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NUR2633 Exam 3 Study Guide Maternal Child Health Nursing
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NUR2633 Exam 3 Study Guide Maternal Child Health Nursing
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Francis Torralba – MCH Exam 2 Study Guide1. Labor – contractions with cervical change
a. Stages of Labor
i. 1st stage (Labor) (dilation 1cm-1.5cm/hr) – can take any time
1. Latent phase
a. Longest and most variable duration (many hours dur)
b. 0-4 cm dilation; some effacement
c. Contractions are irregular, mild to moderate; 5-30 min apart lasting 30-45 sec
d. Mother
i. Talkative and eager, excited
e. Baby
i. Little risk
ii. Ask is the baby moving?
2. Active phase
a. 4-6 hrs duration ( move 1-1.5 cm per hour); 2 hrs for multip
i. Longer than 6 hours decreased perfusion to baby, fatigue of uterus
b. 4-7 cm dilation; rapid effacement
c. Contractions are regular, moderate to strong; 3-5 min apart lasting 40-70 sec
d. Mother
i. Feeling helpless; anxiety; restless; focused and introspective
ii. Pain – best time to medicate at peak of contractions mother (see #4 Pain
Management)
iii. Hyperventilate – paper bag, oxygen mask without oxygen, relaxation and
deep breathing
e. Baby
i. Some fetal descent; hypoxia during contractions
ii. Decreased variability
3. Transition – fastest and most difficult part of labor
a. No longer than 2 hrs!
b. 8-10 cm (complete) dilation
c. Contractions are very strong; 2-3 min apart lasting 45-90 sec
d. Mother
i. Tired, restless, irritable; feeling out of control, “cannot continue”; nausea,
vomiting; urge to push; increased rectal pressure and feeling of BM;
increased bloody show
e. Baby
i. Anything given now will go to baby
ii. Early decels
ii. 2nd stage – Baby delivery/pushing
1. 2 hrs duration (3 hrs with epidural/anesthesia)
2. Full dilation
3. Intense contractions 1-2 min apart
iii. 3rd stage – Placental delivery
1. 5-30 min
2. Placental separation and expulsion
a. Gush of blood
b. Cord lengthening
c. Uterus contracted globular
d. Pressure
3. Schultz – shiny fetal surface emerges first
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, Francis Torralba – MCH Exam 2 Study Guide
4. Duncan – dull maternal surface of placenta emerges first
5. Watch out for PP hemorrhage!
a. Fundal height at umbilicus – hard fundal massage to prevent PP hemorrhage
th
iv. 4 stage – Stabilization/Recovery
1. 2 hrs duration
2. Lochia is scant to moderate rubra
3. Vital signs q15 min; fundal checks q15 for 1 st hour, q30 min afterwards
b. Five factors (“Ps”) that affect and define the labor and birth process: passenger, passageway, powers,
position, and psychologic response.
i. Passenger – consists of the fetus and the placenta.
1. Presentation – the part of the fetus that is entering the pelvic inlet first. It can be the back of
the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet).
2. Lie – the relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis
(spine).
a. Transverse – fetal long axis is horizontal and forms a right angle to maternal axis and
will not accommodate vaginal birth. The shoulder is the presenting part and may
require delivery by cesarean birth if the fetus does not rotate spontaneously.
b. Parallel or longitudinal – fetal long axis is parallel to maternal long axis, either a
cephalic or breech presentation.
3. Attitude – relationship of fetal body parts to one another.
a. Fetal flexion – chin flexed to chest, extremities flexed into torso.
b. Fetal extension – chin extended away from chest, extremities extended.
4. Fetopelvic or fetal position – the relationship of the presenting part of the fetus (sacrum,
mentum, or occiput), preferably the occiput, in reference to its directional position as it
relates to one of the four maternal pelvic quadrants. It is labeled with three letters.
a. The first letter references either the right (R) or left (L) side of the maternal pelvis.
b. The second letter references the presenting part of the fetus, either occiput (O),
sacrum (S), mentum (M), or scapula (Sc).
c. The third letter references either the anterior (A), posterior (P), or transverse (T) part
of the maternal pelvis.
d. Station – measurement of fetal descent in centimeters with station 0 being at the
level of an imaginary line at the level of the ischial spines, minus stations superior to
the ischial spines, and plus stations inferior to the ischial spines.
ii. Passageway – the birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and
introitus (vaginal opening)
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, Francis Torralba – MCH Exam 2 Study Guide
iii. Powers – uterine contractions cause effacement and dilation of the cervix and descent of the fetus
iv. Position – of the woman who is in labor. The client should engage in frequent position changes
during labor to increase comfort, relieve fatigue, and promote circulation.
1. Gravity can aid in the fetal descent in upright, sitting, kneeling, and squatting positions.
v. Psychological response – maternal stress, tension, and anxiety can produce physiological changes
that impair the progress of labor.
c. Mechanism of labor – the adaptations the fetus makes as it progresses through the birth canal during the
birthing process.
i. Engagement – occurs when the presenting part, usually biparietal (largest) diameter of the fetal
head passes the pelvic inlet at the level of the ischial spines. Referred to as station 0.
ii. Descent – the progress of the presenting part (preferably the occiput) through the pelvis. Measured
by station during a vaginal examination as either negative (-) station measured in centimeters if
superior to station 0 and not yet engaged, or positive (+) station measured in centimeters if inferior
to station 0.
iii. Flexion – when the fetal head meets resistance of the cervix, pelvic wall, or pelvic floor. The head
flexes, bringing the chin close to the chest, presenting a smaller diameter to pass through the pelvis.
iv. Internal rotation – the fetal occiput ideally rotates to a lateral anterior position as it progresses from
the ischial spines to the lower pelvis in a corkscrew motion to pass through the pelvis.
v. Extension – the fetal occiput passes under the symphysis pubis, and then the head is deflected
anteriorly and is born by extension of the chin away from the fetal chest.
vi. Restitution and external rotation – after the head is born, it rotates to the position it occupied as it
entered the pelvic inlet (restitution) in alignment with the fetal body and completes a quarter turn to
face transverse as the anterior shoulder passes under the symphysis.
vii. Expulsion – after birth of the head and shoulders, the trunk of the neonate is born by flexing it
toward the symphysis pubis.
d. Physiologic changes preceding labor (premonitory signs)
i. Backache – a constant low, dull backache, caused by pelvic muscle relaxation
ii. Weight loss – a 0.5 to 1.4 kg (1 to 3 lb) weight loss
iii. Lightening – fetal head descends into true pelvis about 14 days before labor; feeling that the fetus
has “dropped;” easier breathing, but more pressure on bladder, resulting in urinary frequency; more
pronounced in clients who are primigravida
iv. Contractions – begin with irregular uterine contractions (Braxton Hicks) that eventually progress in
strength and regularity
v. Bloody show – brownish or blood-tinged mucus discharge caused by expulsion of the cervical mucus
plug resulting from the onset of cervical dilation and effacement
vi. Energy burst – sometimes called “nesting” response
vii. Gastrointestinal changes – less common, include nausea, vomiting, and indigestion
viii. Rupture of membranes – spontaneous rupture of membranes can initiate labor or can occur anytime
during labor, most commonly during the transition phase.
1. Labor usually occurs within 24 hr of the rupture of membranes.
2. Prolonged rupture of membranes greater than 24 hr before delivery of fetus may lead to an
infection.
3. Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt
decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse.
ix. Assessment of amniotic fluid – completed once the membranes rupture
1. Should be watery, clear, and pale- to straw-yellow in color.
2. Odor should not be foul.
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, Francis Torralba – MCH Exam 2 Study Guide
3. Volume is between 500 and 1,200 mL.
4. Nitrazine paper should be used by a nurse to confirm that amniotic fluid is present.
a. Amniotic fluid is alkaline: Nitrazine paper should be deep blue, indicating pH of 6.5
to 7.5. Urine is slightly acidic: Nitrazine paper remains yellow.
e. Laboratory Analysis
i. Group B streptococcus – culture is obtained if results are not available from screening at 36 to 37
weeks.
1. If positive or unsure, intravenous prophylactic antibiotic is prescribed (exceptions are
planned cesarean birth and membranes intact).
ii. Urinalysis – clean-catch urine sample obtained to ascertain maternal:
1. Hydration status via specific gravity
2. Nutritional status via ketones
3. Proteinuria, which is indicative of gestational hypertension
4. Urinary tract infection via bacterial count
iii. Blood Tests
1. CBC (Hgb & Hct)
2. ABO typing and Rh-factor if not previously done
iv. HIV, Hep B, syphilis
f. Induction/Augmentation of Labor
i. Non-pharmacological
1. Nipple stimulation to release endogenous oxytocin
2. Position change, ambulation
3. Artificial rupture of membranes (ROM)
ii. Pharmacological
1. Oxytocin (Pitocin) IV
a. Considerations
i. Fetus must be at least station 0
ii. Via IV piggyback; titrate carefully, begins at 1-2 milliunits in 3ml of fluid
iii. Assess maternal BP, HR, RR q30 min and w/ every dose change
iv. Monitor FHR and contractions q15 min and w/ every dose change
b. Side effects
i. Can cause uterine ruptue, severe fetal hypoxia, uterine hyper-stimulation
or tachysystole of uterus
2. Cervical ripeners
2. Assessments
a. Leopold – palpation of maternal uterus through abdominal wall to determine
i. Number of fetuses
ii. Presenting part, fetal lie, fetal attitude
iii. Degree of descent of presenting part into pelvis
iv. Expected location of point of maximal impulse (PMI)
b. FHR Pattern and Uterine Contraction monitoring (see below)
c. Vaginal Exam
i. Assess
1. Effacement – thinning - centimeters
2. Dilation – opening – how thick/thin
3. Presentation – head, chin, arm is coming out?
4. Station – relative to ischial spine; -2 is above ischial spine; +2 is below ischial spine; +4 is to
the floor!
5. Position (maybe)
4
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