NCLEX-Exam-Maternal-and-Child-HealthNursing-2-30-Items Study Guide for Maternal Child Exam

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NCLEX-Exam-Maternal-and-Child-HealthNursing-2-30-Items Study Guide for Maternal Child Exam 1.Labor – contractions with cervical change a. Stages of Labor i. 1 ststage (Labor) (dilation 1cm-1.... 5cm/hr) – can take any time 1. Latent phase a. Longest and most variable duration (many hours dur) b. 0-4 cm dilation;some effacement c. Contractions are irregular, mild to moderate; 5-30 min apart lasting 30-45 sec d. Mother i. Talkative and eager, excited e. Baby i. Little risk ii. Ask is the baby moving? 2. Active phase a. 4-6 hrs duration ( move 1-1.5 cm per hour); 2 hrsfor multip i. Longer than 6 hours decreased perfusion to baby, fatigue of uterus b. 4-7 cm dilation; rapid effacement c. Contractions are regular, moderate to strong; 3-5 min apart lasting 40-70 sec d. Mother i. Feeling helpless; anxiety;restless; focused and introspective ii. Pain – best time to medicate at peak of contractions mother (see #4 Pain Management) iii. Hyperventilate – paper bag, oxygen mask without oxygen, relaxation and deep breathing e. Baby i. Some fetal descent; hypoxia during contractions ii. Decreased variability 3. Transition – fastest and most difficult part of labor a. No longer than 2 hrs! b. 8-10 cm (complete) dilation c. Contractions are very strong; 2-3 min apart lasting 45-90 sec d. Mother i. Tired,restless, irritable; feeling out of control, “cannot continue”; nausea, vomiting; urge to push; increased rectal pressure and feeling of BM; increased bloody show e. Baby i. Anything given now will go to baby2 ii. Early decels ii. 2 nd stage – Baby delivery/pushing 1. 2 hrs duration (3 hrs with epidural/anesthesia) 2. Full dilation 3. Intense contractions 1-2 min apart iii. 3 rd stage – Placental delivery 1. 5-30 min 2. Placentalseparation and expulsion a. Gush of blood b. Cord lengthening c. Uterus contracted globular d. Pressure 3. Schultz – shiny fetalsurface emergesfirst3 4. Duncan – dull maternal surface of placenta emerges first 5. Watch out for PP hemorrhage! a. Fundal height at umbilicus – hard fundal massage to prevent PP hemorrhage i. 4 th stage – Stabilization/Recovery 1. 2 hrs duration 2. Lochia is scant to moderate rubra 3. Vital signs q15 min; fundal checks q15 for 1 st hour, q30 min afterwards b. Five factors(“Ps”) that affect and define the labor and birth process: passenger, passageway, powers, position, and psychologic response. i. Passenger – consists of the fetus and the placenta. 1. Presentation – the part of the fetus that is entering the pelvic inlet first. It can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet). 2. Lie – the relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine). [Show More]

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