Which is the priority nursing action for a client in the second stage of labor quizlet?

● Perform Leopold maneuvers.

● Perform a vaginal examination as indicated (if no evidence of progress) to allow the examiner to assess whether client is in true labor and whether membranes have ruptured.
◯ Encourage the client to take slow, deep breaths prior to the vaginal exam.
◯ Monitor cervical dilation and effacement.
◯ Monitor station and fetal presentation.
◯ Prepare for impending delivery as the presenting part moves into positive stations and begins to push against the pelvic floor (crowning).

● Assessments related to possible rupture of membranes
◯ When there is suspected rupture of membranes, the nurse should first assess the FHR to ensure there is no fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic fluid.
◯ Verify presence of alkaline amniotic fluid using nitrazine paper (turns blue, pH 6.5 to 7.5).
NOTE: nowadays they use Amnisure which is 99% accurate, more useful then nitrazine paper, which can not tell the difference between amniotic fluid and semen.
◯ A sample of the fluid may be obtained and viewed on a slide under a microscope. Amniotic fluid will exhibit a frond-like ferning pattern. Assess the amniotic fluid for color and odor.
■ Expected findings are clear, straw color, and free of odor.
■ Abnormal findings include the presence of meconium, abnormal color (yellow or port wine), and a foul odor.

● Perform bladder palpation on a regular basis to prevent bladder distention, which can impede fetal descent through the birth canal and cause trauma to the bladder.
◯ Clients might not feel the urge to void secondary to the labor process or anesthesia.
◯ Encourage the client to void frequently.

● Temperature assessment every 4 hr (every 1 to 2 hr if membranes have ruptured)

COHEN STUFF
Fetal Assessment
Labs--U/A, CBC
- Prenatal Labs if no PNC
Psychological Status
Review Childbirth Plans
Contact Provider

Begins with complete dilation and effacement
● Blood pressure, pulse, and respiration measurements every 5 to 30 min
● Uterine contractions
● Pushing efforts by client
● Increase in bloody show
● Shaking of extremities
● FHR every 15 min and immediately following birth

Assessment for perineal lacerations, which usually occur as the fetal head is expulsed. Perineal lacerations are defined in terms of depth.
● First degree: Laceration extends through the skin of the perineum and does not involve the muscles.
● Second degree: Laceration extends through the skin and muscles into the perineum but not the anal sphincter.
● Third degree: Laceration extends through the skin, muscles, perineum, and external anal sphincter muscle.
● Fourth degree: Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall.

COHEN
Assessment
-Typical signs of 2nd stage
-Contraction frequency, duration, intensity
-Maternal vital signs
-Fetal response to labor via FHR
-Coping status of woman and partner

The Apgar test is done by a doctor, midwife, or nurse. The health care provider examines the baby's:

Breathing effort
Heart rate
Muscle tone
Reflexes
Skin color

Each category is scored with 0, 1, or 2, depending on the observed condition.

If the infant is not breathing, the respiratory score is 0.
If the respirations are slow or irregular, the infant scores 1 for respiratory effort.
If the infant cries well, the respiratory score is 2.
Heart rate is evaluated by stethoscope. This is the most important assessment:

If there is no heartbeat, the infant scores 0 for heart rate.
If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.
If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.
Muscle tone:

If muscles are loose and floppy, the infant scores 0 for muscle tone.
If there is some muscle tone, the infant scores 1.
If there is active motion, the infant scores 2 for muscle tone.
Grimace response or reflex irritability is a term describing response to stimulation, such as a mild pinch:

If there is no reaction, the infant scores 0 for reflex irritability.
If there is grimacing, the infant scores 1 for reflex irritability.
If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability.
Skin color:

If the skin color is pale blue, the infant scores 0 for color.
If the body is pink and the extremities are blue, the infant scores 1 for color.
If the entire body is pink, the infant scores 2 for color.

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