Maternal and Newborn Nursing – RN Flashcards

Rapid-review flashcards at NCLEX-RN depth. Core content is at Maternal and Newborn Nursing.

Antepartum

GTPAL, and why para does not equal number of babies

Gravida (total pregnancies), Term births at 37 0/7 weeks or later, Preterm births from 20 0/7 through 36 6/7 weeks, Abortions or losses before 20 weeks, Living children. Para counts pregnancies carried to 20 weeks or beyond, not infants, so a twin birth at 36 weeks is T0, P1, L2.

Naegele's rule and its main limitation

First day of the last menstrual period minus 3 months, plus 7 days, plus 1 year. It assumes a regular 28-day cycle with day 14 ovulation, so it is unreliable with irregular cycles. First-trimester ultrasound is the more accurate dating method.

The only three positive signs of pregnancy

Fetal heart tones auscultated by an examiner, fetal movement palpated by an examiner, and visualization of the fetus on ultrasound. Everything else, including a positive hCG test, is presumptive or probable.

Why hemoglobin falls in a healthy pregnancy

Plasma volume rises proportionally more than red cell mass (total blood volume up 40 to 50 percent), producing dilutional or physiologic anemia. True anemia is suggested below about 11 g/dL in the first and third trimesters and below about 10.5 g/dL in the second.

Supine hypotensive syndrome

mechanism and intervention

After about 20 weeks the gravid uterus compresses the inferior vena cava when supine, reducing venous return, cardiac output, and uteroplacental perfusion. Signs are dizziness, pallor, nausea, hypotension, and fetal heart rate changes. Intervention: reposition to a lateral (classically left lateral) position.

Why a "normal" creatinine can be abnormal in pregnancy

GFR increases about 50 percent, so baseline creatinine and BUN are lower than in nonpregnant adults. A creatinine above about 1.1 mg/dL, or a doubling from baseline, signals renal impairment and is a severe feature of preeclampsia.

Timing of Rho(D) immune globulin

About 28 weeks' gestation, and again within 72 hours after birth of an Rh-positive newborn. Also after miscarriage, ectopic pregnancy, termination, amniocentesis, chorionic villus sampling, external cephalic version, and abdominal trauma. It prevents sensitization and has no effect once anti-D antibodies already exist.

Group B Streptococcus

when to screen and when to treat

Rectovaginal culture at 36 0/7 to 37 6/7 weeks. Treatment is intrapartum IV antibiotic prophylaxis, usually penicillin G, ideally at least 4 hours before birth. Antepartum treatment does not prevent neonatal GBS disease.

Nonstress test

what makes it reactive

At least 2 accelerations in 20 minutes, each 15 beats per minute above baseline lasting 15 seconds, in a fetus 32 weeks or older (10 by 10 before 32 weeks). Reactive is reassuring. A nonreactive test calls for further testing, not automatic delivery.

Contraction stress test

which result is the good one

Negative is the reassuring result, meaning no late decelerations with adequate contractions. This is the one test where "negative" equals normal, which is a common trap.

Hypertensive Disorders

Diagnostic criteria for preeclampsia

After 20 weeks, blood pressure 140/90 mm Hg or higher on two occasions at least 4 hours apart, plus proteinuria (300 mg or more per 24 hours, protein-to-creatinine ratio 0.3 or higher, or 2+ dipstick). It can also be diagnosed without proteinuria when new hypertension occurs with thrombocytopenia, elevated liver enzymes, renal insufficiency, pulmonary edema, or new cerebral or visual symptoms.

Severe features of preeclampsia

Systolic 160 mm Hg or higher or diastolic 110 mm Hg or higher; platelets below 100,000/mm3; transaminases about twice normal or severe persistent right upper quadrant pain; creatinine above 1.1 mg/dL or doubled; pulmonary edema; new cerebral or visual disturbance. Note that the amount of proteinuria is not a severity criterion.

HELLP syndrome and why it is missed

Hemolysis, Elevated Liver enzymes, Low Platelets. It can present with malaise, nausea, and right upper quadrant pain with only modestly elevated blood pressure, so anchoring on blood pressure alone leads to missed diagnosis.

Purpose of magnesium sulfate in preeclampsia

Seizure prophylaxis, not blood pressure control. It is a CNS depressant and smooth muscle relaxant. Blood pressure is treated separately with IV labetalol, IV hydralazine, or oral immediate-release nifedipine.

Magnesium toxicity

order of signs and the antidote

Loss of deep tendon reflexes appears first, then respiratory depression (below 12 per minute), then decreased level of consciousness, then cardiac arrest. Urine output below 30 mL/hour promotes accumulation. Antidote: IV calcium gluconate, kept at the bedside. Flushing, warmth, and sedation are expected effects, not toxicity.

Antihypertensives contraindicated in pregnancy

ACE inhibitors and angiotensin receptor blockers, because of fetal renal injury, oligohydramnios, and death.

Bleeding and Preterm Labor

Placenta previa versus placental abruption

Previa: painless, bright red bleeding, soft nontender uterus, no vaginal or digital exam. Abruption: painful, dark red or concealed bleeding, rigid board-like tender uterus, frequent low-amplitude contractions, high risk of DIC and Category III tracing. A rising fundal height in abruption means concealed blood loss.

Why an ectopic pregnancy can present with shoulder pain

Rupture causes hemoperitoneum, and blood irritating the diaphragm produces referred shoulder pain (Kehr sign). Combined with unilateral pelvic pain, a missed period, positive hCG, and syncope, it is a surgical emergency.

Why antenatal corticosteroids are given and when they help most

Betamethasone 12 mg IM in two doses 24 hours apart (or dexamethasone) between about 24 and 34 weeks accelerates fetal lung maturity, reducing respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Benefit is greatest 24 hours to 7 days after the first dose, which is why tocolysis for roughly 48 hours is worthwhile.

Two different indications for magnesium sulfate in obstetrics

Seizure prophylaxis in preeclampsia with severe features, and fetal neuroprotection (reduced cerebral palsy) when birth is anticipated before about 32 weeks. Magnesium is no longer used as a primary tocolytic.

Confirming rupture of membranes and the false-positive trap

Pooling on sterile speculum exam, nitrazine paper turning blue (alkaline fluid), and ferning on microscopy. Blood, semen, and vaginal infection cause false-positive nitrazine results. With PPROM, limit vaginal exams and watch for chorioamnionitis and cord prolapse.

Intrapartum

True labor versus false labor

the deciding criterion

Cervical change. True labor produces progressive dilation and effacement with regular contractions that intensify, are felt in the back radiating forward, and are not relieved by rest or walking. False labor is irregular, felt in the abdomen, and is relieved by position change or hydration.

Fetal station

The relationship of the presenting part to the maternal ischial spines. 0 station means the presenting part is at the spines and is engaged; negative numbers are above, positive numbers are below, in centimeters.

The most important single indicator of fetal oxygenation on the monitor

Baseline variability. Moderate variability (6 to 25 bpm) is reassuring and strongly predicts the absence of metabolic acidemia. Absent or minimal variability with recurrent decelerations is the ominous combination. Fetal sleep, opioids, and magnesium can reduce variability without hypoxia.

VEAL CHOP

Variable deceleration = Cord compression; Early deceleration = Head compression; Acceleration = OK; Late deceleration = Placental (uteroplacental) insufficiency. Late decelerations are gradual, begin after the contraction starts, and return after it ends.

Category III tracing

definition and response

Absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia, or a sinusoidal pattern. Response: lateral repositioning, stop oxytocin, IV fluid bolus, oxygen per protocol, vaginal exam to rule out prolapse, correct hypotension, notify the provider, and prepare for expedited birth.

Tachysystole and the nurse's independent action

More than 5 contractions in 10 minutes averaged over 30 minutes. The nurse independently decreases or stops the oxytocin infusion, repositions the client, and gives a fluid bolus; terbutaline may be ordered for uterine relaxation.

Cord prolapse management, including what is never done

Call for help, insert a gloved hand and elevate the presenting part off the cord, place the client knee-chest or in steep Trendelenburg or exaggerated Sims, stop oxytocin, give oxygen, keep an exposed cord moist with warm sterile saline gauze, and prepare for emergency cesarean birth. Never attempt to replace the cord into the uterus. The hand stays in place until delivery.

Shoulder dystocia

what to do and what is contraindicated

McRoberts maneuver (sharp hyperflexion of the maternal thighs onto the abdomen) plus suprapubic pressure. Fundal pressure is contraindicated because it worsens impaction and risks uterine rupture. Anticipate postpartum hemorrhage and assess the newborn for brachial plexus injury and clavicle fracture.

Classic presentation of uterine rupture

Sudden severe tearing abdominal pain, loss of fetal station or a suddenly abnormal or absent fetal heart tracing, cessation of contractions, and signs of hypovolemic shock. Highest risk with a prior classical uterine incision. Immediate surgical delivery is required.

Most common serious complication of epidural analgesia and the nursing response

Maternal hypotension with reduced uteroplacental perfusion and fetal heart rate changes. Response: IV fluid bolus per protocol, lateral positioning, oxygen, and a vasopressor such as ephedrine or phenylephrine as ordered. Also monitor for urinary retention, fever, pruritus, and fall risk from motor blockade.

Postpartum

BUBBLE-HE

Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy or perineum, Homan sign or lower extremity and VTE assessment, Emotional status. Homan sign is unreliable and is no longer recommended diagnostically, though it persists in older material.

Expected fundal involution

Firm, midline, at or near the umbilicus within a few hours of birth, then descending about 1 cm (1 fingerbreadth) per day, becoming nonpalpable by roughly 10 to 14 days. Cesarean clients still require fundal assessment.

Boggy fundus versus firm fundus with heavy bleeding

Boggy means atony: massage first, then have the client void or catheterize, then give uterotonics. Firm and midline with heavy bright red bleeding points to a genital tract laceration or hematoma and requires inspection and provider notification, not massage.

Lochia stages and the abnormal findings

Rubra dark red days 1 to 3, serosa pinkish-brown days 4 to 10, alba creamy white or yellow from day 11 to about 4 to 6 weeks. Abnormal: saturating a pad in 1 hour or less, foul odor, large clots, or a return to bright red after progression. Always check underneath the client, because blood pools under the buttocks.

The four T's of postpartum hemorrhage

Tone (uterine atony, roughly 70 to 80 percent of cases), Trauma (lacerations, hematoma, inversion, rupture), Tissue (retained placental fragments), Thrombin (coagulopathy including DIC). Late secondary hemorrhage after 24 hours is most often retained tissue or subinvolution.

Uterotonic contraindications

Methylergonovine is contraindicated in hypertension and preeclampsia (check blood pressure before each dose). Carboprost is contraindicated in asthma (causes bronchospasm; expect diarrhea, nausea, and fever). Oxytocin is first line; misoprostol causes fever and shivering; tranexamic acid is an adjunct given within 3 hours of birth.

Why postpartum vital signs are read differently

Bradycardia of 50 to 70 beats per minute is normal in the first days from increased stroke volume and mobilized blood volume. Tachycardia is the warning sign for hemorrhage, infection, pain, or anxiety. Falling blood pressure is a late sign of hypovolemia; narrowing pulse pressure, restlessness, and cool clammy skin come first.

Postpartum fever thresholds

Up to 100.4 degrees F (38 degrees C) in the first 24 hours may reflect dehydration and exertion. 100.4 degrees F or higher on two occasions after the first 24 hours suggests puerperal infection: endometritis, urinary tract infection, wound infection, or mastitis.

Mastitis management

Usually unilateral localized redness, warmth, tenderness, fever, and flu-like symptoms. Treat with antibiotics, analgesia, rest, fluids, and continued emptying of the breast by feeding or pumping. Stopping breastfeeding worsens stasis and can lead to abscess.

Postpartum blues, depression, and psychosis

Blues: tearfulness and lability affecting most patients, beginning within days and resolving by about 2 weeks; supportive care. Depression: persists beyond 2 weeks or begins later in the first year with impaired function; screen with a validated tool such as the Edinburgh Postnatal Depression Scale and refer for treatment. Psychosis: hallucinations and delusions often centered on the infant, a psychiatric emergency with high risk of suicide and infanticide; the infant is never left alone with the parent.

Two immunization-related discharge items

Rubella-nonimmune clients receive MMR before discharge with teaching to avoid pregnancy for 28 days. Rh-negative clients with an Rh-positive newborn receive Rho(D) immune globulin within 72 hours.

Newborn

Apgar score components and what the score does not do

Heart rate, respiratory effort, muscle tone, reflex irritability, and color, each scored 0 to 2 at 1 and 5 minutes. 7 to 10 reassuring, 4 to 6 moderate difficulty, 0 to 3 severe distress. The Apgar score does not guide resuscitation; resuscitation is initiated based on respirations, heart rate, and tone.

Normal newborn vital sign ranges

Heart rate 110 to 160 bpm awake, respirations 30 to 60 and irregular with pauses under 20 seconds, axillary temperature 97.7 to 99.5 degrees F (36.5 to 37.5 degrees C), blood pressure roughly 60 to 80 over 40 to 50.

Four mechanisms of newborn heat loss with the matching intervention

Evaporation (dry the infant, remove wet linens), conduction (prewarm scales, mattresses, stethoscopes, hands), convection (avoid drafts, vents, open portholes), radiation (move the crib away from cold walls and windows).

The cold stress cascade

Newborns cannot shiver and rely on nonshivering thermogenesis using brown adipose tissue. Cold raises oxygen consumption and metabolic rate, producing hypoglycemia, then anaerobic metabolism and metabolic acidosis, which causes pulmonary vasoconstriction, worsening respiratory distress, and impaired bilirubin binding.

Newborn hypoglycemia

at-risk infants and signs

Risk: large or small for gestational age, preterm or late preterm, infants of diabetic mothers, and any infant with cold stress, sepsis, or asphyxia. Signs are nonspecific: jitteriness, poor feeding, lethargy, hypotonia, weak or high-pitched cry, temperature instability, apnea, cyanosis, seizures. A commonly used treatment threshold is below about 40 to 45 mg/dL. Jitteriness gets a glucose check, not reassurance.

Why newborns need vitamin K

The neonatal gut is sterile at birth and little vitamin K crosses the placenta, so clotting factors II, VII, IX, and X are deficient. Phytonadione is given IM in the vastus lateralis shortly after birth to prevent vitamin K deficiency bleeding.

Physiologic versus pathologic jaundice

Physiologic appears after 24 hours, peaks days 3 to 5, and resolves spontaneously. Pathologic appears within the first 24 hours, rises rapidly, or persists, and suggests hemolysis (Rh or ABO incompatibility), infection, or metabolic disease. Unconjugated bilirubin crosses the blood-brain barrier and can cause kernicterus.

Phototherapy nursing care

Maximize skin exposure, provide eye protection, monitor temperature and hydration, expect loose green stools and possible rash, and promote frequent feeding (8 to 12 times per 24 hours) because bilirubin is excreted in stool. Water supplementation does not lower bilirubin and is not given.

Caput succedaneum versus cephalhematoma

Caput: soft scalp edema, present at birth, crosses suture lines, resolves in days. Cephalhematoma: subperiosteal bleeding, appears hours after birth, does not cross suture lines, resolves over weeks, and increases hyperbilirubinemia risk.

Fontanel expectations

Anterior (diamond) closes at 12 to 18 months; posterior (triangle) closes by about 2 to 3 months. Both should be soft and flat. Bulging suggests increased intracranial pressure; sunken suggests dehydration.

Newborn findings that must be reported

Central or circumoral cyanosis, grunting, nasal flaring, retractions, sustained respirations above 60, apnea longer than 20 seconds, temperature instability, jitteriness, jaundice in the first 24 hours, a single umbilical artery (normal is two arteries and one vein), an asymmetric Moro reflex, and no void within 24 hours or no meconium within 24 to 48 hours.

Signs of adequate breastfeeding intake

At least 6 wet diapers per day by about day 4 to 5, 3 or more stools per day in the early weeks, audible swallowing, appropriate weight gain after an expected initial loss of up to 7 to 10 percent regained by 10 to 14 days, and a comfortable deep latch. Nipple pain and cracking usually indicate a shallow latch.

Engorgement care differs by feeding goal

Breastfeeding: warmth before feeding to promote letdown, frequent feeding or pumping, cold compresses after feeding for comfort. Not breastfeeding: avoid all nipple stimulation and pumping, wear a supportive bra, and use cold compresses only.

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