Nursing Care During Labor & Delivery (Test 2)
Questions With Complete Solution
nursing assessment - Answer->upon admission to L/D:
-review prenatal records; note any risk factors and areas of concern/need
-obtain adm
...
Nursing Care During Labor & Delivery (Test 2)
Questions With Complete Solution
nursing assessment - Answer->upon admission to L/D:
-review prenatal records; note any risk factors and areas of concern/need
-obtain admission data (age, GTPAL, EDC, ROM)
true vs false labor
fetal activity
current meds/allergies
prenatal problems
bloody show vs bleeding
onset of labor/pattern of UC
CB prep/birth plan
feeding method
pediatrician choice
last food/fluid ingested
last void/BM
recent sleep patterns
client/family concerns or questions
physical exam
physical exam data - Answer->abdominal exam (lie, presentation, fundal height, FHR, UC)
EFM or FHR and UC pattern
vital signs
pelvic exam for dilation, effacement, station, fetal position
presence of amniotic fluid, character
-fern test, nitrizine, Amnisure
presence of bleeding
bladder status
fern test - Answer->posterior vaginal swab is allowed to dry on a glass slide and then viewed with a low
power microscope
fern pattern is observed
wide: cervical mucus
thin: amniotic fluid
used to indicate leaking membranes
nitrazine swab - Answer->pH test used to determine if membranes have ruptured
normal vaginal environment is acidic (yellow swab)
amniotic fluid is much less acidic, often neutral (blue swab)
AmniSure - Answer->chemical test used to determine if membranes have ruptured/leaked
reads like a pregnancy dipstick
1 line = control (the test worked)
2 lines = positive for amniotic fluid
Which nursing assessments should be done upon admission to labor? SATA
a. current fetal activity
b. due date of baby
c. status of membranes
d. gravida status - Answer->a, b, c, and d
A laboring woman has a distended bladder. Her nurse advises her to void regularly for what reason?
SATA
a. a full bladder strengthens contractions
b. an empty bladder facilitates descent
c. an empty bladder provides for comfort
d. a full bladder increases risk of hemorrhage - Answer->b and c
Nursing care during Stage 1 (early labor)
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