What nursing care should the nurse focus on during the first stage of labor quizlet?

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What are the nursing responsibilities during the first stage of labor?
Which is the priority in nursing care of the laboring woman during the first stage?
What is the first nursing action in caring for the newborn immediately after birth?
Which of the following happens during the first stage of labor quizlet?

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ANS: A

Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

Notify the health care provider about possible meconium.

Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

◯ Provide teaching to the client and her partner about what to expect during labor and on implementing relaxation measures: breathing (deep cleansing breaths help divert focus away from contractions), effleurage (gentle circular stroking of the abdomen in rhythm with breathing during contractions), diversional activities (distraction, concentration on a focal point, or imagery).

◯ Encourage upright positions, application of warm/cold packs, ambulation, or hydrotherapy if not contraindicated to promote comfort.

◯ Encourage voiding every 2 hr.

■ During first stage, active phase of labor
☐ Provide client/fetal monitoring.
☐ Encourage frequent position changes.
☐ Encourage voiding at least every 2 hr.
☐ Encourage deep cleansing breaths before and after modified paced breathing.
☐ Encourage relaxation.
☐ Provide nonpharmacological comfort measures.
☐ Provide pharmacological pain relief as prescribed.

■ During first stage, transition phase of labor
☐ Continue to encourage voiding every 2 hr.
☐ Continue to monitor and support the client and fetus.
☐ Encourage a rapid pant-pant-blow breathing pattern if the client has not learned a particular breathing pattern.
☐ Discourage pushing efforts until the cervix is fully dilated.
☐ Listen for client statements expressing the need to have a bowel movement. This sensation
is a sign of complete dilation and fetal descent.
☐ Prepare the client for the birth.
☐ Observe for perineal bulging or crowning (appearance of the fetal head at the perineum).
☐ Encourage the client to begin bearing down with contractions once the cervix is fully dilated.

What are the nursing responsibilities during the first stage of labor?

Here are nursing responsibilities in this phase: Inform patient on progress of her labor. Assist patient with pant-blow breathing. Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or depending on the doctor's order.

Which is the priority in nursing care of the laboring woman during the first stage?

The first and most common intervention upon admission of a patient to labor is putting the woman to bed. Bed rest or the recumbent position can result in poor quality contractions, dystocia, slow dilatation and effacement, prolonged labor, and failure to descend.

What is the first nursing action in caring for the newborn immediately after birth?

Immediate care for the newborn One of the first checks is the Apgar test. The Apgar test is a scoring system to evaluate the condition of the newborn at 1 minute and 5 minutes after birth. The healthcare provider or midwife and nurses will evaluate these signs and give a point value: Activity; muscle tone.

Which of the following happens during the first stage of labor quizlet?

Stage 1: The first stage of labor begins with contractions of the uterus and dilation of the opening of the cervix to 10 centimeters (about four inches). Stage 2: The second stage of labor begins when the baby's head moves through the cervix and into the birth canal. This stage ends with the delivery of the baby.