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Maternal and Child Nursing (Notes)
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Precipitous Labor Nursing Interventions | Rationales |
Assess vital signs, particularly blood pressure level. | Hypovolemia may lower blood pressure levels and put the patient at risk for hypotensive episodes that may lead to shock. |
Administer uterotonic agents and other medications as prescribed. | Uterotonic agents are utilized to prevent postpartum hemorrhage. Oxytocin is the first-line prevention of PPH. It is used to decrease the blood flow through the uterus after the delivery of the baby. |
Assist the physician in performing the appropriate procedure to prevent PPH after a precipitous labor. | The team may be required to perform one or more of the following: Uterine massageTransfusion of blood and/or blood productsApplication of pressure on labial or perineal lacerationsEpisiotomy Repair Reduction of uterine inversion using the Johnson method Manual removal of retained placental tissues Surgery such as hysterectomy (removal of the uterus) or laparatomy |
Insert an indwelling Foley catheter as indicated. | To accurately monitor the patient’s urine output which can clearly reflect renal perfusion. |
Commence a fluid balance chart, monitoring the input and output of the patient. Output monitoring should include the amount of blood-soaked pads within 24 hours. | To monitor patient’s fluid balance accurately and to check for any excessive bleeding. |
Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. | To replenish the fluids and electrolytes lost from blood volume loss, and to promote better blood circulation around the body. |
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside. | To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. |
Administer blood transfusion as prescribed. | To increase the hemoglobin level and treat anemia and hypovolemia related to PPH after a precipitous labor. |
After labor, maintain the patient on bed rest with a leg elevation of 20 to 30 degrees. | To promote recovery and reduce fatigue, bed rest is strongly recommended in patients who had a precipitous labor to prevent postpartum hemorrhage. PPH. Leg elevation is important to obtain good venous return for improved blood flow to the brain and other vital organs. This can also help prevent edema. |
Nursing Care Plan for Precipitous Labor 2
Nursing Diagnosis: Anxiety related to situational crisis of precipitous labor as evidenced by increasing tension, decreased attention span, restlessness, shortness of breath, disorganized thought process, and crying
Desired Outcome: The patient will be able to reduce his/her own anxiety level.
Precipitous Labor Nursing Interventions | Rationales |
Assess the anxiety level of the patient, anxiety triggers and symptoms by asking open-ended questions. | To establish a baseline observation of the anxiety level of the patient. Open-ended questions can help explore the thoughts and feelings of the patient regarding the situational crisis. |
Ensure to speak in a calm and non-threatening manner to the patient. Maintain eye contact when communicating with her. Provide a comfortable environment by providing sufficient lighting, good ventilation, and reduced noise levels. Respect the personal space of the client but sit not too far from him/her. | A calm voice and a comfortable environment can help the patient feel secured and comfortable to speak about his/her worries and fears. The client may become more relaxed and open for discussion if she sees the nurse as calm and appears to be in control. |
Do not leave the patient when the anxiety levels are high. Re-assure that the healthcare team are here to help her. | To ensure the patient’s safety. |
Provide factual and honest answer to questions regarding fetal status and contraction pattern. | To ensure that clear information gets to the mother and partner. This might help reduce anxiety levels. |
Monitor the vital signs of the mother and fetus. | To check if the vital signs have stabilized. |
Provide a supportive approach when the patient has anxiety by giving simple and short directions or information. | The patient has a limited attention span and is irritable or restless during a panic attack, thus simple and short directions are important in helping the patient cope with the situation. |
Teach the patient to perform relaxation techniques such as deep breathing exercises, guided imagery, meditation, and progressive muscle relaxation. | To promote relaxation and reduce stress levels. |
Administer “as needed” or PRN sedative medications only when approved by the labor & delivery team. | Mild sedatives may provide tranquilizing and soothing effect to the patient. However, these should be used with extreme caution during labor. |
More Precipitous Labor Nursing Diagnosis
- Risk for Shock (Hypovolemic)
- Fatigue
- Risk for Infection
- Ineffective Coping
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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