NURS 131

jasmine's version from 2016-04-18 05:59


Question Answer
1st stage of labor Latent phase encompasses some effacement, dilation from 0-3 cm and little descent with irregular, mild to moderate contractions every 5 to 30 minutes lasting 30 to 45 seconds. Encourage breathing techniques and comfort measures and provider may provide analgesics; active phase encompasses dilation 4-7 cm and significant descent. Moderate to strong contractions every 3-5 minutes lasting 40-70 seconds. Patient may feel anxiety or feelings of helplessness; transition phase encompasses contractions at peak intensity, full dilation to 10 cm, complete effacement, and further descent. Sharp, intensified contractions every 2-3 minutes lasting 45-90 seconds. Patient may feel restless, tired, irritable, pelvic or rectal pressure, and may express desire to bear down
2nd stage of labor Begins with complete dilation and ends with birth. Instruct to push and allow periods of relaxation.
3rd stage of labor Begins with the birth and ends with the expulsion of the placenta; Provider may prescribe Pitocin after expulsion of placenta
4th stage of labor Last about 2 h after placenta expulsion; Monitor vital signs, fundal location, bleeding, bladder, and perineum
Nursing care in labor and delivery Comfort, emotional support, and encouragement
Overall goal Safe and uncomplicated delivery
Umbilical cord care Shortly after birth to determine number of blood vessels in cord; Redness at base, foul odor, or discharge; Prevent infection and promote drying of cord; Clean around base of cord stump and allow air dry, it promotes cord separation; Clamp removal when dry, usually about 24 h after delivery
Umbilical cord falls off at approximately how many days? 10-14 days
First 2 days Newborns need 60-80 mL of fluid per kg of body weight per day.
Next 4 days Newborns need 100-150 mL/kg/day.
For remainder of first month Newborns need 120-180 mL/kg/day. Monitor intake and output due to little tolerance for fluctuations in fluid balance
First 3 months Infants require 110 kcal/kg/day. Each ounce of breast milk and formula contains about 20 kcal
Important Assess cervical dilation, pain level, and overall maternal and fetal well-being (to include contractions) prior and after administering pain medication