NCLEX HEALTH PROMOTION & MAINTENANCE Labor & Delivery Flashcards

Terms Definitions
lightening
subjective sensation as fetus descends into pelvic inlet
lightening occurs in primipara when
up to 2 wks prior to delivery
lightening occurs in multipara when?
may not occur until labor begins
characteristic findings of onset of labor
lightening
softening of cervix
expulsion of mucus plug (show)
uterine contractions progressive & regular
effacement
progressive thinning and shortening of cervix (0-100%)
dilation
opening of cervix os during labor (0-10cm)
rupture of membranes
rupture of amniotic sac
when rupture of membranes occurs RN should
check fetal heart rate tones/assess for fetal distress
check for prolapsed cord
nurses job in prolapsed cord
call for help
push against presenting part to relieve pressure from cord
place Mom in Trendelenberg or knee-chest position
in order to internally monitor uterine contractiosn and fetal HR, what must have occured
rupture of membranes
dilation of cervix (sufficient)
presenting part must be low
an early sign of fetal hypoxia
tachycardia, >160 bpm lasting longer than 10 minutes
Atropine and Vistaril (antihistamine) can cause fetal _____
hypoxia
a late sign of fetal hypoxia
bradycardia, <110-120 bpm lasting longer than 10 minutes
bradycardia (r/t fetal hypoxia) is associated with
prolonged cord compression
maternal drugs (anesthetics)
fetal congenital heart block
tachycardia (r/t fetal hypoxia) is associated with
maternal fever
fetal anemia
fetal/maternal infection
drugs (atropine, vistaril)
maternal hyperthyroidism
fetal heart failure
Variability
irregular fluctuations in the baseline fetal HR of 2 cycles per minute or greater
absent/decreased variability may be associated with
fetal sleep
fetal prematurity
rxn to drugs (narcotics, barbituates, tranquilizers, anesthetics)
congenital anomalies
hypoxia
acidosis
If absent/decreased variability persists for more than _____ it is a sign of fetal distress
30 minutes
minimal variability in FHR Is associated with....
(0-5 bpm)
mild fetal hypoxia
fetal stimulation; considered nonreassuring
moderate and marked variability in FHR
moderate= (6-25 bpm) deviations from baseline may be significant
marked= (greater than 25 bpm) significance unknown
accelerations
15 bpm rise above baseline followed by a return; usually in response to fetal movement or contractions
indicates fetal well being
decelerations
fall below baseline lasting 15 seconds or more, followed by a return.
Can be early, late or variable
early decelerations
occurs before peak of contraction; most often uniform mirror image of contraction on tracing
associated w/ head compression in 2nd stage with pushing
Benign
late decelerations
onset after contraction established with slow return to bsaeline
indicates fetal hypoxia d/t deficient placental perfusion.
Nonreassuring sign
potential causes of late declerations
PIH (preg. induced HTN)
maternal diabetes
placenta previa
abruption placentae
variable decelerations
transient U/V shaped reduction occurring any time during uterine contracting phase
decrease usually more than 15 bpm and lasting 15 seconds
return to baseline in less then 2 minutes from onset
indicates cord compression
Ominous if repetitive, prolonged, severe or slow return to baseline
variable declerations: what should you do? and what if ominous?
First change mothers position
if ominous, put mother on O2 and stop oxytocin
nursing interventions for late decelerations
position mom left side lying (if not change, move to other side, Trendelenberg or Knee-chest position)
administer O2 by mask
start IV/increase flow rate
stop oxytocin if appropriate
prepare for C section
lie
relationship of fetus' spine to mother's spine
Can be longitudinal (parallel), transverse (perpendicular), oblique (slight angle off a true transverse lie)
presentation
part of the fetus that presents to (enters) maternal pelvic inlet
-Cephalic/vertex (head) 95%
-Breech/buttocks (3-4%)
-Shoulder/transverse lie (rare)
types of breech presentations
frank (most common)-flexion of hips and extension of knees
complete-flexion of hips and knees
footing/incomplete-extension of hips and knees
attitude
relationship of fetal parts to eachother
usually flexion of head and extremities on chest and abdomen to accommodate shape of uterine cavity
position
relationship of fetal reference point to maternal pelvis
expressed as 3 letter abbreviation
(LOA,LOP,ROA,ROP,LSA,RSA)
fetal reference point
can be...
vertex presentation-head, multiple degrees
breech presentation-sacrum
shoulder presentation-scapula
degrees of vertex presentation
full flexion of head-occiput
full extension of head-chin
modertae extension (military)-brow
maternal pelvis is designated by
her right/left and anterior/posterior
(LOA,LOP,ROA,ROP,LSA,RSA) what do these positions stand for?
left occiput anterior
left occiput posterior
right occiput anterior
left sacrum anterior
right sacrum anterior
What is the most common birth vertex presentation
left occiput anterior
station
level of presenting part of fetus in relation to imaginary line between ischial spines (zero station)
-5 to -1 station indicates a presenting part that is _____ zero station
above or "floating"
+1 to +5 indicates a presenting part that is ____ station zero
below
engagement
when the presenting part is at station zero or below
Increment contraction phase
First phase,
steep crescent slope from beginning of the contraction until its peak
acme/peak contraction phase
Second phase,
strongest intensity
decrement contraction phase
third and last phase,
diminshing intensity
contraction frequency less than every ____ minutes should be reported
2 minutes
contraction duration more than ____ seconds should be reported
90 seconds
(risk uterine rupture/fetal distress)
contraction intensity can be somewhat measured by
palpation of fundus
-mild contraction=slightly tense uterus easily indented w/ fingertips
-moderate=firm fundus difficult to indent
strong=rigid, board like fundus
contractions in true labor are...
regular w/ increasing frequency, duration and intensity
DO NOT decrease w/ rest
contractions in false labor are...
irregular w/ usually no change in freqeuncy, duration or intensity
May lessen with activity or rest
Discomfort in true labor is...
radiates from back around the abdomen
discomfort in false labor usually...
is abdominal
the cervix in true labor...
progressively effaces and dilates
the cervix in false labor...
does not change
Stages of Labor
Stage 1 = beginning to complete cervical dilation (0-10cm)
Stage 2 = complete dilation to birth of baby
Stage 3 = birth to delivery of placenta
Stage 4 = first 4 hrs after placenta delivery
Japan childbirth culture characteristic
natural childbirth
may labor silently
Chinese culture childbirth characteristic
stoic response to pain
side lying position for labor and birth
Indian culture childbirth characteristic
female relatives present
Laos culture childbirth characteristic
may use squatting position for birth
Phases of Stage 1 of labor
Phase 1 (latent)= 0-3 cm; contractions 10-30 sec long, 5-30 min apart; mild to moderate

Phase 2 (active) = 4-7 cm, contractions 40-60 sec long, 3-5 min apart; moderate to strong

Phase 3 (transition) = 8-10 cm, contractions 45 - 90 sec long, 1.5 - 2 min apart; strong
Phases of Stage 2 of labor
Phase 1 = 0 - 2+ station, contractions 2-3 min apart
Phase 2 = +2 to +4 station, contractions 2-2.5 min apart; increase in dark red bloody show; increased urgency to bear down
Phase 3 = +4 to birth, contractions 1-2 min apart; fetal head visible; increased urgency to bear down
Nursing intervention if irregular fetal heartbeat during labor
turn client on left side
give supplemental O2
check for cord prolapse
start IV line
nitrous oxide and O2 use in labor
used intermittently with each contraction; patient is able to cooperate in bearing down (unlike w/ some other drugs)
increased danger of neontaal depression w/ continued use after 15-20 minutes
Methoxyflurane (Penthrane) use in labor
self administerd by mom via inhaler
may cause maternal and fetal narcotic depression
Lumbar epidural block use in labor
can be continuous infusion, numbs T10 through S5 (for vaginal)
risk of maternal hypotension
during lumbar epidural monitor...
maternal BP and fetal HR everey 1-2 minutes X15 minutes initially then every 10-15 minutes
treatment of maternal hypotension
mild/moderate = place mom in left lateral position, increase IV rate
administer oxygen by mask
notify MD

severe/prolonged = place mom in Trendelenberg position for 2-3 minutes,
monitor maternal BP and fetal HR
caudal
administered during Stage 2 of labor just before delivery, not commonly used
subarachnoid block "saddle block"
nerves from S1-S4, injection given in sitting position
remain upright for 30 seconds to 2 min
diminishes pushign efforts
HIGH incidence maternal hypotension and fetal hypoxia potential
spinal block
now used primarily just prior to C section
paracervical block analgesics
injection of an anesthetic solution into region aroudn cervical area to relieve pain caused by cervical dilation
Depressing effect on infant respiratory center
intravenous anesthesia
e.g. Pentothal
rarely used, can cause fetal depression
maternal larynogospasm
vomiting and aspiration
postpartal uterine atony (muscle lost strength)
Immediate RN actions for newborn care at delivery
establish airway
observe for Apgar score at 1 and 5 minutes
clamp umbilical cord
maintain warmth
place ID band on baby and mother
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