Quiz 3 HESI Intrapartum Care PDF

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Summary

Pr. Diane DiTomasso PhD, RN
Quiz 3 Material
Intrapartum Nursing Care (HESI, p. 259-267)...

Description

MATERNITY QUIZ 3

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HESI pgs. 259-267: Intrapartum Nursing Care Intrapartum: Begins with true labor and consists of 4 stages: 1. From beginning of regular contractions or ROM to 10cm dilation and 100% effacement Phase

Description

Psychological and Physical Responses

Latent

From beginning of true labor until 3-4 cm cervical dilation

Mildly anxious, conversant Able to continue usual activities Contractions mild: ● Initially 10-20 min apart, 15-20 sec duration ● Later 5-7 min apart, 30-40 sec duration

Active

From 4-7 cm cervical dilation

Increased anxiety and discomfort Unwillingness to be left alone Contractions moderate to severe, 2-3 min apart, 30-60 sec duration

Transition

From 8-10 cm cervical dilation

Changed behavior: ● Sudden nausea, hiccups ● Extreme irritability, doesn’t want to be touched but wants companionship ● Contractions severe, 1.5 min apart, 60-90 sec duration

2. 10cm to delivery of fetus 3. Delivery of fetus to delivery of placenta 4. Lasts about 2 hrs after delivery of placenta (recovery) Initial Exam HESI: be able to differentiate true labor from false labor True Labor

False Labor

Pain in lower back that radiates to abdomen Pain accompanied by regular rhythmic contractions Contractions that intensify with ambulation Progressive cervical dilation and effacement

Discomfort localized in abdomen No lower back pain Contractions decrease in intensity or frequency with ambulation

Nursing Assessment Prodromal labor signs include: ● Lightening: fetus drops into true pelvis ● Braxton hicks contractions: practice contractions ● Cervical softening and slight effacement ● Bloody show or expulsion of mucus plug ● Burst of energy/”nesting instinct” Determine the following: ● Gravidity and parity > 5 = grand multiparity ● Gestational age 38-40 weeks = term gestation ● FHR best heard over fetal back

● Maternal VS ● Contraction frequency, intensity, and duration Perform vaginal exam to determine: ● Fetal presentation and position ● Cervical dilation, effacement, position, and consistency ● Fetal station Assess client for: ● Status of membranes (ruptured/intact) ● Urine glucose and albumin data ● Comfort level

MATERNITY QUIZ 3

● Labor and delivery prep ● Presence of support person

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● Presence of true/false labor

Vaginal Exam Preceded antiseptic cleansing with client in modified lithotomy position: ● Sterile gloves worn ● Exams not done routinely (sharply curtailed after membranes rupture to prevent infection) ● Exams are performed: ○ Before analgesia and anesthesia ○ To determine progress of labor & whether second-stage pushing can begin Purpose of vaginal exam is to determine: ● Cervical dilation: cervix opens from 0-10cm ● Cervical effacement: cervix taken up into upper uterine segment ○ Expressed in % from 0%-100% ○ Cervix “shortened” from 3cm to 20 hrs in primigravida and > 14 hrs in multipara ○ Primigravida dilates an average of 1.2 cm/hr in midactive phase, multipara = 1.5 cm/hr HESI: meconium-stained fluid = yellow-green or gold-yellow (may indicate fetal stress) ● Take client to bathroom or offer bedpan at least every 2 hrs during labor ○ A full bladder may impede labor progress ● Assist woman with use of psychoprophylactic coping techniques: ○ Breathing exercises ○ Effleurage (abdominal massage) HESI: breathing techniques (deep chest, accelerated, cued) not prescribed by stage and phase of labor but by discomfort level of laboring woman (if coping is decreasing switch to new technique) ● Provide mouth care, ice chips, and hard candy as needed for dry mouth ○ Allow sips of clear fluid if no general anesthesia anticipated HESI: hyperventilation results in respiratory alkalosis that is caused by blowing off too much CO2 ● Symptoms = dizziness, tingling fingers, stiff mouth ● Have woman breathe into cupped hands or paper bag to rebreathe CO2 ● Maintain asepsis in labor by means of frequent perineal care and changing linen and underpads ● Offer anesthesia or analgesia in midactive phase of labor ○ If given too early: may retard progress of labor ○ If given too late: increased risk of neonatal resp depression ● Monitor fetus continuously if any high-risk situation occurs ● Notify HCP if: labor progress is retarded, maternal VS abnormal, fetal distress noted Second Stage of Labor Heralded by involuntary need to push, 10 cm of dilation, rapid fetal descent, and birth ● Second stage of labor averages 1 hr for primigravida, 15 min for a multipara ● Addition of abdominal force to uterine contraction force enhances cardinal movements of fetus: ○ Engagement, descent, flexion, internal rotation, extension, restitution, external rotation Nursing Assessment ● Assess BP and pulse q 5-15 min ● Determine FHR with every contraction ● Observe perineal area for the following: ○ Increase in bloody show ○ Bulging perineum and anus ○ Visibility of presenting part ● Palpate bladder for distention

● Assess amniotic fluid for color/consistency Analysis (Nursing Diagnosis) ● Acute pain r/t…

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MATERNITY QUIZ 3

● Risk for injury r/t…

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● Deficient knowledge (specify) r/t….

Nursing Plans & Interventions ● Document maternal BP and pulse q 15 min between contractions ● Check FHR with each contraction or by continuous fetal monitoring ● Continue comfort measures: mouth care, linen change, positioning ● Decrease outside distractions ● Teach mother positions: squatting, side-lying, high-Fowler/lithotomy for pushing ● Teach mother to exhale when pushing or use “gentle” pushing techniques (pushing down on vagina while constantly exhaling through open mouth followed by deep breath) HESI: determine cervical dilation before allowing client to push ● Cervix should be completely dilated (10cm) before client begins pushing ● If pushing starts too early the cervix can become edematous and never fully dilate ● If delivering in another room or setting: ○ Transfer multipara at 8-9 cm, 2+ station ○ Transfer primigravida at 10 cm, with presenting part visible b/w AND during contractions ● Set up delivery table (including bulb syringe, cord clamp, and sterile supplies) ● Perform perineal cleansing ● At crowning put gentle counterpressure against perineum (don’t allow rapid delivery over perineum) ● Make sure client and support person can visualize delivery if they desire ○ If siblings present make sure they’re closely attended to by support person & explain that mom is alright ● Record exact delivery time (complete delivery of baby) Third Stage of Labor From complete expulsion of baby to complete expulsion of placenta ● Average length of third stage of labor = 5-15 min ● The longer the third stage of labor the greater chance for uterine atony or hemorrhage Nursing Assessment ● Signs of placental separation: ○ Lengthening of umbilical cord outside vagina ○ Gush of blood ○ Uterus changes from oval (discoid) to globular Analysis (Nursing Diagnosis) ● Mother describes “full” feeling in vagina ● Risk for deficient fluid volume r/t… ● Firm uterine contractions continue ● Anxiety r/t…. Nursing Plans & Interventions HESI: give oxytocin (pitocin) after placenta is delivered bc the drug will cause uterus to contract ● If oxytocin is administered before placenta is delivered it may result in retained placenta (predisposes client to hemorrhage and infection) ● Place hand under drape and palpate fundus of uterus for firmness and placement at/below umbilicus

MATERNITY QUIZ 3

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○ At signs of placental separation instruct mother to push gently ● Take maternal BP before and after placental separation ● Check patency and site integrity of infusing IV ● Administer oxytocin med immediately after delivery of placenta ● Observe for blood loss and ask physician for estimate of blood loss (EBL) ● Dry and suction infant, perform Apgar assessment, place blanket on mother’s abdomen or allow skin-to-skin contact with mother after delivery ● Place stockinette cap on newborn’s head or cover head to prevent heat loss ● Allow father/support person to hold infant during repair of episiotomy ● Allow any siblings present to hold new family member ● Gently cleanse vulva and apply sterile perineal pad HESI: application of perineal pads after delivery ● Place 2 on perineum ● Do not touch inside of pad ● Apply from front to back (be careful to not drag pad against anus) ● Remove both legs simultaneously if legs are in stirrups ● Provide clean gown and warm blanket ● Lock bed before moving mother and raise side rails during transfer

Uterine Stimulants Drug

Indications

Adverse Rxns

Nursing Implications

Oxytocin, synthetic

Uterine atony

Severe afterpains in multipara HTN

Give immediately after delivery of placenta to avoid a “trapped” placenta Continue to monitor vaginal bleeding and uterine tone May stimulate let-down milk reflex and flow of milk when engorged

Methylergonovine maleate

Uterine atony

HTN

Use with caution in clients with elevated BP or preeclampsia Take BP before admin (if 140/90 or above withhold and notify MD)

Prostaglandin F2

Uterine atony

Headache

Contraindicated for pts with asthma

MATERNITY QUIZ 3

N/v Fever Bronchospasm, wheezing

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May be given intramyometrially by MD Check temp every 1-2 hrs Auscultate breath sounds frequently

HESI: never give methylergonovine or carHESI: methylergonovine not given to clients with HTN bc of vasoconstrictive action (pitocin given instead) boprost to a pt in labor or before delivery or placenta Fourth Stage of Labor (first 1-4 hrs after delivery of placenta) Nursing Assessment ● Review antepartum and labor and delivery records for possible complications ○ Postpartum hemorrhage ○ Uterine hyperstimulation ○ Uterine overdistention ○ Dystocia ○ Antepartum hemorrhage ○ Magnesium sulfate therapy Analysis (Nursing Diagnosis) ○ Bladder distention ● Risk for deficient fluid volume r/t … ● Routine postpartum physical assessment ● Risk for injury r/t… ● Mother-infant bonding ● Risk for impaired parenting r/t.. Nursing Plans & Interventions ● Maintain bed rest for at least 2 hrs to prevent orthostatic hypotension ● Assess BP, pulse, and respirations q 15 min for 1 hr and then every 30 min until stable ○ BP < 140/90, pulse < 100, respiration < 24) ● Assess temp at beginning of fourth stage and before discharge to postpartum room ○ If >38C report to MD and monitor hourly ● Assess fundal firmness and height, bladder, lochia, and perineum q 15min for 1 hr and then every 30 min for 2 hrs ○ Fundus: firm, midline, at or below umbilicus ■ Massage if soft or boggy ■ Suspect full bladder if above umbilicus and to R side of abdomen

HESI: full bladder = one of most common reasons for uterine atony or hemorrhage in first 24 hrs after delivery ● If nurse finds fundus soft, boggy, and displaced above and to the R of umbilicus: perform fundal massage, have client empty bladder, recheck fundus q 15 min for 1hr then q 30 min for 2 hrs ○ Lochia: rubra (red), moderate, and clots < 2-3 cm ■ Suspect undetected laceration if fundus firm and bright-red blood continues to trickle ■ Always check perineal pad and under buttocks ● Report to HCP: ○ Abnormal VS ○ Uterus not becoming firm with massage

MATERNITY QUIZ 3

○ Second perineal pad soaked in 15 min ○ Signs of hypovolemic shock: pale, clammy, tachycardic, lightheaded, hypotensive ● Monitor infusion of IV oxytocin (pitocin) ● Change perineal pads and cleanse vulva and perineum with each change ● Prevent discomfort of afterpains ○ Keep bladder empty (catheterize only if absolutely necessary) ○ Place warm blanket on abdomen ○ Administer analgesics as prescribed (usually codeine, acetaminophen, or ibuprofen) HESI: If narcotic analgesics given raise side rails and place call light within reach. Instruct client not to get out of bed or ambulate without assistance. Caution pt about drowsiness as a side effect. ● Offer fluids when woman is alert and able to swallow ● Apply ice pack to perineum to minimize edema especially if 3rd or 4th degree episiotomy performed or if lacerations are present ● Apply witch hazel compresses to perineum for comfort HESI: ● 1st degree tear: involves only epidermis ● 2nd degree tear: involves dermis, muscle, and fascia ● 3rd degree tear: extends into anal sphincter ● 4th degree tear: extends up rectal mucosa ● Tears cause pain and swelling ● Avoid rectal manipulations ● Support parental emotional needs and promote bonding ○ Allow extended time with newborn ○ Openly share in joy and excitement of childbirth or grieve with parents experiencing loss ○ Encourage initiation of breastfeeding ○ Provide a warm darkened environment so newborn will open eyes ○ Withhold eye prophylaxis for up to 1 hr ○ Perform newborn admission and routine procedures in room with parents

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