NCLEX Test Plan Categories
Health Promotion & Maintenance
Monitor Client in Labor
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Normal Labor
• Theories
– Mechanical Theory
• Uterine stretching
• Hormonal theory
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Normal Labor
• Signs of Impending Labor (continued)
– Lightening
– Seepage or Sudden Outflow of Fluid
– Bloody show
– Braxton Hicks contractions
– True labor
• Progressive cervical dilitation and effacement
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Normal Labor
FALSE LABOR
• Contractions rarely
follow a pattern
• Vary in length and
intensity
• Most noticeable in the
fundus
• Stop with relaxation
interventions
• No effacement/dilation
• No change in fetal
position
TRUE LABOR
• Contractions are regular
• Become closer together,
•
•
•
•
stronger, and last longer
Get stronger with walking
Usually start in lower
back and travel to lower
abdomen
Do not stop with
relaxation techniques
Fetus continues descent
into the pelvis
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Alternative Labor and Delivery Sites
– A plan for delivery should have been
established during the pregnancy.
– Traditional Hospital Settings
– Birthing Centers
– Home
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Process of Labor and Delivery
– Passageway: the pelvis and soft tissue
– Passengers: the fetus and placenta
– Powers: contractions
– Position of mother: standing, walking, side
lying, squatting, on hands and knees
– Psyche: psychologic response
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Passengers
– Fetus
•
•
•
•
•
Fetal attitude
Fetal position
Fetal lie
Fetal presentation
Fetal position
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Figure 26-3
(A, B, From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1997]. Maternity & women’s health care. [6th ed.].
St. Louis: Mosby. C, from Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.].
St. Louis: Mosby.)
Fetal head at term. A, Bones. B, Fontanelles. C, Sutures.
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Passengers (continued)
– Fetus
• Monitoring fetal status
–
–
–
–
Fetal heart rate (FHR)
Variability
Continuous electronic monitors
Deceleration
See Christensen Box 26-2 & 26-3
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Health Promotion & Maintenance
Perform Fetal Heart Monitoring During
Labor
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Figure 26-9
(From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.)
Diagram of internal invasive fetal monitoring with intrauterine catheter and
spiral electrode in place.
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Figure 26-7
(From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1999]. Maternity nursing. [5th ed.]. St. Louis: Mosby.)
Diagram of external noninvasive fetal monitoring with tocotransducer and
ultrasound transducer
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Health Promotion & Maintenance
Monitor Client in Labor
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Passengers (continued)
– Fetus
• Fetal distress
– Hypoxia
– Meconium
– Prolapsed cord
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Passengers (continued)
– Placenta
• The first few strong contractions 5 to 7 minutes
after the birth of the baby shear the placenta from
its base.
• Examined for intactness
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Powers
– Uterine Contractions
• Involuntary/Primary
– Muscles in the upper uterine segment, the fundus,
thicken and contract at intervals.
• Voluntary/Secondary
– Pushing
• Early labor
– Are 15 to 30 minutes apart; last 20 to 35 seconds
• Later labor
– Are 2 to 3 minutes apart; last 60 to 80 seconds
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Position of the Mother
– Gravity assistance
• Squatting
• Semiseated position
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Psychosocial Integrity
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Psyche
– Mother’s psychologic state
– Anxiety, fear, fatigue affect, ability to cope
with pain
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Health Promotion & Maintenance
Monitor Client in Labor
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Mechanisms of Labor
– Engagement
– Descent (See Christensen Figure 26-16)
– Flexion
– Internal rotation
– Extension
– External rotation and restitution
– Expulsion
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Stages of Labor and Delivery
– First stage: dilitation
• Early latent phase
• Mid/active phase
• Transitional phase
– Second stage: delivery
– Third stage: delivery of the placenta
– Fourth stage: stabilization
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Health Promotion & Maintenance
Care of the Newborn
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Labor and Delivery
• Response of the
Newborn to Birth
– Apgar Score (Table 26-4)
– Clear airway
• Mouth
• Nasopharynx
– Warmth
– Position
– Banding
– Footprinting
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Health Promotion & Maintenance
Perform care of postpartum client.
Monitor for postpartum complications.
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Nursing Assessment and
Interventions
•
•
•
•
Nutritional and Metabolic Pattern
Elimination
Activity and Exercise
Sexuality and Reproductive Issues
.
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Psychosocial Integrity
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Nursing Assessment and
Interventions
• Psychosocial Assessment
– Coping and Stress Tolerance
• See Christensen Box 26-7 Breathing techniques
– Roles and Relationships
– Doula
– Father or partner
• See Christensen Box 26-6 Offering support to
father
– Self perception
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Nursing Assessment and
Interventions
• Psychosocial Assessment (continued)
– Cognitive and perceptual issues
– Values and beliefs
– Non English speaking patients
– Precipitous labor/delivery
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Integrated Process:
The Nursing Process
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Nursing Process
• Nursing Diagnoses
– Pain, acute
– Fatigue
– Infection, risk for
– Tissue perfusion, ineffective
– Fluid volume, risk for deficient
– Urinary elimination, impaired
– Injury, risk for
– Knowledge, deficient
– Anxiety; fear
– Coping, ineffective
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
NCLEX Test Plan Categories
Health Promotion & Maintenance
Monitor Client in Labor and Delivery
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Medical Interventions
• Induction
– An attempt to start labor at a time other than
when it begins spontaneously
• Amniotomy
• Prostaglandin gel application
• Oxytocin stimulation
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Medical Interventions
• Forceps Delivery
• Vacuum Extraction
• Cesarean Delivery
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
Ms. K. calls the physician office stating she
thinks her bag of water may have broke.
What data will the nurse collect at this time?
What instructions will the nurse give the Ms.
K.?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
Ms. K. goes to the L&D department. The
prenatal shows that Ms. K is G2 T0 P0 A1 L0.
EDC is 6/10/08.
How many children does Ms. K. have?
What was her LMP?
How many weeks gestation is Ms. K.?
What is the significance?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
What nursing actions will be performed at
this time?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
Nitrazine paper is deep blue.
What does this indicate?
Fetal heart rate is 130-135 with acceleration of 10
bpm noted. Patient denies contractions and
the nurse does not palpate any.
What physician orders the nurse anticipate?
What nursing diagnosis does this patient have?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
Two hours later Ms. K. begins to complain of
contractions and rates her pain 3/10. The
nurse palpates the contractions as mild
occurring every 10 minutes and lasting 45
seconds.
What will the nurse do?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
The physician comes in and performs a
sterile vaginal exam. Ms. K. is dilated to
2cm, 40% effaced and -1.
What do these values mean?
What stage of labor is Ms. K. in?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
3 hours later Ms. K’s VS are T 100.0, P 88,
RR 16, BP 136/78. FHTs 145-150 with
good variability and some accelerations
noted >15 bpm. Contractions are every 4
minutes lasting 60 seconds, strength is
moderate by palpation. Patient rates
pain 5/10.
• What does this data mean?
• What are some nursing
diagnoses/interventions at this time?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
Six hours later Ms. K. is contracting every 23 minutes lasting 90 seconds and the
strength is strong by palpation. VS: T
101.4, P 100, RR 20, BP 140/78. Patient
rates pain 9/10. The nurse notices a late
deceleration on the fetal strip.
What will the nurse do?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
Case Study
The nurse performs a sterile vaginal
examination. Ms. K. is complete and the
baby is at +4.
• What does this SVE mean?
• What stage of labor is Ms. K in now?
• What will the nurse do?
College of DuPage – Grant # CB-15948-07-60-A-17 - PN Program Toolkit
•
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