LABOR Stage I_Active Phase - LABOR:StageIActivePhase

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LABOR: Stage I—Active Phase As contractions increase to moderate intensity in the active phase, and as the cervix dilates from 4 to 8 cm, the  client becomes more involved and focused on the labor process. The active phase lasts approximately 1–2 hr in the  multipara and 3–4 hr in the nullipara. The fetus descends in the birth canal at approximately 2 cm/hr in the multipara  and 1 cm/hr in the nullipara. CLIENT ASSESSMENT DATA BASE Activity/Rest May show evidence of fatigue Ego Integrity May appear more serious and absorbed with labor process Apprehensive about ability to control breathing and/or perform relaxation techniques Pain/Discomfort Contractions are moderate, occurring every 2.5–5 min and lasting 45–60 sec. Safety Fetal heart tones (FHTs) detected slightly below umbilicus in vertex position FHR variability and periodic changes commonly noted in response to contractions, abdominal palpation, and fetal  movement Sexuality Cervix dilates from approximately 4–8 cm (1.5 cm/hr multipara, 1.2 cm/hr nullipara). Moderate amount of bloody show present. Fetus descends to 11–12 cm below ischial spines. NURSING PRIORITIES 1. Promote and facilitate normal progression of labor. 2. Support client’s/couple’s coping abilities. 3. Promote maternal and fetal well-being. NURSING DIAGNOSIS: Pain [acute] May Be Related To: Tissue dilation/muscle hypoxia, pressure on adja- cent structures,  stimulation of both parasympathetic and sympathetic nerve endings Possibly Evidenced By: Verbalizations, distraction behaviors (restlessness), muscle tension DESIRED OUTCOMES/EVALUATION  Identify/use techniques to control pain/ CRITERIA—CLIENT WILL: discomfort. Report discomfort is minimized. Appear relaxed/resting between contractions. Be free of untoward side effects if analgesia/anesthetic agents are  administered.
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ACTIONS/INTERVENTIONS RATIONALE Independent Assess degree of discomfort through verbal and  Attitudes and reactions to pain are individual and  nonverbal cues; note cultural influences on based on past experiences, understanding of  pain response. physiological changes, and cultural expectations. Assist in use of appropriate breathing/relaxation  May block pain impulses within the cerebral  techniques and in abdominal effleurage. cortex through conditioned responses and cutaneous  stimulation. Facilitates progression of normal labor. Assist with comfort measures (e.g., back/leg rubs, Promotes relaxation and hygiene; enhances feeling   sacral pressure, back rest, mouth care, repositioning, of well-being. Note: Lateral recumbent position   shower/hot tub use, perineal care, and linen changes).
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This note was uploaded on 02/01/2011 for the course PNR 182 taught by Professor Toole during the Spring '10 term at Orangeburg-Calhoun Technical College.

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LABOR Stage I_Active Phase - LABOR:StageIActivePhase

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