Chapter 11- Labor and Delivery Process

What are the three clients an intrapartum nurse cares for during labor and delivery?

Fetus, mother, family unit

What stage of labor begins with the onset of labor and ends with full cervical dilation?

First stage

What stage of labor includes pushing and fetal descent?

Second stage

What stage of labor includes delivery of the placenta?

Third stage

What stage of labor focuses on maternal stabilization and recovery?

Fourth stage

What cervical dilation range defines the latent/early phase of labor?

0-5 cm

What cervical dilation range defines the active phase of labor?

6-10 cm

During the latent phase, contractions occur how frequently?

Every 2-30 minutes

During the latent phase, contractions last how long?

30-40 seconds

During the active phase, contractions occur how frequently?

Every 1.5-5 minutes

During the active phase, contractions last how long?

40-90 seconds

Which labor stage is considered the most difficult part of labor?

Active phase

What placental presentation occurs when the shiny fetal side appears first?

Schultze presentation

What placental presentation occurs when the dull maternal side appears first?

Duncan presentation

What term describes a constant dull low backache before labor?

Backache

What prelabor sign involves a weight loss of 1-3.5 pounds?

Weight loss

What term describes fetal descent into the pelvis before labor?

Lightening

Approximately how long before labor does lightening occur in primigravidas?

14 days

What type of contractions occur before true labor begins?

Braxton Hicks contractions

What is the mucus and blood-tinged discharge that occurs before labor called?

Bloody show

What prelabor energy surge is commonly called?

Nesting

What process causes the cervix to soften and begin thinning before labor?

Cervical ripening

What event can occur at any point during labor and may initiate labor?

Rupture of membranes

Labor usually begins within how many hours after rupture of membranes?

24 hours

Rupture of membranes lasting longer than 24 hours increases risk for what?

Infection

What is the nurse's first action after rupture of membranes?

Check FHR

Abrupt fetal heart rate decelerations after membrane rupture may indicate what?

Cord prolapse

What test confirms the presence of amniotic fluid?

Nitrazine test

What color should nitrazine paper turn when amniotic fluid is present?

Blue

What pH characteristic does amniotic fluid have?

Alkaline

What color does nitrazine paper remain when testing urine?

Yellow

A client leaking fluid for 2 days is at risk for what complication?

Infection

Contractions that increase with activity and continue despite hydration indicate what?

True labor

What are the Five P's of labor?

Passenger, passageway, powers, position, psychological response

Which of the Five P's includes the fetus and placenta?

Passenger

Which of the Five P's refers to the birth canal?

Passageway

Which of the Five P's refers to uterine contractions?

Powers

Which of the Five P's refers to maternal positioning?

Position

Which of the Five P's refers to maternal emotions and stress?

Psychological response

What term describes the fetal part entering the pelvis first?

Presentation

What are the four common fetal presenting parts?

Occiput, mentum, scapula, sacrum

What term describes the relationship between maternal and fetal spines?

Lie

Which fetal lie is horizontal and usually requires cesarean birth?

Transverse lie

Which fetal lie is parallel to the maternal spine?

Longitudinal lie

What term describes the relationship of fetal body parts to one another?

Attitude

What fetal attitude has the chin tucked to the chest?

Flexion

What fetal attitude has the chin extended away from the chest?

Extension

What does the first letter in a fetal position abbreviation represent?

Maternal side

What does the second letter in a fetal position abbreviation represent?

Presenting part

What does the third letter in a fetal position abbreviation represent?

Maternal pelvis location

What term measures fetal descent through the pelvis?

Station

What station corresponds to the ischial spines?

Station 0

What station indicates the fetus is above the ischial spines?

Negative station

What station indicates the fetus is below the ischial spines?

Positive station

What process shortens and thins the cervix?

Effacement

What process widens the cervical opening?

Dilation

What force helps expel the fetus during second-stage labor?

Bearing down

Which maternal positions use gravity to assist fetal descent?

Upright, sitting, kneeling, squatting

Maternal stress and anxiety can impair what process?

Labor progress

What assessment technique determines fetal position and presentation through abdominal palpation?

Leopold maneuvers

What monitoring device measures uterine contractions externally?

Tocotransducer

What monitoring device assesses fetal heart rate externally?

External fetal monitor

At what gestational age is Group B strep screening typically performed?

36-37 weeks

What antibiotic route is used for Group B strep prophylaxis?

Intravenous

Urinalysis assesses hydration through which finding?

Specific gravity

What urine finding may indicate gestational hypertension or preeclampsia?

Proteinuria

What urine finding may indicate gestational diabetes?

Glucosuria

What urine finding may indicate impaired nutrition or uncontrolled diabetes?

Ketonuria

How often should maternal temperature be assessed when membranes are ruptured?

Every 2 hours

What internal device measures intrauterine pressure?

Intrauterine pressure catheter

What two conditions are required before placing an intrauterine pressure catheter?

Ruptured membranes and cervical dilation

What is contraction frequency measured from?

Beginning of one contraction to beginning of the next

What is contraction duration measured from?

Start to end of same contraction

How is a mild contraction described on palpation?

Tip of nose

How is a moderate contraction described on palpation?

Chin

How is a strong contraction described on palpation?

Forehead

More than how many contractions in 10 minutes is considered excessive?

More than 5

A contraction lasting longer than how many seconds is concerning?

90 seconds

Excessive contractions can lead to what fetal complication?

Fetal hypoxia

What exam assesses dilation, effacement, station, and fetal position?

Vaginal examination

What mechanism of labor occurs when the fetal head enters the pelvic inlet?

Engagement

What station indicates engagement?

Station 0

What mechanism of labor refers to fetal movement through the pelvis?

Descent

What mechanism of labor occurs when the fetal chin moves toward the chest?

Flexion

What mechanism of labor occurs when the occiput rotates anteriorly?

Internal rotation

What mechanism of labor occurs when the head passes under the symphysis pubis?

Extension

What mechanism of labor occurs when the head realigns with the body after birth?

External rotation

What is another name for external rotation?

Restitution

What is the final mechanism of labor?

Expulsion

During the fourth stage, how often should blood pressure and pulse be assessed?

Every 15 minutes for 2 hours

During the fourth stage, how often should the fundus and lochia be assessed initially?

Every 15 minutes for 1 hour

What nursing action helps prevent postpartum hemorrhage during the fourth stage?

Fundal massage

What medication category helps maintain uterine tone postpartum?

Oxytocics

Why should postpartum clients be encouraged to void?

Prevent bladder distention

What activity should be promoted during the fourth stage?

Maternal-newborn bonding

What should a postpartum client immediately report to the nurse?

Increased bleeding or clots

What type of contractions become stronger, longer, and more frequent?

True labor

What type of contractions decrease with walking or position changes?

False labor

Where are true labor contractions typically felt?

Lower back radiating to abdomen

Where are false labor contractions typically felt?

Above umbilicus or lower back