University:
Lincoln University
Course:
NUR301 | Fundamental of Nursing
Academic year:

2024
Views:

145

Pages:

2
Author:

Bobby E.

Intranatal Nursing Care a.Stage 1 Assessment 1) Stage 1 Latent Phase of Assessment: - Ego integrity: Client appears happy or anxious Pain or discomfort - Regular contractions: there is an increase in frequency, duration and severity - Sexuality The cervix is dilated 0-4 cm and may have mucus that is brownish pink or consists of mucous flakes. 2) Stage 1 Active Phase of Assessment: -;Activity rest: Client appears exhausted - Ego Integrity -The client appears serious and seems lost in the labor process, fearing about her ability to control her breathing - Pain or discomfort Moderate contractions, last 2.5-5 minutes and last 30-40 seconds - Safety The fetal heart rhythm is detected slightly below the center, in the vertex position - Sexuality Cervical dilatation from 4-8 cm (1.5 cm/hour in multiparas and 1.2 cm/hour in primiparas) 3) Stage 1 Assessment Deceleration Phase -Circulation: Blood pressure increases 5-10 mmHg, pulse increases - Ego integrity Sensitive behavior, having difficulty maintaining control over breathing - Food/fluids Nausea/vomiting may occur - Pain or discomfort Strong uterine contractions, minutes. Severe discomfort in the abdominal area andThe client's sacral area is very restless due to pain and fear, leg bruising can occur. - Security The fetal heart rhythm can be heard just above the symphysis pubis. - Sexuality Above the cervix 8-10 cm, excessive amounts of blood appear.