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HESI 101
OB STUDY EXAM - OB TEST Chapter 2023/2024 Update Well
verified Study Guide GRADED A+
OB TEST 3
Chapter 16
Childbirth Preparation Lamaze (psychoprophylactic): Dissociative relaxation, controlled muscle relaxation, and specific breathing patterns are used to promote birth as a normal process. Kitzinger (sensory-memory): Women use chest breathing, abdominal breathing, and their sensory memory to help work through the birthing process. Bradley (partner-coached childbirth): Consists of a 12-week session in which the woman works on controlled breathing and deep abdominopelvic breathing with a focus on achieving a natural HypnoBirthing : Breathing and relaxation techniques help prepare the body to work in neuromuscular harmony to make the birth process easier, safer, and more comfortable. Factors that Affect Labor The birth passageway (birth canal) The passenger (fetus) The physiologic forces of labor The position of the mother The woman's psychosocial considerations Passageway True pelvis Inlet, midpelvis, outlet Four types Gynecoid Android Anthropoid Platypelloid Cause of Labor Unclear OB TEST 3 Between 38 th^ and 42 nd^ week Progesterone relaxes smooth muscle Estrogen stimulates uterine muscle contractions Connective tissue loosens to permit opening of cervix Causes of Uterine Changes Estrogen Stimulates uterine muscle contractions Collagen fibers in the cervix are broken down Increase in the water content of the cervix Uterine and Cervical Changes Physiologic retraction ring
Upper uterine segment thickens and pulls up Lower segment expands and thins out Effacement Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. As the cervix begins to efface, more amniotic fluid collects below the fetal head The increasing amount of amniotic fluid exerts hydrostatic pressure. Complete effacement and dilatation Premonitory Signs of Labor Lightening Braxton Hicks contractions Cervical changes Bloody show Rupture of membranes (ROM) Sudden burst of energy Weight loss Indigestion Nausea and vomiting Diarrhea TRUE LABOR Progressive dilatation and effacement Regular contractions increasing in frequency, duration, and intensity Pain usually starts in the back and radiates to the abdomen Pain is not relieved by ambulation or by resting FALSE LABOR Lack of cervical effacement and dilatation Irregular contractions do not increase in frequency, duration, and intensity Contractions occur mainly in the lower abdomen and groin Pain may be relieved by ambulation, changes of position, resting, or a hot bath or shower Mother Responses to Labor
Burst of energy TRUE LABOR Pain radiates Contractions are more frequent but more intense Consistent/regular contractions Cervix is dilated High BP FHR goes down Chapter 17 Maternal Intrapartal Assessment Maternal Intrapartal Assessment Historical data Physical assessment Psychosocial history and status Cultural assessment Physical Assessment Vital signs and weight Lungs Fundus Edema Hydration Perineum Labor Status Uterine contractions Cervical dilatation Cervical effacement OB TEST 3 Fetal descent Membranes Fetal Status Fetal heart rate (FHR) Presentation Position Activity Psychosocial Assessment Preparation for childbirth Response to labor Anxiety Support system Labor Progress Latent-phase contractions Every 10 to 30 minutes, lasting 30 to 40 seconds, mild Progresses to every 5 to 7 minutes, lasting 30 to 40 seconds, moderate Active-phase contractions Every 2 to 5 minutes, lasting 40 to 60 seconds, moderate to strong Transition-phase contractions Every 1-1/2 to 2 minutes, lasting 60 to 90 seconds, strong
Electronic Monitoring of Uterine Contractions Provides continuous data Routine in some settings High-risk patients Women having oxytocin-induced labor Must be combined with careful nursing assessment Vaginal Examination Cervical effacement Cervical dilatation Fetal station Fetal presenting part Palpation: Advantages Noninvasive Readily accessible, requiring no equipment Increases the "hands-on" care of the patient Allows the mother freedom Palpation: Disadvantages Does not provide actual quantitative measure of uterine pressure No permanent record Maternal size and positioning may prevent direct palpationOB TEST 3 Leopold Maneuvers First maneuver Which part occupies the fundus? Am I feeling buttocks or head? Second maneuver Where is the fetal back? Where are the small parts or extremities? Third maneuver What is in the inlet? Does it confirm what I found in the fundus? Is the presenting part engaged? Fourth maneuver Where is the cephalic prominence or brow? Some practitioners may perform the fourth maneuver first to identify the fetal part in the pelvic inlet Leopold maneuvers for determining fetal position and presentation. First maneuver: Facing the woman, palpate the upper abdomen with both hands. Note the shape, consistency, and mobility of the palpated part. The fetal head is firm and round and moves independently of the trunk. The buttock feels softer, and it moves with the trunk. Second maneuver: Moving the hands on the pelvis, palpate the abdomen with gentle but deep pressure. The fetal back, on one side of the abdomen, feels smooth, and the fetal extremities on the other side feel knobby. Third maneuver: Place one hand just above the symphysis. Note whether the part palpated feels like the fetal head or the breech and whether it is engaged. Fourth maneuver: Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.
- Standard Practice Stage I Fetal Heart Pattern Monitoring Decelerations Stage II
Every 15 minutes
- More often when risk factors involved Fetal Heart Monitoring 2 minutes of clear tracing, uterus at rest (within a 10 minute window) Normal : 110-160 bpm Tachycardia : > 160 bpm Bradycardia : 100-110 bpm Variability : fluctuations from baseline Absent- undetectable Minimal- undetectable to < 5 bpmOB TEST 3 Moderate- 6 – 25 bpm Marked - > 25 bpm Accelerations – 15bpm x 15 seconds EARLY DECELERATIONS – Begin with the contraction and return to baseline after the contraction NO TREATMENT NECESSARY NORMAL Nursing Intervention = continue monitoring LATE DECELERATION – Decelerations in which the FHT does not return to baseline contraction = UTEROPLACENTAL INSUFFICIENCY
- Omnious if coupled with decreased variability
NURSING INTERVENTION = GIVE OXYGEN GIVE FLUIDS ASSESS REPOSITION OFF VENA CAVA – TURN ON LEFT SIDE DC OXYTOCIN INFUSION IF NOT IMPROVED – IMMEDIATE DELIVERY
B TEST 3
VARIABLE DECELRATIONS – V shaped or U shped decelerations of variable onset = UMBILICAL CORD COMPRSSION Ascertain type Position changes Pelvic exam to see if cord has prolapsed OXYGEN BY MASK AT 10 L/MIN
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Normal FHR (baseline rate) 110 to 160 beats/min Tachycardia if >161 beats/min Marked tachycardia is 180 beats/min or above Bradycardia if <110 beats/min Evaluation of Fetal Monitoring: Uterine Contractions Assess uterine contraction pattern Uterine resting tone Frequency, duration, and intensity of contractions Three-Tier FHR Interpretation System Categorize FHR tracing Fetal Tachycardia May be considered an ominous sign if accompanied by certain patterns Late decelerations Severe variable decelerations Decreased variability If associated with maternal fever, treatment may consist of antipyretics and/or antibiotics Fetal Bradycardia May be benign or ominous (preterminal) sign If there is variability, may be considered benign Must consider degree of rate change and duration Considered ominous and a sign of nonreassuring fetal status if decreased variability and late decelerations present LATE DECELERATION – NURSING INTERVENTIONS Patient positioning Left lateral position with changes as warranted until FHR improves or stabilizes Oxygen via facemask at 7 to 10 L/min Alert physician/certified nurse-midwife of status immediately Provide explanation and support to woman and her partner Increase intravenous fluids Discontinue oxytocin immediately if it is being administered Monitor blood pressure and pulse Treat hypotension per orders or protocol Assess cervical status Prepare for possible emergency cesarean birth Document interventions VARIABLE DECELERATIONS – NURSING INTERVENTIONS Facilitate position changes to relieve pressure on umbilical cord Administer oxygen via facemask at 7 to 10 L/min Report findings to physician/certified nurse-midwife and document in chart
OB TEST 3
Provide explanation and support to woman and her partner Prepare for possible cesarean birth Possible amnioinfusion if oligohydramnios is present or severe decelerations persist PROLONGUED DECELERATIONS – NURSING INTERVENTIONS Perform vaginal examination to rule out prolapsed umbilical cord Change maternal position Discontinue oxytocin if being administered Notify physician/certified nurse-midwife of findings and responses to interventions Provide explanation and support to woman and her partner Increase intravenous fluid administration rate Administer tocolytic if tachysystole is occurring Anticipate physician/certified nurse-midwife intervention upon arrival if prolonged deceleration continues or if FHR previously abnormal CLASS NOTES Want to put fetal monitor / stethoscope on fetus's back Leopold's maneuver helps you know where the baby's back is MONITOR SHOULD BE BELOW THE UMBILICUS - GOOD SIGN ABOVE UMBILICUS - NOT A GOOD SIGN Before ruptured membrane mom can walk After ruptured membrane mom has to stay in bed Internal fetal monitor - ONLY IF BABY HEAD IS SHOWING, not the chin, butt, shoulder ONLY HEAD Do not rupture membranes just to put a fetal monitor, has to happen by itself Physician will rupture membrane for other reasons MODERATE VARIBALITY = GOOD , what you want - 6-25bpm FHP POWERPOINT EARLY DECELERATIONS : monitor and document, expected CONTRACTION - DECREASE IN FETAL HEART RATE Early deceleration - FHR and contraction should MIRROR Fhr down and contraction up NURSING INTERVENTION = MONITOR AND DOCUMENT LATE DECELERATIONS - contraction then you see reduction in HR, DOES NOT MIRROR NURSING INTERVENTION = turn on left side (perfuses baby better) , oxygen, IV fluids, CAUSE = UTERAL PLACENTAL INSUFFICIENCY VARIABLE DECELERATIONS: something else causing the drop, heart dropping randomly CAUSE = umbilical cord compression
Normal amniotic fluid = 500-2000 macrsoo.ie
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Admission Care Greet, establish rapport Orientation to room, facilities, equipment Informed consent Essential assessment Notify physician/certified nurse-midwife Document assessment and care ALWAYS GREET AND WELCOME THE PATIENT FIRST** Integration of Family Expectations and Cultural Beliefs During Labor Basic expectation that they will not be harmed and that the labor and birth will be safe Women look to their nurses for Emotional support, including sustained presence, praise, encouragement, reassurance, and companionship Comfort measures such as touch, ice chips and fluid, massage, assistance with care, and bath/shower Information and advice, including information about procedures, interventions as they occur, and reports of labor progress Advocacy to help woman/partner achieve their goals, hopes, and dreams for their labor/birth experience Support of the partner, including encouragement, praise for their efforts, an opportunity for rest breaks, and role modeling Review plan of care Explore wishes of client and family If a request cannot be met, thoroughly explain the reason Culturally sensitive care Recognize impact of beliefs on behaviors Be familiar with beliefs and practices of various cultures in the community Assess individualized preferences and wishes Includes Modesty Pain expression First Stage—Nursing Interventions Assess temperature every 4 hours If temperature >37.5˚C (99.6˚F), monitor every hour After amniotic membranes rupture, usually monitor every 1 to 2 hours Monitor blood pressure (BP), pulse, and respirations every hour If BP >120/80 mmHg or pulse >100, notify physician/certified nurse-midwife and reevaluate BP and pulse more frequently Continually monitor pain Palpate and assess uterine contractions every 30 minutes Auscultate fetal heart rate (FHR) Every 30 minutes for low-risk women Every 15 minutes for high-risk women Continuous electronic FHR monitoring if FHR baseline abnormal or decelerations Active Phase of Labor—Nursing Interventions
OB TEST 3
Palpate contractions every 15 to 30 minutes Limited vaginal exams Auscultate and evaluate FHR Every 30 minutes for low-risk women Every 15 minutes for high-risk women Assess maternal BP, pulse, and respirations with FHR assessment or more often if indicated Catheterization or indwelling Foley catheter may be necessary Amniotic membranes may rupture Assess and document time, amount, color, odor, and consistency of the amniotic fluid and immediately auscultate FHR Meconium-stained fluid warrants continuous electronic FHR monitoring Labor induction may be initiated Rupture of membranes May be accompanied by umbilical cord prolapse Auscultate FHR Decreased FHR may indicate undetected prolapsed cord Immediate intervention is necessary to remove pressure on a prolapsed umbilical cord Transition Phase of Labor—Nursing Interventions Palpate contractions at least every 15 minutes Assess FHR Every 30 minutes in low-risk woman Every 15 minutes in high-risk woman Assess maternal vital signs when FHR is assessed Continuously assess pain level Support with breathing techniques Help prevent pushing prior to complete cervical dilatation Second Stage—Nursing Interventions Sterile vaginal examinations to assess fetal descent Assessment of FHR Every 15 minutes if low risk Every 5 minutes if high risk Assessment of maternal vital signs at least every 5 to 15 minutes Assist with comfortable positioning for pushing Provide information regarding progress of labor Assist physician/certified nurse-midwife in preparation for birth Third Stage—Nursing Interventions Provide initial newborn care Newborn placed on mother's abdomen or under radiant-heated unit Dry newborn immediately Keep newborn in modified Trendelenburg position Keep warm with warmed blankets or skin-to-skin contact with mother Suction nose and mouth as needed Assist with delivery of placenta Recognize signs of placental separation
OB TEST 3
Encourage family to take breaks, maintain food and fluid intake, and rest Decrease anxiety Provide information and establish rapport Active listening Demonstrate genuine concern Remain with the woman Offer praise Comfort Promotion During the Second Stage of Labor Includes all previous comfort measures Cool cloths to the face and forehead Assist with removal of clothing or bed linens as requested Encourage rest between contractions Positioning Sips of fluids or ice chips Positive reinforcement/encouragement Care of the Newborn Maintain respirations Provide and maintain warmth Apgar score Care of umbilical cord Cord blood collection for banking Physical assessment―Normal findings: Respirations 36 to 60, irregular; no retractions, no grunting Apical pulse 120 to 160 and somewhat irregular Temperature above 36.5˚C/ 97.9˚ F Skin color pink with bluish extremities Cord: two arteries and one vein Gestational age: 38 to 42 weeks to remain with parents Sole creases that involve heel Newborn identification Facilitate and enhance attachment Providing Care to Adolescents Assess for complications Assess for fetal well-being Establish trusting relationship Provide emotional support Provide positive reinforcement Administer individualized care Management of Precipitous Delivery Reassure and support mother Send auxiliary personnel for help and emergency birth pack “precip pack” Put mother in comfortable position and give clear instructions Remain calm and do not leave the mother If time permits, scrub with soap and water and don sterile gloves Delivery of infant
OB TEST 3
Management of infant after delivery Delivery of placenta Fundal massage Newborn to breast Clamp and cut umbilical cord Perineal inspection and cleansing
See Powerpoint: summary stages of labor/labor and delivery (16,17,18) 8% Tables:
APGAR, 17-1, 17-2, table 18-
CLASS NOTES
Care of newborn Suction mouth then nose Take out head Umbilical cord Apgar Bracelets Keep warmth throughout the whole process - wrap baby and put beanie Labor to delivery of the baby less than 3 hrs = PRECIPITOUS DELIVERY
- TOO FAST KNOW WHEN TRUE LABOR BEGINS - she could have started labor at home then gotten to the hospital and delivered in an hour PRECIPITOUS DELIVERY - higher risk for postpartum depression Assess baby begining of 3rd stage KNOW APGAR SCORE PRECIPITOUS DELIVERY - TOO QUICK - LESS THAN 3 HRS Hypovolemia Hemorrhage Depression - did not get experience Pneumothorax Chapter 19 SYSTEMIC ANESTHESIA Goal of pharmacologic analgesia is to provide maximum pain relief with minimal risk for mother and fetus Alteration in maternal state affects fetus All medications cross placental barrier Medication action depends on rate it is metabolized High doses may remain in fetus for long periods Administration of Systemic Analgesia When woman is uncomfortable
OB TEST 3
Infection at needle puncture site Maternal blood coagulopathies Increased intracranial pressure Allergy to anesthetic medication Hypovolemic shock Epidural— Patient Preparation Confirm availability of anesthesia provider Encourage woman to void urine Assessment data Maternal pain level, blood pressure (BP), pulse, respirations Fetal heart rate (FHR) Continuous electronic fetal monitoring Frequent monitoring of maternal BP and pulse Initiate intravenous infusion (18-gauge) Bolus of 500 to 1000 mL of IV fluid Nursing Interventions During Epidural Anesthesia Frequent assessment of maternal vital signs until block wears off Promote maternal side-lying position or sitting Frequent repositioning Assess sensorimotor ability every 30 minutes Assess for bladder distention Protect lower extremities from injury SPINAL ANESTHESIA Spinal Anesthesia: Advantages Immediate onset of anesthesia Relative ease of administration Smaller drug volume Maternal compartmentalization of the drug Spinal Anesthesia: Disadvantages High incidence of hypotension Greater potential for fetal hypoxia Uterine tone is maintained, making intrauterine manipulation difficult Spinal Anesthesia: Contraindications Patient refusal Severe hypovolemia Sepsis Infection over the puncture site Allergy to anesthetic agent Coagulation problems Nursing Interventions During Spinal Anesthesia Position woman supine with left uterine displacement Rolled towel or blanket under right hip Monitor maternal blood pressure and pulse per protocol or physician’s order
OB TEST 3
If spinal block used during vaginal birth Monitor uterine contractions Instruct the woman to bear down during a contraction Recovery from Spinal Anesthesia Cautious transfer from birthing bed (or operating room table) Bed rest for 6 to 12 hours following block Restoration of bladder control may take 8 to 12 hours Urinary catheter may be needed if not already in place COMBINED SPINAL-EPIDURAL Can be used for labor analgesia and for cesarean birth Advantages Faster onset than medications injected into epidural space Medication can be added to increase effectiveness Motor function preserved Allows for ambulation with assistance Mild Reactions to Local Anesthetic Agents Palpitations Tinnitus Apprehension Confusion Metallic taste in the mouth Moderate Reactions to Local Anesthetic Agents Include more severe degrees of mild symptoms Also include additional symptoms: Nausea and vomiting Hypotension Muscle twitching, which may progress to convulsions Severe Reactions to Local Anesthetic Agents Sudden loss of consciousness Coma Severe hypotension Bradycardia Respiratory depression Cardiac arrest Precautions During Administration of Local Anesthetics for Regional Anesthesia Intravenous line must be in place Preferred treatment for mild toxic reaction Oxygen IV injection of short-acting barbiturate to reduce anxiety Epidural Side Effects
