NCLEX stages of labor cheat sheet

First Stage of Labor: Phases?

Three phases: Latent, Active, Transition. - Latent: 0-3 cm dilation - Active: 4-7 cm dilation - Transition: 8-10 cm dilation

Second Stage of Labor: Duration?

Varies; typically lasts 20 minutes to 2 hours. Focus on maternal pushing and fetal descent.

True or False: Labor stages do not overlap.

False. Stages may overlap, especially in multiparous women.

What happens during the third stage of labor?

Delivery of placenta. Usually occurs within 5-30 minutes post-birth.

Fourth Stage of Labor: Key focus?

Assessment of mom and baby. - Monitor vital signs - Fundal height - Bonding time

Active Phase: Nursing actions?

- Monitor contractions (frequency, duration) - Assess cervical dilation - Pain management strategies

Latent Phase: Characteristics?

Cervical dilation: 0-3 cm - Irregular contractions - Emotional support is critical

Fill in the blank: Transition phase ends at ____ cm.

10 cm dilation

Signs of impending delivery?

- Increased pressure - Grunting - Bulging perineum

What is the placenta's role in the third stage?

Provides nutrients and oxygen to fetus; must be expelled after birth.

Normal uterine contractions frequency during labor?

Every 2-3 minutes; lasts 60-90 seconds.

What should the nurse monitor in the fourth stage?

Monitor for hemorrhage, vital signs, and uterine tone.

Transition Phase: Symptoms?

- Intense contractions - Nausea - Increased anxiety

Comparison: First vs. Second Stage?

First: Dilation, contractions; Second: Pushing, delivery of baby.

Cause → Effect: Prolonged labor?

Cause: Fatigue. Effect: Increased risk of cesarean delivery.

Normal fetal heart rate during labor?

110-160 bpm; monitor for decelerations.

Assess fetal heart rate patterns.

Normal range: 110-160 bpm. Monitor for decelerations or variability.

True or False: Constant fetal monitoring is required throughout labor.

False. Continuous monitoring is needed for high-risk pregnancies; intermittent is often sufficient for low-risk.

What should you do if the water breaks?

Monitor for color, odor, and time. Assess fetal heart rate; prepare for labor progression.

Compare early vs. late decelerations.

Early: mirrors contractions, indicates fetal head compression. Late: occurs after contractions, indicates uteroplacental insufficiency.

Fill in the blank: Administer ____ for severe pain during labor.

epidural anesthesia or analgesics as per protocol.

What is the purpose of cervical exams?

Assess dilation, effacement, and fetal station; guide labor progress and interventions.

Monitor maternal vital signs every ____ during active labor.

Every 1-2 hours to detect any abnormalities.

Assess contractions: Frequency is measured in _____.

Minutes apart from the beginning of one contraction to the next.

What is the significance of a baseline fetal heart rate?

Establishes a reference point for fetal well-being; significant deviations indicate potential issues.

Cause → Effect: Administering IV fluids.

Cause: To maintain hydration. Effect: Supports uterine function and placental perfusion.

True or False: Maternal position does not affect fetal heart rate.

False. Maternal position can significantly impact fetal heart rate and oxygenation.

What is the priority nursing action for fetal distress?

Change maternal position, provide oxygen, and notify the physician immediately.

Normal maternal heart rate during labor?

60-100 beats per minute (bpm) - stable and consistent throughout labor.

Fetal heart rate baseline range?

110-160 bpm - indicates fetal well-being during labor.

True or False: Maternal blood pressure should increase during labor.

False - should remain stable; significant increases may indicate complications.

Normal maternal respiratory rate in labor?

12-20 breaths per minute - may increase with pain or anxiety.

Normal fetal heart rate variability?

6-25 bpm - indicates healthy fetal response to labor.

Fill in the blank: Normal maternal temperature during labor is ___ degrees Fahrenheit.

98.6°F - higher temperatures may indicate infection.

What are the causes of decreased fetal heart rate variability?

- Fetal sleep - Acidosis - Medications (e.g., narcotics)

Normal uterine contractions frequency during labor?

Every 2-3 minutes - indicates active labor phase.

What is the normal duration of uterine contractions?

30-70 seconds - longer durations may indicate uterine hyperstimulation.

Normal range for fetal scalp pH during labor?

7.20-7.25 - lower pH indicates fetal distress.

Maternal pulse during labor typically increases to?

May increase by 10-20 bpm - stress response to pain.

True or False: Dehydration can affect maternal vital signs.

True - may cause increased heart rate and decreased blood pressure.