Page 183 - كتاب تمريض نسا الاكتروني

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• Retention of urine occurs frequently in labor due to:
o Lack of muscle tone of the urinary bladder.
o Uncomfortable use of bedpan.

o Pressure on the urethra.
o Elongation of the urethra, which inhibits relaxation of the urethral
sphincter.

Observation:
Close observation is important for both the woman and fetus. The nurse should
observe the following:

• Reaction of the woman to labor.
• Vaginal discharge, show, amniotic fluid, and meconium.

• Progress of labor through descent of head and cervical dilatation.
• Uterine action: The frequency, duration and intensity of uterine
contractions should be checked and recorded every 30 minutes. See table .( )

Interval minutes 30 minutes 20 - 15 minutes 2 - 3
Duration seconds 35 - 25 seconds 45 - 35 sseconds 70 - 60

Intensity Mild Moderate Strong

 Maternal condition:
o Temperature is checked and recorded every 4 hours.

o Respiration, pulse, and BP are checked and recorded every hour.
Signs of maternal distress:

• Increased pulse rates over 100 b/min.
• Elevated temperature, more than 37.5°C.
• Decreased blood pressure.

• Sweating and pale face.
• Signs of dehydration.

• Dark vomitus.
• Ketone bodies in urine.

• Irritability and restlessness.
• Anxious expression
.

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