5.Promote safety during the first and second stages of labor.
a. If the client’s membranes are ruptured and the fetal head is not engaged, position the mother prevent cord prolapse.
b.Assess hydration status to avoid dehydration.
c. Offer the client an opportunity to avoid every 1 to 2 hours to prevent trauma to the bladder during pushing and birth of the newborn.
d. Interpret changes in the electronic fetal and maternal monitor strip, and take appropriate action.
6. Prepare for the birth of the newborn.
a. Prepare for delivery when the perineal area is bulging in a primipara and when the cervix is dilated 7 to 8 cm in a multipara.
b. Prepare the delivery area with equipment and supplies.
c. Place the client in the birthing position.
d. Assist the attending physician or nurse, midwife with the birth; help the support person to be supportive, and check all vital signs and FHR.
7. Implement immediate newborn care.
a. Establish and maintain a patent airway; suction with a bulb syringe or a De Lee mucus trap, and place the newborn on his side.
b. Compensate for poor newborn thermoregulation.
i. Dry the newborn immediately with a warm blanket
ii. Place the newborn under a radiant warmer
iii. Wrap the newborn in a warmed, dry blanket, a/or place the newborn on the mother’s skin.
c. Determine the Apgar score at 1 and 5 minutes after delivery.
d. Inspect the umbilical cord for two arteries and one vein.
e. Weigh and measure the newborn as his condition stabilizes.
f. Footprint the newborn’s and fingerprint the mother.
g. Record the newborn’s first voiding and stool passage.
h. Assess the newborn’s gestational age.
i. Administer prophylactic eye medication to protect the conjunctiva from infection.
j. Administer vitamin K (phytonadione [AquaMEPHYTON], if prescribed.
k. Encourage initial parent-newborn bonding by placing the newborn in the mother’s arms with skin-to-skin contact.
D. OUTCOME EVALUATION
1. The woman is properly admitted to the labor and delivery unit.
2. The woman and her partner use their knowledge of normal labor process and progress.
3. The woman and her partner implement food coaching breathing and other relaxation measures.
4. The mother receives physical, emotional, and pharmacologic support as needed and verbalizes increases comfort.
5. The woman experiences maximum safety, and there are no complications.
6. The woman is prepared for the birth of her child.
7. The newborn receives essential immediate care.
8. Parents hold and explore their infant.