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Outline
A 27-year-old female who is 40 weeks and 2 days pregnant, with contractions occurring once every 10 minutes. The patient is checked in, vital signs are normal, fetal heart tones are normal and the mother and father to-be are settled into their room for the night. It is 4 am and the call light goes off. The patient reports she is feeling contractions every 2 minutes now and she thinks her water may have broken.
How can the nurse find out if the patients water has broken?
- Check for fluid exiting the vagina, use a Nitrazine test to evaluate if it is amniotic fluid or urine or vaginal discharge
What color should the test be if the membranes have ruptured?
- Blue/purple
The nurse prepares to test the fluid that has leaked down the patients’ leg. The test comes back positive for amniotic fluid. The nurse informs the doctor and prepares the patient to deliver.
What is the most important thing to have ready at this time?
- An infant warmer, if delivery happens the infant needs to be cleaned and placed under the infant warmer while an APGAR test is performed.
The nurse is prepared for the delivery and is talking the mother through her breathing, the cervix is dilated to 7 cm and the contractions are now 1 minute apart.
Vital signs are as follows:
RR 30 bpm
HR 125 bpm
BP 110/67 mmHg
Fetal HR 133 bpm
The nurse checks the presentation of the baby and notes the baby head is in the vertex position, the bottom is in the frank position and baby is in the -1 station.
What station number means the baby is starting to come out?
- Positive numbers indicate the baby is starting to exit the pelvis.
What cardinal movement is the baby currently in?
- Engagement, also called lighting or dropping.
The nurse monitors mom and baby for another hour and upon re-checking the position of the baby the nurse notes that the baby is now +1 station and the cardinal movement is descent and flexion.
What does the nurse need to make sure has happened?
- The doctor has been brought to bedside and staff is ready for delivery
As the baby is delivered the occiput is facing the right side of the pelvis and towards the front.
What position is the newborn in at delivery?
- Right Occiput Anterior (ROA)
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