Labor & Birth Processes
Thinning and Shortening of cervix. Measured in percentage.
Effacement
When there is a change in condition.
Feels pressure
Feels urge to push
Ruptured bag of water with decrease in fetal HR
Expected parameter for fetal heart rate
110-160 beat per minute
Light stroking of abdomen during a contraction
Effleurage
Which pain medication requires a 1:1 nurse/patient ratio?
Ultiva
Infant's descent in birth canal and is documented as negative and positive
Station
How often should a woman's temperature be assessed once the membranes rupture?
Every 2 hours
Increase in fetal heart rate by 15 beats for 15 seconds
Acceleration
Focusing on an object in the room during a contraction
Distraction
Name 2 safety measures to implement while giving pain meds during labor.
Side rails up (3)
Bed in lowest position
Call light within reach
Assistance with ambulation
Infant is presenting as head first
Cephalic
What is the intensity of a contraction if the abdomen feels like the chin
Moderate
Variability that has fluctuations in fetal heart beat between 6-25 beats
Moderate variability
Thinking about being in another place during a contraction
Imager
If an opioid pain med is given within 4 hours of delivery, what newborn assessment is important?
Respiratory status
Dilation
Name 2 characteristics of True labor
Regular contractions
Felt in lower back/abdomen
Become stronger and more frequent
Become more intense with walking
Blood show present
Name 1 nursing intervention if Fetal heart rate begins to decrease at the beginning of a contraction.
Early Deceleration
Nothing. Encourage client to continue to push with contractions
How should breathing techniques be used during labor?
Begin and end with a cleansing breath
Start with slow breathing pattern with early labor and increase pace of breathing as contractions intensify
Which anesthesia method is used for pain relief during labor?
Epidural
When can a woman start pushing?
10 cm
How often should maternal vital signs and assessments be performed during the 4th stage of labor?
Every 15 minutes
Name 2 nursing interventions if the fetal heart rate begins to decrease at the peak of the a contraction and returns to baseline after the contraction ends
Late Deceleration
Discontinue oxytocin if infusing
Place client in lateral position
Start oxygen at 8-10 L/min - nonrebreather mask
Increase IV fluids
Name 2 signs/symptoms of hyperventilation
Lightheaded
Dizzy
Tingling fingers
Numbness around the mouth
What intervention should be implemented before insertion of epidural or spinal anesthesia?
IV Bolus
Position of infant with chin tucked to chest and arms/legs tucked into main body that allows infant to fit through bony pelvis easier?
General Flexion
Should a vaginal exam be performed if there is active vaginal bleeding?
No
Name 2 nursing interventions if fetal heart rate abruptly decreases and returns to baseline with or without contractions
Variable deceleration
Discontinue oxytocin if infusing
Change maternal position
Start oxygen at 8-10 L/min by nonrebreather mask
Assess for prolapsed cord
Assist with amnioinfusion
Name 2 interventions for hyperventilation
Breath into paper bag or cupped hands
Help client slow breathing rate
Help client regain focus
What is the nurse's role during insertion of epidural and spinal anesthesia?
Help client maintain spine in a curved position
Lying on side with knees pulled up and into abdomen or sitting on side of bed hunched over bedside table
Encourage client to use breathing techniques during contractions