labor and birth

NRS 400

What is the top priority when a woman arrives at the birth center or hospital perinatal unit?

Assessment.

What does the initial screening assessment include?

Interview, physical assessment, and review of laboratory and diagnostic findings to determine maternal/fetal health and labor progress.

What contraction pattern suggests true labor?

Contractions are regular, progressively stronger, and closer together.

Do true-labor contractions continue despite comfort measures?

Yes.

What fetal finding supports true labor?

The presenting fetal part becomes engaged in the pelvis.

What cervical changes support true labor?

Progressive cervical softening, effacement, and dilation.

What contraction pattern suggests false labor?

Contractions are usually irregular and do not become stronger.

How do comfort measures affect false-labor contractions?

They often stop with comfort measures.

What fetal finding is typical of false labor?

The presenting part is usually not engaged in the pelvis.

What cervical changes occur in false labor?

No significant cervical changes.

What contraction details should be collected at labor triage?

When contractions began, their frequency, and their duration.

What membrane-rupture details should be collected at triage?

Time, amount, color, and odor of fluid.

How can rupture of membranes occur?

Spontaneously or artificially.

What happens to nitrazine paper in the presence of amniotic fluid?

It turns blue, indicating an alkaline result.

What can cause a false-positive nitrazine test?

Blood or semen.

What can cause a false-negative nitrazine test?

An insufficient amount of fluid.

How is the fern test performed?

Fluid is placed on a microscope slide, allowed to dry, and examined for a fern-like appearance.

What prenatal record information should the nurse review?

Gravidity/parity, gestational age/EDD, age, obstetric history, present pregnancy history, vital-sign and weight-gain patterns, allergies, fundal height, baseline FHR, and characteristics of previous births.

Which prenatal laboratory results are listed for review?

Blood type/Rh, CBC/Hgb, glucose tolerance testing, HBsAg, Group B Strep, HIV, rubella, VDRL/RPR/syphilis serology, gonorrhea/chlamydia, and type and screen.

What should be reviewed when a patient has a birth plan?

Birth companion and other visitors, environmental preferences, labor activities, medical interventions, comfort/relaxation measures, immediate newborn skin-to-skin, and cultural/religious requirements.

What is the nurse's role if the patient has no written birth plan?

Help the woman formulate a plan from available options.

What is the first item to establish during the patient interview?

The woman's primary reason for coming to the hospital.

What contraction details are explored during the patient interview?

Time and onset, intensity, frequency, and duration.

What discomfort information should be obtained during the labor interview?

Location and character of discomfort.

What vaginal and membrane information should be obtained during the labor interview?

Persistence of contractions, presence/character of vaginal show, and status of amniotic membranes.

Which allergies should be assessed during the labor interview?

Medication and latex allergies.

What preference should be asked about during the labor interview?

Preferred pain management.

What psychosocial cues help the nurse determine needed support?

General appearance and behavior, verbal interactions, body language, perceptual ability, and discomfort level.

Why should the nurse ask about psychosocial history relevant to labor?

Labor can trigger memories of sexual abuse in women with a history of sexual abuse.

What major concerns may contribute to stress during labor?

The childbirth process and its effects, maternal and fetal well-being, and the attitudes/actions of healthcare staff.

Who besides the laboring woman may experience stress?

The father, significant other, or coach.

Why should the nurse avoid judging pain by a woman's vocal behavior?

Cultural expectations range from silence to moaning or screaming and may not indicate the degree of pain.

How can cultural and religious background affect labor care?

It may influence behavior expectations and choice of birth companion.

Why can a language barrier increase anxiety during labor?

The woman may not understand what is being said and may experience loss of control.

What is included in the general systems assessment during labor?

Heart, lungs, skin, edema, DTRs, clonus if indicated, and weight.

Which vital signs are assessed during labor?

Temperature, pulse, respirations, and blood pressure.

Why are initial vital signs important during labor?

They establish a baseline for comparison with future measurements.

What questions do Leopold maneuvers help answer?

Which fetal part is in the uterine fundus, where the fetal back is located, and what the presenting part is.

What components of fetal heart assessment are included in the physical exam?

FHR and its pattern.

What uterine contraction characteristics should be assessed?

Frequency, duration, intensity (mild/moderate/strong), and resting tone.

What labor progress factors must be considered alongside uterine activity?

Cervical dilation, effacement, and degree of fetal descent.

What is assessed during a vaginal examination?

Cervical effacement, dilation, and fetal descent.

When should vaginal examinations be performed?

Only when indicated.

When does the first stage of labor begin and end?

It begins with regular uterine contractions and ends with full cervical dilation and effacement.

What are the three phases of the first stage of labor?

Latent, active, and transition.

What cervical dilation defines the latent phase in this lecture?

0–3 cm.

What contractions are typical in the latent phase?

Irregular, mild-to-moderate contractions 5–30 minutes apart, lasting 30–45 seconds.

What pain and behavior are typical in the latent phase?

Pain is fairly well controlled, often cramping or a low-back ache; the woman may be excited, happy, apprehensive, alert, and open to instructions.

What fetal station and vaginal show are listed for the latent phase?

0 station and a scant amount of show.

What duration is listed for the latent phase?

6–8 hours.

How often are maternal BP, pulse, respirations, FHR/pattern, uterine activity, and vaginal show assessed during latent labor?

Every 30–60 minutes.

How often are maternal appearance, mood, affect, energy, and partner/coach condition assessed during latent labor?

Every 30 minutes.

How often is temperature assessed during latent labor?

Every 2–4 hours; every 4 hours until membranes rupture, then every 2 hours.

When is a vaginal examination performed during latent labor?

As needed to identify labor progress.

What cervical dilation defines the active phase in this lecture?

4–7 cm.

What contractions are typical in the active phase?

Regular contractions 3–5 minutes apart, lasting 40–70 seconds, with moderate-to-strong intensity.

What fetal station is listed for the active phase?

+1 to +2 station.

What vaginal show is listed for the active phase?

Scant to moderate bloody show.

What behavior is typical in the active phase?

The woman may become more serious, apprehensive, fatigued, and doubtful of pain control; she may need more assistance with breathing and relaxation.

What duration is listed for the active phase?

3–6 hours.

How often are maternal BP, pulse, and respirations assessed during active labor?

Every 30 minutes.

How often are FHR/pattern, uterine activity, and vaginal show assessed during active labor?

Every 15–30 minutes.

How often are maternal appearance, mood, affect, energy, and partner/coach condition assessed during active labor?

Every 15 minutes.

What cervical dilation defines the transition phase?

8–10 cm.

What contractions are typical in transition?

Very strong, regular contractions 2–3 minutes apart, lasting 45–90 seconds.

How is the transition phase described?

The hardest but shortest phase.

What fetal station and vaginal show are listed for transition?

+2 to +3 station and copious bloody mucus.

What behaviors or symptoms may occur during transition?

Severe pain, frustration, irritability, loss of control, doubt, vague communication, amnesia between contractions, nausea/vomiting, shaking, and sweating.

What support may a woman need during transition?

Encouragement to focus; she may feel an urge to bear down, tolerate little distraction, and become adverse to touching.

How often are maternal BP, pulse, respirations, and FHR/pattern assessed during transition?

Every 15–30 minutes.

How often are uterine activity and vaginal show assessed during transition?

Every 10–15 minutes.

How often are maternal appearance, mood, affect, energy, and partner/coach condition assessed during transition?

Every 5 minutes.

How often is temperature assessed during transition according to the slide?

Every 2–4 hours.

How often should a laboring patient void during first-stage care?

Every 2 hours.

When may catheterization be used during first-stage labor?

As needed, between contractions.

What hygiene measures are listed during first-stage labor?

Shower/Jacuzzi, pericare, oral hygiene, face care, handwashing, and clean linens/gowns.

What bowel-related issue may occur during labor?

A sensation of rectal pressure.

What should the nurse do if rectal pressure is not from the presenting part?

Assist the woman to the bathroom; cleanse the perineum immediately after stool passage.

What types of supportive care are listed during labor and birth?

Emotional support, physical care/comfort measures, advice and information, partner support, and updates about labor progress.

What elements are included in emotional support during labor?

Presence, encouragement, reassurance, advocacy, and empowerment.

Who may provide continuous support during labor?

The nurse, father/partner, doula, grandparents, or siblings.

How can the nurse support a laboring woman?

Help her maintain control and participate, provide continuity, meet expectations, listen, advocate, support decisions, conserve energy, help cope with pain, control discomfort, and protect privacy.

What nursing diagnoses are listed for the first stage of labor?

Risk for injury (maternal/fetal), impaired fetal gas exchange, impaired urinary elimination, situational low self-esteem, acute pain, ineffective coping, and fatigue.

When does the second stage of labor begin?

At full cervical dilation (10 cm) and complete effacement (100%).

When does the second stage of labor end?

At the infant's birth.

What happens during the latent or 'laboring down' phase of second-stage labor?

Contractions may space out, the woman rests, and the fetus passively descends and rotates to an anterior position.

What nursing interventions support the latent second-stage phase?

Encourage the woman to listen to her body, assist with a comfortable position, encourage relaxation and energy conservation, recognize the natural rest period, and promote fetal descent.

What is Ferguson's reflex?

Stimulation activates a strong urge to push and triggers oxytocin release, which strengthens contractions.

What contraction pattern is listed during active second-stage labor?

Contractions may increase to every 2 minutes and last 90 seconds.

What behaviors may occur during active second-stage labor?

The woman becomes focused on bearing down; the urge to push intensifies, and she may be more vocal, scream, swear, or appear out of control.

What pushing method should the nurse encourage?

Open-glottis pushing, exhaling as the woman pushes.

What pushing method should the nurse discourage?

Prolonged breath-holding/closed-glottis pushing (Valsalva maneuver).

Why is open-glottis pushing encouraged?

It helps maintain adequate oxygen levels for the mother and fetus.

What can prolonged closed-glottis pushing cause?

Increased intrathoracic pressure, decreased cardiac output, and decreased uterine/placental perfusion.

What other nursing interventions are listed during active pushing?

Help change positions, promote relaxation and energy conservation between contractions, cleanse the perineum, provide emotional support and positive reinforcement, keep the woman informed, and offer a mirror.

How often are maternal BP, pulse, and respirations assessed in second-stage labor?

Every 5–30 minutes.

How often are FHR and pattern assessed in second-stage labor?

Every 5–15 minutes.

How often are vaginal show, fetal descent, maternal behavior/energy, and partner/coach condition assessed in second-stage labor?

Every 10–15 minutes.

What should be assessed with every contraction during second-stage labor?

The contraction and the woman's bearing-down effort.

What maternal positions are listed for preparing for birth?

Supine, semirecumbent, or lithotomy; the lecture notes that upright positioning shortens labor.