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A primiparous woman in the transition phase of labor begins to experience intense rectal pressure and an urge to push. What is the most appropriate nursing action?
A primiparous woman in the transition phase of labor begins to experience intense rectal pressure and an urge to push. What is the most appropriate nursing action?
- Administer pain medication to help the patient relax.
- Assess cervical dilation to confirm complete dilation before allowing the patient to push. (correct)
- Prepare for imminent delivery, as these signs indicate the second stage of labor.
- Ask her about the baby's name.
- Encourage the patient to begin pushing with each contraction to facilitate delivery.
During the immediate postpartum period, a nurse assesses a patient and notes a boggy uterus and a steady trickle of blood. Which intervention should the nurse implement first?
During the immediate postpartum period, a nurse assesses a patient and notes a boggy uterus and a steady trickle of blood. Which intervention should the nurse implement first?
- Administer oxygen via face mask at 6 liters per minute.
- Administer a prescribed uterotonic medication such as methylergonovine.
- Increase the intravenous fluid rate to manage potential hypovolemia.
- Massage the fundus until it is firm. (correct)
- Ask the patient about their pain level
A newborn is 2 hours old and being assessed by the nurse. The newborn's heart rate is 170 bpm and respirations are 70 breaths per minute. The nurse knows that these findings:
A newborn is 2 hours old and being assessed by the nurse. The newborn's heart rate is 170 bpm and respirations are 70 breaths per minute. The nurse knows that these findings:
- Are normal during the first period of reactivity. (correct)
- Reflect an infection and the provider should be notified immediately.
- A sign that the newborn is hungry.
- Indicate respiratory distress, requiring immediate intervention.
- Suggest a possible cardiac anomaly that needs further investigation.
A postpartum patient reports heavy lochia and is passing large clots. After assessing the patient, the nurse notes a saturated perineal pad within 15 minutes. What is the priority nursing intervention?
A postpartum patient reports heavy lochia and is passing large clots. After assessing the patient, the nurse notes a saturated perineal pad within 15 minutes. What is the priority nursing intervention?
Which of the following findings in a newborn would indicate the need for further assessment and intervention?
Which of the following findings in a newborn would indicate the need for further assessment and intervention?
A nurse is caring for a newborn who is 12 hours old. Which of the following interventions is most important for the nurse to implement to prevent cold stress?
A nurse is caring for a newborn who is 12 hours old. Which of the following interventions is most important for the nurse to implement to prevent cold stress?
What is the primary purpose of administering Vitamin K prophylaxis to a newborn shortly after birth?
What is the primary purpose of administering Vitamin K prophylaxis to a newborn shortly after birth?
A woman is 6 cm dilated and reports significant back pain during labor. What nursing intervention is most appropriate to alleviate this discomfort?
A woman is 6 cm dilated and reports significant back pain during labor. What nursing intervention is most appropriate to alleviate this discomfort?
During a postpartum assessment, the nurse notes that the patient's fundus is displaced to the right and is boggy. What should the nurse suspect and do first?
During a postpartum assessment, the nurse notes that the patient's fundus is displaced to the right and is boggy. What should the nurse suspect and do first?
A newborn has a cephalohematoma. Which statement by the nurse would best explain this condition to the parents?
A newborn has a cephalohematoma. Which statement by the nurse would best explain this condition to the parents?
A laboring patient suddenly exhibits signs of intense shaking, irritability, and reports feeling overwhelmed. Assessment reveals complete cervical dilation. Which phase of labor is the patient most likely experiencing?
A laboring patient suddenly exhibits signs of intense shaking, irritability, and reports feeling overwhelmed. Assessment reveals complete cervical dilation. Which phase of labor is the patient most likely experiencing?
The nurse is assessing a 2-day-old breastfed newborn for jaundice. What assessment finding would be most concerning?
The nurse is assessing a 2-day-old breastfed newborn for jaundice. What assessment finding would be most concerning?
A patient who is 3 hours postpartum reports severe perineal pain. Upon assessment, the nurse notices a large, firm, and tender mass on the patient's perineum. What does this most likely indicate?
A patient who is 3 hours postpartum reports severe perineal pain. Upon assessment, the nurse notices a large, firm, and tender mass on the patient's perineum. What does this most likely indicate?
Which intervention is most important to include in the plan of care immediately following an amniotomy?
Which intervention is most important to include in the plan of care immediately following an amniotomy?
A nurse is teaching a postpartum patient about lochia. What information should the nurse include regarding the expected progression of lochia?
A nurse is teaching a postpartum patient about lochia. What information should the nurse include regarding the expected progression of lochia?
During the first assessment of a newborn, the nurse notes a single palmar crease (simian crease). What should the nurse do?
During the first assessment of a newborn, the nurse notes a single palmar crease (simian crease). What should the nurse do?
A newborn is classified as large for gestational age (LGA). What is the MOST important nursing intervention related to this classification?
A newborn is classified as large for gestational age (LGA). What is the MOST important nursing intervention related to this classification?
A new mother is concerned because her 2-day-old infant's skin appears yellowish. What is the best response by the nurse?
A new mother is concerned because her 2-day-old infant's skin appears yellowish. What is the best response by the nurse?
A nurse is called to assess a postpartum patient who is complaining of severe perineal pain. Upon examination, the nurse observes a grapefruit-sized, tense, and exquisitely tender mass protruding from the perineum. Which of the following complications is MOST likely?
A nurse is called to assess a postpartum patient who is complaining of severe perineal pain. Upon examination, the nurse observes a grapefruit-sized, tense, and exquisitely tender mass protruding from the perineum. Which of the following complications is MOST likely?
A nurse is caring for a postpartum patient who is at risk for postpartum hemorrhage. Which of the following nursing interventions would be MOST appropriate to prevent this complication?
A nurse is caring for a postpartum patient who is at risk for postpartum hemorrhage. Which of the following nursing interventions would be MOST appropriate to prevent this complication?
Flashcards
Latent Phase
Latent Phase
Up to 3 cm of dilation.
Active Phase
Active Phase
4 to 7 cm of dilation.
Transition Phase
Transition Phase
8 to 10 cm of dilation.
Second Stage of Labor
Second Stage of Labor
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Third Stage of Labor Signs
Third Stage of Labor Signs
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Involution
Involution
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Lochia
Lochia
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Tone
Tone
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Trauma
Trauma
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Tissue
Tissue
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Thrombin
Thrombin
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Apgar Score
Apgar Score
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First Period of Reactivity
First Period of Reactivity
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Second Period of Reactivity
Second Period of Reactivity
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Thermoregulation
Thermoregulation
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Cold stress
Cold stress
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Skeletal System (Newborn)
Skeletal System (Newborn)
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Baseline Measurements Newborn
Baseline Measurements Newborn
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Newborn Reflexes
Newborn Reflexes
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Large for Gestational Age (LGA)
Large for Gestational Age (LGA)
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Study Notes
- The birthing process consists of three stages: the first stage of labor, the second stage of labor, and the third stage of labor.
First Stage of Labor
- The first stage has three phases which are determined by cervical dilation.
- The latent phase is up to 3 cm of dilation.
- The active phase is 4 to 7 cm of dilation.
- The transition phase is 8 to 10 cm of dilation.
Second Stage of Labor
- Begins with full cervical dilation at 10 cm and complete effacement.
- Ends with the delivery of the infant.
Third Stage of Labor
- Involves the delivery of the placenta.
- Key signs include a firmly contracting fundus, a change in the shape of the uterus, a sudden gush of dark blood from the introitus, apparent lengthening of the umbilical cord, and vaginal fullness.
Postpartum Care (Stage 4)
- Focuses on the mother's physiological recovery, psychological well-being, and ability to care for herself and the new baby, as well as the family's adjustment.
- Postpartum assessment includes monitoring stable vital signs, fundus (firm and involution occurring), lochia (dark red to pink), ambulation (assistance needed for the first time), bladder (measure void), bowel (passing flatus), perineum, breasts (colostrum vs breast milk, latch), and bonding.
- Postpartum hemorrhage (PPH) is caused by Tone (uterine atony in 70% of PPH cases), Trauma (genital tract/birth canal), Tissue (retained products of conception), and Thrombin (coagulopathy).
- Nursing interventions for PPH include fundal massage, IV fluids, OB-GYN consultation, oxytocin administration, blood products, OR, and hysterectomy.
Newborn Care
- Initial assessment includes Apgar score, physical assessment (external, chest, abdomen, neurological, genitourinary), and other observations.
- Immediate interventions involve airway maintenance, body temperature maintenance (skin-to-skin contact), eye prophylaxis (for unknown gonorrhea and chlamydia), and Vitamin K prophylaxis (for blood clotting).
Transition to Extrauterine Life
- First Period of Reactivity lasts up to 30 minutes after birth, with the newborn's heart rate increasing to 160-180 bpm and respirations irregular at 60-80 breaths/min.
- Second Period of Reactivity occurs 4-8 hours after birth and lasts 10 minutes to several hours, with tachycardia, tachypnea, meconium passage, increased muscle tone, changes in skin color, and mucous production.
Physiological Adaptations (Newborn)
- Respiratory adaptations involve the initiation of breathing, monitoring for signs of respiratory distress, and maintaining adequate oxygen supply.
- Cardiovascular adaptations include assessing heart rate and sounds, blood pressure, and blood volume.
- Thermogenic adaptations maintaining thermoregulation through thermogenesis and skin-to-skin contact to reduce heat loss, and awareness of cold stress risks.
- Renal adaptations concern fluid and electrolyte balance.
- Gastrointestinal adaptations involve digestion, stools (meconium), and feeding behaviors.
- Hepatic adaptations include iron storage, carbohydrate metabolism, jaundice, and coagulation.
- Immune system needs.
- Integumentary adaptations involve awareness of common skin conditions like caput succedaneum, cephalhematoma, subgaleal hematoma, sweat glands (heat rash), desquamation (post dates), nevi (portwine), and erythema toxicum (NB rash).
- Reproductive system adaptations are specific to females and males, including swelling of breast tissue.
- Skeletal system has more cartilage than ossified bone at birth.
- Neuromuscular system involves newborn reflexes.
Physical Assessment (Newborn)
- Includes general appearance, vital signs, baseline measurements of weight, head circumference, and length, and neurological assessment which includes reflexes like Moro, sucking, rooting, grasping, and Babinski.
- Classification by Gestational Age is defined by these three categories: Large for gestational age as above the 90th percentile, appropriate for gestational age, and small for gestational age as below the 10th percentile.
Common Newborn Problems
- Include physiological jaundice, jaundice associated with breastfeeding (prevents bilirubin breakdown), hypoglycemia, and hypocalcemia (low blood calcium levels).
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