Page 202 - ترم ثاني كتاب تمريض صحة الام الكتروني

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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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