LABOR Stage I_Latent Phase - LABORStageILatentPhase

Info iconThis preview shows pages 1–3. Sign up to view the full content.

View Full Document Right Arrow Icon
LABOR Stage I—Latent Phase The latent phase, or the first phase of stage I labor, begins with the onset of true labor and ends with the cervix  dilated 4 cm. The phase averages approximately 8–10 hr, up to 20 hr for nulliparas and 3–6 hr, up to 14 hr for  multiparas. It usually occurs with client at home, unless specific concerns necessitate inpatient care, e.g., spontaneous  rupture of membranes (SROM), history of rapid labor, unsafe weather conditions/distance from facility. CLIENT ASSESSMENT DATA BASE Ego Integrity May be excited or anxious Pain/Discomfort Regular contractions, increasing in frequency, duration, and severity. Contractions are mild to moderate, 10–20 min apart, progressing to 5–7 min apart, lasting  15–20 sec, progressing to 30–40 sec. Safety Fetal heart tones best heard below level of umbilicus (dependent on fetal position) Sexuality Membranes may or may not have ruptured. Cervix dilates from 0 to 4cm. Fetus may be at station1 to 0 (primigravida) or from 0 to +2 cm (multigravida). Scant vaginal discharge, may be pink or brownish mucus (“show”), or may consist of mucous plug. NURSING PRIORITIES 1. Enhance client’s/couple’s/other involved family members’ emotional and physical preparedness for labor. 2. Promote and facilitate normal labor progress. 3. Support client’s/couple’s/involved family members’ coping abilities. 4. Prevent maternal/fetal complications. DISCHARGE GOALS (Inpatient   care   is   not   required   in   early   labor,   unless   complications   develop   necessitating   hospitalization.) 1. Displays only early, or no, signs of active progression of labor. 2. Demonstrates appropriate coping behaviors. 3. Understands self-care needs and signs of labor progression requiring re-evaluation. NURSING DIAGNOSIS: Anxiety, risk for Risk Factors May Include: Situational crisis, interpersonal transmission, unmet needs Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an  actual  diagnosis]
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
DESIRED OUTCOMES/EVALUATION  Report anxiety is at a manageable level. CRITERIA—CLIENT WILL Use breathing and relaxation techniques proficiently. Appear relaxed appropriate to the labor situation. Remain normotensive. ACTIONS/INTERVENTIONS RATIONALE Independent Provide primary nurse orcontinuous intrapartum  Continuity of care and assessment may decrease  professional support as indicated. stress. Research studies suggest that these clients  require less pain medication, which may result in  shorter labor.
Background image of page 2
Image of page 3
This is the end of the preview. Sign up to access the rest of the document.

Page1 / 9

LABOR Stage I_Latent Phase - LABORStageILatentPhase

This preview shows document pages 1 - 3. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online