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Take a practice exam on the topic: Pregnancy/Prenatal Care/Maternal Hx
Obstetrical history can be determined by two common methods:
Gravidity & Parity-counts pregnancies, not offspring
Gravida: number of times a woman has been pregnant, regardless of outcome
Para: number of deliveries (not children) occurred after 20 weeks gestation.
Multiple births count as one
Pregnancy loss before 20 weeks counted as abortion but add 1 to gravidity
Fetal demise after 20 weeks added to parity
Five digits: GTPAL (Gravidity, Term Births, Preterm Births, Abortions and
Miscarriages, Living Children) represents patients obstetrical history:
G= gravidity (total number of pregnancies_
T= term pregnancies delivered (after 37 weeks)
P= preterm pregnancies (before 37 weeks)
A= abortions (elective or spontaneous); loss before 20 weeks
L= living children
Gestation: using Ngeles rule-Count back 3 months from date of last normal
menstrual period, and add 7 days.
i.e.-if the LMP was March 23, the EDB would be December 30
Fundal Height: 1213 weeks: fundus rises above symphysis (joint connecting left & right
pelvic bone)
20 weeks: fundus at umbilicus
24 to about 36 weeks: fundal height (in cm) from the symphysis pubis is equal to # of
weeks of gestation if this is a single pregnancy
Weight gain: (Optimal weight gain depends on maternal & fetal factors)
Weight gain of 1-2 kg (24 lb) in the first trimester is recommended
Weight gain (0.5 kg) 1 lb/week is normal during 2nd & 3rd trimesters
Common diagnostic test (maternal):
Urine screen (Albumin, Protein-r/t preeclampsia, vaginal secretions, or kidney disease)
Glucose tolerance test (related to gestational diabetes)
Uterine activity
FIG. 6.3 Fundal height assessment. Height of the
fundus of the uterus during pregnancy. The
numbers represent the weeks of gestation, and
the circles represent the height of the fundus
expected at that stage of gestation. The dotted
line at the 40th week indicates that lightening
has occurred.
From Murray SS, McKinney ES. Foundations of
Maternal-Newborn and Womens Health Nursing.
5th ed. Philadelphia: Saunders; 2010.
Warning signs of physical maternal changes: abdominal pain/cramping or pelvic pain;
decreased or absent fetal movement; fever or chills; urinary symptoms; s/s of preterm labor; signs
of hypertensive disorders
Maternal risk factors for complications assessment:
A. Age <17 or >34 years
B. High parity (>5)
C. Recent pregnancy (3 months since last delivery)
D. Hypertension, preeclampsia in current pregnancy
E. Anemia, history of hemorrhage, or current hemorrhage
F. Multiple gestations
G. Rh incompatibility
H. History of dystocia or previous operative delivery
I. Height of 60 inches (5 feet) or less
J. Malnutrition (15% under ideal weight) or extreme obesity (20% over ideal weight)
K. Medical disease during pregnancy (diabetes, hyperthyroidism, hyperemesis, clotting disorders
such as thrombocytopenia)
L. Infection in pregnancy: Toxoplasmosis, Other agents, Rubella, Cytomegalovirus, Herpes simplex
(TORCH diseases); influenza; HIV; Hepatitis B; RPR; Chlamydia; Gonorrhea; human papillomavirus
(HPV)
M. History of family violence, lack of social support
Common diagnostic test (fetal): Quad screen, ultrasound, amniocentesis, chorionic villi
sampling, nonstress test (NST), Biophysical profile, & Uterine activity
Quad screen- includes alpha fetoprotein (AFP), human chorionic gonadotropin (hCG),
estriol, inhibin A; for high risk pregnancy, chromosomal abnormalities & neural tube defect.
Chorionic villi sampling (CVS)- Removal of a small piece of villi (projections off of placenta)
during the period between 10 to 13 weeks of gestation under ultrasound guidance for
genetic & chromosomal disorders at 8-12 weeks; full bladder required; Rh-negative mother
requires RhoGAM (Rho[D] immune globin) post procedure.
Complications: possible spontaneous abortion(<1%) or possible fetal anomalies if done <10
weeks.
Amniocentesis- Removal of amniotic fluid sample from the uterus; performed at 16 weeks
to determine genetic disorders (Down syndrome (trisomy 21), PKU, Tay-Sachs (congenital
disorder of nervous system), AFP level r/t neural tube defects & Trisomy 18 or 21,
creatinine r/t renal maturity, & meconium r/t fetal distress, at 30 weeks to determine lung
maturity; bladder emptied if performed after 20 weeks gestation; Rh-negative mother
requires RhoGAM post procedure.
Complications: Spontaneous abortion (1%), Fetal injury, Infection
*HESI Hint:
When an amniocentesis is performed in early pregnancy, the bladder must be full to help
support the uterus and to help push the uterus up in the abdomen for easy access. When
an amniocentesis is performed in late pregnancy, the bladder must be empty so it will not
be punctured.
Ultrasound: High-frequency sound waves are beamed onto the abdomen;
echoes are returned to a machine that records the fetuss location and size;
multiple purposes (1st trimester-Number of fetuses, Presence of fetal cardiac
movement and rhythm, Uterine abnormalities, Gestational age(2nd & 3rd trimester-Fetal
viability and gestational age, Size/date discrepancies, Amniotic fluid volume (AFV),
Placental location and maturity, Uterine anomalies and abnormalities, Results of
amniocentesis, Fetal heart activity is apparent as early as 67 weeks of gestation, Serial
evaluation of biparietal diameter and limb length can differentiate between wrong dates
and true IUGR, biophysical profile (BPP); patient must have full bladder.
Instruct the woman to drink three to four glasses of water before coming
for examination and not to urinate. When the fetus is very small (in the first
and second trimesters), the clients bladder must be full during the
examination to help support the uterus for imaging. (A full bladder is not
needed if ultrasound is done transvaginally instead of abdominally.)
Position the woman with pillows under the neck and knees to keep
pressure off bladder; late in the third trimester, place wedge under right
hip to displace uterus to the left.
Position display monitor so woman can watch if she wishes.Ultrasound: High-frequency sound waves are beamed onto the abdomen;
echoes are returned to a machine that records the fetuss location and size;
multiple purposes (1st trimester-Number of fetuses, Presence of fetal cardiac
movement and rhythm, Uterine abnormalities, Gestational age(2nd & 3rd trimester-Fetal
viability and gestational age, Size/date discrepancies, Amniotic fluid volume (AFV),
Placental location and maturity, Uterine anomalies and abnormalities, Results of
amniocentesis, Fetal heart activity is apparent as early as 67 weeks of gestation, Serial
evaluation of biparietal diameter and limb length can differentiate between wrong dates
and true IUGR, biophysical profile (BPP); patient must have full bladder.
Instruct the woman to drink three to four glasses of water before coming
for examination and not to urinate. When the fetus is very small (in the first
and second trimesters), the clients bladder must be full during the
examination to help support the uterus for imaging. (A full bladder is not
needed if ultrasound is done transvaginally instead of abdominally.)
Position the woman with pillows under the neck and knees to keep
pressure off bladder; late in the third trimester, place wedge under right
hip to displace uterus to the left.
Position display monitor so woman can watch if she wishes.
Nonstress test (NST): used to determine fetal well-being in high-risk pregnancy
and is especially useful in postmaturity (notes response of the fetus to its own
movements); Via ultrasound transducer records fetal movement & HR after 28
weeks; increase in HR (reactivity) expected in healthy fetus.
A healthy fetus will usually respond to its own movement by means of an FHR
acceleration of 15 beats, lasting for at least 15 seconds after the movement,
twice in a 20-minute period at 32 weeks and greater
Biophysical profile (BPP): is made to ascertain fetal well-being
Five variables are assessed: fetal breathing movements, gross body movements,
fetal tone, reactivity of FHR, and AFV.
A score of 2 or 0 can be obtained for each variable. An overall score of 10
designates that the fetus is well on the day of the examination.
Uterine activity: electronic fetal monitoring (variables monitor-contractions, FHR;
nonreassuring warning signs, nonreassuring ominous signs), NST, OCT
Intrapartum Nursing Care
Labor: Begins with true labor and consists of four stages
First stage of labor: from the beginning of regular contractions to 10 cm of
dilatation and 100% effacement; Duration from 8-20 hours in primipara & 5-14
hours in multipara. Includes 3 phases: latent (0-3cm), active (4-7 cm), & transition
(8-10 cm). (See Hesi comprehensive review book, p. 189/Table 6.1 1st stage of labor)
Second stage of labor: from 10 cm to delivery of the fetus; begins w/complete
cervical dilatation; expulsion ending w/birth of baby. This stage lasts a few
minutes to 2 hours.
Third stage of labor: delivery of the fetus to delivery of the placenta; Begins
w/birth of baby & ends w/the expulsion of placenta. This process can last up to
30 minutes, w/average length of 5-10 minutes.
Fourth stage of labor: arbitrarily lasts about 2 hours (1st 1-4 hours) after delivery
of the placenta (recovery); Monitor for excessive bleeding & uterine atony.Intrapartum Nursing Care
Labor: Begins with true labor and consists of four stages
First stage of labor: from the beginning of regular contractions to 10 cm of
dilatation and 100% effacement; Duration from 8-20 hours in primipara & 5-14
hours in multipara. Includes 3 phases: latent (0-3cm), active (4-7 cm), & transition
(8-10 cm). (See Hesi comprehensive review book, p. 189/Table 6.1 1st stage of labor)
Second stage of labor: from 10 cm to delivery of the fetus; begins w/complete
cervical dilatation; expulsion ending w/birth of baby. This stage lasts a few
minutes to 2 hours.
Third stage of labor: delivery of the fetus to delivery of the placenta; Begins
w/birth of baby & ends w/the expulsion of placenta. This process can last up to
30 minutes, w/average length of 5-10 minutes.
Fourth stage of labor: arbitrarily lasts about 2 hours (1st 1-4 hours) after delivery
of the placenta (recovery); Monitor for excessive bleeding & uterine atony.
HESI Hint
Be able to differentiate between true labor and false labor.
True Labor
Pain in lower back that radiates to the abdomen
Pain accompanied by regular rhythmic contractions
Contractions that intensify with ambulation
Progressive cervical dilatation and effacement
False Labor
Discomfort localized in the abdomen
No lower back pain
Contractions decrease in intensity or frequency with
ambulation and no cervical change
BOX 6.1 Leopold Maneuvers
Description: abdominal palpations used to determine fetal
presentation, lie, position, and engagement
A. With client in supine position, place both cupped hands over
fundus and palpate to determine whether breech (soft,
immovable, large) or vertex (hard, movable, small).
B. Place one hand firmly on side and palpate with other hand
to determine presence of small parts or fetal back. (FHR is
heard best through fetal back.)
C. Facing client, grasp the area over the symphysis with the
thumb and fingers, and press to determine the degree of
descent of the presenting part. (A ballotable or floating head
can be rocked back and forth between the thumb and fingers.)
D. Facing the clients feet, outline the fetal presenting part with
the palmar surface of both hands to determine the degree of
descent and attitude of the fetus. (If cephalic prominence is
located on the same side as small parts, assume the head is
flexed.)HESI Hint
Be able to differentiate between true labor and false labor.
True Labor
Pain in lower back that radiates to the abdomen
Pain accompanied by regular rhythmic contractions
Contractions that intensify with ambulation
Progressive cervical dilatation and effacement
False Labor
Discomfort localized in the abdomen
No lower back pain
Contractions decrease in intensity or frequency with
ambulation and no cervical change
BOX 6.1 Leopold Maneuvers
Description: abdominal palpations used to determine fetal
presentation, lie, position, and engagement
A. With client in supine position, place both cupped hands over
fundus and palpate to determine whether breech (soft,
immovable, large) or vertex (hard, movable, small).
B. Place one hand firmly on side and palpate with other hand
to determine presence of small parts or fetal back. (FHR is
heard best through fetal back.)
C. Facing client, grasp the area over the symphysis with the
thumb and fingers, and press to determine the degree of
descent of the presenting part. (A ballotable or floating head
can be rocked back and forth between the thumb and fingers.)
D. Facing the clients feet, outline the fetal presenting part with
the palmar surface of both hands to determine the degree of
descent and attitude of the fetus. (If cephalic prominence is
located on the same side as small parts, assume the head is
flexed.)
Labor Progression/Vaginal Exam: Before analgesia and anesthesia, To
determine the progress of labor, To determine whether second-stage pushing can
begin
Cervical dilation-stretching of the cervical os to allow passage of the infant (from
0-10cm)
Cervical effacement-thinning & shortening of the cervix (0%-100%)
Cervical position & consistency (firm to soft)
Fetal Station-location of the presenting part in relation to the midpelvis or ischial
spines, measured in cm above & below, using a scale from -5 to +5 or -3 to +3
Station 0 = engaged
Station +2 = 2cm below the level of the ischial spines
+5 = crowning
Fetal presentation-part of the fetus that presents to the inlet (vertex-
head/cephalic, shoulder (acromion), or breech (buttocks)
Fetal position, lie, & attitude (fetal parts to one another, flexion or extension)Labor Progression/Vaginal Exam: Before analgesia and anesthesia, To
determine the progress of labor, To determine whether second-stage pushing can
begin
Cervical dilation-stretching of the cervical os to allow passage of the infant (from
0-10cm)
Cervical effacement-thinning & shortening of the cervix (0%-100%)
Cervical position & consistency (firm to soft)
Fetal Station-location of the presenting part in relation to the midpelvis or ischial
spines, measured in cm above & below, using a scale from -5 to +5 or -3 to +3
Station 0 = engaged
Station +2 = 2cm below the level of the ischial spines
+5 = crowning
Fetal presentation-part of the fetus that presents to the inlet (vertex-
head/cephalic, shoulder (acromion), or breech (buttocks)
Fetal position, lie, & attitude (fetal parts to one another, flexion or extension)
FIG. 6.5 Stations of presenting part (degree of engagement). In
this diagram, the presenting part has reached the +1 station.
The lower pelvis, from the ischial spines to the pelvic floor,
represents positive stations (+1, +2, +3), and the upper pelvis,
from the inlet or pelvic brim to the ischial spines, represents
negative stations (3, 2, 1).
From Perry SE, Hockenberry MJ, Lowdermilk DL, Wilson D.
Maternal Child Nursing Care. 5th ed. St. Louis: Mosby; 2014.
Nursing Interventions & Management:
Assessment-
Baseline maternal VS including pain
Medication Hx
Physical Assessment
Nutrient & fluid intake: hydration & bladder status, need for catheter, IV
therapy
Bowel elimination
Ambulation & positioning: upright, sitting, squatting (best position)
Lab & diagnostic tests
Emotional & cultural responsesNursing Interventions & Management:
Assessment-
Baseline maternal VS including pain
Medication Hx
Physical Assessment
Nutrient & fluid intake: hydration & bladder status, need for catheter, IV
therapy
Bowel elimination
Ambulation & positioning: upright, sitting, squatting (best position)
Lab & diagnostic tests
Emotional & cultural responses
Labor Assessment:
Onset of labor & progression
Vaginal exam (assess dilation, effacement, station, position, & fetal
presentation; do not perform in presence of bleeding, which could
indicate placenta previa or abruption)
Status of membranes
Bloody show
Fetal heart rate (FHR) pattern
Complications: infection, pregnancy-induced hypertension (PIH), or
gestational HTN (GH), bleeding, prolapsed cord, fetal distress
Assessment of contractions (uterine activity pattern)Labor Assessment:
Onset of labor & progression
Vaginal exam (assess dilation, effacement, station, position, & fetal
presentation; do not perform in presence of bleeding, which could
indicate placenta previa or abruption)
Status of membranes
Bloody show
Fetal heart rate (FHR) pattern
Complications: infection, pregnancy-induced hypertension (PIH), or
gestational HTN (GH), bleeding, prolapsed cord, fetal distress
Assessment of contractions (uterine activity pattern)
Drugs used during Labor:
Analgesia and anesthesia are usually withheld until the mid-active
phase of labor.
1. If given in the early latent phase of the first stage of labor, it may retard the
progress of labor.
2. If given late in the transition or second stage, it may depress the newborn
(some narcotic analgesics- i.e. fentanyl, morphine sulfate, hydromorphone).
B. Most drugs used for systematic pain relief and relaxation cause CNS
depression, which can slow labor and harm fetus.
C. Regional blocks (epidural, caudal, and subarachnoid) cause a
temporary interruption of nerve impulses (especially pain) but also ca
use vasodilation in the area below block, causing pooling of blood and
hypotension.Drugs used during Labor:
Analgesia and anesthesia are usually withheld until the mid-active
phase of labor.
1. If given in the early latent phase of the first stage of labor, it may retard the
progress of labor.
2. If given late in the transition or second stage, it may depress the newborn
(some narcotic analgesics- i.e. fentanyl, morphine sulfate, hydromorphone).
B. Most drugs used for systematic pain relief and relaxation cause CNS
depression, which can slow labor and harm fetus.
C. Regional blocks (epidural, caudal, and subarachnoid) cause a
temporary interruption of nerve impulses (especially pain) but also ca
use vasodilation in the area below block, causing pooling of blood and
hypotension.
Postpartum Maternal Assessment: BUBBLE HA Tool
B-Breasts: Assess for consistency (soft, firm, filling, engorged), nipples (intact, sore,
flat, everted or inverted), masses
U-Uterus/Fundal Involution: Immediately after delivery-fundus is several cm below
umbilicus; Within 12 hours-fundus rises to umbilicus; Descends 1 cm
(fingerbreadth) a day for 9-19 days, then fundus is below symphysis pubis; Should
be midline & firm
B-Bladder: Measure output; assess for distention or retention
B-Bowel: Assess for distention, passing flatus, & bowel sounds
L-Lochia: Endometrial sloughing from rubra (red); serosa (pink); alba (white)
L-Leg(s): Assess for s/s of thrombosis
E-Episiotomy: Assess episiotomy or laceration repair for intactness, hematoma,
edema, bruising, redness, & drainage
H-Hemorrhoids: Treat w/sitz bath, Tucks, ointments
A-Attachment: Assess maternal-infant interaction for bonding behaviorsPostpartum Maternal Assessment: BUBBLE HA Tool
B-Breasts: Assess for consistency (soft, firm, filling, engorged), nipples (intact, sore,
flat, everted or inverted), masses
U-Uterus/Fundal Involution: Immediately after delivery-fundus is several cm below
umbilicus; Within 12 hours-fundus rises to umbilicus; Descends 1 cm
(fingerbreadth) a day for 9-19 days, then fundus is below symphysis pubis; Should
be midline & firm
B-Bladder: Measure output; assess for distention or retention
B-Bowel: Assess for distention, passing flatus, & bowel sounds
L-Lochia: Endometrial sloughing from rubra (red); serosa (pink); alba (white)
L-Leg(s): Assess for s/s of thrombosis
E-Episiotomy: Assess episiotomy or laceration repair for intactness, hematoma,
edema, bruising, redness, & drainage
H-Hemorrhoids: Treat w/sitz bath, Tucks, ointments
A-Attachment: Assess maternal-infant interaction for bonding behaviors
Involution of uterus. From Murray S, McKinney E, Holub K,
Jones, R. Maternal-newborn and womens health nursing. 7th
ed. Elsevier; 2019.
HESI Hint
Assessments should be made before notifying the HCP about any
abnormal finding. Assess fundal height and firmness; assess
perineal integrity; check for signs and symptoms of
thromboembolism; assess pulse, respirations and BP; assess
clients subjective description of symptoms (e.g., burning on
urination, pain in leg, excessive tenderness of uterus).
HESI Hint
Full bladder is one of the most common reasons for
uterine atony or hemorrhage in the first 24 hours
after delivery. If the nurse finds the fundus soft,
boggy, and displaced above and to the right of the
umbilicus, what action should be taken first? First,
perform fundal massage; then have the client
empty her bladder. Recheck fundus every 15
minutes for 1 hour, then every 30 minutes for 2
hours.HESI Hint
Assessments should be made before notifying the HCP about any
abnormal finding. Assess fundal height and firmness; assess
perineal integrity; check for signs and symptoms of
thromboembolism; assess pulse, respirations and BP; assess
clients subjective description of symptoms (e.g., burning on
urination, pain in leg, excessive tenderness of uterus).
HESI Hint
Full bladder is one of the most common reasons for
uterine atony or hemorrhage in the first 24 hours
after delivery. If the nurse finds the fundus soft,
boggy, and displaced above and to the right of the
umbilicus, what action should be taken first? First,
perform fundal massage; then have the client
empty her bladder. Recheck fundus every 15
minutes for 1 hour, then every 30 minutes for 2
hours.
Complications of Childbearing:
Chronic Hypertension-HTN or proteinuria in pregnant women: Chronic HTN before 20 weeks of
gestation & persistent after 12 weeks postpartum
Superimposed Preeclampsia or Eclampsia-Development of preeclampsia or eclampsia in woman
w/chronic HTN before 20 weeks gestation
Gestational Hypertension (GH)-HTN in pregnant women without proteinuria; Risk factors-obesity,
prior kidney DO, advanced maternal age (AMA)
Preeclampsia-HTN w/proteinuria; Risk factors-nulliparity, AMA, placental problems, Hx of prior HTN,
family hx of preeclampsia
Early intervention can optimize maternal and fetal outcomes. Teach clients to report immediately any of the
following danger signs.
Possible Indications of Preeclampsia and Eclampsia are
Visual disturbances
Swelling of face, fingers, or sacrum
Severe, continuous headache
Persistent vomiting
Epigastric pain
Signs of Infection
Chills; temperature over 38C; dysuria; pain in abdomen
Fluid discharge or bleeding from vagina (anything other than normal leukorrhea)
Change in fetal movement or increased FHRComplications of Childbearing:
Chronic Hypertension-HTN or proteinuria in pregnant women: Chronic HTN before 20 weeks of
gestation & persistent after 12 weeks postpartum
Superimposed Preeclampsia or Eclampsia-Development of preeclampsia or eclampsia in woman
w/chronic HTN before 20 weeks gestation
Gestational Hypertension (GH)-HTN in pregnant women without proteinuria; Risk factors-obesity,
prior kidney DO, advanced maternal age (AMA)
Preeclampsia-HTN w/proteinuria; Risk factors-nulliparity, AMA, placental problems, Hx of prior HTN,
family hx of preeclampsia
Early intervention can optimize maternal and fetal outcomes. Teach clients to report immediately any of the
following danger signs.
Possible Indications of Preeclampsia and Eclampsia are
Visual disturbances
Swelling of face, fingers, or sacrum
Severe, continuous headache
Persistent vomiting
Epigastric pain
Signs of Infection
Chills; temperature over 38C; dysuria; pain in abdomen
Fluid discharge or bleeding from vagina (anything other than normal leukorrhea)
Change in fetal movement or increased FHR
CLINICAL MANIFESTATIONS OF PREECLAMPSIA AND ECLAMPSIACLINICAL MANIFESTATIONS OF PREECLAMPSIA AND ECLAMPSIA
Nursing Interventions & Management: Preeclampsia
Decrease stimulation in room
Explain procedures
Maintain IV
Monitor BP q 15-30 minutes
Monitor urine for protein q 1 hour
HCP may prescribe magnesium sulfate
Nursing Interventions & Management: Eclampsia
Stay w/patient
Turn patient on side
Notify RN if patient starts having seizures
Do not attempt to force objects into patients mouth
Remember that seizures can occur postpartum
Administer O2 & have suction available
Notify RN if respirations are < 12 breaths/minNursing Interventions & Management: Preeclampsia
Decrease stimulation in room
Explain procedures
Maintain IV
Monitor BP q 15-30 minutes
Monitor urine for protein q 1 hour
HCP may prescribe magnesium sulfate
Nursing Interventions & Management: Eclampsia
Stay w/patient
Turn patient on side
Notify RN if patient starts having seizures
Do not attempt to force objects into patients mouth
Remember that seizures can occur postpartum
Administer O2 & have suction available
Notify RN if respirations are < 12 breaths/min
Gestational diabetes: Screening
One hour glucose screen between 24 & 26 weeks
Blood glucose level is higher than 140 mg/dL 1 hour after consuming glucose solution
Goal: strict blood glucose control
Generally, glyburide or insulin is used during pregnancy
Insulin does not cross the placenta, & glyburide only minimally crosses it
Spontaneous Abortion: Assessment
Vaginal bleeding at week 20 or less of gestation
Uterine cramping, backache, & pelvic pressure
May have symptoms of shock
Assess patients & family members emotional status, needs, & provide support
Nursing Interventions & Management:
Monitor VS, LOV, & amount of bleeding
Prepare patient to receive IV fluids or blood
If patient is Rh negative, administer RhoGAMGestational diabetes: Screening
One hour glucose screen between 24 & 26 weeks
Blood glucose level is higher than 140 mg/dL 1 hour after consuming glucose solution
Goal: strict blood glucose control
Generally, glyburide or insulin is used during pregnancy
Insulin does not cross the placenta, & glyburide only minimally crosses it
Spontaneous Abortion: Assessment
Vaginal bleeding at week 20 or less of gestation
Uterine cramping, backache, & pelvic pressure
May have symptoms of shock
Assess patients & family members emotional status, needs, & provide support
Nursing Interventions & Management:
Monitor VS, LOV, & amount of bleeding
Prepare patient to receive IV fluids or blood
If patient is Rh negative, administer RhoGAM
Ectopic Pregnancy: any pregnancy in which the gestational sac is implanted
outside of the uterine cavity. Most (95%) ectopic pregnancies are tubal
Assessment-
Missed period, but early signs of pregnancy absent
Positive pregnancy test
Rupture
Sharp, unilateral pelvic pain
Vaginal bleeding
Referred shoulder pain
Syncope can indicate shock
Nursing Interventions & Management:
Monitor hemodynamic status
Prepare patient for surgery & administration of IV fluids, including blood;
Methotrexate used to dissolve residual tissue if needed
Use a contraceptive method for 3 months to allow body to healEctopic Pregnancy: any pregnancy in which the gestational sac is implanted
outside of the uterine cavity. Most (95%) ectopic pregnancies are tubal
Assessment-
Missed period, but early signs of pregnancy absent
Positive pregnancy test
Rupture
Sharp, unilateral pelvic pain
Vaginal bleeding
Referred shoulder pain
Syncope can indicate shock
Nursing Interventions & Management:
Monitor hemodynamic status
Prepare patient for surgery & administration of IV fluids, including blood;
Methotrexate used to dissolve residual tissue if needed
Use a contraceptive method for 3 months to allow body to heal
Abruptio Placentae & Placenta Previa:
Abruptio Placentae-
Bleeding: Concealed or overt
Uterine tone: tense without relaxation to rigid & board-like
Pain: Persistently painful
FHR: Usually abnormal (complete abruption= absent FHR)
Placenta Previa-
Bleeding: Bright red vaginal (usually in 3rd trimester)
Uterine tone: soft
Pain: painless
FHR: usually normal unless bleeding is severe & mother becomes hypovolemic
*HESI Hint: Clients with abruptio placentae or placenta previa (actual or suspected) should not
undergo abdominal or vaginal manipulation.
No Leopold maneuvers
No vaginal examination (placenta previa)
No rectal examinations, enemas, or suppositories
No internal monitoring
Nursing Interventions & Management
DIC: Disseminated Intravascular Coagulation (abnormal blood clotting
throughout the body)
Risk factors for DIC in pregnancy
Fetal demise (may develop as a result of the release of thromboplastin from the
fetal autolysis process)
Infection/sepsis
PIH (preeclampsia)
Abruptio placentae
Dystocia: Dysfunctional labor (dystocia) is a long, difficult, or abnormal
labor
A difficult birth resulting from problems involving the five Ps (Powers, Passage,
Passenger, Psyche, or Position)
I.E. such as lack of progress in cervical dilation, delay in fetal descent,
malpresentation/cephalopelvic disproportion (tx-cesarean delivery), or change in
the characteristics of uterine contraction (tx-IV oxytocin, sedation/rest).
Maintain hydration, monitor intake and output, and administer oxygen as needed;
administer any prescribed abxDIC: Disseminated Intravascular Coagulation (abnormal blood clotting
throughout the body)
Risk factors for DIC in pregnancy
Fetal demise (may develop as a result of the release of thromboplastin from the
fetal autolysis process)
Infection/sepsis
PIH (preeclampsia)
Abruptio placentae
Dystocia: Dysfunctional labor (dystocia) is a long, difficult, or abnormal
labor
A difficult birth resulting from problems involving the five Ps (Powers, Passage,
Passenger, Psyche, or Position)
I.E. such as lack of progress in cervical dilation, delay in fetal descent,
malpresentation/cephalopelvic disproportion (tx-cesarean delivery), or change in
the characteristics of uterine contraction (tx-IV oxytocin, sedation/rest).
Maintain hydration, monitor intake and output, and administer oxygen as needed;
administer any prescribed abx
Postpartum Complications:
Hemorrhage-postpartum hemorrhage is defined as the loss of 500 mL or more of
blood after vaginal birth and 1000 mL or more after cesarean birth
Assess fundal location & consistency (feels soft, boggy)
Assess vaginal bleeding; saturating 1 pad/hour indicates hemorrhage
Monitor for s/s of shock (weak, rapid pulse; low BP; pallor; restlessness)
Assess for bladder distention; can prevent involution & lead to hemorrhage
Medical tx: Uterine atony- Oxytocic medications, Bimanual compression of the uterus/
Massage uterine fundus to stimulate contractions
Venous Thromboembolism (VTE/DVT/PE)-highest incidence is within the first
3 weeks after birth; r/t change in blood coagulation during pregnancy and a
decrease in partial thromboplastin time, along with engorgement of the veins of
the lower extremities and pelvis, which leads to pooling of blood and venous stasis
Assess for leg pain, tenderness, & swelling; Tx w/bed rest, anticoagulants, elevate legs, &
analgesia
Infection- infection of the genital canal that occurs within 28 days after
miscarriage, abortion, or childbirth. i.e. perineal, endometritis (lining of uterus),
mastitis (breast), cystitis (UTI), or parametritis (pelvic cellulitis).Postpartum Complications:
Hemorrhage-postpartum hemorrhage is defined as the loss of 500 mL or more of
blood after vaginal birth and 1000 mL or more after cesarean birth
Assess fundal location & consistency (feels soft, boggy)
Assess vaginal bleeding; saturating 1 pad/hour indicates hemorrhage
Monitor for s/s of shock (weak, rapid pulse; low BP; pallor; restlessness)
Assess for bladder distention; can prevent involution & lead to hemorrhage
Medical tx: Uterine atony- Oxytocic medications, Bimanual compression of the uterus/
Massage uterine fundus to stimulate contractions
Venous Thromboembolism (VTE/DVT/PE)-highest incidence is within the first
3 weeks after birth; r/t change in blood coagulation during pregnancy and a
decrease in partial thromboplastin time, along with engorgement of the veins of
the lower extremities and pelvis, which leads to pooling of blood and venous stasis
Assess for leg pain, tenderness, & swelling; Tx w/bed rest, anticoagulants, elevate legs, &
analgesia
Infection- infection of the genital canal that occurs within 28 days after
miscarriage, abortion, or childbirth. i.e. perineal, endometritis (lining of uterus),
mastitis (breast), cystitis (UTI), or parametritis (pelvic cellulitis).
Normal Newborn Parameters (approximate for full term):
Length: 18-22 inches
Weight: 5.5-9.5 lbs.
Head circumference: 13.2-14 inches
Sutures palpable w/fontanels
Fontanel closure: Anterior-by 18 months; Posterior-6 to 8 weeks
Umbilical cord should have 3 vessels2 arteries & 1 vein
A 2 vessel cord may be indicative of an abnormality or associated
w/chromosomal & renal defects
Extremities should be flexed
Major gluteal folds should be even
Ortolanis sign & Barlows sign for developmental dysplasia of the hip
Newborn cont...
Creases should present on soles of feet
Pulses should be palpable (radial, brachial, femoral)
Nursing Interventions & Management:
Keep newborn warm
Suction airway as needed
Observe for respiratory distress
Normal or physiological jaundice appears after the 1st 24 hours in full-term
newborns
Pathological jaundice occurs before this time & may indicate early hemolysis of
RBCs
Assess the hemoglobin & hematocrit (H & H) & blood glucose levels
Weigh daily
Monitor I&O; weigh diapers if necessary (1 g = 1 ml of urine)Newborn cont...
Creases should present on soles of feet
Pulses should be palpable (radial, brachial, femoral)
Nursing Interventions & Management:
Keep newborn warm
Suction airway as needed
Observe for respiratory distress
Normal or physiological jaundice appears after the 1st 24 hours in full-term
newborns
Pathological jaundice occurs before this time & may indicate early hemolysis of
RBCs
Assess the hemoglobin & hematocrit (H & H) & blood glucose levels
Weigh daily
Monitor I&O; weigh diapers if necessary (1 g = 1 ml of urine)
Monitor temperature
Observe for any cracks in skin
Administer eye medication within 1 hour after birth
Provide cord care
Provide circumcision care; teach patient how to care for circumcision site
Supine position (back to sleep) to prevent SIDs
Observe for abnormal stool & passage of meconium
Test the newborns reflexes Monitor temperature
Observe for any cracks in skin
Administer eye medication within 1 hour after birth
Provide cord care
Provide circumcision care; teach patient how to care for circumcision site
Supine position (back to sleep) to prevent SIDs
Observe for abnormal stool & passage of meconium
Test the newborns reflexes
HESI Hint
Suction the mouth first and then the nose. Stimulating the
nares can initiate inspiration, which could cause aspiration of
mucus in oral pharynx.
Physiologic jaundice occurs at 23 days of life. If it occurs
before 24 hours or persists beyond 7 days, it becomes
pathologic. Typically, NCLEX-RN questions ask about the normal
problem of physiologic jaundice, which occurs 23 days after
birth due to the immature livers normal inability to keep up
with RBC destruction and to bind bilirubin. Remember,
unconjugated bilirubin is the culprit.HESI Hint
Suction the mouth first and then the nose. Stimulating the
nares can initiate inspiration, which could cause aspiration of
mucus in oral pharynx.
Physiologic jaundice occurs at 23 days of life. If it occurs
before 24 hours or persists beyond 7 days, it becomes
pathologic. Typically, NCLEX-RN questions ask about the normal
problem of physiologic jaundice, which occurs 23 days after
birth due to the immature livers normal inability to keep up
with RBC destruction and to bind bilirubin. Remember,
unconjugated bilirubin is the culprit.
Newborn Care (Delivery Room):
Immediately dry infant under warmer or skin-to-skin contact with mother;
suction mouth and nose with bulb syringe; keep head slightly lower than body;
and assess the airway status
Assess for five symptoms of respiratory distress: retractions; tachypnea (rate
>60); dusky color, circumoral cyanosis; expiratory grunt; flaring nares
Do not hyperextend the newborn neck at any time (may close glottis). Place
infant in sniff position (neck slightly extended as if sniffing the air) to open
airway
Obtain Apgar score at 1 and 5 minutes
Continue to allow maternal/parent contact if newborn is stable
Keep the neonates head covered
Do a quick gestational age assessment
Examine the cord for presence of three vessels (two arteries, one vein), and
document
Newborn Care (Delivery Room) cont...
Ensure that the cord blood is collected for analysis and sent to laboratory: Rh,
blood type, Hct, and possible cord blood gases
Document passage of meconium or urine after delivery
Place two identity bands on neonate and one identity band on mother
Obtain newborn footprints and maternal thumb and fingerprint. Follow
institutional policy regarding identification procedures
Perform brief physical examination of the newborn
Check for gross anomalies: spina bifida, hydrocephaly, and cleft lip or palate.
Elicit reflexes: Moro (startle) and rooting (suck).
Examine cord clamp for closure, absence of blood oozing from cord; again
check for presence of three vessels.
Eye prophylaxis (Erythromycin ointment) may be instilled in delivery roomNewborn Care (Delivery Room) cont...
Ensure that the cord blood is collected for analysis and sent to laboratory: Rh,
blood type, Hct, and possible cord blood gases
Document passage of meconium or urine after delivery
Place two identity bands on neonate and one identity band on mother
Obtain newborn footprints and maternal thumb and fingerprint. Follow
institutional policy regarding identification procedures
Perform brief physical examination of the newborn
Check for gross anomalies: spina bifida, hydrocephaly, and cleft lip or palate.
Elicit reflexes: Moro (startle) and rooting (suck).
Examine cord clamp for closure, absence of blood oozing from cord; again
check for presence of three vessels.
Eye prophylaxis (Erythromycin ointment) may be instilled in delivery room
Major Newborn Complications:
Respiratory distress syndrome-Caused by inability to produce surfactant;
resulting in hypoxia & acidosis
Torch Infections- Infections caused by one of the following: Toxoplasmosis, Other
agents, Rubella, Cytomegalovirus, Herpes simplex (TORCH diseases); influenza; HIV;
Hepatitis B; RPR; Chlamydia; Gonorrhea; human papillomavirus (HPV)
Meconium Aspiration Syndrome- Fetal distress increases intestinal peristalsis;
Releases meconium into the amniotic fluid
Hypoglycemia- Assess risk factors in maternal hx (infant of diabetic mother) &
environmental factors (cold stress/can lead to hypoglycemia)
Perform a heelstick blood glucose assessment
Normal serum glucose is 4080 mg/dL; Report blood glucose levels < 40 mg/dL
Feed the baby early (breast milk or formula) if a low glucose level is detected
Hemorrhagic Disorders: administer vitamin K to prevent hemorrhagic disordersMajor Newborn Complications:
Respiratory distress syndrome-Caused by inability to produce surfactant;
resulting in hypoxia & acidosis
Torch Infections- Infections caused by one of the following: Toxoplasmosis, Other
agents, Rubella, Cytomegalovirus, Herpes simplex (TORCH diseases); influenza; HIV;
Hepatitis B; RPR; Chlamydia; Gonorrhea; human papillomavirus (HPV)
Meconium Aspiration Syndrome- Fetal distress increases intestinal peristalsis;
Releases meconium into the amniotic fluid
Hypoglycemia- Assess risk factors in maternal hx (infant of diabetic mother) &
environmental factors (cold stress/can lead to hypoglycemia)
Perform a heelstick blood glucose assessment
Normal serum glucose is 4080 mg/dL; Report blood glucose levels < 40 mg/dL
Feed the baby early (breast milk or formula) if a low glucose level is detected
Hemorrhagic Disorders: administer vitamin K to prevent hemorrhagic disorders
BOX 6.3 Heelstick Procedure for Newborns
Wash hands and put on gloves.
Clean heel with alcohol and dry with a gauze pad.
Choose a site for puncture that avoids the plantar artery in
the middle of the heel.
Use only the lateral surfaces of the heel.
Puncture deep enough to trigger a free flow of blood. Wipe
away first drop with sterile gauze pad.
Collect blood in appropriate tube, on card, or on glucose test
strip.BOX 6.3 Heelstick Procedure for Newborns
Wash hands and put on gloves.
Clean heel with alcohol and dry with a gauze pad.
Choose a site for puncture that avoids the plantar artery in
the middle of the heel.
Use only the lateral surfaces of the heel.
Puncture deep enough to trigger a free flow of blood. Wipe
away first drop with sterile gauze pad.
Collect blood in appropriate tube, on card, or on glucose test. The practice exam must be written at the level of the University. The practice exam must be written in the English language. Below are the answers. The number of questions that the practice exam must contain is 30.

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