Stages of Labor NCLEX Review

Stage 1

Defined as the first onset of contractions through the complete dilation of the cervix, with 3 separate phases. Stage 1 is the longest phase. Throughout this phase, keep in mind the following interventions:

  • Monitor maternal and fetal vital signs.
  • Continually assess FHR before, during, and after contractions.
  • Assess fetal descent, cervical dilation, and effacement.
  • Assess fetal station presentation and position.
  • Encourage frequent position changes and/or ambulation if not contraindicated.
  • Involve patient and support person in labor process and what to expect.

Latent Phase

To start, I will add another definition here, prodromal labor. This is latent phase labor that has lasted several days.

The latent phase is usually defined by:

  • Cervical dilation is 1 to 4 cm.
  • Uterine contractions occur q15-30 mins and last 15-30 sec.
  • Lasts an average length of 5-8 hrs
  • Contractions are of mild intensity

In this stage, mom’s will most likely be feeling a variety of emotions. They are also usually able to participate in their own care and may not quite ask for pain control interventions at this time. Keep in mind that each mom is unique and requires individual assessment!

Active Phase

This phase consists of:

  • Cervical dilation of 4 to 7 cm.
  • Uterine contractions q3-5 min and last 30-60 sec.
  • Lasts an average length of 2-5 hrs.
  • Some fetal descent.
  • Contractions are moderate-strong intensity.

During this phase of labor, mom’s behavior will start to shift. She will start breathing heavier and may not be able to talk through contractions. She will benefit from a quiet environment and pain control interventions. Pain interventions do not have to be medication, as promoting comfort with back rubs, sacral pressure, and position changes can be effective and beneficial.

Transition Phase

This phase is arguably the “most difficult” phase of labor.

  • Cervical dilation is 8 to 10 cm.
  • Uterine contractions occur q2-3 min and last 45-90 sec in duration.
  • The contractions are of strong intensity.
  • Fetal descent.

During this phase, mom may have increased anxiety, apprehension, and discomfort. She will experience increased pressure, bloody show, and may verbalize the urge to push. Contrary to the active phase of labor, she may not want to be touched. Rest is encouraged between contractions.

Stage 2

Stage 2 is defined as the period from complete cervical dilation and effacement to the delivery of the fetus, or “Expulsive” phase.

  • Contractions continue to occur q2-3 min lasting 60-75 sec.
  • Increase in bloody show occurs.
  • Mom will experience voluntary or involuntary urge to “bear down.”
  • This stage can last minutes to 4 hours.

Sources of pain during the 2nd stage of labor change from pain in a more generalized area to localized to the distention of the vagina and perineum and pressure on adjacent structures.

It is important to complete assessments every 5 minutes. Normal FHR is 110-160 bpm before, during, and after contractions.

Cardinal movements of labor:

  • Descent
  • Flexion
  • Internal Rotation
  • Extension
  • Restitution
  • External Rotation
  • Expulsion

Stage 3

The process of labor does not stop once the baby has been born! This 3rd stage is from the delivery of the infant to the expulsion of the placenta. Contractions continue to occur until this is completed.
Image source: https://www.newlifeblessings.com/blog/category/placenta

  • Schultze Mechanism: “Shiny shultze” – center of the placenta separates first, and the shiny portion of the placenta emerges first.
  • Duncan Mechanism: “Dirty duncan” – the margin of the placenta separates first and the dull, rough, red portion of the placenta emerges first.

Signs of placental separation:

  • Uterus becomes globular shaped
  • Rise of the fundus in the abdomen
  • Sudden gush or trickle of blood
  • Further protrusion of the umbilical cord out of the vagina

Be sure to continue involving the mother and support person in this stage about the steps of delivering the placenta while also promoting parental-neonatal attachment. The uterine fundus should be firm and should be located 2 fingerbreadths below the umbilicus.

A placenta is considered retained if more than 30 minutes has elapsed since the birth of the infant.

Stage 4

Stage 4 is known as the Recovery Stage. This stage is defined from the delivery of the placenta to the immediate recovery of the mother.

It is important to perform maternal assessments q15min for 1 hour, q30min for 1 hour, and hourly for 2 hours, or according to facility policy. Apply ice packs to the perineum, and massage the uterus as needed to keep it firm.

The mother may also experience chills, a hypotonic bladder, and a variety of emotions related to the birth process. Encourage continued bonding between the infant and parents, and provide breast-feeding support as needed.

References and Additional Resources

All image sources are linked near or under the image on this page. I do not own the rights to images posted on this page.

Continue your NCLEX Review Journey by checking out some of my other NCLEX Review posts!


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How to Answer Priority and Delegation NCLEX Questions

Everytime I see one of these questions, I want to pull my hair out! They intimidate me and I often feel the least prepared for these types of questions. Here I will break down how to answer NCLEX-style priority and delegation questions.

A lot of this material comes from the Saunder’s Comprehensive NCLEX Review. If you’ve seen any of my other posts, you have probably run across this book. I wish I would have purchased this book my first semester of school. I bought it my third semester and kicked myself for not getting it sooner. It has been worth every penny to me!

Another great resource is the Brilliant Nurse Course for NCLEX prep. It has practice questions, detailed rationales, videos, strategy sessions, and case studies. The prices are very competitive with other similar online NCLEX-prep websites.

Priority

Prioritizing patient care is an essential nursing skill. It will determine who gets care first, and the order in which you perform your tasks. Often in the clinical setting, it can be easier to spot your priorities because you have access to a lot of information. NCLEX-style questions can be tough simply because you are given 1-2 sentences of limited information with which you must make the decision.

These types of questions can be multiple choice, select all that apply, ordered response, exhibit questions, etc. Any type of question is game!

Priority Guidelines

  • ABC’s – Airway, Breathing, Circulation
  • Remember Maslow’s Hierarchy of Needs
  • Consult your patients about their priorities and needs
  • Use the nursing process to guide you

When you are given a set of choices, read them all before making your decision. Hopefully you can eliminate 1-2 choices right off the bat. After that, use your ABC’s. If any answer choices fall into that, it is probably your answer.

Delegation

The key to answering delegation questions is understanding the scope of practice for yourself and each of your colleagues. You must also analyze the tasks that need to be done and the importance of completing them. Then, assign tasks to a competent individual.

When you assign a task to someone else, the nurse who owns the task is accountable for it.

Always ensure patient safety when delegating tasks. In general, non-invasive interventions such as ambulation and hygiene measures can be delegated to UAP’s (Unlicensed Assistive Personnel). An LPN or LVN can do some invasive procedures such as catheterization and suctioning.

Remember that a Registered Nurse is responsible for assessment, planning care, initiating teaching, and administering medications intravenously.

Never assign an unstable patient to UAP’s or LVN’s.

I hope this helps explain how to approach these questions! Practice makes perfect. Use one of the resources listed above to do practice questions! The more you expose yourself to these tough questions, the better you will get at it!


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Changing Careers (or Majors) to go to Nursing School

When I graduated high school, I wanted to be an Aerospace Engineer and work for NASA. I applied and got accepted to some of the top engineering schools in the country like University of Texas at Austin and Colorado School of Mines. I eventually chose a scholarship at the University of Colorado Boulder. My engineering journey lasted three semesters, and then I discovered that I was entirely unhappy with my life. I had a fancy engineering internship, I had great friends, and I lived in a beautiful city. What on earth could be wrong with that?

The bottom line is that engineering was not for me. It wasn’t God’s plan for me. At first I was upset that I had wasted so much time in that field, but looking back, I have used a lot of those skills in my daily life and my new nursing career.

A Diversion is Not A Waste of Time

There are so many people out there who choose nursing as a second, even third career. Some of my thoughts getting accepted into nursing school at age 24 were, “It’s about time,” and “I can’t believe I didn’t think of this sooner.”

It has taken about three semesters of school for me to be content with all of the other life choices I’ve made. I had a really rough patch, and I made a lot of choices that I regret.

If you have those types of life experiences, deal with the emotions, and use it to your advantage. I’ll use the cliche, learn from your mistakes. I am better able to handle the monstrosity of nursing school because of what I went through to get there. I would not be able to handle nursing school if I went right out of high school. I know that and I am thankful for it.

Tip: Write out your biggest life regrets/bad choices. On a separate piece of paper, write out positive lessons you learned from them. Then burn the first page with your regrets.

Have a Plan Before Quitting Your Current Job

This is something I did NOT do. Although there were many other factors in my quitting engineering school, I did not plan anything out. I left school for about a year before going back. I knew I did not want to do Aerospace, but I wanted to finish a degree. I decided to take some biology classes.

Some more life stuff happened and I switched to online, part-time school. By this time, I knew I wanted to be a nurse. I had spent so much time in the hospital that I fell in love with the art of nursing.

If I had a plan after the first time I left school, I would have been better off. But that didn’t happen. I had no idea how to start. I did zero research. I straight up just quit.

Tip: If you aren’t sure which major you want, take your basics first. Each state has different requirements, so check those out. Get your English, Math, and electives out of the way.

Do Your Research About Nursing

Nursing is a one-of-a-kind career. Nursing school is rigorous and life-changing. You will lose sleep. You will have less time with your family. You will cry. You will want to quit.

Do your research about nursing. There are a lot of misconceptions about what the job entails. If you have friends or family in nursing, ask them questions.

Listen To Your Heart

If you have a passion for it, go for it. If you are 100% sure you want to be a nurse, go for it. Any roadblocks along the way just makes it more fun when you get to your goals.

If you do all of this research and soul-searching and you still aren’t sure, you are an adult and can make your own decisions. However, I can tell you from personal experience that you need your whole heart to make it through nursing. Even when I hate school, I love it. Wouldn’t trade it for anything.

Take some time to better yourself. Read some personal development books. They are not all “if you believe it you can achieve it” cheesy. Take a look at some of my favorites below –>

Thanks for reading!



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How to Study Health Assessment in Nursing School

Assessment is one of the skills that set you apart from a lot of other medical careers. CNA’s, MA’s, Techs, and other UAP’s do not have the assessment skills that registered nurses have. It is one of those skills that is pounded in nursing school, but never truly mastered until years and years of practice. This guide will hopefully give you a better idea of how to study Assessment in Nursing School and answer HESI and NCLEX style questions.

Your textbook may be different, but we used Jarvis’s Physical Examination and Health Assessment, 7th ed.💎

Anatomy & Physiology

Most programs in the United States require A&P I and II. I’ve rarely seen some programs squish all of that in one class. You need to be a master at your anatomy and physiology. Review cardiopulmonary, abdomen, and neuro anatomy before school starts. You will need to be able to pretty much label and/or draw from memory most of your body systems. A lot of people in my class had trouble with Assessment most likely because they were weak in anatomy. I personally had trouble with the cardiovascular system for this very reason.

Vocabulary

There will be a lot of big medical terms that you’ll need to know! Hopefully you’ve picked up a lot from A&P, Patho, and your other Biology classes. When you study, make flashcards of all of the terms you do not know and study them every single day. These words WILL be on your exams, HESI, and NCLEX. Learn them now.

Normal vs. Abnormal

Assessment is all about knowing what you are supposed to be seeing, hearing, and feeling (namely inspecting, auscultating, and palpating). Establishing this foundation is very important! I took notes in two columns. One side was “normal” findings, and the other side was “abnormal” findings.

In your practice, you should be able to tell when something is wrong. You may not know 100% what is going on, but you should be able to tell your doctor over the phone what your findings are.

Study Habits + Repetition

Assessment is a tough subject. It is a lot to chew, especially with your other classes. You need to establish excellent study habits. This means no more going out every weekend, no more binge watching TV. You gotta get up earlier and go to bed later. Check out my Top 10 Study Tips to get some more tips on how to establish excellent study habits!⬇️

Repetition is key with Assessment. I probably studied each set of material more than ten times. I rewrote notes, drew pictures, and answered plenty of practice questions. I made it a goal to know the material inside and out. I probably spent the most amount of time studying for the class during my first semester.

Practice

As much fun reading out of a book is, nursing isn’t all about reading a patient’s chart. You need to practice! Practice on everyone that will let you. Friends, family, strangers (JK, that might be weird). Get used to going through your full head to toe on different people. Talk through your assessment, even if the other person has no idea what you’re saying!

Patience

These skills will come to you. Like I said in the beginning, you will not master these skills until you’ve been in practice for a long time. Don’t be too hard on yourself and don’t be afraid to seek help! As always, I am here to answer your questions!



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FIVE Things I Wish I Knew Before I Started Nursing School

1) Straight-A …Student

If you are/were a straight-A student, get ready to get knocked down a notch or two. I don’t know anybody in my class of about 100 people who have gotten all A’s. I know there were maybe two in the class ahead of us? Point is, get ready for that not to happen.

I came in head-strong thinking, “I know everyone has been saying this but I can do it. I get can all A’s.”

The first round of exams went through and I thought, “Okay. That’s doable.” But then the second and third round came and eventually I was just doing everything I could to stay afloat.

My advice is this: do your best, do not compare yourself to your classmates, and ask for help when you need it. Your grades are not reflective of your capabilities as a nurse.

2) Mental Health > Study Time

“Don’t pound yourself into the ground with studying because self-care is just as important.”

My mentee

Don’t get me wrong, you need to study hard and make it a good habit. But you also need to realize that if you wear yourself out, no amount of studying is going to help you.

Make a study schedule and stick to it. Study every day, schedule breaks and rewards, and do not study outside of your allotted time. I stop studying around 8-9pm every night, and I always get my 7-9 hours of sleep.

3) Roll with the Punches

I had an expectation that nursing school would be organized, the instructions would be clear, and that there would always be a strict schedule. Boy oh boy was I wrong!!

You will have to learn to “roll with the punches.” Don’t sweat the small details. Be ready to adjust and readjust your schedule. Nursing school is very fluid!

I remember one week last semester where they said, “Oh by the way, this small group of people needs to put together a project and present it at this location. And you have five days.” I remember thinking, you want me to do that and my million other things I have going on?

I go to class every day expecting that something else will be thrown our way. That way, I’m not surprised.

4) Nurse-Administrator

The administrative/paperwork stuff added another level of stress to nursing school. The beginning was extra stressful because you have to submit a lot of paperwork to the state board of nursing. It helps to become ultra-organized with your vaccine records, identification documents, health insurance, CPR certifications, background check documents, drug screen, etc. There are 32 separate documents I have submitted JUST to be eligible to register for classes.

You will most likely also submit additional paperwork for each of your clinical sites. You will also be expected to keep up with your resume and portfolio.

If your school tells you to start working on paperwork before school starts, DO IT RIGHT AWAY. If you wait until school starts, you will be stressed out about the administrative stuff and that will cut into your study time.

5) Tick-tick-tick-DONE

When I got my acceptance letter for school, I thought that the two years would take forever, and I questioned whether or not I wanted to commit to two years of my life.

Now I’ll be starting my last semester of school and I cannot believe how fast time has gone by! When did I get here? I feel like I just woke up and now it’s time for me to apply for big girl jobs!

Nursing school keeps you so busy that time passes by really fast. Each week is so jam-packed that seven days don’t seem like enough time.

Don’t forget to enjoy life in those little moments!



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Cardiac Drugs Quick Sheet!

Just a quick overview for the major cardiac/ACLS drugs as pertaining to adults. This is essentially what my flash cards would pertain! Get your AHA ACLS Manual here!

Digoxin

  • Action
    • Positive inotrope – increases the force of cardiac contraction
    • Decrease HR
    • Allow for more complete emptying of the ventricles, thus increasing CO
    • Decrease conduction through the AV node, reduce automaticity of the SA node
  • Indications
    • Heart failure
    • A-fib and A-flutter
    • Paroxysmal atrial tachycardia
  • Special Considerations
    • Monitor potassium levels
    • Count apical for 1 min prior to administration

Atropine

  • Action
    • An anticholinergic drug and increases the firing of the SA node by blocking the action of the vagus nerve.
    • Increases HR
  • Indications
    • 1st line for symptomatic bradycardia
  • Special Considerations
    • Anticholinergic S/E
    • Increases myocardial oxygen demand à be careful in presence of myocardial ischemia

Adenosine

  • Action
    • Antiarrhythmic that decreases conduction through the AV node
  • Indications
    • Paroxysmal Supraventricular Tachycardia
  • Special Considerations
    • Commonly causes a few seconds of asystole
    • Very short half-life (6-10 seconds)
    • Push FAST
    • Patient may feel “like they got punched in the chest”

Amiodarone

  • Action
    • Delay repolarization resulting in prolonged duration of action potential and refractory period
    • Class III Potassium Channel Blocker
    • Decreases heart rate and contractility
  • Indications
    • Pulseless V-fib or V-tach
    • Oral – Atrial fibrillation
  • Special Considerations
    • Do NOT use with cardiogenic shock or severe sinus bradycardia à may cause hypotension
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Epinephrine

  • Action
    • Stimulate beta1 receptors à cardiac stimulation
    • Increased HR, CO, and contractility
  • Indications
    • Cardiogenic shock, Anaphylactic shock, Septic shock
    • Cardiac arrest, pulseless ventricular tachycardia, ventricular fibrillation, asystole
  • Special Considerations
    • Raises BP and increases HR à may cause myocardial ischemia, angina
    • May contribute to post-resuscitation myocardial dysfunction

Dopamine

  • Action
    • Positive inotropic
    • Increased myocardial contractility, increased automaticity, increased AV conduction, increased HR, CO, BP, MAP
  • Indications
    • Cardiogenic shock
    • 2nd line for symptomatic bradycardia
  • Special Considerations
    • Correct hypovolemia with volume replacement before using dopamine
    • DO NOT mix with Sodium Bicarb

Lidocaine

  • Action
    • Sodium channel blocker
  • Indications
    • V-fib, V-tach – with and without pulse
  • Special Considerations
    • *REMOVED from ACLS Guidelines*
    • Can cause toxicity!

Sources: 2018 ACLS Guidelines (Provider Manual), Medical-Surgical Nursing : Assessment and Management of Clinical Problems, 10th Ed (Lewis)



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Emergency Room Essentials

I know what you’re thinking – there’s no such thing as a “typical” day in the ED. In fact, the only thing you can rely on is that your day will be unpredictable. As a nurse intern in a busy adult ED, I have quickly figured out which items are essential during my shift, and which ones I really do not need. I do not currently work in a trauma center–we see most of the city’s STEMI’s, CVA’s, and transplant patients. We also see minor fractures, lacerations, dislocations, etc.

Our ED is divided into “Stations,” and each station has somewhat of a different category of patients. The “front rooms” are the most critical, we have a special room for eye trauma, and we have about 40 beds.

My job as a student intern involves shadowing/helping an Emergency Room RN. I’ve gotten to the point now where I am a helpful partner to my preceptor. When we get a new patient, I know exactly what my role is!

My first day, I showed up with a pocket full of extra supplies that only weighed me down throughout the day. I’ve narrowed down my everyday essentials to just 7 items!

  1. Stethoscope. My beautiful Littman III Classic in matte black is my closest friend in the ED. When assessing ABC’s, lung sounds can give you a clue as to what someone’s respiratory status is. It also isn’t uncommon to uncover distant heart sounds indicating cardiac tamponade.
  2. Retractable badge Sharpie. This is my second most used item! It takes out the possibility of setting your pen/marker down somewhere and losing it forever. I use it to label lines, specimen tags, patient belongings, sign EMS handoff, write down vitals on my glove, and the list goes on.
  3. Pen light. Neuro checks are important for ANY type of patient. If a patient comes in with a sprained ankle, I still do a neuro check. No matter what the patient tells you, they could be making something up because they don’t remember what happened. I also use my pen light for Foley placements and quick airway checks.
  4. Trauma shears. Mine can cut through thick leather! Although we are not a trauma center, I have still cut my fair share of clothing. It is also useful for cutting tape, medication packaging, and during wound care.
  5. Saline flushes. Not something you bring from home, but I always grab a handful at the beginning of my shift. You’ll find that you always need one or two when your hands are already full doing something else.
  6. White board marker. Our rooms are supposed to have their own whiteboard markers. We all know this doesn’t happen. Updating the boards aren’t necessarily the top priority, but I try to update them when I can. It helps patients feel more comfortable if they know the names of their care team.
  7. Black pen. This is probably my least used item, and I often lose it, but it’s good to have!

I hope this can help some of my fellow students. I was so nervous on my first ED shift and I had no idea what I would need! I ended up filling my pockets with 4 pens, a small notebook, and all of my other regular clinical supplies. It was just too much.



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Top 10 Study Tips!

1. Make a study schedule and stick to it.

2. Pace yourself. Study every day, even if it’s just for 30 minutes.

3. If you don’t understand something, find a different resource (ask a friend, find a YouTube video, email the instructor, etc.).

4. Study for 50 minutes at a time and take a 10-15 minute break in between.

5. During those breaks, don’t just be on your phone or computer. Get up. Move around. Get your blood flowing!

6. Make time for yourself. If you like to read leisurely, do it. If you work out, do it.

7. SLEEP. for the love of God. Get 7-9 hours of sleep a night.

8. Find a method that works for you. Flashcards, outlines, Quizlet, recording yourself, drawing pictures, etc. It’s all trial and error.

My less than artistic attempt at understanding the cardiac system.

9. DON’T CRAM. If you don’t know the material the night before the test, chances are you won’t know it for the test.

10. Studies show that you need to review material 7 times to retain 90% of the information.


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Pharmacology: Seizures and Epilepsy

Definitions:

Convulsion: abnormal motor phenomena (jerking, movements, tics, rigors)
Seizure: a sudden, excessive synchronous electrical discharge of neurons in the brain that can spread to other foci
Epilepsy: group of chronic neurological disorders characterized by recurring seizures

Main Types of Seizures:

Simple Partial: discrete motor, sensory, autonomic and psychoillusionry symptoms. No loss of consciousness. Persists 20-30 seconds.
Tonic-Clonic: major convulsions characterized by a period of muscle rigidity (tonic phase) followed by synchronous muscle jerks (clonic phase). Immediate loss of consciousness. Followed by postictal state. Lasts 90 seconds or less.

Therapeutic Goals:

  • Enable patient to live a normal life.
  • Ideally eliminate seizures, but may not be possible

How do Anti-Epileptic Drugs Work?

  • suppress discharge of neurons within a seizure focus
  • suppress the spread of seizure activity from the focus to other areas of the brain
  • decrease in sodium influx, decrease in calcium influx, increase in potassium influx

Traditional AED’s

  • Phenytoin (Dilantin): Therapeutic range: 10-20mcg/mL, can cause gingival hyperplasia and nystagmus
  • Carbamazepine (Tegretol): Also treats trigeminal neuralgia and bipolar disorder. Contraindicated if patient has bone marrow depression or hypersensitivity. Avoid grapefruit juice!
  • Valproic Acid (Depakote): Also treats migraines and bipolar disorder. Therapeutic range: 50-100mcg/mL. Highly teratogenic! Can cause hepatotoxicity, pancreatitis and hypersensitivity.
  • Ethosuximide (Zarontin): Treats absence seizures. Therapeutic range: 40-100mcg/mL. Generally devoid of adverse effects.
  • Phenobarbital: Older drug, long-acting. Toxicity can cause nystagmus and ataxia. Overdose can cause respiratory depression and possibly death. Has a sedative effect, cognitive/learning impairment, CNS depression and drug dependence. May make children hyper.

Status Epilepticus

A MEDICAL EMERGENCY in which a patient is continually having tonic-clonic seizures for 20-30 minutes and is not conscious the whole time.

Immediate treatment includes: turning patient to the side, administering oxygen, removing objects that could potentially harm, having padded bedrails, suction secretions, and DO NOT restrain the patient or put anything in their mouth. Administer one of the following medications:

  • Diazepam (Valium): Used for emergency treatment of status epilepticus. Short half-life. May develop physical dependence and withdrawal symptoms.
  • Lorazepam (Ativan): Drug of choice used in status epilepticus because of prolonged effects. A rectal gel is available for out of hospital use.

Source: Lehne Pharmacology for Nursing Care, 9th Edition, Chapter 24