1. Assessment during the first stage of labor should include
    • antepartal history
    • past obsteteric history
    • lab results
  2. 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
  3. 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
  4. 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
  5. nursing care regarding psychosocial needs during first stage of labor
    • verbalization of feelings
    • explain all procedures
    • reinforcement
  6. 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
  7. 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
  8. nursing care for transition phase of labor
    • stay with patient
    • continue to coach through contractions
  9. 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
  10. nursing care for second stage of labor
    • emotional suppport
    • safety
    • assistance with medical management
  11. assessment for third stage of labor
    • time elapsed
    • signs of placental separation
    • maternal response
  12. nursing care for third stage of labor
    • prevent uterine atony
    • facilitate infant parent bonding
    • health teaching
  13. 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
  14. nursing care for fourth stage of labor
    • comfort measures
    • nutrition/hydration
    • promote bonding
    • health teaching
  15. leopold's maneuvers (definition)
    useful for determining fetal position, presentation, lie and to locate FHT's
  16. lepold's maneuvers
    • 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)
  17. 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
  18. immediate care of newborn
    • airway
    • thermoregulation
    • identification
    • physical assessment
    • facilitate attachement
Card Set
Intrapartal Nursing Care