NUR 211: Maternal Newborn Nursing
True labor signs ( answer)- Leads to cervical dilation and effacement
- Can begin irregularly, but become stronger in frequency
- Stronger, last longer, and more frequent
- Felt in lower back, radiating to abdomen
- Walking can increase contraction intensity
- Contractions continues despite comfort measures
- Progressive change in dilation and effacement
- Moves to anterior position
- Bloody show
- Fetus: presenting part engages in pelvis
False labor signs ( answer)- Painless, irregular frequency, and intermittent
- Decrease in frequency, duration, and intensity with walking or position changes
- Felt in lower back or abdomen above umbilicus
- Often stop with sleep or comfort measures (hydration, emptying the bladder)
- Cervix is assesses and little to no change in dilation or effacement
- Often remains in posterior position
- No significant bloody show
- Fetus: Presenting part is not engaged in pelvis
What are the five factors that affect and define the labor and birth process? ( answer)Passenger: fetus
and placenta
Passageway: the birth canal
Powers: contractions
Position: of the woman
Psychological response
Passenger ( answer)The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal
position affect the ability of the fetus to navigate the birth canal.
,NUR 211: Maternal Newborn Nursing
Fetal presentation (under Passenger) ( answer)This part of the fetus that is entering the pelvic inlet
first and leads through the birth canal during labor. It can be....
- the back of the head, occiput
- the chin, mentum
- the shoulder, scapula
or
- breech, sacrum or feet
Fetal lie (under Passenger/Presentation subcategory) ( answer)The relationship of the maternal
longitudinal axis (spine) to the fetal longitudinal axis (spine).
- Transverse; think of a cross (perpendicular); will not accommodate vaginal birth; c/s
- Parallel/longitudinal (most common; expected)
Fetal attitude (under Passenger) ( answer)Relationship of fetal body parts to one another
Fetal flexion: Chin flexed to chest, extremities flexed into torso
Fetal extension: Chin extended away from chest, extremities extended
Fetopelvic or fetal position (under Passenger): ( answer)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.
- Right (R) or Left (L): references the side of the maternal pelvis
- Occiput (O), sacrum (S), mentum (M), or scapula (Sc): the second letter references the presenting
part of the fetus
,NUR 211: Maternal Newborn Nursing
- Anterior (A), posterior (P), or transverse (T): the third letter references the part of the maternal
pelvis
Station (under Passenger) ( answer)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
Passageway ( answer)The birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina,
and introitus (vaginal opening)
Powers ( answer)Uterine contractions cause effacement (shortening and thinning of the cervix) during
the first stage of labor and dilation of the cervix (enlargement or widening of the cervical opening and
canal) that occurs once labor has begun and the fetus is descending. Involuntary urge to push and
voluntary bearing down in the second stage of labor helps in the expulsion of the fetus.
Position ( answer)The client should engage in frequent position changes during labor to increase
comfort, relieve fatigue, and promote circulation.
Position during the second stage is determined by maternal preference, provider preference, and the
condition of the monitor and fetus
Psychological response ( answer)Maternal stress, tension, and anxiety can produce physiological
changes that impair the progress of labor
Stages of labor ( answer)First stage (Latent, Active, Transition)
Second stage (30-2hr)
Third stage (5-30 min)
Fourth stage (1-2 hr)
First stage of labor: Latent Phase ( answer)Onset of labor:
Contractions are
- irregular, mild, to moderate
, NUR 211: Maternal Newborn Nursing
- frequency of 5 to 30 min
- duration: 30 to 45 seconds
Some dilation and effacement ( 0 cm to 3 cm)
Client is talkative and eager
First stage of labor: Active phase ( answer)Contractions:
- more regular, moderate to strong
- frequency of 3 to 5 min
- duration of 40 to 70 seconds
Rapid dilation and effacement (4 cm to 7 cm)
Some fetal descent
Feelings of helplessness
Anxiety and restlessness increase as contractions become stronger
First Stage of labor: Transition ( answer)Contractions are
- strong to very strong
- frequency of 2 to 3 min
- duration 45 to 90 seconds
Complete dilation (8 cm to 10 cm)
Tired, restless, irritable
Feeling out of control, client often states cannot continue
True labor signs ( answer)- Leads to cervical dilation and effacement
- Can begin irregularly, but become stronger in frequency
- Stronger, last longer, and more frequent
- Felt in lower back, radiating to abdomen
- Walking can increase contraction intensity
- Contractions continues despite comfort measures
- Progressive change in dilation and effacement
- Moves to anterior position
- Bloody show
- Fetus: presenting part engages in pelvis
False labor signs ( answer)- Painless, irregular frequency, and intermittent
- Decrease in frequency, duration, and intensity with walking or position changes
- Felt in lower back or abdomen above umbilicus
- Often stop with sleep or comfort measures (hydration, emptying the bladder)
- Cervix is assesses and little to no change in dilation or effacement
- Often remains in posterior position
- No significant bloody show
- Fetus: Presenting part is not engaged in pelvis
What are the five factors that affect and define the labor and birth process? ( answer)Passenger: fetus
and placenta
Passageway: the birth canal
Powers: contractions
Position: of the woman
Psychological response
Passenger ( answer)The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal
position affect the ability of the fetus to navigate the birth canal.
,NUR 211: Maternal Newborn Nursing
Fetal presentation (under Passenger) ( answer)This part of the fetus that is entering the pelvic inlet
first and leads through the birth canal during labor. It can be....
- the back of the head, occiput
- the chin, mentum
- the shoulder, scapula
or
- breech, sacrum or feet
Fetal lie (under Passenger/Presentation subcategory) ( answer)The relationship of the maternal
longitudinal axis (spine) to the fetal longitudinal axis (spine).
- Transverse; think of a cross (perpendicular); will not accommodate vaginal birth; c/s
- Parallel/longitudinal (most common; expected)
Fetal attitude (under Passenger) ( answer)Relationship of fetal body parts to one another
Fetal flexion: Chin flexed to chest, extremities flexed into torso
Fetal extension: Chin extended away from chest, extremities extended
Fetopelvic or fetal position (under Passenger): ( answer)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.
- Right (R) or Left (L): references the side of the maternal pelvis
- Occiput (O), sacrum (S), mentum (M), or scapula (Sc): the second letter references the presenting
part of the fetus
,NUR 211: Maternal Newborn Nursing
- Anterior (A), posterior (P), or transverse (T): the third letter references the part of the maternal
pelvis
Station (under Passenger) ( answer)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
Passageway ( answer)The birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina,
and introitus (vaginal opening)
Powers ( answer)Uterine contractions cause effacement (shortening and thinning of the cervix) during
the first stage of labor and dilation of the cervix (enlargement or widening of the cervical opening and
canal) that occurs once labor has begun and the fetus is descending. Involuntary urge to push and
voluntary bearing down in the second stage of labor helps in the expulsion of the fetus.
Position ( answer)The client should engage in frequent position changes during labor to increase
comfort, relieve fatigue, and promote circulation.
Position during the second stage is determined by maternal preference, provider preference, and the
condition of the monitor and fetus
Psychological response ( answer)Maternal stress, tension, and anxiety can produce physiological
changes that impair the progress of labor
Stages of labor ( answer)First stage (Latent, Active, Transition)
Second stage (30-2hr)
Third stage (5-30 min)
Fourth stage (1-2 hr)
First stage of labor: Latent Phase ( answer)Onset of labor:
Contractions are
- irregular, mild, to moderate
, NUR 211: Maternal Newborn Nursing
- frequency of 5 to 30 min
- duration: 30 to 45 seconds
Some dilation and effacement ( 0 cm to 3 cm)
Client is talkative and eager
First stage of labor: Active phase ( answer)Contractions:
- more regular, moderate to strong
- frequency of 3 to 5 min
- duration of 40 to 70 seconds
Rapid dilation and effacement (4 cm to 7 cm)
Some fetal descent
Feelings of helplessness
Anxiety and restlessness increase as contractions become stronger
First Stage of labor: Transition ( answer)Contractions are
- strong to very strong
- frequency of 2 to 3 min
- duration 45 to 90 seconds
Complete dilation (8 cm to 10 cm)
Tired, restless, irritable
Feeling out of control, client often states cannot continue
