EDAPT INTRAPARTUM PERIOD NURSING CARE
The birthing process represents a major life event for clients and their families, regardless of the number
... [Show More] of
previous deliveries. The nurse is responsible for caring for the pregnant woman, family, and fetus throughout
labor and delivery.
When admitting a client to the labor and delivery unit, which is the priority assessment?
The assessment and evaluation of contractions are necessary to establish baseline data. Without adequate
frequency and duration of contractions, labor may fail to progress.
Though it is important to understand the client's pregnancy history, as this may impact the speed and
progression of labor, it is not the priority assessment. While having a labor partner is helpful as labor
progresses, it is not the priority assessment during admission. Documenting the time of last meal is important,
especially if cesarean birth is necessary. However, this is not the priority assessment during admission.
The nurse is caring for a client in labor who is receiving oxytocin. Which assessment finding requires
immediate action?
Uterine tachysystole (hyperstimulation) is defined as more than 5 contractions in 10 minutes (or contractions
closer than 2 minutes in frequency). Tachysystole can result in decreased fetal oxygenation and requires
immediate action.
Urine output of at least 30 mL/hour is not concerning. Fetal heart rate between 110-160 bpm with moderate
variability is normal. Contraction duration of 50-60 seconds is an indication for oxytocin use.
What are indications for labor induction? Select all that apply.
Indications for labor induction may include:
Maternal factors:
premature or prolonged rupture of membranes
preeclampsia/eclampsia
history of fetal stillbirth or demise
diabetes mellitus
history of precipitous (less than 3 hours) labor
chorioamnionitis
oligohydramnios
post-term gestation
Fetal factors:
intrauterine growth restriction (IUGR)
non-reassuring fetal heart rate and pattern
fetal complications, such as erythroblastosis fetalis and hydrops
significant congenital anomalies
Maternal request for convenience is not an indication for induction of labor. Labor induction is contraindicated
with placenta previa. A cesarean birth is necessary.
Maternity nursing is a highly specialized area of nursing, which includes terminology that may be new. It may
be helpful to keep a reference guide handy for use in the clinical area as you become familiar with maternity
nursing terms.
AROM: Augmented (also called artificial) rupture of membranes
Cephalic Presentation: Fetus positioned head down; most common fetal presentation
Dilation: Progressive opening of cervix caused by uterine contractions; 0–10 cm
Effacement: Shortening and thinning of the cervix within stage one of labor
EFM: Electronic fetal monitoring
Engagement: Fetal presenting part reaches true pelvis
FHR: Fetal heart rate
Fundus: Upper aspect of the uterus
Intrapartum: Onset of labor to birth
Lightening: Descent of fetal presenting part into the pelvic cavity, often 38 weeks gestation (or 2 weeks before
labor onset in primiparas)
NST: Nonstress test; fetal assessment for well-being, (2) accelerations documented with 15 bpm above
baseline × 15 seconds in length minimum = (+) NST
PROM: Premature rupture of membranes; no contraction or no dilation noted, but SROM occurred
SROM: Spontaneous rupture of membranes
Station: Relation of the presenting part to the ischial spines of maternal pelvis
SVE: Assessment performed by RN to determine cervical dilation, station, and effacement [Show Less]