Podcast
Questions and Answers
What is the correct heart rate classification for an APGAR score of 1?
What is the correct heart rate classification for an APGAR score of 1?
Which nursing action should be performed when findings of placental separation are observed?
Which nursing action should be performed when findings of placental separation are observed?
During the fourth stage of labor, how often should vital signs be assessed for the first two hours?
During the fourth stage of labor, how often should vital signs be assessed for the first two hours?
What APGAR score classification describes a good cry?
What APGAR score classification describes a good cry?
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Which action is NOT part of the assessment during the fourth stage of labor?
Which action is NOT part of the assessment during the fourth stage of labor?
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What is the key focus of nursing responsibilities during the assessment of labor?
What is the key focus of nursing responsibilities during the assessment of labor?
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During the first stage of labor, what should be monitored every 30 to 60 minutes?
During the first stage of labor, what should be monitored every 30 to 60 minutes?
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What action is crucial during the active phase of labor to facilitate comfort?
What action is crucial during the active phase of labor to facilitate comfort?
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What should be assessed every 5 to 30 minutes during the second stage of labor?
What should be assessed every 5 to 30 minutes during the second stage of labor?
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Which type of perineal laceration involves extension through the skin and muscles but not the anal sphincter?
Which type of perineal laceration involves extension through the skin and muscles but not the anal sphincter?
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What is a key nursing action to prepare for during the second stage of labor?
What is a key nursing action to prepare for during the second stage of labor?
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What is a critical assessment to ensure during the initial stages of labor?
What is a critical assessment to ensure during the initial stages of labor?
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What should be done if membranes have ruptured during the first stage of labor?
What should be done if membranes have ruptured during the first stage of labor?
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Which APGAR score indicates that the infant has a good respiratory rate?
Which APGAR score indicates that the infant has a good respiratory rate?
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What is an expected finding of the maternal assessment during the fourth stage of labor?
What is an expected finding of the maternal assessment during the fourth stage of labor?
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Which nursing action is recommended after observing the findings of placental separation?
Which nursing action is recommended after observing the findings of placental separation?
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In the assessment during the fourth stage of labor, which aspect is NOT included?
In the assessment during the fourth stage of labor, which aspect is NOT included?
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During the assessment of an infant, which APGAR score classification is associated with a completely pink appearance?
During the assessment of an infant, which APGAR score classification is associated with a completely pink appearance?
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What is an appropriate nursing action during the active phase of the first stage of labor?
What is an appropriate nursing action during the active phase of the first stage of labor?
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Which of the following vital signs assessments is appropriate during the first stage of labor after membranes have ruptured?
Which of the following vital signs assessments is appropriate during the first stage of labor after membranes have ruptured?
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What indicates a first-degree perineal laceration?
What indicates a first-degree perineal laceration?
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During the second stage of labor, how often should fetal heart rate (FHR) be assessed?
During the second stage of labor, how often should fetal heart rate (FHR) be assessed?
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Which of the following is a key assessment during the latent phase of the first stage of labor?
Which of the following is a key assessment during the latent phase of the first stage of labor?
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What is a primary goal when assisting with patient-centered care during labor?
What is a primary goal when assisting with patient-centered care during labor?
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What is assessed to confirm if a mother is in true labor during the first stage?
What is assessed to confirm if a mother is in true labor during the first stage?
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What is a common nursing action to promote comfort during the second stage of labor?
What is a common nursing action to promote comfort during the second stage of labor?
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Study Notes
Nursing Care During Labor Stages
-
Nursing Responsibilities in Labor:
- Labor status assessment (baseline data, teaching needs, vaginal/cervical assessments, progress of labor, patient-centered care, cultural competence, client preferences)
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First Stage of Labor Assessment:
- Leopold maneuvers
- Vital signs (VS) every 30-60 minutes
- Vaginal exams
- Ensure labor is true labor
- Pain management monitoring
- Monitor dilation
- Bladder palpation
- Temperature every 4 hours (every 2 hours if membranes have ruptured)
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Latent Phase:
- Nursing Actions include monitoring.
-
Active Phase:
- Client and fetal monitoring
- Frequent position changes
- Voiding at least every 2 hours
- Catheterization if needed
- Deep breathing exercises
- Relaxation techniques
- Non-pharmacological pain relief
- Pharmacological pain relief
-
Transition Phase:
- Vital signs every 5-30 minutes
- Uterine contractions monitoring
- Client pushing efforts assessment
- Assessment of bloody show increase
- Assessment of shaking or extremities
- Fetal heart rate (FHR) every 5-15 minutes
Second Stage of Labor Assessment
- Vital signs every 5-30 minutes
- Uterine contractions monitoring
- Client pushing efforts
- Assessment of bloody show increase
- Assessment of shaking
- Fetal heart rate (FHR) every 5-15 minutes
- Nursing Actions: Continue to monitor the client and fetus.
Third Stage of Labor Assessment
- Vital Signs every 15 minutes
- Assessment of 1- and 5-minute APGAR scores
Perineal Lacerations
- First Degree: Lacerations extend through the skin of the perineum, not the muscle.
- Second Degree: Lacerations extend through the skin and muscles into the perineum but not the anal sphincter.
- Third Degree: Lacerations extend through the skin, muscles, perineum, and the external anal sphincter.
- Fourth Degree: Lacerations extend through the skin, muscles, perineum, anal sphincter, and the anterior rectal wall.
Fourth Stage of Labor Assessment
- Mother: VS every 15 minutes (first 2 hours then q 4 hours, for first 8 hours)
- Baby: Assessment of fundus and lochia q 15 minutes for the first hour
- Fundus: Massage uterine fundus, administer oxytocics if needed
- Lochia: Assess and monitor lochia
- Urinary Output: Monitor and record urinary output
- Baby-friendly activities: Encourage activities
- Nursing Actions (Fourth Stage): Continuously monitor VS, fundus, lochia, assess episiotomy or laceration repair, encourage voiding and bonding with the baby.
APGAR Scoring
- A scoring system to assess a newborn's health immediately after birth. Assesses heart rate, respiratory rate, muscle tone, reflexes, and color.
Nursing Actions for Placental Separation
- Instruct client to push when placental separation is found.
- Administer oxytocics to stimulate uterine contractions
- Admin pain meds
- Gently clean perineal area with warm water and put pad and ice.
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Description
This quiz focuses on the critical nursing responsibilities and assessments needed during the different stages of labor. It covers essential techniques like Leopold maneuvers, monitoring vital signs, and pain management strategies. Ideal for nursing students looking to deepen their understanding of labor nursing care.
