Page 180 - كتاب تمريض نسا الاكتروني

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- Molding of the fetal skull

 The maternal condition

- Pulse, blood pressure and temperature

- Urine (volume, protein, acetone)

- Drugs and IV fluids

- Oxytocin regime.
 Nursing Diagnosis

• Alteration in comfort: acute pain related to uterine contraction.
• Anxiety related to impending labor and delivery.
• Alteration in tissue perfusion. Placental perfusion to the

• fetus decreases due to supine position.
• Fluid volume deficit related to decreased fluid intake.

• Sleep pattern disturbances related to labor process.
• Knowledge deficit related to process of labor, appropriate relaxation
techniques, and hospital procedures.

• Alteration in oral mucus membrane related to mouth breathing.
• Alteration in nutrition to less than body requirements related to decreased

oral intake.
• Self-care deficit related to immobility during labor.
• Ineffective individual coping related to lack of support system.

Planning and Implementation

Nutrition and Hydration
• During labor, there is an excessive loss of fluids, and increased tendency
to exhaustion and dehydration due to strong muscular exercise.

• The woman's need for energy is met through nourishing oral fluids at
frequent intervals to maintain the fluid balance.

• Sometimes IV fluids are given to provide energy and prevent dehydration
in case of vomiting, ketosis and possible use of anesthesia.
• During early labor, the woman should receive about 75 ml of fluid per

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