Nursing Assessment in Labor

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Questions and Answers

What is the minimum cervical dilation considered for active labor?

4 cm (correct)

6 cm

8 cm

2 cm

Which of the following is NOT a sign that indicates immediate danger in a woman in labor?

Moderate abdominal pain (correct)

Heavy vaginal bleeding

Severe headaches

Loss of consciousness

What is the normal blood pressure range for a pregnant woman in labor?

110/70 mmHg to 130/90 mmHg

80/50 mmHg to 100/70 mmHg

120/80 mmHg to 140/90 mmHg

90/60 mmHg to 120/80 mmHg (correct)

Why is it important to assess the color of the amniotic fluid after membrane rupture?

To identify meconium presence Signup and view all the answers

Which piece of equipment is essential to monitor contractions?

Timer Signup and view all the answers

What should be assessed if a woman reports a decrease in fetal movement?

Fetal distress Signup and view all the answers

When a woman does not meet the admission criteria for labor, what is the recommended course of action?

Advise her to return home Signup and view all the answers

Which symptom requires urgent referral during the initial assessment?

Shortness of breath Signup and view all the answers

What is the minimum cervical dilation indicating a woman is in active labor?

4 cm Signup and view all the answers

Which vital sign is NOT typically monitored during labor?

Pupil dilation Signup and view all the answers

What should be documented regarding the fetal heart rate during labor?

Response to contractions Signup and view all the answers

If a woman is not in active labor, what is an appropriate action?

Allow her to stay near the facility for observation Signup and view all the answers

What is the focus of continuous monitoring during labor admission?

Cervical dilation and fetal descent Signup and view all the answers

What does a discrepancy between fundal height and gestational age typically suggest?

Potential complications Signup and view all the answers

Which of the following correctly describes the three classifications of uterine contraction intensity?

Mild, Moderate, Strong Signup and view all the answers

What is the primary purpose of a vaginal examination during labor?

To determine if labor has started and its progress Signup and view all the answers

What does a fetal station of +1 indicate?

Baby is descending into the birth canal Signup and view all the answers

Which of the following is NOT included in the essential information documented during the admission process?

Patient’s previous medical history Signup and view all the answers

How often should vaginal exams be performed during labor to limit infection risk?

Every 4 hours Signup and view all the answers

What is assessed during the monitoring of uterine contractions?

Duration, Interval, and Frequency Signup and view all the answers

What does fetal presentation refer to during a vaginal examination?

The orientation of the fetus at delivery Signup and view all the answers

What is the normal range for fetal heart rate (FHR)?

120-160 bpm Signup and view all the answers

Which of the following could indicate a serious complication during pregnancy?

Elevated blood pressure Signup and view all the answers

What does GPTPALM stand for in pregnancy history recording?

Gravidity, Parity, Term births, Preterm births, Abortions, Living children, Multiple pregnancies Signup and view all the answers

What does a large abdominal size may indicate during examination?

Twins or excess amniotic fluid Signup and view all the answers

What should be noted about the pattern of contractions during labor assessment?

Frequency and intensity are key factors Signup and view all the answers

What does an oval shape of the abdomen typically indicate during physical examination?

Cephalic presentation Signup and view all the answers

What is the normal maternal pulse rate range during pregnancy?

80-100 bpm Signup and view all the answers

When assessing fetal position, which technique is performed?

Leopold’s Maneuver Signup and view all the answers

Study Notes

Admitting and Assessing a Woman in Labor

Immediately determine if a woman in labor needs emergency care.
Active labor criteria: at least 4 cm cervical dilation, 2-3 contractions every 10 minutes.
If the woman does not meet admission criteria, she may be advised to return home or wait near the facility.
Essential equipment: prenatal record, gloves, Doppler, thermometer, timer, blood pressure cuff, bedpan.

Focused Admission Assessment

Labor Progression:
- Contractions: Ask frequency, duration, and intensity (mild, moderate, strong).
- Membrane Rupture: Assess amniotic fluid color and odor, green may indicate meconium.
- Fetal Movement: Decreased fetal movement may indicate distress.
- Fetal Heart Rate (FHR): Normal range 120-160 bpm, abnormalities may indicate distress.

Vital Signs

Blood Pressure: Normal range 90/60 mmHg to 120/80 mmHg, elevated may indicate preeclampsia.
Pulse Rate: Normal maternal pulse 80-100 bpm.
Temperature: Normal is 36.5°C to 37.4°C, fever may indicate infection.

Detailed History Taking

Sociodemographic Information: Obtain name, age, address, occupation, and other personal details.
Labor Status: Record complaints like labor pains and ruptured membranes.
Contractions: Note frequency, intensity, duration.
Pregnancy History: Record GPTPALM (Gravidity, Parity, Term births, Preterm births, Abortions, Living children, Multiple pregnancies).
Determine gestational age by calculating the Estimated Date of Confinement (EDC) or Expected Date of Delivery (EDD).
Record gestational age based on the Last Menstrual Period (LMP) or fetal quickening.

Physical Examination

Inspection of the Abdomen (3 "S" mnemonic):
- Size: Large abdomen may indicate twins or excess amniotic fluid, small may suggest intrauterine growth restriction (IUGR).
- Shape: An oval shape is typical for a head-down presentation. A round shape may indicate an abnormal fetal position.
- Scarring: Look for scars from previous cesarean sections as they pose a risk of uterine rupture.
Palpation of the Abdomen (Leopold's Maneuver):
- Assess fetal position and lie. Feel for the fetal head and the presenting part.
- Check fundal height to gauge the baby's development, discrepancy between fundal height and gestational age could suggest complications.
- Auscultate the fetal heart rate using a Doppler immediately after a contraction for at least 60 seconds.

Monitoring Uterine Contractions

Duration: Time from the beginning to the end of a single contraction.
Interval: Time from the end of one contraction to the beginning of the next.
Frequency: Time from the beginning of one contraction to the beginning of the next.
Assessing Intensity:
- Mild: Feeling like the tip of your nose.
- Moderate: Feeling like your chin.
- Strong: Feeling like your forehead.

Vaginal Examination

Purpose: Determine if labor has started and assess its progress.
Cervical Dilation & Effacement: Measure how far the cervix has opened and thinned to allow the baby's passage.
Fetal Presentation: Check if the baby is head-first (cephalic) or another presentation like breech.
Fetal Station: Baby's position relative to the ischial spines in the pelvis.
- Negative numbers (-3, -4): Baby is high in the pelvis.
- Zero (0): Baby is fully engaged in the pelvis.
- Positive numbers (+1, +2): Baby is descending into the birth canal.
Station Assessment: Determines if the baby is moving down the birth canal effectively.
Vaginal exams should be performed every 4 hours to limit infection risk.

Documenting the Admission Process

Essential Information:
- Patient's name, age, demographic data.
- Gravidity and parity (GPTPALM).
- Gestational age and Estimated Date of Delivery (EDD).
- Labor status: frequency, duration, intensity of contractions.
- Cervical Dilation & Effacement.
- Fetal Presentation and Station.
- Status of the Membranes: intact or ruptured, characteristics of amniotic fluid.
- Vital Signs: blood pressure, pulse, temperature.
- Fetal Heart Rate (FHR): Record the response to contractions.
- Maternal Coping: Document the woman's ability to manage pain and stress.

Admission Criteria

Admit if the woman is in active labor: 4 cm dilation, regular contractions.
Document all findings in the patient record.
Notify the attending physician or midwife and transfer the woman to the labor room for further monitoring and care.

Patient Care During Admission

Provide continuous monitoring for labor progression, focusing on:
- Cervical dilation and fetal descent.
- Fetal heart rate and movement patterns.
- Maternal vitals to assess any signs of distress.

Prepare for Delivery

Once full dilation (10 cm) is achieved, prepare the woman for the second stage of labor - the delivery of the baby.

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Description

This quiz focuses on the critical assessments required when admitting and assessing a woman in labor. It covers active labor criteria, vital signs monitoring, and essential equipment needed for a thorough evaluation. Test your knowledge on recognizing signs of distress and understanding labor progression.