1. Know the purpose of fontanelles.

The purpose of fontanelles is to facilitate easier passage of

the infant’s large head through the birth canal. Instead of
being completely made of bone, there are large areas of
thick connective tissue covered by a membrane that will
eventually close as the skull forms more bone. They help the
baby’s head conform to the size of the birth canal by being
much more flexible than bone would be. Once a baby is
born, theses fontanelles take several months to several
years to close completely, though you may notice the frontal
one closing after the first few months of life.

2. Describe the strength and intensity throughout labor.

Refer to question #5.

3. Know the events leading to the delivery of the placenta.

After the infant is born, the uterus contracts firmly,
diminishing its capacity and the surface area of placental
attachment. The placenta begins to separate because of this
decrease in surface area. This separation is accompanied by
bleeding, leading to the formation of hematoma between
the placental tissue and the remaining decidua. This
hematoma accelerates the separation process. The
membranes are the last to separate. They are peeled off of
the uterine wall as the placenta descends down the vagina.

4. Know about how to estimate stations.

Station refers to the relationship of the presenting part to
an imaginary line drawn between the ischial spines of the
maternal pelvis. If the presenting part is higher than the
ischial spines, a negative number is assigned, noting
centimeters above zero station. Station -5 is at the inlet,
and station +4 is at the outlet.

5. Be able to describe each stage of labor and the intensity

and frequency of contractions.
Stage 1: Latent Phase The latent phase is the beginning of
active labor and will carry you about half way through the
birth of your baby. This phase of the active stage of labor
begins when your contractions become progressively longer,
stronger and closer together and ends when your cervix is
about 4 or 5 centimeters dilated. The latent phase of active
labor can last anywhere from a few hours to 10 hours or
more. Contractions will grow longer, stronger and closer
together. The timing of these contractions can vary widely
from woman to woman. Some start with contractions 30
minutes apart, others start right out at 7 or even as few as
5 minutes apart.
Active Phase: The active phase of labor will continue with
contractions that grow longer stronger and closer together.
This is the part of your experience that really warrants the
label ‘labor’. It begins about the time you are 4 to 5
centimeters dilated and ends at about 9 centimeters. The
active phase of active labor can last anywhere from a couple
of hours to 10 hours or more. The contractions will grow
longer, stronger and closer together. The timing of these
contractions can vary widely from woman to woman. In
general, contractions through this stage start at about 5
minutes apart and grow closer together until they are
coming about every 2 minutes or so.
Transition Phase: As its name suggests, transition marks the
period when your body completes its labor and prepares to
move into birthing your baby. Transition is perhaps the most
intense part of the labor process, both physically and
emotionally. While it is a very trying time, you can take
comfort in the knowledge that it is also the shortest phase
of labor and that soon your dilation will be complete and
you can begin pushing. Transition will last from ten minutes
to an hour and encompass as few as three to as many as 25
contractions. The contractions come closer together,
perhaps one to two minutes apart. They will last from one
minute to ninety seconds.
Second Stage: The second stage of labor begins when the
cervix is completely dilated and ends with the birth of the
infant. The second stage is typically completed within 2
hours after the cervix is completely dilated. Contractions
continue with a frequency of 1 ½ to 2 minutes, a duration 0f
60 to 90 seconds and strong intensity.
Third Stage: The third stage of labor is defined as the period
of time from the birth of the infant until the completed
delivery of the placenta.
Fourth Stage: The fourth stage of labor is the time 1-4 hours
after birth in which physiologic readjustment of the mothers
body begins.

6. How is the duration of a contraction timed? Frequency?

Intensity?
When timing contractions you start counting from the
beginning of one contraction to the beginning of the next.
Frequency refers to the time between the beginning of one
contraction and the beginning of the next contraction.
Intensity refers to the strength of the uterine contraction
during acme. In most instances, the intensity is estimated
by palpating the contraction, but it may be measured
directly with an intrauterine catheter attached to an
electronic fetal monitor.

7. Know the difference between true and false labor:

The contractions of true labor produce progressive
dilatation and effacement of the cervix. They occur regularly
and increase in frequency, duration, and intensity. The
discomfort of true labor contractions usually starts in the
back and radiates around to the abdomen. The pain is not
relieved by ambulation. The contractions of false labor do
not produce progressive cervical effacement and dilatation.
Classically, they are irregular and do not increase in
frequency, duration, and intensity. The discomfort may be
relieved by ambulation.

8. When is the fetus said to be engaged?

Engagement of the presenting part occurs when the largest
diameter of the presenting part reaches or passes through
the pelvic inlet.

9. Explain the purpose of each of the cardinal movements.

The typical sequence of positions assumed by the fetus as it
descends through the pelvis during labor and delivery. The
positions are usually designated as engagement, flexion,
descent, internal rotation, extension, external rotation or
restitution, and expulsion. The birth canal is a curved
cylinder; the head must enter it in a downward, transverse
direction but exit it in a more forward, anteroposterior
direction. In a vertex presentation, engagement of the head
in the pelvic inlet requires that it have flexion with the chin
on the chest. After descent the head must undergo
extension to turn forward and be born under the symphysis.
The pelvic inlet is heart-shaped, and the fetal head enters it
facing obliquely. However, the pelvic outlet is diamond-
shaped, and the head usually exits it facing posteriorly and
must undergo internal rotation to do so. After delivery of
the head, the shoulders remain for a time in the oblique
plane, and the head undergoes external rotation or
restitution to allow the widest diameter of the shoulders to
be delivered from the longer anteroposterior diameter of
the pelvic outlet.
 10. Explain the back pain when the cervix is dilating.

11. Be able to interpret data concerning dilatation,

effacement, and station.
Cervical dilatation is when the cervical os and cervical canal
widen from less than 1 cm to approximately 10 cm, allowing
birth of the fetus.
Effacement is the taking up of the internal os and the
cervical canal into the uterine side walls. The cervix changes
progressively from a long, thick structure to a structure that
is tissue-paper thin.
Station refers to the relationship of the presenting part to
an imaginary line drawn between the ischial spines of the
maternal pelvis. If the presenting part is higher than the
ischial spines, a negative number is assigned, noting
centimeters above zero station. Station -5 is at the inlet,
and station +4 is at the outlet.

12. What are some of the behaviors as labor continues?

During the first stage of labor, in the latent phase, the
woman feels able to cope with the discomfort. She may be
relieved that labor has finally started. The woman is often
talkative and smiling and is eager to talk about herself and
answer questions.
In the active phase, the woman’s anxiety begins to increase
and she begins to fear a loss of losing control and may use a
variety of coping mechanisms.
In the transition phase, the woman will demonstrate
significant anxiety. She may become restless, frequently
changing postion.
In stage 2 of labor, some women feel an act of control now
that they can be involved. However, some women may be
frightened. In stage 4, the woman may be thirsty and
hungry. She may experience a shaking chill.

13. Know when each stage of labor ends and begins.

Refer to question #5.

14. Know the behaviors of a lady in the transition phase:

The transition phase is the last part of the first stage. When
the woman enters the transition phase, she may demonstrate
significant anxiety. She may become restless, frequently
changing positions. By the time she enters the transition
phase she is often inner directed and tired. She may fear
being left alone at the same time the support person may be
feeling the need for a break. The nurse should reassure the
woman that she will not be left alone. The woman may
become apprehensive and irritable.

15. What are the most priority assessments for the lady
immediately after delivery and the next few hours?
The fourth stage is usually defined as lasting from 1 to 4 hours
after the birth or until vital signs are stable. Nursing care in
this phase involves the basics of postpartum nursing care.
Immediately after the placenta is expelled, the episiotomy or
vaginal lacerations are repaired. The uterus is palpated are
frequent intervals, usually every 15 minutes for an hour until
bleeding is within normal limits, to ensure that it remains
firmly contracted. As soon as immediate care is completed,
the new mother is usually eager to cuddle and explore her new
baby. In addition to encouraging family celebration of the
birth, the immediate recovery period involves assessing both
maternal bleeding and newborn stabilization. The most
significant source of bleeding is from the site where the
placenta was implanted and where uterine vessels previously
provided pooling of maternal blood to nourish the fetus. It is
therefore critical that the fundus stay well contracted to clamp
off these uterine vessels and prevent hemorrhage. The fundus
should be firm at the umbilicus or lower and in midline. The
uterus should be palpated but not massaged unless boggy. It
is the nurse’s responsibility to assess the mother’s blood
pressure, pulse, firmness and position of fundus, and amount
and character of vaginal blood flow every 15 minutes for the
first 1-2 hours. Deviations from the normal ranges require
more frequent checking. The nurse inspects the bloody
vaginal discharge, called lochia, for amount and charts it as
minimal, moderate, or heavy. It should be bright red. All
measures should be taken to enable the mother to void. If she
is unable to void, catheterization is necessary. The perineum
is inspected for edema and hematoma formation. With an
episiotomy or laceration, an ice pack often reduces swelling
and alleviates discomfort. The following conditions should be
reported to md: hypotension, tachycardia, uterine atony,
excessive bleeding, or a temp over 100F.

16. Be able to identify fetal positions:

Three notations are used to describe the fetal position:
1. Right ® or Left (L) side of the maternal pelvis.
2. The landmark of the fetal presenting part: occiput,
mentum, sacrum, or acromion process.
3. Anterior, posterior, or transverse depending on whether the
landmark is in the front, back, or side of the pevis.
17. Know the cardinal movements:
1. Descent 2. Flexion 3. Internal Rotation 4. Extension 5.
Restitution 6. External Rotation 7. Expulsion

18. Be able to identify different stages of labor:

First stage: divided into the latent, active, and transtion
phases
(Table 22-6)
Latent phase begins with the onset of regular contractions.
Active Phase, her anxiety tends to increase as she senses the
intensification of contractions and pain. The cervix dilates
from about 4 to 7 cm.
Transition phase, she may demonstrate significant anxiety.
Cervical dilation slows as it progresses from 8 to 10 cm and the
rate of the fetal descent increases.
Second Stage: Begins when the cervix is completely dilated
10cm and ends with the birth of the infant.
Third Stage: Period of time from the birth of the infant until
the completed delivery of the placenta.
Fourth Stage: The time from 1-4 hours after birth in which
physiologic readjustment of the mother’s body begins.

19. Know attitude, lie, presentation, and position:

Attitude: refers to the relation of the fetal parts to one
another. The normal attitude of the fetus is one of moderate
flexion of the head, flexion of the arms onto the chest, and
flexion of the legs onto the abdomen.
Fetal lie: refers to the relationship of the cephalocaudal axis
(spinal column) of the fetus to the cephalocaudal axis of the
woman. The fetus may assume either a longitudinal or a
transverse lie.
Fetal presentation: is determined by fetal lie and by the body
part of the fetus that enters the maternal pelvis first. This
portion of the fetus is referred to as the presenting part. Fetal
presentation may be cephalic, breech or shoulder.
Position: Refer back to question #16.

20. Know the different types of lie:

Longitudinal lie: when the axis of the fetus is parallel to the
woman’s spine.
Transverse lie: when the axis of the fetal spine is at right
angles to the woman’s spine. This type can lead to
complications.
21. Know about Braxton Hicks contractions and their
relationship to cervical dilatation:
Braxton Hicks contractions are irregular contractions of the
uterus that occur intermittently throughout pregnancy. They
help stimulate the movement of blood through the intervillous
spaces of the placenta. In late pregnancy as these
contractions increase in frequency, they can become
uncomfortable and may be confused with true labor
contractions. The pain is in the lower abdomen and groin, but
no cervical dilatation is seen with the false labor signs.

22. What are the signs that birth are imminent?

Lightening, Cervical changes, bloody show, rupture of
membranes, sudden burst of energy, contractions at regular
intervals, intervals shorten between them, contractions
increase in duration and intensity, discomfort begins in back
and radiates around to abdomen, and cervical dilatation and
effacement are progressive.

44. What is the nursing assessment of the most likely side

effects of an epidural anesthetic?
The most common complication of an epidural block is
maternal hypotension. This is generally prevented by
preloading with a rapid infusion of intravenous fluids, then
providing intravenous fluids continuously. Also, changing the
patients position.

45. Be able to describe which infants would likely experience

respiratory depression:
Preterm infants, Surfactant deficiency disease, True post-term
infants, drug dependent newborn, difficult birthing process,
me conium in amniotic fluid, low birth weight, multiple births,
sepsis, congenital heart disease, mothers who smoked while
pregnant.

46. Know the appropriate adult dose for Narcan:

For reversal of respiratory depression in the laboring woman,
initial recommended dosage is 0.4mg to 2mg intravenously; if
necessary, the dose may be repeated at 2-to3-minute
intervals. If no response is obtained after a total of 10mg has
been administered, diagnosis of narcotic-induced depression
should be questioned.

47. Know the purposes of Vistaril, Valium, Demerol and

Stadol:
Vistaril: used to decrease anxiety or nausea.
Valium: primarily used to treat anxiety.
Demerol: used as a pain medication
Stadol: Pain medication

48. Be able to identify which patient would need an IM

injection:

49. Neonatal respiratory depression is most likely associated

with which medications?

50. Be able to assess patient data and nursing interventions:

51. What are the effects of epinephrine on marcaine?

It prolongs the anesthesia.

52. Which local anesthetic agents used for epidural

administration would most likely cause bradycardia due to
maternal uptake and crossing the placenta?
Marcaine, Carbocaine, and Xylocaine

53. What medication is used to increase blood pressure?

Epinephrine

54. Know the contraindications of epidural block.

1. maternal refusal
2. local or systemic infections
3. coagulation disorders
4. actual or anticipated maternal hemorrhage
5. low platelet count
6.hypovolemia
7. allergy to a specific class of local anesthetic
8. suspicion of a neurologic disease
9. long term use of ASA or anti-inflammatory agents
10.abruption placentae
11.acute infection at the epidural site
12. lack of trained staff

55. What are the most common side effects of epidural

anesthesia?
maternal hypotension

56. What is the goal of AMOL active management of labor?

To manage the labor from beginning to end. In this process
labor is managed from the beginning
with amniotomy, timed cervical examinations, and
augmentation of labor with
intravenous oxytocin if progress is not made.

57. Be able to assess a patient and the need for Pitocin

autmentation of labor.
Oxytocin augmentation can be implemented if adequate
contractions do not occur.

58. How are placenta previa and abruption placentae similar?

Both are due from the placenta being separated from the
uterus. Both cause bleeding.

59. What would be omitted from the physical assessment of a

patient with vaginal bleeding:
vaginal exam

60. What is the nurse's role in emotional support for a patient

who has recieved news that she has a placenta previa and a c-
section is necessary?
Factual reassurance and an explanation of the procedures and
what is happenening are essential for
the emotional well being of the expectant couple.

61. What is the treatment for prolapsed cord?

If a loop of cord is discovered, the nurse's gloved fingers are
left in the vagina, and the presenting part is pushed upward to
lift the fetal part off the cord and relieve cord compression
until the physician or CNM arrives. This is a life saving
measure. Oxygen is administered, and FHR is monitored by
EFM to see id the cord compression is adequately relieved.

62. Know the signs of hypotonic labor:

Uterine contractions are irregular and of low amplitude and
there is commonly less than 1 cm cervical dilation per hour or
there has been no change of cervical dilation for 2 hours.

63. Know the nursing interventions for a lady with hypertonic

labor:
The nurse should evaluate the relationship between the
intensity of the pain being experienced and the degree to
which the cervix is dilating and effacing. The nurse should note
whether anxiety is negatively affecting labor progress.

64. What is Erb's palsy and what is the cause:

With erb's palsy the newborn's arm lies limply at the side. The
elbow is held in extension, with the forearm pronated. The
newborn is unable to elevate the arm, and therefore the Moro
reflex cannot be elicited on the affected side. It occurs most
commonly when strong traction is exerted on the head of the
newborn in an attempt to deliver a shoulder lodged behind the
symphysis pubis In the presence of shoulder dystocia.

86. Know about classical incision:

Was the method of choice for many years but it is used
infrequently now. This vertical incision was made into the
upper uterine segment. More blood loss resulted, and it was
more difficult to repair. Most important, it carried an increased
risk of uterine rupture with the next pregnancy, labor and
birth.

87. Know about hydramnios:

Occurs when there is over 2000 ml of amniotic fluid. It often
occurs in cases of major congenital abnormalities. It also can
occur if the neonate is thought to urinate excessively. There
are two types chronic and acute. The chronic type is when fluid
volume gradually increases and is a problem in the third
trimester. When the amount is over 3000 ml the woman
experiences shortness of breath and edema in the lower
extremities. If the accumulation is severe enough
hospitalization and removal of the excess fluid are required.

88. Know about vacuum extraction:

A soft cup is placed on the fetal head and suction applied to
facilitate birth. It is used in the same manner as forceps with
contractions and you will usually see good descent with the
first two pulls. The procedure should not last longer than 30
minutes. Neonatal complications include scalp lacerations,
bruising, subgaleal hematomas, cephalhematomas,
intracranial hemorrhages, subconjuctival hemorrhages,
neonatal jaundice ect.

89. When is amnioinfusion used?

In cases of oligohydramnios where cord compression could
occur which would result in fetal distress also used to flush or
dilute heavy meconium stained fluid.

90. What is the Bishop score and what does it include?

This score examines the dilation, effacement, consistence and
position of the cervix. Each is scored 0-3 and the higher the
score the more favorable the cervix is for induction, a sore of 9
is associated with a 100% success rate.

91. What should the nurse do when the patient's partner is not
allowed to be in the operating room to allow the partner to feel
a part of delivery?
Allowing the partner to be near the operating room, where he
can hear the newborn's first cry, encouraging the partner to
carry or accompany the infant to the nursery for the initial
assessment, involving the partner in postpartal care in the
recovery room.

92. When is augmentation of labor indicated?

In the presence of Diabetes, renal disease, preeclampsia,
hypertensive crisis, PROM, chorioanmnionitis, fetal demise,
posttrerm gestation, IUGR, isoimmunization, history of rapid
labor, mild abruption placentae, nonreasuring antepartal
testing, severe oligohydramnios, macrosomia.

93. Know about fetal demise and the risk of developing DIC.
Prolonged retention of the dead fetus may lead to DIC in the
mother. After the release of thromboplastin from the
degenerating fetal tissues into the maternal bloodstream, the
extrinsic clotting system is activated, triggering the formation
of multiple tiny blood clots.

94. Know about CPD cephalopelvic disportion.

A contracture in the birth passageway can result in CPD.
Abnormal fetal presentation and positions occur in CPD as the
fetus moves to accommodate passage through the maternal
pelvis. Android and platypelloid types are predisposed to CPD.

95. Know signs of abruption and previa.

Previa- External bright red bleeding, no pain, no uterine
tenderness, and fetal heart tones are usually present.
Abruptio- external or concealed bleeding, dark blood, severe
and steady pain, uterine tenderness may have present or
absent fetal heart tones.