True Labor vs. False Labor
A client at 38 weeks reports painful contractions every 4 minutes. After walking and drinking two glasses of water, the contractions remain regular and her cervix has progressed from 3 cm to 5 cm
true labor
When labor progress slows or stops, the nurse must categorize assessment findings into these five critical components before selecting an intervention
passageway, passenger, powers, position, and psyche
The nurse recognizes this pelvic shape as round with a wide pubic arch, making it the classic and most favorable pelvic structure for vaginal birth
gynecoid pelvis
Upon inspecting a newborn's scalp immediately after birth, the nurse notes localized edema that crosses suture lines
caput succedaneum
A fetus is in an LOP or ROP orientation, and the laboring client reports severe back labor pain due to the fetal head pressing on this maternal structure
maternal sacrum
During a vaginal examination, the nurse palpatory locates the fetal presenting part at the level of the maternal ischial spines and documents this station
station 0 (engagement)
This stage of labor begins with the onset of true labor contractions and ends when the cervix achieves full dilation (10 cm)
Stage 1 of labor
A client at 9 cm dilation is irritable, reports intense rectal pressure, and states, "I have to push right now." The nurse identifies the client is in this phase of labor
transition phase
Immediately after a client experiences spontaneous rupture of membranes, the nurse performs this priority assessment before changing linens or performing hygiene care
assessing the fetal heart rate (FHR)
To prevent maternal hypotension prior to epidural anesthesia administration, the nurse gives this ordered IV intervention
500 to 1000 mL Lactated Ringer's fluid bolus
During the second stage of labor, the nurse instructs the client to use this pushing technique rather than prolonged closed-glottis Valsalva pushing to maintain fetal oxygenation
open-glottis pushing (exhaling while bearing down for 6-8 seconds)
This assessment finding is considered the "gold standard" for confirming true labor, as regular painful contractions alone do not confirm labor progress
progressive cervical effacement and dilation
A client exhibits labor arrest due to true cephalopelvic disproportion (CPD). The nurse knows that oxytocin will not resolve the issue because it cannot correct abnormalities in this specific "P"
passageway
A client's pelvic assessment indicates a heart-shaped pelvis. The nurse prepares for potential labor complications because this pelvic type increases the risk for this condition
dystocia
A newborn presents with a collection of blood between the cranial bone and periosteum that does not cross suture lines, placing the infant at an increased risk for this metabolic condition
hyperbilirubinemia
To relieve severe back labor pain and encourage rotation of a fetus in an occiput-posterior (OP) position, the nurse assists the client into this posture
the hands-and-knees position
The nurse notes crowning during the birth process when the fetal station reaches this numerical range
+4 to +5 station
During the first 1 to 4 hours following placental delivery, the nurse focuses primary care on maternal stabilization and frequent surveillance for this complication
hemorrhage
When a laboring client at 8 cm dilation demands to push, the nurse intervenes with this immediate action to prevent cervical injury
encouraging panting/breathing support and preventing pushing
Following rupture of membranes, a sudden drop in fetal heart rate (bradycardia) or recurrent variable decelerations alerts the nurse to this life-threatening emergency
umbilical cord prolapse / cord compression
Following epidural placement, the client's blood pressure drops and the fetal heart rate tracing becomes nonreassuring. The nurse's first priority actions include stopping oxytocin and placing the client in this position
turning the client onto her left side (left lateral tilt)
The nurse observes a sudden dark blood gush, cord lengthening, and a firm globular uterus, recognizing these as classic signs of this event
placental separation- third stage of labor: placental delivery
manage with oxytocin (Pitocin) administration
Placental inspection
Retained placenta risk
A pregnant client arrives at triage with irregular contractions that decrease in frequency after taking a warm bath and resting
false labor
When evaluating the "Passenger" factor during labor assessment, the nurse assesses these six specific fetal variables
fetal size, attitude, lie, presentation, position, and station
This flat, transversely oval pelvic shape presents a risk for transverse arrest during fetal descent
platypelloid pelvis
The nurse notes cranial-bone overlap on a newborn's head, recognizing it as a normal adaptation that allowed the head to pass through the maternal pelvis
molding
The nurse notes that the fetal long axis is perpendicular to the maternal spine, indicating this lie that cannot deliver vaginally
transverse lie
During the cardinal movements of labor, this specific movement rotates the fetal occiput anteriorly to navigate the pelvis
internal rotation
Immediately following the delivery of the infant in Stage 3, the nurse prepares to administer this medication and inspect this organ
oxytocin and the placenta
This phase of Stage 1 labor spans from 0 to 3 cm dilation, characterized by milder contractions and generally good maternal coping
latent phase- longest phase
When documenting amniotic fluid characteristics after membrane rupture, the nurse uses the mnemonic TACO, which stands for these four observations
Time, Amount, Color, and Odor
This regional nerve block provides local perineal coverage without affecting maternal blood pressure or baseline fetal heart rate
pudendal block
To prevent neonatal cold stress immediately after birth, the nurse performs these three immediate interventions
drying the newborn, removing wet linens, and promoting skin-to-skin contact
Rather than judging labor progress based solely on maternal pain levels, the nurse performs this priority assessment strategy over time
trending cervical change
A nurse evaluates involuntary uterine contractions and voluntary maternal pushing efforts to assess this specific component of the Five Ps
powers
This pelvic shape is oval in the anteroposterior direction and frequently favors an occiput-posterior fetal position
anthropoid pelvis
When educating parents on neonatal scalp swelling, the nurse explains that caput succedaneum typically resolves in several days, whereas a cephalohematoma may take this long to resolve
weeks to months
This fetal attitude, where the chin is tucked completely onto the chest, presents the smallest fetal head diameter to the pelvis
complete flexion
This cardinal movement occurs when the fetal head passes under the symphysis pubis and is delivered
extension
During Stage 4 of labor, the nurse performs frequent assessments on these four maternal components to detect early complications
fundus, lochia, vital signs, and bladder
Spanning from 4 to 7 cm dilation, this phase is characterized by stronger, regular contractions and rapid cervical change
the active phase
The nurse utilizes these two bedside diagnostic tests to confirm whether leaking fluid is amniotic fluid
Nitrazine paper testing and fern testing under microscope
State all the disadvantages for receiving an epidural block
hypotension
Longer 2nd stage
Loss of bladder sensation
Urinary retention
In the fourth stage of labor, the nurse assesses a client's fundus and finds it boggy, prompting an immediate assessment for this postpartum complication
postpartum hemorrhage
In addition to contraction pattern and cervical dilation, these three defining physical findings help the nurse evaluate labor progression during assessment
fetal engagement, anterior cervical change, and bloody show
A laboring client displays extreme anxiety, fear, and lack of coping support. The nurse recognizes that these findings fall under this psychological "P" that can slow labor progress
psyche
During normal labor, the soft tissues adapt as the upper uterine segment contracts and thickens while this occurs to the lower uterine segment
thinning of the lower segment- becomes thin and passive
Soft tissue adaptation: Uterine segments, Cervix effaces, and pelvic floor rotates fetus anteriorly as it descends toward vaginal introitus
To differentiate between caput succedaneum and cephalohematoma during a physical exam, the nurse assesses these three defining characteristics
timing of appearance, location/crossing suture lines, and resolution time
The nurse documents a fetal position of LOA or ROA, recognizing these acronyms as representing these favorable maternal-fetal orientations
Left Occiput Anterior and Right Occiput Anterior
Following delivery of the fetal head, this cardinal movement turns the head externally to align with the shoulders
restitution (external rotation)
During Stage 2 of labor, primary nursing actions focus on these three priorities
guiding pushing, monitoring the fetus, and preparing for birth
The nurse refrains from encouraging bearing-down efforts until this objective clinical benchmark is verified
complete cervical dilation (10 cm)
The nurse prioritizes immediate FHR assessment over hygiene care upon membrane rupture because fluid loss can cause the cord to slip into this position
below the presenting part
Following regional anesthesia, the nurse frequently assesses the maternal abdomen for this specific retention risk due to decreased sensation
bladder distention- check every 2 hours; insert indwelling catheter as ordered
Standard newborn assessment protocols require the nurse to assign Apgar scores at these two specific time intervals post-birth
1 minute and 5 minutes