NSG 222 Family Nursing Exam 2 - Questions and Answers

NSG 222 Family Nursing Exam 2 - Questions and Answers Braxton Hicks Contractions Braxton Hicks contractions are typically felt as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually spread downward before relaxing. In contrast, true labor contractions are more commonly felt in the lower back. These contractions aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix. Braxton Hicks contractions usually last about 30 seconds but can persist for as long as 2 minutes True Labor Regular contractions, becoming closer together, usually 4-6 minutes apart lasting 30-60 seconds Stronger contractions with time, vaginal pressure is felt Discomfort starts in the back and radiates around towards the front of the abdomen Contractions continue no matter what positional change is made Stay home till contractions are 5 min apart lasting 45-60 seconds and are strong enough that conversation during one is not possible False Labor Irregular, far apart contractions Weak contractions not getting stronger with time or alternating between strong and weak Abdominal discomfort not in the back Contractions may slow or stop with walking or changing positions What is the Passenger? The fetus (with placenta) is the passenger. Partner in Birth A caring partner can use massage, light touch, acupressure, hand-holding, stroking, and relaxation; can help the woman communicate her wishes to the staff; and can provide a continuous, reassuring presence, all of which bring some degree of comfort to the laboring woman. Although the presence of the mother's significant other at the birth provides special emotional support, a partner can be anyone who is present to support the woman throughout the experience Basic Prenatal Education Basic prenatal education can help women manage the labor process and feel in control of the birthing experience. The literature indicates that if a woman is prepared before the labor and birth experience, the labor is more likely to remain natural without the need for medical intervention Prenatal education teaches the woman about the childbirth experience and increases her sense of control. She is then able to work as an active participant during the labor and birth experience Vaginal Examination The purpose of performing a vaginal examination is to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding Prepare the woman by informing her about the procedure, what information will be obtained from it, how she can assist with the procedure, how it will be performed, and who will be performing it. Performing Leopold Maneuvers Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse's hands with the fingers together palpate the uterus A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: · Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? · Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) · Maneuver 3: What is the presenting part? · Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Fetal Assessment During Labor and Birth A fetal assessment identifies well-being or signs that indicate compromise. The character of the amniotic fluid is assessed, but the fetal assessment focuses primarily on determining the FHR pattern. Umbilical cord blood analysis and fetal scalp stimulation are additional assessments performed as necessary in the case of questionable FHR patterns. Analysis of Amniotic Fluid Amniotic fluid should be clear when the membranes rupture. Rupturing of membranes is either spontaneous or artificial by means of an amniotomy, during which a disposable plastic hook (an Amnihook) is used to perforate the amniotic sac. Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation. If it is determined that meconium- stained amniotic fluid is due to fetal hypoxia, the maternity and pediatric teams work together to prevent meconium aspiration syndrome, which can lead to respiratory distress. This would necessitate suctioning after the head is born before the infant takes a breath and perhaps direct tracheal suctioning after birth if the Apgar score is low. In some cases, an amnioinfusion (introduction of warmed, sterile normal saline or Ringer's lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero to assist in preventing meconium aspiration syndrome. Analysis of Fetal Heart Rate Monitoring of the FHR throughout labor and birth is essential to assure fetal well-being to optimize neonatal outcomes. Analysis of the FHR is one of the primary evaluation tools used to determine fetal oxygen status indirectly. FHR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally Category 1 Fetal Heart Rate Category 1 Normal: Baseline 110-160 bpm Baseline variability moderate Present or absent accelerations Present or absent early decelerations No late or variable decelerations Can be monitored with intermittent auscultation during labor Category 2 Fetal Heart Rate Category 2 Indeterminate: Not predictive of abnormal fetal acid-base status, but requires evaluation and continued surveillance Fetal tachycardia (over 160) Fetal bradycardia (less than 110) not accompanied by absent baseline variability Absent baseline variability not accompanied by recurrent decelerations Minimal or marked variability Recurrent late decelerations with moderate baseline variability Recurrent variable decelerations accompanied by minimal or moderate baseline variability, overshot, or shoulders Prolonged decelerations over 2 min but less than 10 min Category 3 Fetal Heart Rate Category 3 Abnormal: Abnormal fetus acid-base status, requires intervention Fetal bradycardia (less than 110) Recurrent late decelerations Recurrent variable decelerations (absent or declining) Sinusoidal Pattern (smooth, undulating baseline) Non-Pharmacological Measures for Birth Nonpharmacologic measures are usually simple, safe, and inexpensive to use. Many of these measures are taught in childbirth classes, and women should be encouraged to try a variety of methods prior to the real labor. Many of the measures need to be practiced for best results and coordinated with the partner or coach. The nurse provides support and encouragement for the woman and her partner using nonpharmacologic methods. Continuous Labor Support- Continuous labor support involves offering a sustained presence to the laboring woman by providing emotional support, comfort measures, advocacy, information and advice, and support for the partner. Hydrotherapy-Hydrotherapy is the external use of any form of water for health promotion. Ambulation and Position Changes-Positioning during labor is influenced by cultural factors, obstetric practices, place of childbirth, technology, and the preferences of the mother and health care providers. Application of Heat and Cold Breathing Techniques Attention Focusing and Imagery-Visualization or guided imagery uses many of the senses and the mind to focus on stimuli Effleurage and Massage Effleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions. Effleurage and massage use the sense of touch to promote relaxation and pain relief.