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Maternal Newborn
Normal Birth
| Question | Answer |
|---|---|
| Which part of the uterus is palpated (first leopold maneuver) to differentiate between the buttom and head? Both are ____? The bottom is ____ and the head is ___ & moves ___? | fundus (top) both are rounded, the bottom is soft and the head is firm and moves independently from the body |
| Which part of the uterus is palpated (second leopold maneuver) to find the fetal back? The back is ___ & ____ and the front is ____? | lateral. The back is long and round and the front is knobby |
| Which part of the uterus is palpated (third leopold maneuver) to ensure the fetal head is down? | bottom of the uterus, use thumb and fingers |
| The fourth leopold maneuver is used to feel for the ____ or occiput when the head is down | brow |
| listening for fetal heart tones is best if done over the fetal ___ | back |
| acute pain r/t cell ____ caused by contractions | hypoxia |
| The baby's head is going to put pressure on ____ | all pelvic structures |
| impared elmination r/t ____ decreased sensation for urge to voide sence of bladder fullness | epidural - foley may be helpful if long stage of labor |
| How often should pt void during labor | every 2 hrs |
| impared fetal ____ excange: fetal inolerance of labor, fetal distress | gas |
| prior to touching the patient, a _____ is needed | informed consent. Established by the doctor and witnessed by the nurse |
| comon positioning during labor | side lying, semi-fowlers and pelvic tilt |
| If pt prefers to lie in less than 45 degree angle, what needs to be done | wedge the right hip to prevent vena cava syndrome |
| At what phase of labor can the pt walk around | latent (1st) |
| Activity level of active 2nd phase | sit, lie on side, activity diminished |
| Why are ice chips the only intake during labor | possibility of intubation in case something goes wrong and need to do GA, get GI tract empty |
| T/F The GI tract shuts down during labor | True - decreased gastric emptying time |
| During labor, why is the perineum often cleaned and dried | amniotic fluid is slowly leaking and gets uncomfortable for pt - wear gloves |
| What is used after delivery of the placenta to prevent atony(muscle that has lost its strength) of the uterus | IV oxytocin to prevent post partum hemorrhage |
| Why is breastfeeding encouraged immediately after delivery | body produces oxytocin which contracts the uterus |
| ____ - displacement to the right | dextroverted. This happens when the bladder fills, the uterus displaces to the right and atony occures |
| ____ birth - occures without healthcare provider present | precipitious birth, the nurse may be present, most labor rooms have a pack set up including sterile gloves, blub syringe, clamp, scissors ect |
| Why should the newborn's head be lower then abdomen right after birth | facilitate mucus drainage |
| laboring down is possible if pt has ____ control | pain |
| What station may occure during laboring down | +2 +3 |
| ____ - mother's body pressing the baby down into the birth cana without her volutary effort of pushing | laboring down - breathing or grunting slightly during contractions allowing her body to do the pushing |
| ____ down is beneficial during the second stage of labor | laboring down - do not want to push during the 2nd stage |
| When does the urge to push come | when the baby has reached the vagina = spontaneous bearing down reflex, occure at approx +2 station (1/2 way down the birth canal |
| What is done with a pt on an epidural dilated 10cm without the urge to push | call anesthesiologist to adjust the rate of continuous epidural down |
| the pain cycle starts with fear and ends with pain, what is in the middle | fear - anxiety - muscle tension - pain |
| using the ____ theory, pain can be blocked, this is used for childbirth education | gate control theory - gating mechanism |
| Pain of stage one includes dilation of cervix which causes | hypoxia of uterine muscle cells during contraction, stretching of lower uterine segment, pressure on adjacent structures (bladder) |
| Pain of stage two include | hypoxia of uterine muscle cells related to contraction, distention of vagina and perineum due to descent, pressure on adjacent structures (bladder) |
| Systemic analgesia includes ____ to lower perception of pain | narcotic (opioid) |
| Most commonly used systemic analgesia, also used as a mixture for regional analgesia - does not cause as much neonatal depression as ___ & ___ | Fentanyl - 50-10mcgQHIV by PCA tiny dose, does not cause as much neonatal depression as stadol and nubain |
| How much of the system analgesia stadol and nubain are used | Stadol = 0.5 - 2mg Q3-4HIV (peak 30). Nubain = 10mg Q 3-6H IV |
| What three systemic analgesia are used as adjunctives to lower anxiety and nausea | Phenergan (issue r/t vessle damage at injection site not used much), benadryl (causes neonatal resp depression not used much), barbiturates (seconal) to induce sleep if long latent labor |
| side effects/ nursing implications of narcotics | Peak action of narcotic around the time baby is born = high risk for respiratory depression - do not give mother Narcan, give to infant if needed after delivery via IM or IV |
| Regional analgesia used to block pain | epidural or intrathecal (subarachnoid space) |
| common mixture for epidural | fentanyl, sufentanil or morphine plus local anesthetic agent (bupivacaine) |
| why is demerol not used much anymore | side effects of the narcotic |
| how does the epidural work | sensory/motor nerve block |
| Why nursing implications are used before giving epidural | fluid preload/bolus - 500-1000 of NS or LR to fill vascular space in case vasodilation occures |
| During pain the vessles constrict, so when an epidural is administered the vessles | vasodilation due to pain relief - make sure plenty of fluid on board |
| T/F some of the best labor nurses have never been pregnant | True - try to refrain from sharing your experience with labor, pt don't really care how you did it |
| What is the best pelvic anatomy for vaginal delivery | gynecoid |
| Which pelvic anatomy is similar to the male pelvis | android - probably end up with CS |
| Which pelvic anatomy is apelike with long anteroposterior diameter with narrow transverse diameter | anthropoid - okay for vaginal delivery |
| Which pelvis does not work well for vaginal birth - other than android | platipoid |
| The false pelvis is the upper part that provides support during pregnancy, and the true pelvis is ___ | what the fetus must pass through |
| The fetal head goes through a small pelvis by ____ due to suture lines | molding - suture lines are membranous tissue the sagital suture has fontanels at each end and the bones on either side will overlap |
| ____ - relationship of fetal parts to each other | attitude |
| ____ - head flexed so chin rests on chest - this is what the fetus's attitude should be | flexion |
| ____ - head not on chest and or legs not on abdomen | extension, makes vaginal delivery difficult |
| ____ - relation ship of the cephalolcaudal axis of the fetus to the cephocaudal axis of the mother | lie - transverse lie is an automatic CS |
| After ___ weeks the baby is too big to change position in utero | 38 weeks - turning (less than 37 weeks) fetal cord could get wrapped aound or dislodge placenta. |
| ____ - body part of fetus that enters the pelvis first and covers the internal cervical os | presentation |
| ____% of all births are cephalic | 97%, most breach births are delivered by elective CS, shoulder is very rare |
| Vaginal delivery of a breach fetus delivers easily but the head can get stuck and could lead to ____ damage | brain damage due to oxygen deprivation |
| ____ the space between fontanels | vertex |
| When the fetus has flexted its chin on the chest what presents | occiput (occipital bone) |
| When the fetus has an extended neck, what presents | face when fully extended, usually has edematous and bruised face due to baby moving against the bony pelvis |
| What is the difference between complete and frank breach | complete buttocks and feet present, frank only buttocks present |
| ____ happens when the largest diameter of the presenting part reaches or passes through the pelvic inlet | engagement (lightening), pt reports ability to breath better, baby dropped |
| ____ is the relationship of the presenting part to the ischial spines of the maternal pelvis | Station |
| How does the nurse determine what station the baby is in from the ischial spines | With two fingers feel through the vaginal wall to the ischial spines (smooth rounded prominences) this is station 0. -1 is 1 cm above, +1 is 1 cm below, way to mark the progress of fetal descent |
| ____ is the relationship of landmark of presenting fetal part to the front, sides and back of the mothers pelvis | position |
| What is the most comfortable position - presenting fetal part for delivery | occiput presentation anteriorly, if it is posterior "back labor" occiput is pressing right on the sacrum |
| ____ - from start of one contraction to start of next | frequency |
| ____ is the length of time a contraction lasts | duration |
| ___ is identifiable on external exam or mm of mercury by IUPC | strength |
| What does a mild, medium and strong contraction fell like as the fundal part of uterus is palpated with the fingertips | Mild - easily indent like feeling your chin, Medium fels like tip of your nose and strong feels like forhead |
| ____ is drawing up of the internal os (cervical opening) and the cervical canal into the uterine side walls | effacement - complete effacement is when cervix doesn't exist any more (starts out 5cm long) |
| ____ cervical os and cervical canal widen to 10cm | dilation - at 10cm then fetal head should be able to pass through |
| oxytocin, estrogen, fetal cortisol and prostaglandins are all factors that do what | stimulate uterine contractions |
| What hormone quiets uterine contractions | progesterone, a smooth muscle relaxant |
| premonitory signs of labor include: | lightening, braxton hicks contractions, cervix changes, bloody show (mucus plug comes out), ROM, sudden burst of energy, other weight loss, diarrhea, indigestion, NV and bachache |
| Biggest theory for preterm labor | UTI, vaginal infections |
| What hormone is released close to term causing uterine contractions | oxitocin |
| What is relased during menstration that cause cramps as well as stimulate uterine contractions and are relased close to labor | prostaglandins - cause cervix to ripen (become soft) by breaking down collagen fibers |
| if a pt is to be induced, the night before will receive a ____ agent inserted around area of cervix to cause cervix to ripen (soften) | prostaglandin agent such as Cervidil |
| characteristics of true labor | contraction regular and rhythmic, pain moves from back to front, fetal movement is unchanged, fetal descent is progressing, show is pinkish mucus and cervix progressing effacement and diolation |
| Characteristics of false labor | contractions are irregular, pain is relieved by walking, fetal movement may intensify, fetal descent is unchanged, no show, cervix unchanged after 1-2 hours |
| What is the most important assessment in distinguishing true and false labor | chervical change |
| nursing intervention to determine if a woman is in true labor | check cervix (if at 1cm), have pt relax and take a walk and come back in 1 hr, check cervix again, if changed in true labor, if still at 1cm is in false labor |
| T/F second stage of laber has three phases | False - first stage of labor has three stages (latent, active and transition) |
| What is the diameter of dilation for all three stages of the first phase of labor | Latent: 0-3cm, Active: 4-7cm, Transition: 8-10cm |
| The second stage of labor begins with what and ends with what | 2nd stage begins with complete cervical dilation and ends with delivery of the fetus - this is where pushing takes place |
| What happens during the third stage of delivery | The placenta is delivered. Starts immediately after fetus is born and ends when the placenta is delivered |
| How long does the fourth stage of labor last | 1 - 4 hours after the placenta is delivered until maternal homeostatic stabilization |
| knowledge deficit (fear/anxiety), acute pain, impaired elimination, and impaired fetal gas exchange are all common ____ | nursing diagnoses during labor |
| ___ of the presenting part occurs when the largest diameter of the presenting part reaches or passes through the pelvic inlet? | Engagement “lightening” once the fetus enters the pelvis there is less pressure on diaphragm breathing is easier. Where baby has reached the ischial spines |
| _____: relationship of the cephalocaudal axis of the fetus to the cephalocaudal axis of the mother Longitudinal lie is ___; Transverse and Oblique are ___ babies | Lie: relationship of the cephalocaudal axis of the fetus to the cephalocaudal axis of the mother Longitudinal lie is normal; Transverse and Oblique are C-Section babies |
| _____: body part of fetus that enters the pelvis first and covers the internal cervical os. It can be a __ or ___? | Presentation: body part of fetus that enters the pelvis first and covers the internal cervical os. It can be a cephalic or Breeched |
| _____: relationship of the presenting part to the ischial spines of the maternal pelvis. Must do vaginal exam. Once ROM occurs they can have up to __exams bc infection can occur. ____ means head is out | Station: relationship of the presenting part to the ischial spines of the maternal pelvis. Must do vaginal exam. Once ROM occurs they can have up to 7 exams bc infection can occur. + 5 means head is out |
| _____ means that the face is coming out up or face first. | Extension means that the face is coming out up or face first. |
| Effacement basically means thinning of the ____? measured in ___? | Thinning of the cervix.drawing up of the internal os and the cervical canal into the uterine side walls described in %. Walls thining |
| What hormones causes uterine congtractions? | oxytocin, estrogen, fetal cortisol, prostaglandins |
| The most common way is _____, and this allows the easiest measurement to clear the pelvis. This position is especially helpful because the head can pivot up against the pubic bone, allowing the chin's appearance to finish the delivery of the full head. | face-down (Occiput Anterior) |
| Face-up, called _____ (back of the head down), is a more difficult delivery because the baby can't flex the head on exit. It's like delivering a baby a pound bigger. | Occipital Posterior (back of the head down) Face-up |
| If the head is sideways, then the rotation necessary for delivery is incomplete. Called "______," the head can usually be gently rotated by the obstetrician to face-down ____ for a normal delivery. | If the head is sideways, then the rotation necessary for delivery is incomplete. Called "Occiput Transverse," the head can usually be gently rotated by the obstetrician to face-down (Occipital Anterior) for a normal delivery. |
| During what phase of labor is the contraction duration 30sec; 10-30 min betweeen frequency and the mother is typically excited and anxious? | Latent Phase of stage 1 of Labor |
| What phase of labor is the contraction duration 40-60secs; 2-5 mins between frequency and the mother's anxiety increases with contractions and pain? | Active Phase of Stage 1 of Labor |
| During what phase of labor is the contraction duration 60-90 sec; 1.5-2 min between frequency and mother is restless, changes posistions frequently, and shows increased anxiety? | Transition Phase of Stage 1 of Labor |
| What is the difference between prepared and unprepared mothers? | Prepared mothers have taken breathing classes to prepare for childbirth; unprepared mothers have not taken the class and will need to be coached on how to breath through the pain |
| T/F Breathing does not become an automatic response to pain? | False Breathing becomes an automatic response to pain |
| T/F Mom who uses breathing techniques will remain in a more relaxed state and will respond more positively to pain? | True |
| The steady rhythmm of breathing is ___ during labor? | calming during labor |
| Breathing provides a sense of ____ and a measure of ___? | Breathing provides a sense of well being and a measure of control |
| Breathing provides for more oxygen which provides ___ and ___ for mother and baby? | Breathing provides more oxygen, which provides more strength and energy for mother and baby |
| Breathing brings ___ to each contraction,making them more ____? | Breathing brings purpose to each contraction, making them more productive |
| T/F Patterned breathing and relaxation do not become habits for life's everyday stressors? | False breathing patterns and relaxation become habits for life's everyday stressors |
| ____ breathing begins when coontractions are intense enough that you can no longer walk or talk without pausing? | Slow breathing |
| When should you change breathing patterns? | Switch to another pattern if you become tense and can no longer relax during contractions. If the breathing pattern works why change |
| What is the slow breathing technique? | Slowly inhale through your nose and exhale through your mouth, allowing all the air to flow out with a sigh. Pause until you need to take another breath. With each exhale focus on relaxing a different part of your body. |
| T/F slow breathing technique uses focus attention? | true |
| In ___ breathing take an organizing breath. A big sigh as soon as contraction begins. Release all tension as you breath out? | slow breathing |
| When should you switch to light breathing? | If slow breathning no longer works. Switch to light breathing during active phase of labor. |
| What is light breathing? | breath in and out rapidly through your mouth about 1 breath per second. Keep breathing light and shallow. |
| In light breathing inhalation should be ___ and exhalation ___? | inhalation should be quiet and exhalation clearly audile |
| What is transistion breathing? | Variation of light breathing,referred to as "pant-pant-blow" It combines light and shallow breathing with more pronounced exhalation. |
| When should you use transistion breathing? | use if overwhelmed, unable to relax, in despair, or exhausted |
| Which breathing type combines light shallow breathing with more pronounced exhalation? | transition breathing |
| What are the steps of transition breathing? | 1. take an organizing breath 2. focus attention on focal point 3. breath trough mouth in light shallow breaths. At a rate of 5-20 breaths every 10sec during contraction. 4. after 2nd-5th breathe blow out a longer breathe |
| What is important to do after a contraction ends when a patient is using the transition breathing technique? | When contraction ends take 1-2 deep relaxing breathes with a sigh |
| admission assessment: right-occiput-posterior position, longitudinal lie, cervical dilation 4 cm, -3 station, and spontaneous ROM. Ms. E states she has pressure in her pelvic area & needs to urinate more frequently. Where do u auscultate the FH sounds? | The fetal heart tones will be heard below the maternal umbilicus in a cephalic presentation. |
| Baby is in a ____ position so the fetal head presents a larger diameter than in an anterior position. | posterior position |
| A ___ position will increase the pressure on your sacral nerves, causing backache & pelvic pressure. As a result, you may feel the urge to push earlier than needed. | posterior position |
| The nurse notes that the placenta is expelled with the fetal (shiny) side presenting. What is this know as? | This is known as the Schultze mechanism or, more commonly, shiny Schultze. |
| The nurse recalls that labor affects the gastric motility and gastric pH. What are these effects? | During labor gastric motility and absorption of solid food are reduced. The acidity of gastric contents increases. |
| The nurse is caring for a 24-year-old woman in labor. The client is G1P0. She has ROM and the cervix is dilated at 5 cm. The contractions are occurring every 3 minutes with a duration of 50 seconds. What phase of labor is this client in? | She is in the active phase of labor. |
| The cl's cervix is dilated at 8 cm. Contractions are occurring every 2 min w/ a duration of 70 sec. cl is anxious, restless, & feels rectal pressure w/ the urge to bear down. The cl asks for assistance to the toilet. What should the nurse do? | Reassess the cervix. As dilatation approaches 10 cm, there may be increased rectal pressure and an uncontrollable urge to bear down. |
| The client has delivered a healthy infant. Five minutes after the birth, the nurse notes a rise of the fundus in the abdomen with a sudden gush of blood and further protrusion of the umbilical cord out of the vagina. What nursing actions are indicated? | The signs of placental separation are a rise of the fundus in the abdomen, a sudden gush of blood, & further protrusion of the umbilical cord out of the vagina. The nurse guides the placenta into a basin. |
| When does placental separation usually occur? | The signs of placental separation usually appear around 5 minutes after birth of baby |
| What causes cervical dilatation? | As the uterus elongates with each contraction, the longitudinal muscle fibers are pulled upward over the presenting part. This action and the hydrostatic pressure of the fetal membranes cause cervical dilatation. |
| After the cervix is completely dilated (approximately 10 cm), the maternal abdominal musculature contracts as the woman pushes. What might happen if the woman pushes before the cervix is completely dilated? | If the cervix is not completely dilated, bearing down and pushing can cause cervical edema (which retards dilatation), possible tearing and bruising of the cervix, and maternal exhaustion. |
| With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. What is effacement? | Effacement is the taking up of the internal os and the cervical canal into the uterine side walls. The cervix changes progressively from a long, thick structure to a structure that is tissue-paper thin. |
| In primigravidas, effacement usually precedes ____. | In primigravidas, effacement usually precedes dilatation. |
| A G4P3 client in the transition phase of labor asks the nurse, "How much longer will it be before I have my baby?" What would be the best estimate that the nurse could provide? | 1 hour |
| A laboring client complains of nausea and vomiting and increasing rectal pressure. She states, "I can't take any more." The nurse correctly assesses that this client is in which phase of labor? | transition |
| A client at 39 weeks' gestation calls the clinic nurse with complaints of pelvic pressure, increased urinary frequency, and vaginal secretions. The nurse would correctly interpret these as signs and symptoms of a(n)\: | impending labor |
| A laboring client complains to the nurse about intense pain located primarily in her back. Which fetal presentation should the nurse expect to see written on the client's chart? | left-occiput-posterior |
| Delivery of the placenta is characterized by a _____? | Delivery of the placenta is characterized by a decrease in fundal height. |
| A nurse is caring for a client admitted to the birthing unit with rupture of membranes. A pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged. Which possible complication should the nurse anticipate? | prolapsed cord |
| A nurse is caring for a client during the fourth stage of labor. What are the expected assessment findings at this time? | decreased blood pressure and increased pulse |
| A laboring client's blood pressure is 88/60. What should be the initial nursing action? | Position client on the left side. |
| A pregnant client asks the nurse, "How will I know when I am in labor?" The nurse correctly states that an important sign and symptom of labor is\: | loss of weight |
| Early decelerations are viewed as a ____ FHR pattern unless seen with lack of descent of the fetal head. | Early decelerations are viewed as a reassuring FHR pattern unless seen with lack of descent of the fetal head. |
| Late or variable decelerations are viewed as ___? | non reassuring |
| What is the most common birthing position or most desigered? | LOA Left Occiput Anterior |
| The nurse assesses the fluid from the vagina. The fluid is clear without a foul smell. How does the nurse further assess for the presence of amniotic fluid? | Amniotic fluid is clear, without a foul smell. The nurse would use Nitrazine test tape to test for amniotic fluid. Amniotic fluid would have a pH between 6.5 and 7.5, and the test tape color would turn a bluish color. called intrapartal vaginal exam |
| The nurse has auscultated a fetal heart rate of 80. What should be the nurse's initial action? | Check maternal pulse |
| The nurse assesses a laboring client whose contractions occur every 5-7 minutes and last for 30 seconds. Which phase of labor is this client in? | latent |
| The physician orders internal fetal monitoring for a laboring client. What criteria must the client meet prior to this procedure? | rupture of Membranes |
| A client is admitted to the birthing center with possible rupture of membranes. What substance in the fluid could contribute to a false positive reading on Nitrazine test tape? | lubracant |
| A nurse is planning to perform Leopold's maneuvers on a laboring client. What should be the nurse's initial action? | Have client void |
| The fetal monitor has shown several late decelerations over the past 10 minutes. What does this pattern indicate? | uteroplacental insufficiency causes late decelerations and umbilical cord depression causes variable decelerations. |
| A G3P0 client in active labor is admitted to the birthing center. Which data set should the nurse interpret as being within the normal range? | 99.4 and bp 140/88 |
| A laboring client in the birthing center has a hematocrit of 49. The nurse should anticipate that this finding is related to\: | dehydration |
| A Hmong client has just given birth to a 5-pound baby girl. What culturally sensitive nursing action is appropriate at this time? | offer mom a hard boiled egg to eat |
| A laboring client complains of numbness of nose, fingers, and toes and spots before her eyes. What should be the initial action by the nurse? | encourage slow shallow breaths |
| A nurse is caring for a laboring client who received an epidural block 1 hour ago. What fetal monitor pattern would alert the nurse to a serious problem developing? | decreased FHR variability and late decelerations |
| A laboring client has been ordered butorphanol tartrate (Stadol) for pain. What should be the nurse's initial action prior to administering the medication? | #1 Assess for allergies. Monitor maternal vital signs.Monitor fetal heart rate. Assess cervical dilation. |
| The nurse is to administer naloxone (Narcan) intravenously. Which medication order would be the most appropriate initial dose for a laboring client? | 0.4-0.8 mg |
| A laboring client has received naloxone (Narcan) intravenously. When should the nurse anticipate the peak effect? | 5-15mins |
| A laboring client has an epidural, and the anesthesiologist plans to inject a narcotic into the epidural space immediately after birth to provide analgesia for approximately 24 hours. Which narcotic should the nurse anticipate that the physician will use? | duramorph |
| A nurse is caring for a laboring client who just received an epidural block. What is the major side effect that the nurse should observe for? | hypotension |
| What do you want to give if a baby is having respiratory problems bc mom was given stadol 2hrs prior to delivery? | Narcan |
| If mom wants an IV pain relief what type will you give? | narcotic analgesic |
Created by:
cgwayland
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