Chapter 14: Nursing Care During Stages of Labor

What are the four stages of labor?

First stage, Second stage, Third stage, and Fourth stage.

What occurs during the first stage of labor?

From the onset of regular contractions until complete cervical dilation (10 cm).

What occurs during the second stage of labor?

From complete cervical dilation until the birth of the baby.

What occurs during the third stage of labor?

From birth of the baby until delivery of the placenta.

What occurs during the fourth stage of labor?

Recovery period during the first 2 hours after delivery of the placenta.

What should the nurse assess before admitting a laboring client?

Labor status, antepartum history, birth plan, fetal heart rate, contractions, maternal vital signs, and membrane status.

When should vaginal examinations be avoided?

When vaginal bleeding is present or placenta previa/abruption has not been ruled out.

What is the most important indicator of labor progress?

Cervical dilation.

What factors affect labor progress?

Fetal head size, presentation, lie, attitude, position, and uterine contractions.

What is the latent phase of labor?

0-5 cm cervical dilation.

What is the active phase of labor?

6-10 cm cervical dilation.

Describe contractions during the latent phase.

Irregular, mild to moderate, every 5-30 minutes, lasting 30-45 seconds.

Describe contractions during the active phase.

Regular, moderate to strong, every 2-5 minutes, lasting 60-90 seconds.

What maternal behaviors are common during the latent phase?

Talkative, calm, able to walk and talk through contractions.

What maternal behaviors are common during the active phase?

Serious, inward focused, anxious, irritable, severe pain, nausea, vomiting, urge to push.

What assessment should always be performed first if membranes rupture?

Assess the fetal heart rate.

Why is fetal heart rate assessed first after rupture of membranes?

To detect umbilical cord prolapse.

What test uses nitrazine paper?

Testing for rupture of membranes.

What color does nitrazine paper turn if amniotic fluid is present?

Blue.

What pH indicates amniotic fluid on nitrazine testing?

6.5-7.5.

What test identifies a ferning pattern?

Microscopic examination of amniotic fluid.

What is the normal appearance of amniotic fluid?

Clear or straw-colored with no odor.

What abnormal findings may be present in amniotic fluid?

Meconium, yellow or green color, or foul odor.

Why should laboring clients void frequently?

A distended bladder decreases pelvic space and can slow fetal descent.

How often should maternal temperature be checked during labor?

Every 4 hours, or every 2 hours if membranes have ruptured.

What nonpharmacologic comfort measures can be used during labor?

Breathing techniques, effleurage, imagery, distraction, ambulation, hydrotherapy, warm or cold packs.

What breathing technique is encouraged during active labor?

Slow breathing with prolonged inhalation and exhalation.

When should pushing be discouraged?

Until the cervix is fully dilated.

What indicates complete cervical dilation?

The client's uncontrollable urge to push.

What is crowning?

The appearance of the baby's head at the perineum.

What begins the second stage of labor?

Complete cervical dilation and effacement.

How often should fetal heart rate be assessed during the second stage?

Every 5-15 minutes.

What is a first-degree perineal laceration?

Involves only the skin of the perineum.

What is a second-degree perineal laceration?

Involves skin and perineal muscles but not the anal sphincter.

What is a third-degree perineal laceration?

Extends through the anal sphincter.

What is a fourth-degree perineal laceration?

Extends through the rectal wall.

What nursing actions promote effective pushing?

Assist positioning, encourage pushing with contractions, allow rest between contractions, and provide feedback.

Why should a nurse trained in neonatal resuscitation be present during birth?

To provide immediate newborn resuscitation if needed.

What should be prepared before birth for the newborn?

A preheated radiant warmer.

What begins the third stage of labor?

The birth of the newborn.

What ends the third stage of labor?

Delivery of the placenta.

What are the three classic signs of placental separation?

Lengthening of the umbilical cord, gush of dark blood, and a firm globular fundus.

When should the client push during the third stage?

After signs of placental separation appear.

Why is oxytocin administered after delivery?

To stimulate uterine contractions and prevent postpartum hemorrhage.

What baby-friendly activities should occur immediately after birth?

Skin-to-skin contact, breastfeeding, bonding, and private family time.

What begins the fourth stage of labor?

Delivery of the placenta.

How long does the fourth stage last?

At least the first 2 hours postpartum.

What assessments are priorities during the fourth stage?

Vital signs, fundus, lochia, urinary output, perineum, and bonding.

How often should blood pressure and pulse be assessed during the first 2 hours postpartum?

Every 15 minutes.

How often should the fundus and lochia be assessed during the first hour postpartum?

Every 15 minutes.

How often should the fundus and lochia be assessed during the second hour postpartum?

Every 30 minutes.

Why is the uterine fundus massaged after delivery?

To maintain uterine tone and prevent hemorrhage.

Why should the client void soon after delivery?

To prevent bladder distention and uterine displacement.

What should the nurse assess on an episiotomy or laceration repair?

Redness, healing, and signs of infection.

What is the expected fetal heart rate during labor?

110-160 beats/minute.

How often should fetal heart rate be monitored during the first stage?

Every 15-30 minutes.

How often should fetal heart rate be monitored during the second stage?

Every 5-15 minutes.

What is the priority nursing intervention for a laboring client with vaginal bleeding?

Defer vaginal examinations until placenta previa or abruptio placentae is ruled out.

What is the priority assessment when rupture of membranes is suspected?

Fetal heart rate.

What is the priority teaching during labor?

Relaxation techniques, breathing, frequent position changes, and avoiding pushing until fully dilated.