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Assessment during the first stage of labor should include
antepartal history
past obsteteric history
lab results
upon admission the nurse should assess/find:
emotional status
maternal VS
UA
fetal heart tones/contractions q 15-30 minutes
maternal response to labor
vaginal discharge
labor progress
comfort measures provided by the nurse in the first stage of labor
maintain hydration
reduce dry lips
relieve backache
encourage particpation of coach
encourage ambulation if appropriate
nursing care regarding physical needs in the first stage of labor
encourage frequent voiding
encourage relaxation
prevent compression of vena cava and promote placental perfusino
provide fluids if appropriate
manage discomfort
nursing care regarding psychosocial needs during first stage of labor
verbalization of feelings
explain all procedures
reinforcement
nursing care for latent phase of labor
provide encouragement
comfort measures
coach through contractions
encourage ambulation if appropriate
telephone guidance
admission procedures, orientation
establish rapport, trust
identify birth plan
provide teaching and information
nursing care for active phase of labor
coach through contractions
comfort measures (focus on areas of tension)
keep aware of progress
offer analgesics if ordered
provide hygiene
monitor progress of labor and response
nursing care for transition phase of labor
stay with patient
continue to coach through contractions
second stage of labor assessment
maternal response to labor
FHT and contractions
VS
time elapsed
vaginal discharge
response to regional anesthesia
bearing down efforts
fetal position
nursing care for second stage of labor
emotional suppport
safety
assistance with medical management
assessment for third stage of labor
time elapsed
signs of placental separation
maternal response
nursing care for third stage of labor
prevent uterine atony
facilitate infant parent bonding
health teaching
assessment for fourth stage of labor
VS q 15 min for 1 hr then q 30 min for 1 hr then if stable q 4hr or q shift
location and tone of fundas
character and amount of lochia
bladder status
nursing care for fourth stage of labor
comfort measures
nutrition/hydration
promote bonding
health teaching
leopold's maneuvers (definition)
useful for determining fetal position, presentation, lie and to locate FHT's
lepold's maneuvers
first
second
third
fourth
what is in the fundus
where is the fetal back
what is presenting part
what is the first cephalic prominence (is head flexed or extended)
vaginal examination
done when?
not done by a nurse
when symptoms indicate change
before administering meds/ tx
to reassess progress if longer than expected
in presence of active vaginal bleeding
unless indicated, especially if ROM
immediate care of newborn
airway
thermoregulation
identification
physical assessment
facilitate attachement
Author
amber1026
ID
7757
Card Set
OB
Description
Intrapartal Nursing Care
Updated
2010-02-28T21:49:30Z
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