1. List 5 prodromal signs of labor the nurse might teach the client.
1. Lightening, Braxton Hicks contractions, increased bloody show, loss of mucous plus, burst of energy, and nesting behaviors
2. How is true labor discriminated from false labor?
2. True labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back, and cervical changes. False labor: irregular rhythm, abdominal pain (not in back) that decreases with ambulation.
3. State two ways to determine if the membranes have truly ruptured (ROM).
3. Nitrazine testing: paper turns dark blue or balck. Demonstration of fluid "ferning" under microscope.
4. Are psychoprophylatctic breathing techniques prescribed for use by the state and phase labor?
5. No, clients should use these techniques according to their dis omfort level and change techniques when one is no longer working for relaxation.
5. Identify 2 reasons to withhold anesthesia and analgesia until the mid-active phase of Stage I labor.
5. If given too early, can retard labor: if given too late, can cause fetal distress.
6. Hypoventilation ofen occurs to the laboring client. What results from hyperventilation and what actions should the nurse take to relieve the condition?
6. Respiratory alkalosis occurs which is caused by blowing off CO2 and is relieved by breathing into a paper bag or cupped hands.
7. Describe maternal changes that characterize the transition phase of labor.
7. Irritability, unwillingness to be touched but does not want to be left alone, nausea and vomiting, and hiccupping.
8. When should a laboring client be examined vaginally?
8. Vaginal exams should be done prior to analgesia/anesthesia, to rule out cord prolapse, to determine labor progress if it is questioned, and to determine when pushing can begin.
9. Define cervical effacement.
9. The taking up of the lower cervical segment into the upper segment; shortening of the cervix expressed in percent from 0 to 100% of complete effacement.
10. Where is the FHR best heard?
10. Through the fetal back in vertex, OA positions.
11. Normal FHR in labor is _______, normal maternal BP in labor is _______, normal maternal pulse in labor is ________, normal maternal temperature in labor is ______.
11. 110 to 160 bpm. <140/90. <100bpm. <100.4F
12. List 4 nursing actions for the 2nd stage of labor.
12. Make sure cervix is completely dilated before pushing is allowed. Assess FHR with each contraction. Teach woman to hold breath for no longer than 5 seconds. Teach pushing technique.
13. List 3 signs of placental separation.
13. Gush of blood, lengthening of cord, and globular shape of uterus.
14. When should the postpartum dosage of Pitocin be administered? Why is it administered?
14. Give immediately after placenta is delivered to prevent postpartum hemorrhage/atony.
15. State 1 contraindication to the use of ergot drugs (Methergine).
15. HTN
16. State 5 symptoms of respiratory distress in the newborn.
16. Tachypnea, dusky color, flaring nares, retractions, and grunting
17. If meconium was passed in utero, what action must the nurse take in the delivery room?
17. Arrange for immediate endotracheal tube observation to determine the presence of meconium below the vocal cords (prevents pneumonitis/meconium aspiration symdrome).
18. What score is considered a "good" Apgar score?
18. 7 to 10.
19. What is the purpose of eye prophylaxis for the newborn?
19. Prevent ophthalmia neonatorum, which results from exposure to gonorrhea in vagina
20. What is the danger associated with regional blocks?
20. Hypotension resulting from vasodilation below the block, which pools blood in periphyery reducing venous return.
21. What is the major cause of maternal death when general anesthesia is administered?
21. Aspiration of gastric contents.
22. Why are PO medications avoided in labor?
22. Gastric activity slows or stops in labor, decreasing absorption from PO route; may cause vomiting.
23. State the best way to administer IV drugs in labor.
23. At beginning of contraction, push a little medication in while uterine blood vessels are constricted, thereby reducing dose to fetus.
24. When is it dangerous to administer butorphanol (Stadol), an agonist, antagonist narcotic?
24. When the client is undiagnosed drug abuser of narcotics, it can cause immediate withdrawal symptoms.
25. Hypotension often occurs after the laboring client receives a regional block. What is one of the first signs the nurse might observe?
25. Nausea
26. State 3 actions the nurse should take when hypotension occurs in a laboring client.
26. Turn client to left side. Administer O2 by mask at 10L/min. Increase speed of IV infusion (if it does not contain medication).
27. The 4th stage is defined as:
27. The first one to four hours after delivery of placenta.
28. What actions can the nurse take to assist in preventing postpartum hemmorhage?
28. Massage the fundus (gently!!!) and keep the bladder emptied.
29. To promote comfort, what nursing interventions are used for a 3rd degree episiotomy, which extends into the anal sphincter?
29. Ice pack, witch hazel compresses, and no rectal manipulation.
30. What nursing interventions are used to enhance maternal-infant bonding during the 4th stage of labor?
30. Withhold eye prophylaxis fo rup to 2 hours. Perform newborn admission/routin procedures in room with parents. Encourage early initiaition of breastfeeding. Darken room to encourage newborn to open eyes.
31. List 3 nursing interventions to ease the discomfort of afterpains.
31. Keep bladder empty. Provide a warm blanket to abdomen. Administer analgesics prescribed by healthcare provider.
32. List symptoms of a full bladder, which might occur in the 4th stage of labor.
32. Fundus above umbilicus, dextroverted (to the right side of abdomen), increased bleeding (uterine atony)
33. What action should the nurse take first when a soft, boggy uterus is palpated?
33. Perform fundal massage.
34. What are the symptoms of hypovolemic shock?
34. Pallor, clammy skin, tachycardia, lightheadedness, and hypotension.
35. How often should the nurse check the fundus during the 4th stage of labor?
35. q15minutes x 4 (1 hour), q30 minutes x 2 hours if normal