labor

delivery of the fetus to delivery of the placenta

fourth stage of labor

arbitraily lasts about 2 hours after delivery of placenta (recovery).

true labor

pain lower back that radiates to abdomen, pain accompanied by regular rhythmic contractions, contractions that intensify with ambulation, progressive cervical dilatation and effacement.

false labor

discomfort localized in abdomen, no lower back pain, contractions decrease in intensity or frequency with ambulation.

prodromal labor signs

ligenting (fetus drops into true pelvis), braxton. hicks contractions (practice contractions), cervical softening and slight effacement, bloody show or expulsion of mucous plug, burst of energy "nesting instict"

nursing assessment in intrapartum nursing care

gravidity and parity >5 (grand multiparity), gestational age 38-40 weeks (term gestation), FHR best heard over fetal back, maternal vital signs, contraction frequency, intensity and duration.

vaginal examination is done to determine

cervical dilation (cervix opens from 0-10 cm), cervical effacement (cervix is taken up into the upper uterine segment, expressed in percentages from 0-100 %, cervix is shortened from 3 cm to <0.5 cm in length, often called thinning of the cervix, which is a misnomer Cervical position ( cervix can be directly anterior and palpated easily, or can be posterior and difficult to palpate. cervical consistency (firm to soft), fetal station (location of presenting part in relation to midpelvis or ischial spines , expressed as cm above or below the spines. Fetal presentation (part of the fetus that presents to the inlet)

assess the client for:

status of membranes (ruptured or intact), urine glucose and albumin data, comfort level, labor and delivery preparation, presence of support person, presence of true or false labor

latent phase

first stage of labor, from beginning of true labor until 3-4 cm of cervical dilation. responses may be mildly anxious, conversant, able to continue usual activities, contractions mild, initially 10-20 minutes apart, 15-20 sec duration, later 5-7 minutes apart, 30-40 sec duration

active phase

first stage of labor from 4-7 cm cervical dilatation, increased anxiety, increased discomfort, may be unwilling to be left alone, contractions moderate to severe, 2-3 min apart 30-60 sec duration

transition stage of labor

first stage of labor, from 8-10 cm cervical dilation. Changed behavior, sudden nausea, hiccups, extreme irritability and unwillingness to be touched, although desirous of companionship, contractions severe, 1.5 minutes apart, 60-90 second duration

leopold maneuvers

abdominal palpations used to determine fetal presentation, lie , position and engagement.

station 0

engaged

station -2

2 cm above the ischial spines

vertex

fetal presentation, (head, cephalic)

shoulder

fetal presentation (acromion)

breech

fetal presentation (buttocks)

fetal position

the relationship of the point of reference on the fetal presentation part to the mother's pelvis

fetal lie

the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother it can be longitudinal, transverse, or oblique

fetal attitude

relationship of the fetal parts to one another (flexion or extension, but flexion is desirable because the smallest diameters of the presenting part move through the pelvis.

if membranes or bag of waters has ruptures

nitrazine paper turns black or dark blue, vaginal fluid ferns under microscope, color and amount of amniotic fluid should be noted. Woman should be allowed to ambulate during labor only if the FHR is within a normal range and if the fetus is engaged (zero station). If the fetus is not engaged, there is an increased risk that a prolapsed cord will occur.

meconium stained fluid

yellow green or gold yellow and may indicate fetal stress.

respiratory alkalosis

caused by hyperventilation (blowing off too much CO2), symptoms include dizziness, tingling of fingers, stiff mouth.

second stage of labor signs

involuntary need to push, 10 cm of cervical dilation, rapid fetal descent and birth. averages 1 hour for primigravida, 15 minutes for multipara.

nursing assessment during second stage of labor

assess BP and pulse every 5-15 minutes, determine FHR with every contraction, observe perineal area for the following (increased bloody show, bulging perineum and anus, visibility of presenting part), palpate bladder for distention, assess amniotic fluid for color and consistency.

nursing plans and interventions during second stage of labor

document maternal BP and pulse every 15 minutes between contractions, check FHR with each contraction or by continuous fetal monitoring, continue comfort measures (mouth care, linen change, positioning), decrease outside distractions, teach mother positions such as squatting, side lying or high fowler/lithomy for pushing, teach mother to exhale when pushing or use gentle pushing technique, set up delivery table, perform perineal cleansing, make sure client and support person can visualize delivery if they desire, record exact delivery time.

gentle pushing technique

pushing down on vagina while constantly exhaling through open mouth, taught during second stage of labor.

what happens if pushing begins too early?

cervix should be completely dilated (!0 cm) before the client begins pushing. If pushing starts too early the cervix can become edematous and never fully dilate.

third stage of labor definition

from compe expulsion of the baby to complete expulsion of the placenta. Average third stage of labor is 5-15 minutes, the longer the third stage of labor, the greater the chance for uterine atony or hemorrhage to occur.

nursing assessment third stage of labor

signs of placental separation, mother describes a full feeling in vagina, firm uterine contractions continue

signs of placental separation

third stage of labor, lengthening of umbilical cord outside vagina, gush of blood, uterus changes from oval to globular.

when is oxytocin (pitocin) given?

after the placenta is delivered because the drug will cause the uterus to contract. If it is administered before the placenta is delivered, it may result in retained placenta, which predisposes the client to hemorrhage and infection

fourth stage of labor definition

first 1-4 hours after delivery of placenta

nursing assessment fourth stage of labor

review antepartum and labor and delivery records for possible complications

possible complications- fourth stage of labor

postpartum hemorrhage, uterine hyperstimulation, uterine overdistention, dystocia, antepartum hemorrhage, MgSO4 therapy, bladder distention, routine postpartum physical assessment, mother infant bonding.

first degree perineum tear

involves only the epidermis

second degree perineum tear

involves dermis, muscle and fascia.

third degree tear

extends into anal sphincter

fourth degree tear

extends up the rectal mucosa.