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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

7757

Card Set

Description

Intrapartal Nursing Care

Updated

2010-02-28T21:49:30Z

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