NURS 415 Final (100% correct solutions)

Describe when the first stage of labor starts & how many phases its split up into correct answers When regular uterine contractions start until full cervical effacement & dilation Split up into 3 different phases 1. latent phase- up to 6cm; typically takes the longest (a primigravida will usually take longer than a multigravida) 2. active phase - 4-7cm dilated 3. transition phase - 8 to 10 cm dilated What assessments should you be doing in the first stage of labor? correct answers Where is someone in labor? Pt: prenatal history, vitals, pain, coping & support Fetus: NST, position & movement Contractions: frequency, dilation & intensity cervix: dilation (how open), effacement (how thin - %) and station in correlation to ischial spines What laboratory & diagnostic tests should look at/do in the first stage of labor? correct answers UA - protein if BP is high, ketone dip for dehydration Blod tests: CBC type & screen to determine blood type amniotic fluid: intact, SROM, prom & color GBS status: screen at 37 weeks, should receive 2 doses of penicillin G STD Vitals What STD causes you to not be able to deliver vaginally? correct answers Herpes! After a membrane has ruptured, what is the typical timeframe you don't want to go over? correct answers 18 hours - it puts the newborn at higher risk of infection and the baby will be placed on sepsis protocol (watch for 48 hours) What if a person's water is brown/greenish? correct answers Meconium could indicate the baby was stressed (increase their peristalsis) OR the baby is term & was ready to take a poop What are plan of care/interventions for the first stage of labor? correct answers SUPPORT! Asses pain & coping, general hygiene, monitoring oral intake & IV fluids, make sure pt. voids at least q2h, ambulation + positioning (moving helps get baby into position)