● Perform Leopold maneuvers. Show ● Perform a vaginal examination as indicated (if no evidence of progress) to allow the examiner to assess whether client is in true labor and whether membranes have ruptured. ● Assessments related to possible rupture of membranes ●
Perform bladder palpation on a regular basis to prevent bladder distention, which can impede fetal descent through the birth canal and cause trauma to the bladder. ● Temperature assessment every 4 hr (every 1 to 2 hr if membranes have ruptured) COHEN STUFF Begins with complete dilation and effacement Assessment for perineal lacerations, which usually occur as the fetal head is expulsed. Perineal lacerations
are defined in terms of depth. COHEN The Apgar test is done by a doctor, midwife, or nurse. The health care provider examines the baby's: Breathing effort Each category is scored with 0, 1, or 2, depending on the observed condition. If the infant is not
breathing, the respiratory score is 0. If there is no heartbeat, the infant scores 0 for heart rate. If muscles are loose and floppy, the infant scores 0 for muscle tone. If there is no reaction, the infant scores 0 for reflex irritability. If the skin color is pale blue, the infant scores 0 for color. ANS: D Reddish-haired women have tissue that is less distensible than darker-skinned women and therefore may have less efficient healing. First-time mothers are also at greater risk, especially with breech births, long second-stage labors, or rapid labors during which the time for the perineum to stretch is insufficient. The rate of episiotomies is higher when obstetricians rather than midwives attend the births. The woman in the first scenario (a) is at low risk for either damaging lacerations or an episiotomy. She is multiparous, has dark skin, and is being attended by a midwife, who is less likely to perform an episiotomy. Reddish-haired women have tissue that is less distensible than that of darker-skinned women. Consequently, the client in the second scenario (b) is at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy. The fact that the woman in the third scenario (c) is experiencing a prolonged labor might increase her risk for lacerations. Fortunately, she is dark skinned, which indicates that her tissue is more distensible than that of fair-skinned women and therefore less susceptible to injury. ANS: A Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, then the nurse would expect to find the uterus boggy and displaced to the side. ANS: A, B, C, D The presence of companions, clothing to be worn, care and handling of the newborn, medical interventions, and environmental modifications all might be included in the couple's birth plan. Other items include the presence of nonessential medical personnel (students), labor activities such as the tub or ambulation, preferred comfort and relaxation methods, and any cultural or religious requirements. The expected date of delivery would not be part of a birth plan unless the client is scheduled for an elective cesarean birth. What behavior does the nurse expect in a patient who is in the transition phase during the first stage of labor quizlet?What behavior does the nurse expect in a client who is in the transition phase during the first stage of labor? 1 The client remains calm and silent. 2 The client doubts her ability to control pain.
What happens during the first stage of labor quizlet?During the first stage of labor, contractions help your cervix to thin and begin to open. This is called effacement and dilation. Cervix beginning to dilate Your cervix opens to 4 centimeters. You will probably spend most of early labor at home.
What occurs during the transition stage of labour quizlet?What happens during the transition phase? the cervix dilates (8 to 10 cm) contractions are usually very strong (60-90 seconds) and occur every few minutes.
Which of the following occurs during the first stage of labor?During the 1st stage of labour, contractions make your cervix gradually open (dilate). This is usually the longest stage of labour. At the start of labour, your cervix starts to soften so it can open. This is called the latent phase and you may feel irregular contractions.
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