Nursing care during labor and delivery (test 2)
Study online at https://quizlet.com/_364h2d
1. nursing assessment: upon admission to L/D:
-review prenatal records; note any risk factors and areas of concern/need
-obtain admission data (age, GTPAL, EDC, ROM)
true vs false labor
fetal activity
current meds/allergies
prenatal problems
bloody show vs bleeding
onset of labor/pattern of UC
CB prep/birth plan
feeding method
pediatrician choice
last food/fluid ingested
last void/BM
recent sleep patterns
client/family concerns or questions
physical exam
2. physical exam data: abdominal exam (lie, presentation, fundal height, FHR, UC)
EFM or FHR and UC pattern
vital signs
pelvic exam for dilation, effacement, station, fetal position
presence of amniotic fluid, character
-fern test, nitrizine, Amnisure
presence of bleeding
bladder status
3. fern test: posterior vaginal swab is allowed to dry on a glass slide and then viewed
with a low power microscope
fern pattern is observed
wide: cervical mucus
thin: amniotic fluid
used to indicate leaking membranes
4. nitrazine swab: pH test used to determine if membranes have ruptured
normal vaginal environment is acidic (yellow swab)
amniotic fluid is much less acidic, often neutral (blue swab)
5. AmniSure: chemical test used to determine if membranes have ruptured/leaked
reads like a pregnancy dipstick
, Nursing care during labor and delivery (test 2)
Study online at https://quizlet.com/_364h2d
1 line = control (the test worked)
2 lines = positive for amniotic fluid
6. Which nursing assessments should be done upon admission to labor?
SATA
a. current fetal activity
b. due date of baby
c. status of membranes
d. gravida status: a, b, c, and d
7. A laboring woman has a distended bladder. Her nurse advises her to void
regularly for what reason? SATA
a. a full bladder strengthens contractions
b. an empty bladder facilitates descent
c. an empty bladder provides for comfort
d. a full bladder increases risk of hemorrhage: b and c
8. Nursing care during Stage 1 (early labor): orient to room and procedures, staff
resta nd refreshment for support person
establish nurse-patient relationship
enema, perineal prep as ordered
assess learning needs and begin teaching
comfort measures
positions changes
fluids as allowed, monitor fluid status
focus assessments
BP, P, R qh
T q4h (q2 if ROM)
FHR qh
UC q30min
bladder status
coping and pain control
assess delivery room supplies and readiness
9. fetal heart rate monitoring during labor: let mom get up and move
-labor progression
-pain control
constant monitoring is indicated with pitocin and epidural
10. Nursing care during Stage 1 (active): comfort measures
position changes
breathing
IV as needed, monitor fluid status
, Nursing care during labor and delivery (test 2)
Study online at https://quizlet.com/_364h2d
analgesia and anesthetic prn
focused assessment
BP, P, R qh
T q4 (q2 if ROM)
FHR, UC q30min
bladder status
vaginal bleeding/discharge
assess delivery room supplies and readiness
during Transition:
BP, TPR q30min
FHR, UC q15min
11. supplies needed for delivery: you need at least:
gloves
cord clamp
delivery location
something to clear baby's airway
12. maternal signs of transition: involuntary pushing (when mom feels pressure
on bowel)
moisture on upper lip
urge to bear down
cleansing breaths at the beginning and end of contractions
13. A woman has contractions q2-5min and a duration of 45-60 seconds. Which
assessments would the RN include in her care? SATA
a. FHR
b. frequency of contractions
c. pain level of the client
d. woman's coping techniques: a, b, c, and d
14. During which stage of labor is there the highest risk?: 2 (pushing)
15. Nursing care during Stage 2 (pushing): coach/support
maternal positioning
comfort measures
physician/CNM contact
bladder status
UC, FHR q5min
16. Nursing care during Stage 3 (placenta): give Oxytocics as ordered (pitocin,
methergine)
assess maternal and newborn well-being
Study online at https://quizlet.com/_364h2d
1. nursing assessment: upon admission to L/D:
-review prenatal records; note any risk factors and areas of concern/need
-obtain admission data (age, GTPAL, EDC, ROM)
true vs false labor
fetal activity
current meds/allergies
prenatal problems
bloody show vs bleeding
onset of labor/pattern of UC
CB prep/birth plan
feeding method
pediatrician choice
last food/fluid ingested
last void/BM
recent sleep patterns
client/family concerns or questions
physical exam
2. physical exam data: abdominal exam (lie, presentation, fundal height, FHR, UC)
EFM or FHR and UC pattern
vital signs
pelvic exam for dilation, effacement, station, fetal position
presence of amniotic fluid, character
-fern test, nitrizine, Amnisure
presence of bleeding
bladder status
3. fern test: posterior vaginal swab is allowed to dry on a glass slide and then viewed
with a low power microscope
fern pattern is observed
wide: cervical mucus
thin: amniotic fluid
used to indicate leaking membranes
4. nitrazine swab: pH test used to determine if membranes have ruptured
normal vaginal environment is acidic (yellow swab)
amniotic fluid is much less acidic, often neutral (blue swab)
5. AmniSure: chemical test used to determine if membranes have ruptured/leaked
reads like a pregnancy dipstick
, Nursing care during labor and delivery (test 2)
Study online at https://quizlet.com/_364h2d
1 line = control (the test worked)
2 lines = positive for amniotic fluid
6. Which nursing assessments should be done upon admission to labor?
SATA
a. current fetal activity
b. due date of baby
c. status of membranes
d. gravida status: a, b, c, and d
7. A laboring woman has a distended bladder. Her nurse advises her to void
regularly for what reason? SATA
a. a full bladder strengthens contractions
b. an empty bladder facilitates descent
c. an empty bladder provides for comfort
d. a full bladder increases risk of hemorrhage: b and c
8. Nursing care during Stage 1 (early labor): orient to room and procedures, staff
resta nd refreshment for support person
establish nurse-patient relationship
enema, perineal prep as ordered
assess learning needs and begin teaching
comfort measures
positions changes
fluids as allowed, monitor fluid status
focus assessments
BP, P, R qh
T q4h (q2 if ROM)
FHR qh
UC q30min
bladder status
coping and pain control
assess delivery room supplies and readiness
9. fetal heart rate monitoring during labor: let mom get up and move
-labor progression
-pain control
constant monitoring is indicated with pitocin and epidural
10. Nursing care during Stage 1 (active): comfort measures
position changes
breathing
IV as needed, monitor fluid status
, Nursing care during labor and delivery (test 2)
Study online at https://quizlet.com/_364h2d
analgesia and anesthetic prn
focused assessment
BP, P, R qh
T q4 (q2 if ROM)
FHR, UC q30min
bladder status
vaginal bleeding/discharge
assess delivery room supplies and readiness
during Transition:
BP, TPR q30min
FHR, UC q15min
11. supplies needed for delivery: you need at least:
gloves
cord clamp
delivery location
something to clear baby's airway
12. maternal signs of transition: involuntary pushing (when mom feels pressure
on bowel)
moisture on upper lip
urge to bear down
cleansing breaths at the beginning and end of contractions
13. A woman has contractions q2-5min and a duration of 45-60 seconds. Which
assessments would the RN include in her care? SATA
a. FHR
b. frequency of contractions
c. pain level of the client
d. woman's coping techniques: a, b, c, and d
14. During which stage of labor is there the highest risk?: 2 (pushing)
15. Nursing care during Stage 2 (pushing): coach/support
maternal positioning
comfort measures
physician/CNM contact
bladder status
UC, FHR q5min
16. Nursing care during Stage 3 (placenta): give Oxytocics as ordered (pitocin,
methergine)
assess maternal and newborn well-being
