ATI Maternity ch 14-16 Study Guide
Nursing Care During Stages of Labor - ✅4 stages
Nursing responsibilities: orient partner & patient to unit
-provide culturally competent care that respects cultural care
-conduct admission history & labor
-monitor baseline fetal heart tones and uterine contractions pattern for 20-30 min
-obtain vitals, and check status of amniotic membrane
-perform assessment throughout labor and right after birth
-avoid vaginal exams in the presence of vaginal bleeding or until palcenta previa or
abruptio is ruled out
-cervical dilation is most important indicator of progress
-progress of labor is affected by fetal lie, presentation, attitude and fetal size in
relationship to mothers pelvis
-frequency, duration and strength of uterine contractions cause fetal descent and
cervical dilation
Cultures - ✅-Hispanic: prefer mom to be present rather than partner
-African American: prefer female family member for support
-Asian: prefer mom to be present. partner not active participant. labor in silence. c
section undesireable
-Native American: prefer female nursing personel, family involved, use of herbs during
labor, squat for birth
-European American: birth is public concern, focus on technology, partner expected to
be involved, provider seen as head of health team
First Stage of Labor - ✅-leopold maneuver performed
-perform a vaginal exam as indicated to allow examiner to assess whether client is in
true labor and whether membranes have ruptured
-encourage the client to take slow, deep breaths prior to vaginal exam
-monitor the dilation and effacement
-monitor station and fetal presentation
-prepare for impending delivery as the presenting part moves into positive stations and
begins to push against pelvic floor
-bladder palpation on regular basis to prevent bladder distention
-BP, pulse and resp measurements: latent phase every 30-60, active every 30,
transition 15-30
-temp every 4 hours
-contraction: latent 30-60 active 15-30, transition 10-15
-FHR monitoring 110-160 normal
Assessment of Membrane Rupture - ✅FHR to ensure there is no fetal distress for
possible umbilicl chord prolapse
-ph 6.5-7.5
-sampel of fluid: color clear straw and free of odor
, -presence of meconium, abnormal color or odor is bad
Nursing Intervention During First Stage - ✅teaching about what to expect during labor
and relaxation measures: breathing (deep cleansing breaths)
-effleurage (gentle circular stroking of abdomen in rhythm with breathing during
contractions)
-diversional activities (distraction, concentration on a focal point, imagery)
-upright position, warm/ cold packs, ambulation, hydrotherapy
-void every 2 hours
First Active Phase - ✅-client and fetal monitor, frequent position changes, voiding every
2 hours, deep cleansing breaths before and after paced breathing
-relaxation, non pharm comfort, pharm as prescribed
First Transition Phase - ✅-void every 2 hours, monitor and support, rapid pain pain
blow breathing pattern
-no pushing efforts until full dilation
-listen for statements expressing need to have a bowel movement (complete dilation)
-prep for birth
-observe for perineal bulging/ crowning
-bear down w. contractions with dilation
Second stage of Labor - ✅-begins with complete dilation and effacement
-BP, pulse and resp Q5-30 min
-uterine contractions
-pushing efforts
-increase in bloody show
-FHR every 15 min & after birth
-assessment for perineal lacerations: first degree (through skin no muscle), 2nd (skin
and muscle into perineum), 3rd (through skin, muscle, perineum and anal spinster) 4th
(skin, muscle, sphincter and anterior rectal wall_
NURSING: monitor, assist in position for pushing, assist in partner involvement with
pushing, rest between contraction, comfort, cleanse perineal area if feces, prep for
episiotomy, provide feedback to client, prep for care of neonate
-check oxygen, radiant warmer, lay out stethoscope and bulb shrine, resusc. equip,
suction
Third Stage of Labor - ✅Assess: blood pressure, pulse, respiration Q15
-placenta separation from uterus: funds firm contracting, gush of blood from introits,
umbilical cord appears to lengthen, vaginal fullness
-1 and 5 min apgar scores
NURSING: push once signs of separation indicated, promote baby friendly activities
between family and newborn, facilitating release of maternal oxytocin
Nursing Care During Stages of Labor - ✅4 stages
Nursing responsibilities: orient partner & patient to unit
-provide culturally competent care that respects cultural care
-conduct admission history & labor
-monitor baseline fetal heart tones and uterine contractions pattern for 20-30 min
-obtain vitals, and check status of amniotic membrane
-perform assessment throughout labor and right after birth
-avoid vaginal exams in the presence of vaginal bleeding or until palcenta previa or
abruptio is ruled out
-cervical dilation is most important indicator of progress
-progress of labor is affected by fetal lie, presentation, attitude and fetal size in
relationship to mothers pelvis
-frequency, duration and strength of uterine contractions cause fetal descent and
cervical dilation
Cultures - ✅-Hispanic: prefer mom to be present rather than partner
-African American: prefer female family member for support
-Asian: prefer mom to be present. partner not active participant. labor in silence. c
section undesireable
-Native American: prefer female nursing personel, family involved, use of herbs during
labor, squat for birth
-European American: birth is public concern, focus on technology, partner expected to
be involved, provider seen as head of health team
First Stage of Labor - ✅-leopold maneuver performed
-perform a vaginal exam as indicated to allow examiner to assess whether client is in
true labor and whether membranes have ruptured
-encourage the client to take slow, deep breaths prior to vaginal exam
-monitor the dilation and effacement
-monitor station and fetal presentation
-prepare for impending delivery as the presenting part moves into positive stations and
begins to push against pelvic floor
-bladder palpation on regular basis to prevent bladder distention
-BP, pulse and resp measurements: latent phase every 30-60, active every 30,
transition 15-30
-temp every 4 hours
-contraction: latent 30-60 active 15-30, transition 10-15
-FHR monitoring 110-160 normal
Assessment of Membrane Rupture - ✅FHR to ensure there is no fetal distress for
possible umbilicl chord prolapse
-ph 6.5-7.5
-sampel of fluid: color clear straw and free of odor
, -presence of meconium, abnormal color or odor is bad
Nursing Intervention During First Stage - ✅teaching about what to expect during labor
and relaxation measures: breathing (deep cleansing breaths)
-effleurage (gentle circular stroking of abdomen in rhythm with breathing during
contractions)
-diversional activities (distraction, concentration on a focal point, imagery)
-upright position, warm/ cold packs, ambulation, hydrotherapy
-void every 2 hours
First Active Phase - ✅-client and fetal monitor, frequent position changes, voiding every
2 hours, deep cleansing breaths before and after paced breathing
-relaxation, non pharm comfort, pharm as prescribed
First Transition Phase - ✅-void every 2 hours, monitor and support, rapid pain pain
blow breathing pattern
-no pushing efforts until full dilation
-listen for statements expressing need to have a bowel movement (complete dilation)
-prep for birth
-observe for perineal bulging/ crowning
-bear down w. contractions with dilation
Second stage of Labor - ✅-begins with complete dilation and effacement
-BP, pulse and resp Q5-30 min
-uterine contractions
-pushing efforts
-increase in bloody show
-FHR every 15 min & after birth
-assessment for perineal lacerations: first degree (through skin no muscle), 2nd (skin
and muscle into perineum), 3rd (through skin, muscle, perineum and anal spinster) 4th
(skin, muscle, sphincter and anterior rectal wall_
NURSING: monitor, assist in position for pushing, assist in partner involvement with
pushing, rest between contraction, comfort, cleanse perineal area if feces, prep for
episiotomy, provide feedback to client, prep for care of neonate
-check oxygen, radiant warmer, lay out stethoscope and bulb shrine, resusc. equip,
suction
Third Stage of Labor - ✅Assess: blood pressure, pulse, respiration Q15
-placenta separation from uterus: funds firm contracting, gush of blood from introits,
umbilical cord appears to lengthen, vaginal fullness
-1 and 5 min apgar scores
NURSING: push once signs of separation indicated, promote baby friendly activities
between family and newborn, facilitating release of maternal oxytocin
