Online Reference Notes: VI. Stages of Labor

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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

VI. Stages of Labor

A. First Stage (Stage of Dilatation) – begins with true labor pains and ends with complete dilatation of the cervix.
1. Power/Forces: Involuntary uterine contractions
2. Phases:
a. Latent – early time in labor
 Cervical dilatation is minimal because effacement is occurring
 Cervix dilates 3-4 cm. only
 Contractions are of short duration and occur regularly 5-10 minutes apart (during which time the pregnant woman may seek admission to the hospital)
 Mother is excited, with some degree of apprehension but still with ability to communicated
 Takes up 8 of the 12-hour first stage
b. Active/accelerated
 Cervical dilatation reaches 4-8 cm.
 Rapid increase in duration, frequency and intensity of contractions
 Mother fears losing control of herself
2. Nursing Care
a. Hospital admission – provide privacy and reassurance from the very start
 Personal data – name, age, address, civil status
 Obstetrical data – determine EDC; obstetrical score; amount and character of show; and whether or not membranes have ruptured
b. General physical examination, internal exam and Leopold’s maneuvers are done to determine:
 Effacement and dilatation
 Station – relationship of the fetal presenting part to the level of the ischial spines
 Station 0 – at the level of the ischial spines; synonymous to engagement
 Station -1 – presenting part above the level of the ischial spines
 Station +1 – presenting part below the level of the ischial spines
 Station +3 or +4 – synonymous to crowning (= encirclement of the largest diameter of the fetal had by the vulvar ring)
 Presentation – relationship of the long axis of the fetus to the long axis of the mother; also known as lie
Presenting part – the fetal part which enter the pelvis first and covers the internal cervical os

Table 6. Types of Presentation

I. VERTICAL
A. Cephalic – he is the presenting part
1. Vertex – head sharply flexed, making the parietal bone the presenting part
2. Face)
3. Brow) if in poor flexion
4. Chin )

B. Breech – buttocks are the presenting parts
1. Complete – thighs flexed on the abdomen and legs are on thighs
2. Frank – thighs are flexed and legs are extended, resting on the anterior surface of the body
3. Footling
a. Single – one leg unflexed and extended; one foot presenting
b. Double – legs unflexed and extended; feet are presenting

II. HORIZONTAL – Transverse lie – Shoulder presentation

 In vertex and breech presentations, fetal heart sounds are best heard, at the area of the fetal back; in face presentations, at the area of the fetal chest
 In vertex presentations, FHS are usually located in either the left or right lower quadrant (RLQ or LLQ); in breech presentation, at or above the level of the umbilicus (RUQ or LUQ)
 Hazards of breech delivery:
o Cord compression
o Abruptio placenta
o Erb-duchenne paralysis
 Horizontal lie is very rare (1%) and maybe due to a relaxed abdominal wall because of multiparity, pelvic contraction or placenta previa
 Position – relationship of the fetal presenting part to a specific quadrant of the mother’s pelvis
 The pelvis is divided into four quadrants
o Right anterior
o Right posterior
o Left anterior
o Left posterior
o Posteriors positions result in more backaches because of pressure fetal presenting part on the maternal sacrum
 Points of direction in the fetus:
o Occiput – in vertex presentations
o Chin (mentum) – in face presentations
o Buttocks/feet – in breech presentations
o Scapula (acromic) – in horizontal presentation
 Possible fetal positions
o Vertex
LOA – left occipitoancetior (most common and favorable position at birth)
LOP – left occipitoposterior
LOT – left occipitoetransverse
ROA – right occipitoanterior
ROP – right occipitoposterior
ROT – right occipitotransverse
o Breech
LSA – left sacroanterior
LSP – left sacroposterior
LST – left sacrotransverse
RSA – right sacroanterior
RSP – right sacroposterior
RST – right sacrotransverse
o Face
LMA – left mentoanterior
LMP – left mentoposterior
LMT – left mentotransverse
RMA – right mentoanterior
RMP – right mentoposterior
RMT – right mentotransverse
o Shoulder
LADA – left acromiodorsoanterior
LADP – left acromiodorsoposterior
RADA – right acromiodorsoanterior
RADP – right acromiodorsotransverse

c. Monitoring and evaluation of important aspects
 Uterine contractions – fingers should be spread lightly over the fundus
o Duration – from the beginning of one contraction to the end of the same contraction (A to B)
 Duration during early labor – 20-30 seconds
 Duration late in labor – 60 to 70 seconds (SHOULD NEVER BE LONGER)
o Interval – from the end of one contraction to the beginning of the next contraction (B to C)
 Interval early in labor – 40-45 minutes
 Interval late in labor – 2-3 minutes
o Frequency – from the beginning of one contraction to the beginning of the next contraction (A to C) Time 3-4 contractions to have a good picture of the frequency of contractions
o Intensity – strength of contractions. May be mild, moderate or string. Intensity is measured by the consistency of the fundus at the acme of the contraction. When estimating intensity, check fundus at the end of contractions to determine whether it relaxes.
o Blood pressure – should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions.
 BP readings should be taken at least every half hour during active labor
 When a woman in labor complains of a headache, the first nursing action is to take the BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia)
o Fetal heart rate – should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate)
 Normally 120-160 per minute
 Should not be taken also during a uterine contraction because it tends to decrease. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, caused bradycardia
 Should be taken every hour during the latest phase of labor; every half hour during the active phase and every 15 minutes during the transition phase
 For any abnormality in FHR, the initial nursing action is to change the mother’s position.
 Signs of fetal distress:
o Bradycardia (= FHR less than 100/minute) or tachycardia (=FHR more than 180/minute)
o Meconium-stained amniotic fluid in non-breech presentation
o Fetal thrashing – hyperactivity of the fetus as it struggles for more oxygen
d. Emotional support is provided for the woman in labor by keeping her constantly informed of the progress in labor.
e. Healthy Teachings
 Bath – is advisable if contractions are tolerable or not too close to one another. Will make the mother feel more comfortable
 Ambulation – during the latent phase of labor helps shorten the first stage of labor. But definitely not allowed anymore if membranes have ruptured.
 Solid or liquid foods are to be avoided because:
o Digestion is delayed during labor
o A full stomach interferes with proper bearing down
o May vomit and cause aspiration
 Enema – NOT a routine procedure
o Purposes:
 A full bowel hinders the progress of labor- effectiveness of enema in labor is shown by evaluating change in uterine tone and amount of show
 Expulsion of feces during second stage of labor predisposes mother and baby to infection.
 Full bowel predisposes to post-partum discomfort
o Procedure of enema administration
 Enema solution may either be soap suds or fleet enema
 Optimal temperature of the enema solution – 105oF to 115oF ( 40.5oC – 46.1oC)
 Patient on side-lying position
 When there is resistance while inserting the rectal catheter, withdraw the tube slightly while letting a small amount of solution enter
 Clamp rectal tube during s contraction
 Important nursing action: Check FHR after enema administration to determine fetal distress
o Contraindications to enema in labor :

 Vaginal bleeding
 Premature labor
 Abnormal fetal presentation or position
 Ruptured membranes
 Crowning
 Encourage the mother to void very 2-3 hours by offering the bedpan because:

 A full bladder retards fetal descent
 Urinary stasis can lead to urinary tract infection
 A full bladder can be traumatized during delivery
 Perineal Prep – done aseptically
Use “No.7” method, always from front to back.
 Perineal shave – maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth
 Encourage Sim’s position because :

 It favors anterior rotation of the fetal head
 It promotes relaxation between contractions
 It prevents continual pressure of the gravid uterus on the inferior vena cava ( the blood vessel which brings unoxygenated blood back to the heart), pressure results in Supine Hypotensive Syndrome, also called Vena Cava Syndrome. Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial BP.

 Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the first stage because:

 It leads to unnecessary exhaustion
 Repeated strong pounding of the fetus against the pelvic floor will lead to cervical edema, thus interfering with dilatation
 Abdominal breathing – is advised for contractions during the first stage in order to reduce tension and prevent hyperventilation.
f. Administer analgesics as ordered. The dosage is based on the patient’s weight, status of labor and size and stage of gestation.
 Narcotics are the most commonly used, specifically Demerol.
 Pharmacologic effect: Depresses the sensory portion of the cerebral cortex. It is not only a potent analgesic, it is also a sedative and an antispasmodic.
 It is not given early in labor because it can retard labor progress ( is an antispasmodic), but cannot also be given if delivery is only one hour away because it causes respiratory depression in the newborn ( that is why it can be given only if cervical dilatation is 6-8cm.)
 Given 25-100mg.,depending on the body weight
 Takes effect in 20 minutes – patient experiences a sense of well-being and euphoria
 Narcotic antagonists (e.g. Narcan or Nalline) are given to counteract the toxic effects of Demerol
g. Assist in administration of regional anesthesia – preferred over any other form of anesthesia because it does not enter maternal circulation and thus does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved.
 Xylocaine is anesthesia of choice
 Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucose aids uterine muscles in proper functioning.
 Types of Anesthesia:
 Paracervical – transvaginal injection into either side of the cervix. Patient on lithotomy position. Coupled with a local anesthetic, results in “painless childbirth” ( uterine contractions are not felt by mother)
 Pudendal – through the sacro-spinous ligament into the posterior areolar tissues to reduce perception of pain during second stage and make mother comfortable. Patient on lithotomy. Side effect : an ecchymotic (purplish discoloration of the skin due to blood in the subcutaneous tissues) area or hematoma in the right of the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling
 Low Spinal
 Epidural – injection of local anesthetic at the lumbar level outside the dura mater
 Saddle block – injection into the 5th lumbar space, causing anesthesia into the parts of the body that come in contact with a saddle (perineum, upper thighs and lower pelvis). Blocks nerves that transmit pain of first stage of labor. In sitting or side-lying position, with back flexed.

 Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second-stage pushing
 Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time of needle insertion. Management : Flat on bed for 12 hours and increase fluid intake
 Common side-effects:
 Hypotension – because Xylocaine is a vasodilator. Management : turn to side; prompt elevation of legs; administration of vasopressor and oxygen, as ordered
 Fetal bradycardia
 Decreased maternal respirations
h. A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are transported from LR to the DR when the cervix is fully dilated or when there is bulging of the perineum; multiparas are transported at 7-8cm cervical dilatation.

B. Transition Period – when the mood of the woman suddenly changes and the nature of the contractions intensify.
1. Characteristics :
a) If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument e.g. Kelly or Allis forceps or amniohook to allow amniotic fluid to drain), is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position changes. Amniotomy, however cannot be if station is still “minus” as this (can lead to cord compression).
b) Show becomes prominent.
c) There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distention of neck veins are seen.
d) Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption.
e) In primis, baby is delivered within 20 contractions (=40 minutes); in multis, in 10 contractions (=20 mintues)

2. Nursing actions are primarily comfort measures:
a) Sacral pressure ( applying pressure with the heel of the hand on the sacrum) relieves discomfort from contractions
b) Proper bearing down techniques: push with contractions
c) Controlled chest ( costal) breathing during contractions
d) Emotional support

C. Second Stage ( stage of Expulsion) – begins with complete dilatation of the cervix and ends with delivery of the baby.
1. Power/forces : In voluntary uterine contractions and contractions of the diaphragmatic and abdominal muscles
2. Mechanisms of Labor/ Fetal Position Changes : (D FIRE ERE)

a. Descent ( may be preceded by engagement)
b. Flexion – as descant occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest
c. Internal Rotation – from AP to transverse, then AP to AP
d. Extension – as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear
e. External Rotation ( also called restitution - anterior shoulder rotates externally to the AP position
f. Expulsion – delivery of the rest of the body

3. Nursing Care
a. When positioning legs or lithotomy, put them up at the same time to prevent injury to the uterine ligaments
b. As soon as the fetal head crowns, instruct mother not to push, but to pant instead ( rapid and shallow breathing) to prevent rapid expulsion of the baby. If panting is deep and rapid, called hyperventilation the patient will experience light-headedness and tingling sensation of the fingers leading to carpopedal spasms, because of respiratory alkalosis. Management: let the patient breath into brown paper bag to recover lost carbon dioxide; a cupped hand will serve the same purpose.
c. Assist in episiotomy – incision made in the perineum primarily to prevent lacerations.
 Other purpose of episiotomy:
o Prevent prolonged and severe stretching of muscles supporting bladder or rectum
o Reduce duration of second stage when there is hypertension or fetal distress
o Enlarge outlet, as in breech presentation or forceps delivery
 Types of episiotomy:
o Median – from middle portion of the lower vaginal border directed towards the anus
o Mediolateral – begun in the midline but directed laterally away from the anus
 Natural anesthesia is used in episiotomy, i.e., no anesthetic is injected because pressure of fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily deadened.
d. Apply the Modified Ritgen’s Maneuver:
 Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the smallest sub-occipitobregmatic diameter of the fetal head is presented.
 Ease the head out and immediately wipe the nose and mouth of secretions to establish and maintain a patent airway (REMEMBER: the first principle in the care of the newborn is establish and maintain a patent airway). (The head should be delivered in between contractions.)
 Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck (nuchal cord). If so, but loose, slip it down the shoulders or up over the head; but if tight; clamp cord twice, an inch apart, and then cut in between.
 As the head rotates, deliver the anterior shoulder by exerting a gentle downward push and then slowly give an upward lift to deliver the posterior shoulder
 While supporting the head and the neck, deliver the rest of the body. Take note of the exact time of delivery of the baby.
e. Immediately after delivery, newborn should be held below the level of the mother’s vulva for a few minutes to encourage flow of blood from the placenta to the baby.
f. The infant is held with his head in a dependent position (-head lower than the rest of the body) to allow for drainage of secretions. REMEMBER: Never stimulate a baby to cry unless you have drained him out of his secretions first.
g. Wrap the bay in a sterile diaper to keep him warm. REMEMBER: Chilling increases the body’s need for oxygen.
h. Put the bay on the mother’s abdomen. The weight of the baby will help contract the uterus.
i. Cutting of the cord is postponed until the pulsations have stopped because it is believe that 50 – 100 ml of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart, and then cut in between
j. Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse.

D. Third Stage (Placental Stage) – begins with the delivery of the baby and
ends with the delivery of the placenta.
1. Signs of placental separation:
a. Uterus becoming round and firm again, rising high to the level of the umbilicus (Calkin’s sign) – the earliest sign of placental separation
b. Sudden gush of blood from the vagina
c. Lengthening of the cord from the vagina
2. Types of placental delivery:
a. Schultz – if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny. 80% of placentas separate in this manner (“Shiny” for Schultz)
b. Duncan – if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red, beefy, irregular and “dirty”. Only about 20% of placentas separate this way. (”Dirty” of Duncan)
3. Nursing Care
a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Just watch for the signs of placental separation.
b. Tract the cord slowly, winding it around the clamp until placenta spontaneously comes out, rotating it slowly so that no membranes are left inside the uterus, a method called Brandt-Andrews maneuver.
c. Take not of the time of placental delivery; it should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother.
d. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death
e. Palpate the uterus to determine degree of contraction. If relaxed, boggy or non-contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction.
f. Inject oxytocin (Methergin – 0.2. mg/ml or Syntocinon = 10 U/ml) – IM to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery because placental entrapment can occur.
 Categories of lacerations (tend to heal more slowly because of ragged edges):
o First degree – involves the vaginal mucous membranes and skin
o Second degree – involves not only the vaginal mucous membranes and skin, but also the muscles
o Third degree – involves not only the muscles, vaginal mucous membranes and skin, but also the external sphincter of the rectum
o Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and skin, but also the mucous membranes of the rectum
 Assist the doctor in doing episiorrhaphy (- repair of episiotomy or lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. Note: Vaginal packs have to be removed after 24 – 48 hours
g. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vagina. Soiled napkins should be removed from front to back.
h. Position the newly-delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra-abdominal pressure.
i. The newly-delivered mother may suddenly complain of chills due to the rapid decrease of pressure, fatigue or cold temperature in the delivery room. Management: Provide additional blankets to keep her warm.
j. May give initial nourishment, e.g., milk, coffee, or tea
k. Allow patient to sleep in order to regain lost energy

E. Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs.
1. Assessment:
a. Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline and, during the first 12 hours postpartum, is a little above the umbilicus. First nursing action for a non-contracted uterus: massage.
b. Lochia – should be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after 30 minutes.
c. Bladder – a full bladder is evidenced by a fundus which is to the right of the midline, dark-red bleeding with some clots.
d. Perineum – is normally tender, discolored and edematous. It should be clean, with intact sutures.
e. Blood pressure and pulse rate – may be slightly increased from excitement and effort of delivery, but normalize within one hour.
2. Lactation-suppressing agents – estrogen-androgen preparation given within the first hours postpartum to prevent breastmilk production in mothers who will not (or cannot) breastfeed. E.g., diethylstilbestrol,
TACE or deladumone. These drugs tend to increase uterine bleeding and retard menstrual return.
3. Rooming-in concept – mother and baby are together while in the hospital. The concept of a family, therefore, is felt at the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents and newborn. Eye-to-eye contact is immediately established, releasing maternal caretaking responses.

Online Reference Notes

Bullets

VI. Stages of Labor

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