Labor and Birth: Positions
What are the 5 P's?
Passageway, passenger, Powers, Position & Psychologic response
The nurse applies an ice pack to mom's episiotomy area immediately following vaginal delivery to reduce discomfort by what?
Minimizing the amount of edema
"Oh no I think my water just broke". The nurse tests the fluid with a nitrazine swab and confirms rupture of membranes if the swab turns what color?
Blue
A woman in labor received an opioid close to delivery time. The nurse should assess baby for which effect?
Respiratory depression
To supplement proteinuria
What type of delivery does the nurse anticipate when the baby is in a shoulder presentation?
Cesarean
In what stage is baby delivered?
Stage 2
Stage of expulsion: begins with complete cervical dilation and ends with delivery of baby
What criteria must be met for mom to receive continuous internal electronic fetal monitoring?
Cervical dilation of 2 cm or more fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.
Assess fetal heart rate
The assessment for fetal heart rate is the most important task. Fetal heart rate determines how the baby is doing
A pt is diagnosed with Gestational HTN and is receiving magnesium sulfate. Which finding would the nurse interpret that the pt is receiving the therapeutic level of medication?
A. Urinary output 20mL/hr
B. RR 10 breaths/min
C. Normal DTR's
D. Difficulty arousing
C.
With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.
The nurse assessment of the fetus reveals the buttocks as the presenting part with the legs extended upward. Which type of breech position is this?
Frank
Which action is a priority when caring for a woman during the 4th stage of labor?
A. Assess uterine fundus
B. Offer fluids as ordered
C. Encourage mom to void
D. Assist with perineal care
A.
During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.
A womans amniotic fluid is cloudy and has a foul odor. The nurse suspects what?
Possible infection
What is a normal FHR?
110-160 beats/min
Which compound would the nurse have readily available for a mom receiving magnesium sulfate to treat severe preeclampsia?
Calcium gluocante
Fetal position is documented as LSA. The nurse interprets this information to mean that which part is the presenting part?
Buttocks
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?
Effacement
Immediately following the administration of epidural anesthesia the nurse's 1st assessment should be what?
Maternal BP
A side effect of the epidural anesthesia is maternal hypotention, therefore the nurse should check the BP immediately after administration of the drug. Although the maternal drop in BP can cause FHR decels the mothers BP would be the priority.
What are 3 risk factors the nurse may identify that may contribute to a complicated labor?
bleeding, abnormal fetal presentation, poverty, poor nutrition, lack of prenatal care, mental illness, PTSD, smoking, ETOH use, drug use
What are the 4 H's of eclampsia?
HA, Heartburn, hyperreflexia and hemoconcentration
Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station?
0
A mom is in active labor. Checking the EFM tracing the nurse notes abnormal variables. What would be the nurse's first nursing intervention?
Help mom change positions
What diagnostic test would the nurse anticipate to perform for a pregnant mom with elevated BP?
Urine protein dip
For babies in a cephalic presentation where is the FHR best heard?
The lower quadrants of moms abdomen
HA, Oliguria, hyperreflexia, pulmonary edema, vision disturbances, thrombocytopenia, epigastric pain, RUQ pain (HELLP)