Which parameter is closely monitored in a client during the latent phase of the first stage of labor quizlet?

Which description of the phases of the second stage of labor is accurate?

A. Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes
B. Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes
C. Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies
D. Transition phase: client "laboring down," fetal station is 0, duration is 15 minutes

Notify the health care provider about possible meconium.

Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

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Terms in this set (12)

Which type of vaginal discharge is more common during the transition phase of the first stage of labor?

1) bloody mucus
2) pale pink mucus
3) brownish discharge
4) pink-to-bloody mucus

1

*cervix is dilated to 8 to 10 cm, which results in the appearance of bloody mucus in the vaginal discharge. Pale pink mucus is seen in the latent phase, in which the cervix dilates to not more than 3 cm. Brownish discharge may also be observed during the latent phase of the first stage of labor. Pink-to-bloody mucus is observed in the active phase of cervical dilation.

Which clinical findings are associated with the early phase of labor for a nulliparous client who is 2cm dilated?
Select all that apply.

1) zero station
2) bloody mucus
3) client takes direction easily
4) scant amount of vaginal discharge
5) presence of mild to moderate contractions

3, 4, 5

Which parameter is closely monitored in a client during the latent phase of the first stage of labor?

1) FHR
2) cervical dilation
3) maternal temperature
4) external cephalic version

1

Which client behavior is expected during the transition phase of the first stage of labor?

1) remains calm & silent
2) doubts her ability to control pain
3) vomits
4) attention is directed inward

3

Which statement describes the nursing instructions for a client in the second stage of labor with an epidural?

1) "take a big deep breath in, and push down during your contraction"
2) "when you feel rectal pressure, take a cleansing breath in and push down"
3) "only push if you feel like you need to, otherwise take slow deep breaths"
4) "take a deep breath in, and let your breath out slowly while pushing down"

4

Which statement indicates effective learning regarding the manifestations of true labor?

1) the fetus isn't engaged in the pelvis
2) the cervix is soft and felt posteriorly
3) contractions become more intense with walking
4) contractions are felt above the navel

3

Which type of laceration is expected in a client who has suffered perineal tears?

1) vaginal
2) cervical
3) urethral
4) vaginal vault

1

*vaginal lacerations are associated with perineal lacerations
*cervical lacerations occur at lateral angles of the external ox when cervix retracts over fetal head
*urethral lacerations are uncommon/rare
*vaginal vault lacerations from rapid fetal descent, precipitous birth & forceps use

Which circumstances would warrant the nurse to perform a vaginal examination? Select all that apply.

1) on admission at the start of labor
2) when accelerations in FHR are noted
3) on maternal perception of perineal pressure or the urge to bear down
4) when ROM occurs
5) when bright red bleeding is observed

1, 3, 4

which supportive care measure is appropriate for a client complaining of back labor pain?

1) lie on her back for a while with knees bent
2) do less walking
3) take deep, cleansing breaths
4) lean over a birth ball with her knees on the floor

4

Which clinical signs are associated with the placenta separating from the uterine wall after birth?
Select all that apply.

1) increased vaginal bleeding
2) shortening of the umbilical cord
3) increase in uterine contractions
4) presence of fetal membranes at the introitus
5) change in contour of the uterus

1, 4, 5

Which nursing intervention is performed to reduce the extent of vaginal or perineal lacerations?

1) placing clean material under the client's buttocks
2) touching the client's vaginal area to promote birth
3) applying gentle pressure toward the client's vagina
4) allowing rapid birth of the fetal head

3

Which are signs of potential complications of labor?
Select all that apply.

1) contractions lasting 90 seconds or longer
2) urine-smelling vaginal discharge
3) irregular FHR; suspected arrhythmias
4) more than five contractions in 5 minutes
5) relaxation between contractions lasting shorter than 30 seconds
6) intrauterine pressure of above 80 mmHg or resting tone above 20 mm Hg

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Which parameter should be closely monitored in a patient during the latent phase of the first stage of labor?

During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions.

Which of the following signals the first stage of labor?

The first phase of the first stage of labor is called the latent phase, when contractions are becoming more frequent (usually 5 to 20 minutes apart) and somewhat stronger. However, discomfort is minimal. The cervix dilates (opens approximately three or four centimeters) and effaces (thins out).

What happens during the first stage of labor quizlet?

During the first stage of labor, contractions help your cervix to thin and begin to open. This is called effacement and dilation. Cervix beginning to dilate Your cervix opens to 4 centimeters. You will probably spend most of early labor at home.

Which observations suggest that a woman is the latent phase of the second stage of labor quizlet?

Passive descent of the fetus and relaxed maternal behaviors are characteristic of the latent phase of the second stage of labor.