NSG 3500
EXAM 2 STUDY GUIDE
Unit 4, 5 & 6 Study Guide
Nursing Practice – Maternal Health
Galen College of Nursing
, lOMoARcPSD|51648332
NSG 3500 Unit 4, 5, 6, Study Guide
Stages of Labor:
First Stage
Begins with onset of true labor and ends with full dilation of the cervix at 10
cm.
Early labor or the latent phase is characterized by contractions typically
five to 10 minutes apart and lasting 30 to 45 seconds with mild intensity. The
cervix is dilated 1 to 3 cm, and effacement has begun. Spontaneous rupture
of membranes may occur.
Assessment
1. FHR and contractions at least once per hour
2. Maternal state
3. Fetal status
4. Woman's psychosocial state
Goals / Expected Outcomes
1. Woman and fetus remain free from injury
2. Anxiety is reduced
3. Pain is manageable
4. Woman and partner understand labor process
Active labor is characterized by contractions that occur every two to five
minutes, lasting 45 to 60 seconds, and are of moderate to strong intensity.
The cervix should dilate progressively from 4 to 8 cm with rapid effacement.
Fetal descent begins.
Assessment
1. FHR and contractions
2. Labor progress
3. Fetal status
4. Maternal status
5. Woman's psychosocial state
The transition phase of labor is characterized by contractions occurring
every two to three minutes, lasting 60 to 90 seconds, and of strong intensity.
The uterus should relax completely between uterine contractions. Cervical
examination during this time reveals dilation between 8 and 10 cm. The
Downloaded by Benjamin Luca ()
, lOMoARcPSD|51648332
woman may be nauseated, vomit or report needing to have a bowel
movement. There is an urge to push and bloody show.
Assessment
1. Monitor for signs that woman has reached transition phase
2. Fetal status
3. Maternal status and ability to cope
4. Woman may express irritability, restlessness, and may feel out of
control. She may tremble or cry.
Second Stage
Expulsion of the fetus. Enter into second stage of labor when fully dilated
and effaced and ends with birth of the baby.
Assessment
1. Monitor BP, P, and R every 15 to 30 minutes
2. Assess the contraction pattern every 15 minutes
3. Assess fetal status
4. Asses the woman's report of an uncontrollable urge to push
5. Check FHR every 15 minutes for the low-risk woman, every five
minutes for woman at-risk for labor complications
Third Stage
Ends with delivery of the placenta.
Assessment
1. Monitor for signs of placental separation
2. Woman's psychosocial state
Fourth Stage
Recovery.
Assessment
1. Signs of hemorrhage
2. Assess lochia: color and quantity
3. Signs of infection
4. Monitor for suprapubic distension
5. Comfort level
6. Woman's psychosocial state
7. Assess initial bonding behaviors
Downloaded by Benjamin Luca ()
EXAM 2 STUDY GUIDE
Unit 4, 5 & 6 Study Guide
Nursing Practice – Maternal Health
Galen College of Nursing
, lOMoARcPSD|51648332
NSG 3500 Unit 4, 5, 6, Study Guide
Stages of Labor:
First Stage
Begins with onset of true labor and ends with full dilation of the cervix at 10
cm.
Early labor or the latent phase is characterized by contractions typically
five to 10 minutes apart and lasting 30 to 45 seconds with mild intensity. The
cervix is dilated 1 to 3 cm, and effacement has begun. Spontaneous rupture
of membranes may occur.
Assessment
1. FHR and contractions at least once per hour
2. Maternal state
3. Fetal status
4. Woman's psychosocial state
Goals / Expected Outcomes
1. Woman and fetus remain free from injury
2. Anxiety is reduced
3. Pain is manageable
4. Woman and partner understand labor process
Active labor is characterized by contractions that occur every two to five
minutes, lasting 45 to 60 seconds, and are of moderate to strong intensity.
The cervix should dilate progressively from 4 to 8 cm with rapid effacement.
Fetal descent begins.
Assessment
1. FHR and contractions
2. Labor progress
3. Fetal status
4. Maternal status
5. Woman's psychosocial state
The transition phase of labor is characterized by contractions occurring
every two to three minutes, lasting 60 to 90 seconds, and of strong intensity.
The uterus should relax completely between uterine contractions. Cervical
examination during this time reveals dilation between 8 and 10 cm. The
Downloaded by Benjamin Luca ()
, lOMoARcPSD|51648332
woman may be nauseated, vomit or report needing to have a bowel
movement. There is an urge to push and bloody show.
Assessment
1. Monitor for signs that woman has reached transition phase
2. Fetal status
3. Maternal status and ability to cope
4. Woman may express irritability, restlessness, and may feel out of
control. She may tremble or cry.
Second Stage
Expulsion of the fetus. Enter into second stage of labor when fully dilated
and effaced and ends with birth of the baby.
Assessment
1. Monitor BP, P, and R every 15 to 30 minutes
2. Assess the contraction pattern every 15 minutes
3. Assess fetal status
4. Asses the woman's report of an uncontrollable urge to push
5. Check FHR every 15 minutes for the low-risk woman, every five
minutes for woman at-risk for labor complications
Third Stage
Ends with delivery of the placenta.
Assessment
1. Monitor for signs of placental separation
2. Woman's psychosocial state
Fourth Stage
Recovery.
Assessment
1. Signs of hemorrhage
2. Assess lochia: color and quantity
3. Signs of infection
4. Monitor for suprapubic distension
5. Comfort level
6. Woman's psychosocial state
7. Assess initial bonding behaviors
Downloaded by Benjamin Luca ()
