Nursing Care During Stages of Labor PDF
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Northwestern State University
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Summary
This document provides an overview of nursing responsibilities during different stages of labor, including assessments, interventions, and postpartum care. It covers topics such as labor status, pain management, and fetal monitoring, which are essential for student nurses and midwives.
Full Transcript
Nursing Responsibilities in labor: - ASSESSMENT - LABOR STATUS - BASELINE DATA - TEACHING NEEDS - VAGINAL AND CERVICAL ASSESSMENTS - PROGRESS OF LABOR - PATIENT-CENTERED CARE - CULTURAL COMPETENCE - CLIENT PREFERENCES First Stage of Labor -...
Nursing Responsibilities in labor: - ASSESSMENT - LABOR STATUS - BASELINE DATA - TEACHING NEEDS - VAGINAL AND CERVICAL ASSESSMENTS - PROGRESS OF LABOR - PATIENT-CENTERED CARE - CULTURAL COMPETENCE - CLIENT PREFERENCES First Stage of Labor - ASSESSMENT - VS q 30 -- 60 min - Leopold maneuver - Vaginal exam - Make sure mom is in true labor - Pain management - Monitor dilation - Preform bladder palpation - Temp q 4 hr (every 2 if membranes have ruptured) - NURSING ACTIONS - LATENT PHASE - - ACTIVE PHASE - Client / fetal monitoring - Frequent position change - Voiding at least every 2 hr - In and out Cath if needed - Deep breathing - Relaxation - Nonpharmacological pain relief - Pharmacological pain relief - TRANSITION PHASE Second Stage of Labor - ASSESSMENT - VS q 5 -- 30 min - Uterine contraction - Pushing efforts by client - Increase in bloody show - Shaking or extremities - FHR every 5 -- 15 min - NURSING ACTIONS - Continue to monitor the client / fetus - Assist in positioning - Assist in partner involvement - Promote rest between contractions - Provide comfort measures like cold compresses - Prepare for episiotomy - Provide feedback on labor progress - Prepare care for newborn - PERINEAL LACERATIONS - FIRST DEGREE - Lac extend through the skin of the perineum and does not involve the muscle - SECOND DEGREE - Lac extends through the skin and muscles into the perineum but not the anal sphincter. - THIRD DEGREE - Lac extends through the skin muscles, perineum, and external anal sphincter muscle. - FOURTH DEGREE - Lac extends through skin muscles, anal sphincter, and the anterior rectal wall. Third Stage of Labor - ASSESSMENT - VS q 15 min - Assessment of 1- and 5-min APGAR score - APGAR SCORING APGAR SCORE 0 1 2 --------------------- ------------ --------------------------------------------------- ---------------------- Heart Rate Absent Slow, less than 100 Greater then 100/min Respiratory Rate Absent Slow, weak cry Good cry Muscle Tone Flaccid Some flexion of extremities Well-flexed Reflex Irritability None Grimace Cry Color Blue, Pale Pink body, cyanotic hands and feet (acrocyanosis) Completely pink - NURSING ACTIONS - Instruct client to push once findings of placental separation are present. - Admin oxytocics to stimulate uterus contraction - Admin pain meds - Gently cleans the perineal area with warm water and put pad and ice. - PLACENTAL SEPARATION - Fourth Stage of Labor - ASSESSMENT - Mom - Baby - Fundus - Lochia - Urinary output - Baby-friendly activities - NURSING ACTIONS - VS q 15 min for first 2 hr. then q 4 hr for first 8 hr. - Assess fundus and lochia q 15 min for the first hr. - Massage the uterine fundus and or admin oxytocics. - Encourage voiding - Assess episiotomy or laceration repair. - Promote bonding with baby.
