Maternal Newborn ATI Study Guide

Learn/Master the BASIC principles and PROCEDURES of NURSING
o Critical Thinking
o Evidence-based Practice
o Patient-centered Care
o Clinical Application
o Nursing Process (A.D.P.I.E.)
o Therapeutic Communication
**hCG is KEY in order to verify her PREGNANCY** (It rhymes)
 hCG = Human Chorionic Gonadotropin (the BASIS of PREGNANCY TESTING)
o hCG is excreted by the placenta and promotes the excretion of progesterone and
estrogen
o Higher levels of hCG could indicate the following:
 Multifetal Pregnancy
 Ectopic Pregnancy
 Hydatidiform mole (Gestational Trophoblastic Disease)
 Hydatidiform moles = uncontrolled growths in the uterus arising
from placental or fetal tissue in early pregnancy
 Nursing Consideration for Hydatidiform mole
o Pregnancy must be avoided for 1 year
 Rationale: In order for the client to closely monitor
for manifestations of this condition
 Genetic abnormality (e.g. Down Syndrome)
o Lower blood levels of hCG could indicate the following:
 Miscarriage
 Ectopic Pregnancy
**Normal Fetal Heart Rate Baseline = 110 to 160 bpm**
 Fetal Heart Rate below 110 BPM or above 160 BPM should be reported to the
provider
**Put some “Jelly” on that “Thang”** (referring to infant being circumcised)
 Nursing Consideration
o The client should apply petrolatum to the penis with each diaper change (for the
first few days)
 Rationale: To protect the incision from contact with urine and feces
**Things you should ALWAYS REPORTS TO THE PROVIDER**
 Nasal Flaring
 Grunting
 Respiratory muscular retractions
o Rationale: all of these findings indicate serious breathing problems
**Get up off yo ASS if you want to pass GAS** (Relate to client reporting intestinal gas
pain)
 Nursing Consideration/Educate for Intestinal gas pain
o Assist the client to ambulate/walk in the hallway
 Rationale: Walking helps to stimulate peristalsis and promotes the
release of Gas
o Note: Drinking Fluids through a straw causes more ingestion of air and MORE
GAS INSIDE OF YOU
 Which means we should not tell anyone to use a straw if they have
trapped gas (it’ll just cause more gas)
o Note: Drinking carbonated beverages (soda, sprinkling water, etc.) will cause
more ingestion of air and MORE GAS INSIDE OF YOU
**Know how to calculate date of delivery using Naegele’s Rule**
 How to calculate using Naegele’s Rule
o Subtracting 3 months from the FIRST DAY of the LAST MENSTRUAL
PERIOD and adding 7 days
o Example: If a client’s last menstrual period started on January 20th, what would
be the expected date of delivery?
 Answer: October 27th
**THE FIVE P’s** (ATI: Chapter 11 – Page 76)
 Passenger (e.g. Fetus and Placenta)
 Passageway (e.g. Birth Canal)
 Powers (e.g. Contractions)
 Position (e.g. the mother’s position)
 Psychological (e.g. the psychological response)
Lamaze Method (to manage pain during labor)
 The Lamaze philosophy is based on prophylaxis by using the mind
 The method is based on the theory that through stimulus-response conditioning, clients
can learn to use controlled breathing to reduce pain during labor

Nursing Consideration for Lamaze Method
o Educate the patient that with the Lamaze Method that they will learn how to
prevent pain during labor by focusing your mind to control your breathing
Planning Care for Pregnant women
 Expected laboratory tests the nurse will obtain
o Group-B Streptococcus B-hemolytic (@ 35 to 37 weeks gestation)
 The nurse should obtain a vaginal/anal group-B Streptococcus BHemolytic (GBS) culture at 35 to 37 weeks gestation to screen for
infection
 Prophylactic antibiotics should be given during labor to clients who are
positive for GBS
o 1-Hour glucose tolerance test (@ 24 to 28 weeks gestation)
 Nurse should obtain a 1-hour glucose tolerance test at 24 to 28 weeks
gestation to screen for gestational diabetes (Glucose tolerance test
result of 120 mg/dL is within expected reference range)
 Laboratory Testing and Diagnostic Procedures
 Routine urinalysis with glycosuria
 Glucose tolerance test
o 50 g oral glucose load, followed by plasma glucose
analysis 1 hour later performed at 24 to 28 weeks of
gestation
o Fasting not necessary
o A positive blood glucose screening is 140 mg/dL or
greater
o Additional testing with a 3-hour glucose tolerance test is
indicated

3-hour glucose tolerance test
o Following overnight fasting, avoidance of caffeine, and
abstinence from smoking for 12-hour prior to testing
o A fasting glucose is obtained
o A 100-gram Glucose load is given, and serum glucose
levels are determined at 1, 2, and 3-hour following glucose
ingestion

Reportable Finding for Glucose tolerance test:
 A value of 130 to 140 mg/dL or greater for a 1-hour glucose
tolerance test indicates a positive test result and should be
reported to the provider

Nursing Consideration for Glucose Tolerance Test
 Monitor HbA1c
 Monitor for Ketones
 Biophysical Profile (BPP) to ascertain fetal well-being
 Amniocentesis with alpha-fetoprotein
o Blood Type (@ 28 weeks gestation)
 Nurse should obtain a maternal blood type and factor at the first prenatal
visit to determine if the client will need to receive Rho(D) immune
globulin at 28 weeks gestation
Formula feeding to the guardian of a newborn
 Nursing consideration
o Always hold the bottle and never prop it
o Avoid supine position during feeding (danger of aspiration)
o Hold newborn close and at 45-degree angle during feeding
o Place the nipple on top of the newborn’s tongue
o The guardian should use sterile water or water that has been boiled for 2
minutes when mixing powdered formula
 In addition, the guardian should mix 1 scoop in 2 oz of water
o The guardian should boil nipples and bottles for 5 minutes before using them for
the first time.
o Stored breastmilk should be used within 48 hours
 Discard unused formula when the newborn is finished feeding and after
opened for 1 hour because of an increased possibility of bacterial
contamination
o How to Store Breastmilk
 Pumped milk should be stored in the middle or the back of the
refrigerator to keep it cold (Do not store in the door of the refrigerator –
milk does not stay as cold)
o Warm cold bottles by placing the bottle under warm running tap water (or
in a pan of hot water)
 Can also defrost cold bottles (breastmilk) in the refrigerator
Teaching Postpartum women how to swaddle her newborn
 Nursing consideration
o Educate parent to discontinue swaddling the baby once the baby is able to
roll over (which occurs around 2 months of age)
 Rationale: rolling over can tighten the swaddle and keep the baby from
breathing properly
o Educate parent to swaddle the newborn with the hips slightly flexed and enough
room in the blanket for the newborn to move the knees
o Educate parent that they should be able to fit 2 to 3 fingers between the
newborn’s chest and the swaddled blanket (swaddle shouldn’t be too tight)
o Educate parent to lay newborn on their back after swaddling (to reduce the risk
of sudden infant death syndrome)
Cervical cerclage (in relation to incompetent cervix)
 Cervical cerclage prevents premature opening of the cervix during pregnancy
 Nursing Consideration
o Educate the client that they should immediately go to a facility for evaluation if
she experiences any manifestations of labor while the cerclage is in place.
Vacuum-assisted vaginal delivery
 Nursing Considerations
o Educate client that vacuum-assisted birth increases the risk of jaundice as the
bruises caused by the device dissipate
o Use of vacuum-assisted device will result in caput succedaneum (which is a
swelling on the scalp that generally resolves without treatment in 3 to 4 days)
o Providers choose vacuum-assisted birth when a client has a prolonged second
stage of labor or when the fetus is in distress
Chapter 9: Medical Conditions (Maternal Newborn Nursing ATI Book)
Gestational Diabetes Mellitus (GDM)
 An impaired tolerance to glucose with the first onset or recognition during pregnancy
o Ideal blood glucose level during pregnancy
 60 to 99 mg/dL before meals or fasting
 less than or equal to 120 mg/dL 2 hours after meals
Gestational Hypertension
 Hypertensive disorders of pregnancy whereby the client has an elevated blood pressure
at 140/90 mm Hg or greater recorded on two different occasions
o Typically begins after the 20th week of Pregnancy

Preeclampsia
o Gestational Hypertension with the addition of proteinuria of greater than or
equal to 1+. (headache, irritability, and edema may be present)

Severe Preeclampsia
o Consists of blood pressure that is 160/110 mm Hg or greater
o Proteinuria greater than 3+
o Oliguria
o Elevated blood creatinine greater than 1.1 mg/dL
o Cerebral or Visual Disturbance (Headache and Blurred Vision)
o Hyperreflexia with possible ankle clonus
o Pulmonary or Cardiac Involvement
o Extensive peripheral edema
o Hepatic Dysfunction
o Epigastric and Right Upper-Quadrant pain
o Thrombocytopenia

Eclampsia
o Severe preeclampsia manifestations with the onset of seizure activity or coma
o Headache
o Severe Epigastric Pain
o Hyperreflexia
o Hemoconcentration
HELLP Syndrome (associated with expected findings of preeclampsia)
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Variant of Gestational Hypertension in which hematologic conditions coexist with
severe preeclampsia involving hepatic dysfunction
Diagnosed by laboratory tests
o H = Hemolysis resulting in anemia and jaundice
o EL = Elevated liver enzymes resulting in
 elevated ALT and AST
 Epigastric pain
 Nausea and Vomiting
o LP = Low platelets (less than 100,000/mm3), resulting in:
 Thrombocytopenia
 Abnormal bleeding and clotting time
 Bleeding gums
 Petechiae and possible DIC
Nursing Interventions for Hypertension/Gestational Hypertension in Pregnancy
 Assess level of Consciousness
 Obtain pulse oximetry
 Monitor Urine Output
 Obtain daily weights
 Monitor blood pressure
 Encourage Lateral Positioning
 Perform NST and daily kick counts
 Instruct the client to monitor I&O
 Administer medications
o Antihypertensive medications
 Used to keep blood pressure less than 160/110 mm Hg
 Methyldopa
 Nifedipine
 Hydralazine
 Labetalol
 NOTE: Avoid ACE Inhibitors and ARBs (Angiotensin II Receptor
Blockers)
o Magnesium Sulfate (Anticonvulsant medication)
 Medication of choice for prophylaxis or treatment
 Reduces seizure threshold (depression of the CNS)
 Decreases blood pressure as it relaxes smooth muscles
 Nursing Intervention for Magnesium Sulfate
 Inform the client that she may initially feel flushed, hot, and
sedated with the magnesium sulfate bolus (nausea/vomiting may
occur)
 Monitor vital signs, LOC, reflexes, renal perfusion, output, etc.
 Place client on fluid restrictions and maintain urinary output
greater than 30 mL/hr

Monitor for Magnesium Sulfate Toxicity
o Absence of patellar deep tendon reflexes
o Urine output less than 30 mL/hr
 IMPORTANT: ALWAYS REPORT FOR
URINE OUTPUT LESS THAN 30 mL/hr
o Respirations less than 12/min
o Decreased LOC
o Cardiac dysrhythmias
Hypoglycemia Newborn Information: A serum glucose level of less than 40 mg/dL
 Contributing Factors
o Maternal diabetes mellitus
o Preterm infant
o LGA or SGA
o Stress at birth “such as cold stress and asphyxia (occurs when the body is
deprived of oxygen)”
 Which is why it is important to dry the infant immediately after delivery

Manifestations: Objective Data – Physical Assessment Findings (for newborn)
o Poor feeding
o Jitteriness/tremors
o Hypothermia
o Diaphoresis
o Weak cry
o Lethargy
o Flaccid muscle tone
o Seizures/coma

Nursing Interventions for Hypoglycemic Newborn
o Perform heel stick for blood glucose within 2 hours of birth
o Provide frequent oral and/or gavage feedings
o Monitor the neonate’s blood glucose level closely per facility protocol
o Monitor IV if the neonate is unable to orally feed
Manifestations of Hypoglycemia (for mother)
 Nervousness
 Headache
 Weakness
 Irritability
 Hunger
 Blurred vision
 Tingling of mouth or extremities
 Diaphoresis
 Shallow respiration
Manifestations of Hyperglycemia
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Thirst
Nausea
Abdominal pain
Frequent Urination
Flushed dry skin
Fruity breath
Note: Boggy Uterus can/could indicate uterine hemorrhage
 Nursing Intervention
o Massage the Fundus
o Oxytocic Agents (medications used to promote Uterine Contractions)
Note: Vaginal exams are contraindicated with Vaginal bleeding (because it may cause
more damage/bleeding)
Ectopic Pregnancy
 The abnormal implantation of a Fertilized Ovum outside of the uterine cavity usually in
the fallopian tube (which can result in a tubal rupture causing a fatal hemorrhage)
 When the fertilized egg implants in tissue outside of the uterus and the placenta; then
the fetus begins to develop in this area
o The most common site is within a fallopian tube
o Most cases of Ectopic Pregnancy = scarring caused by a previous tubal infection
or tubal surgery
o 2nd most frequent cause of bleeding in early pregnancy
o Leading cause of infertility

Risk Factors for Ectopic Pregnancy
o Any factor that compromises tubal patency
 STIs (ex. Pelvic Inflammatory Disease – PID)

Expected Findings for Ectopic Pregnancy
o Unilateral stabbing pain and tenderness in the lower-abdominal quadrant
o Irregular, lighter than usual, and/or delayed Menses (1 to 2 weeks)
 Including missed menses
o Scant, dark red, or brown vaginal spotting 6 to 8 weeks after last menses
 Red, vaginal bleeding if rupture has occurred
o Referred shoulder pain
 Rationale: blood in the peritoneal cavity irritating the diaphragm or
phrenic nerve after tubal rupture
o Findings of hemorrhage and shock (hypotension, tachycardia, pallor, dizziness)
 typically occurring if a large amount of bleeding has occurred
Placenta Previa (when placenta partially or totally covers the mother’s cervix) Chapter 7
– Page 44
 Contributing Factors
o Placenta implants completely or partially over cervical os

Risk Factors for Placenta Previa
o Previous Placenta Previa
o Uterine Scarring (e.g. Previous C-Section Birth, Curettage, endometritis)
o Advance Maternal Age (e.g. Age greater than 35)
o Multifetal Gestation/High Gravidity (e.g. Multiple Pregnancies)
o Multiple Gestations (Being pregnant with more than one baby at a time)
o Smoking (e.g. Cigarette Smokers)
o African-American Women (or of other minority races)
o Giving birth to a male fetus

Expected Findings for Placenta Previa
o Vaginal Bleeding:
 Usually bright red in color (Painless, Bright Red Bleeding)
 Typically during the second or third trimester
 May begin scant and progress to profuse
 Can range from minimal to severe and life-threatening
o Uterus soft, relaxed, and nontender with normal tone
o Fundal height greater than usually expected for gestational age
o Fetus in a breech, oblique, or transverse position
o Vital signs within normal limits
o Decreasing Urinary Output (better indicator of blood loss)
o Pain:
 Often none
o Maternal effect:
 Hemorrhage
 Shock
 Death
o Fetal effect
 Anoxia
 CNS trauma
 Death

Contraindication for Placenta Previa
o Oxytocin

Treatment for Placenta Previa
o Partial previa might be treated with bed rest
o Complete previa will be treated as with abruptio placentae

Nursing Care for patient with Placenta Previa
o Assess for bleeding, leakage, or contractions
o Assist the woman in maintain bed rest
 Ambulation to the bathroom is allowed if no bleeding is notes
o Assess fundal height
o Refrain from performing vaginal exams
 Rationale: Can exacerbate/worsen the bleeding
o Administer IV fluids, blood products, and medications as prescribed
o Have oxygen equipment available in case of fetal distress
Abruptio Placentae
 Contributing Factors
o Trauma (to the abdomen)
 Ex. Trauma related to falling or car accident
o Preeclampsia
o Multiparity (e.g. Multiple Pregnancies)
o Cocaine use/COCAINE ABUSE

Laboratory Test for Abrutop Placentae?
o Kleihaur-Betke Test
 Rationale: used to determine if fetal blood is in maternal circulation
 Test is useful to determine if Rh immune globulin therapy should be
administered to a client who is Rh-negative

Expected findings of Abruptio Placentae
o Vaginal bleeding:
 Usually dark red in color
 Can range from absent to moderate dependent on the grade of abruption
 Persistent uterine contractions
o Pain:
 Abdomen “board-like” and very tender
 Sudden and ferocious onset
o Maternal effect:
 Hemorrhage
 Shock
 Death
o Fetal effect
 Anoxia
 CNS trauma

Death
o Treatment for Abruptio Placentae
 Emotional support
 Immediate cesarean birth
 Blood transfusions (to replace loss)
 Monitor for DIC
 IV fluid replacement (to keep urine output at minimum 30mL/hr)
o Nursing Considerations/Interventions for Abruptio Placenta
 Palpate for uterine tone and presence of tenderness
 Monitor for bleeding
 Note the rate, amount, and color
 Monitor FHR patterns (for signs of distress)
 Monitor maternal vital signs
 Assess maternal respiratory and cardiac sounds
 Monitor Urinary output
 Monitor level of Consciousness
Psychological and Physiological adaptations of pregnancy (with nursing interventions)
First Trimester of Pregnancy
 Ambivalence
o Conflicting feelings (such as joy, pleasure, sorrow, and/or hostility) about the
pregnancy
o Nursing Intervention
 Assess meaning of pregnancy to the client/partner and socioeconomic
supports

Breasts (size, striae, tenderness)
o Nursing Intervention
 Tech the fullness and sensitivity are hormone-related.
 Instruct about supportive bra and that over-the-counter products do not
reduce stretch marks

Nausea/vomiting
o Nursing Intervention
 Educate client on diet to eat: such as eating dry crackers, Five to six
small meals, Ginger, Raspberry
 Avoid fried, odorous, spicy foods and foods with strong smells
 Assess weight, urine output, and signs of hyperemesis
 Educate client to call if:
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unable to eat/drink for more than 24 hours
Urine becomes scant and dark
Heart pounds
Client becomes Dizzy

Urinary Frequency (for 1st and 3rd Trimester)
o Nursing Intervention
 Assess for urinary tract infection (UTI)
 Teach frequent voiding
 Do not decrease fluids
 Urinate after intercourse
 Educate client to call if:
 Dysuria, cloudy or foul-smelling urine
 Flank pain
 Educate client to do Kegel exercises

Nutrition (for every Trimester)
o Nursing Intervention
 Assess/teach weight gain patterns
 Average weight gain = 25 to 35 pounds
 Caloric increase 300 to 400 kcal/day;
 Protein increase by 25 g/day
 Iron intake 30 mg/day
 Folate intake 600 mcg/day
 Educate client to take prenatal vitamins
 Educate client to limit caffeine intake

Abdominal Ultrasounds
o Nursing Considerations/Interventions
 Educate patient to have a full bladder during the Ultrasound
 Rationale: A full bladder helps lift the gravid uterus out of the
pelvis during the examination (helps obtain the most accurate
image of the fetus)
Second Trimester of Pregnancy
 Accepting
o Nursing Intervention
 Assess if ambivalence is increased and how the client views the fetus

Skin (2nd and 3rd Trimester): Striae, linea nigra (vertical dark line that develops
across the belly), chloasma (dark, brownish patches of skin, mostly on the forehead)
o Nursing Intervention
 Discuss that commercial treatments are not useful
 Pigmentation usually disappears after pregnancy
 Striae may fade

Breasts: Colostrum (2nd and 3rd Trimester)
o Nursing Intervention
 Teach that colostrum may be expressed as early as 16 weeks (Colostrum
= Liquid Gold)
 Discuss Breast care (use pads?)
 Discuss Nipple care: keep them dry

Respiratory: Dyspnea (2nd and 3rd Trimester)
o Nursing Intervention
 Educate client to sleep propped or sitting up
 Lightening (fetus begins descent into pelvis) between 38 to 40 weeks
 Describes the engagement of the fetal head into the pelvis
o Mother will be able to breathe easier
o And urination is more frequent

Cardiovascular (varicose veins) 2nd 3rd Trimester
o Nursing Intervention
 Assess activity (such as sitting/standing)
 Assess rather client is wearing constrictive clothing and/or crossing legs
 Teach client about leg elevation, position changes
 Teach client to use support hose and to exercise

Constipation (2nd and 3rd Trimester)
o Nursing Intervention
 Teach client about activity, fluids, and fiber intake (to avoid constipation)

Heartburn (2nd and 3rd Trimester)
o Nursing Intervention
 Encourage small meals; sit upright for 30 minutes or more after eating
 Wait at least 2 hours after meals before lying down
 Avoid spicy, fatty foods.
 Educate client to drink hot herbal tea
 Drinking sips of milk to relieve heartburn temporarily

Leukorrhea (2nd and 3rd Trimester) = mild odorless discharge from the vagina that is
clear and milky in color
o Nursing Intervention
 Teach that this is normal;
 Educate client to not douche
 Maintain good hygiene; wear perineal pads
 Report if accompanied by pruritus (Itching), foul odor, or change in
character
Braxton Hicks (2nd and 3rd Trimester)
o Nursing Intervention
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Teach difference between Braxton Hicks and true labor (Review table on
false vs true labor)
Third Trimester
 Leg Cramps (ATI: Chapter 4 – Page 24)
 Preparing for birth
o Nursing Intervention
 Teach manifestations of onset of labor
 Teach newborn care, feeding methods
 Teach birth control options, and home preparations for baby
 Review birthing plan
 View First and Second Trimester for the rest
Non-stress Test (NST)
 Monitors for accelerations of the fetal heart rate over a 20-minute period.
o The fetus can be asleep and experience hypoactivity
o Rationale: May give the mother orange juice during testing to stimulate fetal
movements
 Most widely used test for evaluating fetal well-being
 Non-invasive
 Monitors response of the fetal heart rate (FHR) to fetal movement
 An NST will take about 20 to 30 minutes to complete
 Indications for NST
o Assess for fetal well-being and an intact CNS during the third trimester
o Assess fetus of clients with high-risk pregnancies (such as maternal diabetes
mellitus, hypertension, heart disease, IUGR, or decreased fetal movement)

Interpretation of Findings
o Reactive NST (normal)
 Two or more fetal heart rate accelerations (increase in FHR of at least
15/min above the baseline and last 15 seconds) within a 20-minute period
 Before 32-weeks gestation, acceleration is defined as increase of at least
10 beats/min last at least 10 seconds in FHR
o Non-reactive NST (considered abnormal)
 Does not produce two or more qualifying accelerations in 20-minutes
 If does not meet criteria in 40-minutes, additional testing is indicated:
 Such as doing a contraction stress test (CST)
o Rationale: used if positive for NST test
 Or doing a Biophysical Profile (BPP)
o Rationale: used if positive for NST test

Nursing Intervention for Nonstress Test (NST)
o Seat the client in a reclining chair or place in a semi-fowler’s or left-lateral
position
o Apply two belts and transducers to the client’s abdomen
Prenatal Care: Monitor for infections
 Infections
o Group B Strep (test mother at 35 weeks)
 Culture obtained at 35 to 36 weeks
 Treat positive culture with PCN IVPB every 4 hours during labor
o Monitor newborn for infection
What to screen for at 16 to 22 weeks gestations
 Screen for Neural tube defects (NTDs) with maternal serum alpha-fetoprotein
What to screen for at 28 weeks gestations
 Screen for diabetes mellitus
 Administer Rho(D) immune globulin (RhoGAM) if Rh-negative
 Begin Nonstress testing twice a week for any pregnancy at risk for intrauterine fetal
death
What to screen for at 35 weeks gestations
 test for group B strep
Pharmacological management for Cardiac Disease
 Propranolol (Beta-blocker drug)
o Used to treat tachyarrhythmias
o To lower maternal blood pressure
 Ampicillin antibiotic
o Prophylaxis given to prevent endocarditis

Heparin Sodium (anticoagulant)
o Used in treating clients with pulmonary embolus
o Treating deep-vein thrombosis, prosthetic valves
o Treating Cyanotic heart defects and Rheumatic heart disease

Digoxin (Cardiac glycoside)
o Used to increase cardiac output during pregnancy
o May be prescribed if fetal tachycardia is present
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Anticoagulant therapy (ex. Heparin Therapy)
o Adverse effects
 Anemia
 Bleeding (increased risk for bleeding)
 Rashes
 Thrombocytopenia
o Nursing Considerations for Heparin Therapy
 Teach client about bleeding precautions
 ex. educate patient to use soft toothbrush to prevent trauma and
bleeding
 Educate client to report any bleeding
Contributing Factors of Hypertension
 Maternal age younger than 20 or older than 40
 First pregnancy
 Morbid obesity
 BMI greater than 30
 Multifetal gestation
 Chronic Hypertension
 Rh incompatibility
 Diabetes Mellitus
o Pregestational Diabetes Mellitus
 Previous history of Gestational Hypertension
 family history of preeclampsia
Medications used in Labor and Delivery
 Oxytocin (stimulates the uterine muscles to contract)
o Smooth muscle relaxant that causes contractions of the uterus
 Induces labor or contracts the uterus after delivery;
 Stop immediately in the presence of late decelerations
o Indication of Oxytocin
 Stimulate uterine contractions
 May be used in all stages of labor
 Intrauterine growth restriction
 Rationale: to induce labor
 Prolonged rupture of membrane
 Post-term pregnancy
 Rationale: to induce labor
o Contraindication of Oxytocin
 Clients with an Active Genital Herpes infection
 Rationale: Since oxytocin is used to help induce labor, given this
drug would cause the fetus to get herpes when passing through
the birth canal
o Which is why a C-Section birth is recommended for
clients with an Active Genital Herpes Infection
o Nursing Intervention for Oxytocin
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The nurse should palpate the uterine fundus to determine consistency or
tone to determine if the medication is effective (e.g. Fundal consistency)
Monitor contractions and FHR
Monitor vital signs
Stop immediately for late decelerations or tachysystole
(hyperstimulation)
 Tachysystole = greater than 5 contractions in 10 minutes
(over the course of 30 minutes)
 Nursing Consideration for Tachysystole
o Oxygen should be applied 10 L/min via face mask
 Rationale: Tachysystole can lead to fetal
hypoxia/Fetal Asphyxia
 which can be noticed via abnormal FHR
pattern
 Which can lead to insufficiency (because
inadequate oxygen transfer to the placenta
will result in fetal asphyxia)
Have tocolytic (such as terbutaline) immediately available for
tachysystole
Note: When client is receiving Oxytocin postpartum, the flow of
lochia is often scant until the effects of the medication wear off
Methylergonovine Maleate (acts directly on the smooth muscle of the uterus and
increases the tone, rate, and amplitude of rhythmic contractions)
 Contracts the uterus after delivery
 Used to treat postpartum hemorrhage
 Need baseline blood pressure before administering
o Indication
 Stimulate uterine contractions after delivery
 Treat postpartum hemorrhage
o Nursing Intervention
 Monitor bleeding and uterine tone
 Obtain baseline blood pressure
 Massage fundus
 Administer 0.2 mg IM or PO as prescribed

Medroxyprogesterone
o An intramuscular or subcutaneous injection given to a female client every 11 to
13 weeks
o Indication
 It inhibits ovulation and thickens cervical mucus
o Client Education for Medroxyprogesterone
 Do not massage after IM injections
 Rationale: it decreases the absorption and effectiveness of the
medication
 Could impair Glucose tolerance for clients who have diabetes mellitus
 Can increase diabetes risk for clients who do not have diabetes
mellitus
 Vigorously shake the contents of the vial before drawing up the dosage of
medication
 Rationale: to ensure a uniform suspension of the medication
o Contraindications for administration of Medroxyprogesterone
 Breast Cancer
 Current cardiovascular disease
 Abnormal liver function
 Live tumor
 Unexplained vaginal bleeding

Calcium Gluconate
o Indication
 Antidote for magnesium sulfate toxicity
o Nursing Interventions
 Administer calcium gluconate 1 g for signs of toxicity

Terbutaline (help to prevent and slow contractions of the uterus)
 Beta Adrenergic agonist
 Last resort for preterm labor
 Call provider for HR greater than 130
o Indication
 Tocolytic used for preterm labor
o Contraindication for the Administration of Terbutaline
 Preeclampsia
 Cardiac disease
 Gestational diabetes
 Severe gestational hypertension
o Nursing Interventions
 Monitor contractions and FHR
 Monitor Vital Signs
 Monitor for adverse effects (tremors, dizziness, headache,
tachycardia, hypotension, anxiety)
 Do not administer if client reports chest pain


Administer beta blocking agent as antidote
Indomethacin (reduces the number and frequency of contractions)
 Prostaglandin synthetase inhibitor
 Can be used as tocolytic in preterm labor
o Indication
 May be used as Tocolytic for preterm labor
o Nursing Interventions
 Monitor contractions and FHR
 Monitor vital signs (can mask maternal fever)
 Administer with food to decrease side effect of GI distress
 Only administer if gestational age is less than 32 weeks

Magnesium Sulfate (Tocolytic)
o Indication
 Tocolytic used for preterm labor
 CNS depressant to prevent seizure in preeclampsia
o Adverse effects
 Feeling of warmth (while Magnesium Sulfate is being infused)
o Nursing Intervention for Preterm Labor
 Monitor contractions and FHR
 Monitor fetal movement and FHR variability
 Monitor vital signs and urine output
o Nursing Intervention for Preeclampsia
 Monitor magnesium levels (therapeutic range 4 to 8 mg/dL)
 Administer calcium gluconate 1 g for signs of toxicity
 Observe neonate for signs of:
 respiratory depression
 Hypotonia, lethargy, and hypocalcemia
 Contraindicated for women with myasthenia gravis

Naloxone HCl
o Indication
 Antidote for opioid-induced respiratory depression
 Reverse pruritus from epidural opioid
o Nursing Interventions
 Monitor respiratory effort
 Do not administer if mother is opioid-dependent

Betamethasone (Preterm labor 24 to 32 weeks)
o Stimulate production or release of lung surfactant in preterm fetus

Misoprostol (softens the cervix to induce labor; Softens and thins the cervix)
o Indication
 Pre-induction cervical ripening (Bishop score 4 or less)
o Nursing Interventions for Misoprostol
 Can administer Oxytocin (no sooner than 4 hours) after the last dose of
Misoprostol
 Oxytocin administered following misoprostol for clients who have
cervical ripening and have not begun labor
 Evaluate Bishop score
 Monitor vital signs
 Use cautiously in women with history of:
 Asthma, Glaucoma, Renal
 Hepatic or Cardiovascular disorders
 Contraindicated in presence of fetal distress or vaginal bleeding
Regional blocks
 Most commonly used
 They include pudendal, epidural, and intrathecal blocks
Pudendal block
 Provides local anesthesia to the perineum, vulva, and rectal areas during delivery
 It is administered 10 to 20 minutes before delivery
Epidural block
 Consists of a local anesthetic along with an analgesic morphine or fentanyl injected into
the epidural space at the level of the fourth or fifth lumbar vertebra
 Continuous infusion or intermittent injections may be administered through an
indwelling epidural catheter.
 Note: Hypotension is most common adverse effect when using Epidural block
RhoGAM information
 RhoGAM is given to Rh-negative mothers after a miscarriage
 At 28 weeks gestation
 Within 72 hours after delivery if baby is Rh-positive and RhoGAM is indicated
NCLEX Quick Labor and Delivery Notes:
 OB client with tachycardia; then think hemorrhage FIRST
 Quick onset of epigastric pain is often the aura to seizure activity (implement safety
precautions)
 Oxygen administration should be at 8-10 L/min via non-rebreather face mask


Non-pharmacologic measures should be used in combination with pharmacologic
interventions
Never provide Fundal Pressure with shoulder dystocia (however, suprapubic pressure is
okay; can also assist with McRoberts maneuver)
Nursing Intervention for Prolapsed cord
 Call for assistance immediately
 Use sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on
either side of the cord to the fetal presenting part to elevate it off the cord
 Reposition in a knee-chest or Trendelenburg position
Phases of Maternal adjustment (page 212 in pink book)
 Taking in
o Characteristics
 24 to 48 hours after birth
 Dependent and passive
 Focuses on own needs; excited and talkative
o Collaborative care
 Assist with care; provide comfort, nutrition, and hygiene
 Listen to them

Taking hold
o Characteristics
 Second to tenth day postpartum, or up to several weeks
 Focuses on maternal role and care of newborn
 Mother is eager to learn; however, may develop postpartum blues
o Collaborative care
 Provide teaching, written material, follow-up appointments, and
community resources
 Assess emotional status and discuss about postpartum blues

Letting go
o Characteristics
 Focuses on family and individual roles
o Collaborative care
 Assess progress
 Discuss community resources
APGAR: Five Categories (each scored as 0, 1, or 2)
 Heart rate
 Respiratory effort
 Muscle tone


Reflex irritability
Color

APGAR Ratings:
o 7 to 10 is within normal limits
o 4 to 6 is moderately distressed
o 0 to 3 is severely distressed
Newborn Medications (need to remember these)
 Eye Prophylaxis
o Erythromycin or Tetracycline administered within 1 hour after birth


Vitamin K IM administered with 1 hour of birth
Hepatitis vaccine administered within 12 hours of birth (Hep. B)
Nursing Interventions to promote successful breastfeeding
 Explain breastfeeding techniques to the mother
o Have the mother wash her hands, get comfortable, and have fluids to drink
during breastfeeding

Offer the newborn the breast immediately after birth and feed every 2 to 3 hours

Explain the let-down reflex (e.g. Stimulation of maternal nipple releases oxytocin that
causes the letdown of milk)
Maternal Infant/OB: Manifestation of illness to report
 Instruct parents regarding the manifestations of illness and to report them
immediately.
o Temperature greater than 38° C (100.4° F) or less than 36.5° C (97.9° F)
 Normal Temperature Range = 97.7 to 99.5 (with 98.6 being
average)
 If the newborn becomes chilled (cold stress), oxygen
demands can increase and acidosis can occur
o Poor feeding or little interest in food
o Forceful vomiting or frequent vomiting
o Decreased urination
o Diarrhea or decreased bowel movements
o Labored breathing with flared nostrils or an absence of breathing for greater
than 15 seconds
o Jaundice
o Cyanosis
o Lethargy
o Inconsolable crying
o Difficulty waking
o Bleeding or purulent drainage around umbilical cord or circumcision
o Drainage developing in eyes
Umbilical Cord Care
 Goal of cord care is to prevent or decrease risk for infection and hemorrhage
 Nursing Action
o Cord clamp stays in place for 24 to 48 hr.
o Recommendations for cord care include cleaning the cord with water
(using cleanser sparingly if needed to remove debris) during the initial bath of
the newborn.
 Cleaning the base with water
o Assess stump and base of cord for erythema, edema, and drainage with each
diaper change.
o The newborn’s diaper should be folded down and away from the umbilical
stump.
o Bathing infant by submerging in water should not occur until the cord has fallen
off.
o Most cords fall off within the first 10 to 14 days.
Complications related to newborn home care
 Infected cord or circumcision from improper care or tub bathing too soon
Newborn Physical Assessment
 Expected finding/Manifestation
o Positive Babinski reflex
o Two umbilical arteries visible and one vein
o Acrocyanosis
Carboprost Tromethamine (Vasoconstrictor) Note: Vasoconstrictor can cause hypertension
 Uterine Stimulant
 Indication
o Used for Post-partum hemorrhage
 Adverse effect
o Hypertension
o Fever
o Diarrhea
o Chills
o Headache, nausea, and vomiting

Nursing Actions
o Assess Uterine tone and vaginal bleeding
o Monitor for adverse reactions
FHR (fetal Heart Rate)
Pattern
Cause (What is causing the type of
Fetal Heart Rate)
V.E.A.L.
Priority Intervention (what to do for
the type of FHR Pattern)
C.H.O.P.
M.I.N.E.
Variable Decelerations
Cord Compression
Move Mother
Early Decelerations
Head Compression
Intervention not necessary
Accelerations
Ok
No intervention needed
Late Decelerations
Placental Insufficiency (causing Inadequate
fetal oxygenation)
 Preeclampsia
 Maternal diabetes mellitus
 Maternal hypotension, placenta
previa, abruptio placentae, Uterine
tachysystole with oxytocin
Evaluate for why
 Stop Pitocin/Oxytocin
 Give Oxygen (by mask at 8 to 10
L/min via non-rebreather face
mask)
 Give Fluid (ex. increasing the
rate of IV Fluid)
 Reposition mom (e.g. side-lying
position)
 Possible C-Section if persist
 Notify the provider
Nursing Interventions for measuring contractions (type of contractions)

How to Measure Frequency of Mother’s Contractions
o Evaluate the time from the beginning of a Contraction to the beginning of the
Next Contraction

How to Measure the Strength/Intensity of the Contraction
o Palpating the firmness of the uterus during a Contraction

How to Measure the Resting Period between Contractions
o Calculating/Measuring the time from the End of One Contraction to the
Beginning of the Next Contraction
How to Measure the Duration of the Contractions
o By Measuring the time from the Beginning of a Contraction to the End of the
Same Contraction


How to Measure the Interval of the Contractions
o Measuring the Interval from the beginning of one contraction to the beginning
of the next contraction.
 ex. Contraction lasting 60 secs with a relaxation period of 3 minutes =
contractions every 4 minutes.
Neonatal Abstinence Syndrome (NAS)
 Group of conditions caused when a baby withdraws from certain drugs they are exposed
to in the womb before birth
o Example: Newborn experiencing Opioid Withdrawal
Neonatal Abstinence Syndrome Clinical Manifestations:
 Tremors, Vomiting, Fevers, Diarrhea
 Tachypnea and Apnea
 Nasal Flaring and Sneezing
 Retractions
 Incessant Crying (prolonged crying without pause or interruptions) and Shrill Cry
 Mottling of the Skin
 Excessive sucking and Exaggerated Moro Reflex (Movement that occurs after baby is
startled by loud sound or movement)
o Moro Reflex Expected Findings
 Thumb and Forefinger forming a “C”
 Legs extending before pulling upward
 abduction of arms and legs
 “complete embrace” after startling
Nursing Intervention for Patient with a deviated, firm fundus indicates a full bladder?
 First: Ask the client when she last voided
 Second: Nurse should assist the client to void
Amniocentesis for a client who is Rh-Negative: Nursing Consideration/Action
 Administer Immune Globulin to the client to prevent Fetal Isoimmunization
o Rationale: Rh immune globulin is administered after the procedure to prevent
fetal isoimmunization or help ensure maternal antibodies will not form against
any placental red blood cells that might have accidentally been released into the
maternal bloodstream during the procedure
Amniocentesis (ATI: Chapter 6 – Page 35)
 This procedure = the aspiration of amniotic fluid for analysis by insertion of a needle
transabdominally into a client’s uterus and amniotic sac
 Using direct ultrasound guidance to help locate the placenta and determining the
position of the fetus

Indication for Amniocentesis
o A Family history of neural tube defects
o Alpha-fetoprotein (AFP) level for fetal abnormalities
o Lung maturity assessment
o Prenatal diagnosis of a genetic disorder or congenital anomaly of the fetus

Nursing Considerations/Actions (Pre-procedure)
o Educate the patient to empty the bladder prior to the procedure to reduce its size
and reduce the risk of inadvertent puncture

Nursing Considerations/Actions (Intra-procedure)
o Obtain and document baseline vital signs and FHR prior to the procedure
o Prepare client for an ultrasound to locate the placenta
o Educate patient there will be a feeling of slight pressure as the needle is inserted
 Client may feel slight uterine cramping when the needle comes into
contact with the uterus
 Which is why a local anesthetic is applied to the client’s skin
 Rationale: So the client doesn’t feel pain when the needle pierces
the skin

Nursing Considerations/Actions (Post-procedure)
o Monitor fetal heart rate
o Client Education
 Reports to the provider if they are experiencing the following
 Fever
 Chills
 Leakage of fluid or bleeding from the insertion site
 Decreased fetal movement
 Vaginal bleeding
 Uterine contractions
Polyhydramnios – The presence of excessive amniotic fluid surrounding the unborn
fetus.
 Expected Findings
o Gastrointestinal malformations and neurological disorders
o Fetal Gastrointestinal Anomaly
o Fundal Height greater than expected for gestational age
o Increase in weight gain
Progesterone
 Maintains the lining of the uterus, which maintains the pregnancy (it also reduces
uterine contractility)
 Decreased progesterone results in an increase in muscle tone throughout the body
 Complications of Low Progesterone
o Preterm labor
ATI Chapter 3: Expected Physiological Changes During Pregnancy (Signs of Pregnancy)
 Presumptive Signs
o Presumptive signs are changes that the client experiences that make them think
that they might be pregnant
o Subjective manifestations or Objective findings
o Signs also might be a result of physiological factors other than pregnancy
(Peristalsis, infections, stress)
o Expected Findings for Presumptive Signs
 Amenorrhea
 Fatigue





Nausea and Vomiting
Urinary Frequency
Breast Changes (darkened areolae, enlarged Montgomery’s glands)
Quickening (slight fluttering movements of the fetus felt by the client;
Usually between 16 to 20 weeks of gestation)
Uterine Enlargement

Probable Signs
o Probable signs are changes that make the examiner suspect a client is pregnant
(primarily related to physical changes of the uterus)
o Signs can be caused by physiological factors other than pregnancy (pelvic
congestion, tumors)
o Expected Findings for Probable Signs
 Abdominal Enlargement (related to changes in uterine size, shape, and
position)
 Hegar’s Sign (Softening and compressibility of lower uterus)
 Chadwick’s Sign (deepened violet-bluish color of cervix and vaginal
mucosa)
 Goodell’s Sign (softening of cervical tip)
 Ballottement (rebound of unengaged fetus)
 Braxton Hicks Contractions (false contractions that are painless,
irregular, and usually relieved by walking)
 Positive Pregnancy Test
 Fetal Outline

Positive Signs
o Positive signs are those that can be explained only by pregnancy)
o Expected Findings for Positive Signs
 Fetal Heart Sounds
 Visualization of Fetus by Ultrasound
 Fetal Movement/Palpable fetal movement
Phototherapy: Nursing Consideration/Nursing Care (**THIS MOST LIKELY WILL BE
ON THE EXAM)
 Maintain an eye mask over the newborn’s eyes for protection of corneas and retinas.
 Keep the newborn undressed.
o For a male newborn, a surgical mask should be placed (like a bikini) over the
genitalia to prevent possible testicular damage from heat and light waves.
o Be sure to remove the metal strip from the mask to prevent burning.
 Avoid applying lotions or ointments to the skin because they absorb heat and can cause
burns.
 Remove the newborn from phototherapy every 4 hours, and unmask the newborn’s eyes,
checking for inflammation or injury.
 Reposition the newborn every 2 hour to expose all of the body surfaces to the
phototherapy lights and prevent pressure sores.





Encourage the parents to hold and interact with the newborn when phototherapy lights
are off.
Monitor elimination and daily weights, watching for evidence of dehydration.
Check the newborn’s axillary temperature every 4 hour during phototherapy
because temperature can become elevated.
Feed the newborn early and frequently, every 3 to 4 hr.
Monitoring effects of Phototherapy for newborns
o Bronze discoloration: not a serious complication
o Maculopapular skin rash: not a serious complication
o Development of pressure areas
o Dehydration: poor skin turgor, dry mucous membranes, decreased urinary
output
o Elevated temperature
Understanding the connection between Oxytocin and breastfeeding the newborn (and
why encouraging mothers to breastfeed is important)
 Oxytocin is released in responses to breastfeeding
 In addition, Oxytocin causes the uterus to contract
o The release of this hormone decreases the risk for postpartum hemorrhage and
increases involution (e.g. involution = the shrinkage of the uterus… which is a
good thing)
Understanding Potential Complications associated with Preeclampsia
 Double Vision
 Blurred Vision
 Visual Disturbances
Meconium-Stained Amniotic fluid (Chapter 16 – Page 110)
 Nursing Consideration
o Document color and consistency of stained amniotic fluid
o Notify neonatal resuscitation team to be present at birth
o Gather equipment needed for neonatal resuscitation
Oligohydramnios
 (scant amount or absence of amniotic fluid) caused by any of the following
o Uteroplacental insufficiency
o Premature rupture of membranes
o Post-maturity of the fetus
o Renal system dysfunction
o Obstructive Uropathy
o Absence of fetal kidneys will cause Oligohydramnios
 Volume of amniotic fluid that is less than 300 mL during the third trimester of
pregnancy
Hypertonic Uterine Dysfunction (excessively frequent uterine contraction)
 Nursing Consideration/Management
o Hydrotherapy
o Analgesia
o Helping the patient relax and sleep
Hypotonic Uterine Dysfunction (abnormal labor patterns; leading to prolonged or protracted
delivery)
 Nursing Consideration/Management
o Oxytocin
o Ambulation
Internal Fetal Scalp (Continuous Internal Fetal Monitoring – Chapter 13, Page 92)
 How does it work?
o Performed by attaching a small spiral electrode to the presenting part of the
fetus to monitor the FHR
 Indication of Internal Fetal Scalp?
o Main Advantages of Internal Fetal Scalp?
 Helps to detect abnormal FHR patterns early (e.g. abnormal FHR
patterns may be indicative of fetal distress)
 Helps to determine accurate assessment of FHR variability
 Helps to determine accurate measurement of uterine contraction
intensity
o Main Disadvantages of Internal Fetal Scalp?
 Membranes must be ruptured to use this monitoring device
 Cervix must be adequately dilated (e.g. 2 to 3 cm.)
 Potential Risk for Infection (to the Mother and the Fetus)
 Potential risk for injury to fetus if device is not put on properly
Hyperemesis Gravidarum (ATI – Chapter 9, Page 60)
 Excessive nausea and vomiting that last past 16 weeks of gestation or that is excessive
and causes the following:
o Weight Loss
o Dehydration
o Nutritional Deficiencies
o Electrolyte imbalances
o Ketonuria

Risk Factors of Hyperemesis Gravidarum
o Maternal Age younger than 30 years
o Multifetal Gestation
o Diabetes
o Gastrointestinal Disorders
o Family history of hyperemesis

Expected Findings of Hyperemesis Gravidarum
o Prolonged periods of excessive vomiting
o Increased pulse rate
o Decreased blood pressure
 Rationale: Vomiting = less volume/fluid volume
 Less Volume/Fluid Volume = lower blood pressure
o Dehydration (with possible electrolyte imbalance)

IMPORTANT Lab Test for Hyperemesis Gravidarum
o Urinalysis = The Most important initial laboratory test
 Rationale: Urinalysis (UA) helps detects Ketones and Acetones (the
breakdown of protein and fat)

Nursing Consideration/Care for Hyperemesis Gravidarum
o Monitor I&O
o Monitor Vital Signs
o Monitor Weight
o Administer Pyridoxine
 Rationale: to help correct the fluid and electrolyte imbalances
o Administer Metoclopramide
o Note: ensure the client remain NPO until vomiting stops
Understanding Fetal Position (with Image)
 Most Common = ROA or LOA
 Right (R) or Left (L):
o The First letter = Side of the Maternal Pelvis

Occiput (O), Sacrum (S), Mentum (M), or Scapula (Sc):
o The Second letter = Presenting part of the Fetus

Anterior (A), Posterior (P), or Transverse (T):
o The Third letter = Part of the Maternal Pelvis
Maternal Position
 Nursing Considerations
o Frequent position changes (e.g. for comfort, relieve fatigue, and promote
circulation)
o Gravity helps in upright, sitting, kneeling, and squatting positions
Understanding Perineal Tenderness, Laceration, and Episiotomy
 Nursing Consideration/Care
o Apply ice/cold packs to the perineum for the first 24 hours
 Rationale: to reduce edema, provide anesthetic effect, and provide
comfort (DURING THE FIRST 24 HOURS)
o Encourage Sitz Baths at a hot or cool temperature for a least 20 minutes for at
least twice a day
 A Cool Sitz bath = Recommended within the first 24 hours
 Rationale: to reduce edema and promote comfort
 A Warm Sitz bath = Appropriate AFTER THE FIRST 24 HOURS
postpartum
 Rationale: Used to increase circulation and promote healing and
comfort
o Administer analgesics for pain and comfort:
 Nonopioids (Acetaminophen/Tylenol)
 Nonsteroidal anti-inflammatories (Ibuprofen/Motrin)
 Opioids (Codeine, Hydrocodone)
o Promote measures to help soften the client’s stools
o Encourage patient to sit on firm surfaces
 Avoid soft surfaces such as soft pillows or donut pillows
 Rationale: Because it separates the buttocks and decrease venous
blood flow – resulting in more pain and discomfort
Intrauterine Pressure Catheter
 Sterile solid or fluid-filled intrauterine pressure catheter inside the uterus to measure
intrauterine pressure
o Device used to monitor the frequency, intensity, and duration of contractions
 Note: Membrane/Sac must be ruptured and the cervix must be sufficiently dilated
ATI Chapter 14: Nursing Care During Stages of Labor – Page 95 (Understanding Stages
of Labor)
First Stage:
Latent Phase
First Stage:
Active Phase
First Stage:
Transition
Second Stage
Third Stage
Fourth Stage
- Onset of Labor
- Contractions
 Irregular,
mild to
moderate
 Frequency: 5
to 30
minutes
 Duration: 30
to 45
Seconds
 Dilation: 0
to 3 cm
- Contractions
 More
regular,
moderate to
strong
 Frequency: 3
to 5 minutes
 Duration: 40
to 70
seconds
 Dilation: 4
to 7 cm
- Contractions
 Strong to
very strong
 Frequency: 2
to 3 minutes
 Duration: 45
to 90
seconds



Full dilation of
the Cervix
Progresses to
intense
contractions
every 1 to 2
minutes
*pushing out
the baby
stage*


Delivery
of the
neonate
Last from
the birth
of Fetus to
the
placenta is
delivered
First Stage of Labor
 From onset of regular uterine contractions to full effacement and dilation of cervix
 Nursing Action
o Encourage upright positions, application of warm/cold packs, ambulation, or
hydrotherapy
o Encourage voiding every 2 hours

Maternal Characteristics: Latent Phase
o Some dilation and effacement
o Talkative and eager

Maternal Characteristics: Active Phase
o Rapid dilation and effacement
o Some fetal descent (“heading” towards zero station)
o Feelings of helplessness
o Anxiety and restlessness increase as her contractions become stronger

Maternal Characteristics: Transition Phase
o Tired, restless, an irritable
o Nausea and Vomiting (potentially)
o Urge to push (don’t want to push too soon though)
o Increased rectal pressure and feelings of needing to have a Bowel Movement
o MOST DIFFICULT PART OF LABOR

Nursing Action During the Active Phase
o Provide client/fetal monitoring
o Encourage frequent position changes
o Encourage voiding at least every 2 hours
o Encourage relaxation
o Provide nonpharmacological comfort measures
o Hydrotherapy
 Should not be initiated for pain relief until the client has entered the
active stage of labor

Delivery
of
Placenta

Rationale: Early introduction of hydrotherapy is associated with a
prolonged labor
o Provide pharmacological pain relief as prescribed
 Note: Important to know how many centimeters the cervix is dilated
before administering an analgesic
 Rationale: Too early administration to the time of delivery could
cause respiratory depression in the newborn

Nursing Action During the Transition Phase
o Continue to encourage voiding every 2 hours
o Continue to monitor and support the client and fetus
o Encourage “pant-pant-blow” breathing pattern
o DISCOURAGE pushing efforts until the cervix is fully dilated
o Prepare the client for the birth
o Observe for perineal bulging or crowning
Second Stage of Labor (page 97)
 Lasts from the time the cervix is fully dilated to the birth of the fetus
 Nursing Actions for Second Stage of Labor
o Continue to monitor the client/fetus
o Assist in positioning the client for effective pushing
o Promote rest between contractions
o Prepare for care of neonate
 Have resuscitation equipment in working order and emergency
medications available
o Check suction apparatus
Third Stage of Labor
 Lasts from the birth of the fetus until the placenta is delivered
 Nursing Actions for Third Stage
o Instruct the client to push once findings of placental separation are present
o Administer oxytocics as prescribed to stimulate the uterus to contract and thus
prevent hemorrhage
o Promote baby-friendly activities between the family and the newborn
 Rationale: helps with the release of endogenous maternal oxytocin
 Example: skin-to-skin contact immediately following the birth
Fourth Stage of Labor
 Begins with the delivery of the placenta and includes at least the first 2 hours after birth
 Nursing Action for Fourth Stage of Labor
o Assess maternal blood pressure and pulse every 15 minutes for the first 2 hours
 determine temperature then reassess every 4 hours for the first 8 hours
after birth
o Encourage voiding to prevent bladder distention
o Assess fundus and lochia every 15 minutes for the first hour then as often as
needed according to protocol
o Massage the Uterine FUNDUS and/or Administer Oxytocics
 Rationale: To maintain uterine tone and to prevent hemorrhage
A Direct Coombs’ test vs Indirect Coombs’ test
 Direct Coombs’
o Reveals the presence of antibody-coated Rh-positive RBCs in the newborn

Indirect Coombs’
o Used to find antibodies in a recipient’s or donor’s blood before a transfusion
o Helps to determine whether a woman has Rh-Positive or Rh-negative blood
Relation of Estrogen to Maternal Newborn
 Estrogen increases vascularity and connective tissue growth
o Expected Finding
 Nasal Stuffiness
 Rationale: due to increased vascularity of the mucus membranes
within the nasal passages
 Nausea
 Breast tenderness
 Fluid retention

Decreased estrogen is associated with
o breast engorgement
o Diaphoresis
o Diuresis (increased formation and excretion of urine) of excess extracellular fluid
accumulated during pregnancy
o Decreased estrogen diminishes vaginal lubrication
Mother experiencing nausea and vomiting
 Nursing consideration
o Encourage/Educate patient to have a small snack before bedtime
 Rationale: Can relieve nausea and vomiting through the night and
prevent the client from feeling too hungry on waking
o Encourage client to eat some crackers before rising from bed in the morning
 Rationale: Eating Dry foods help to prevent morning sickness caused by
the buildup of hCG
o Eat foods served at cool temperatures
o Decrease fluid intake with meals
 Rationale: to prevent overdistention of the stomach
o Acupressure bands worn ON THE WRISTS
 Rationale: can reduce nausea and vomiting
Breast Engorgement Information (ATI Chapter 19 – Page 133)
 Instruction on preventing Engorgement/Breast Engorgement education
o Apply ice packs; cool compresses (after feedings)
 Rationale: can assist in reducing the discomfort of engorgement
 Note: Cold compresses 15 minutes on and 45 minutes off
o Educate client to wear a well-fitted and supportive bra for the first 72 hours
after delivery
 Rationale: to assist with suppression of lactation
 Note: Cold Cabbage leaves can be place inside the bra
o Take a warm shower or apply warm compresses before breastfeeding
 Rationale: to promote letdown and milk flow
 Note: avoid breast stimulation and running warm water over the breast
for PROLONGED periods until no longer lactating
o Empty each breast completely at feedings
o Apply breast creams as prescribe and wear breast shells in the bra
 Rationale: to soften the nipples if they are irritated and cracked
 Cracked nipples = risk for infection
o Mild analgesics or anti-inflammatory meds can be used for pain and discomfort
Chorionic Villus Sampling (ATI: Chapter 6 – Page 37)
 The assessment of a portion of the developing placenta (e.g. Chorionic Villi)
 A First-trimester alternative to amniocentesis that helps with earlier diagnosis of any
abnormalities
o Ideally performed at 10 to 13 weeks of gestation

Indication for Chorionic Villus Sampling
o Client at risk for giving birth to a neonate who has a genetic chromosomal
abnormality (example: Down syndrome, Klinefelter Syndrome, Turner
Syndrome)

Nursing Consideration/Action
o Obtain inform consent (DUH!!)
o Provide ongoing education and support
o Drink 1 to 2 glasses of fluid before test and avoid urination for several hours
before testing
 Rationale: Full bladder is necessary for testing

Complications of Chorionic Villus Sampling
o Spontaneous abortion
o Miscarriage
o Chorioamnionitis and rupture of membranes
Maternal Newborn Practice Questions
(Answer located on last page)
1. A woman diagnosed with Hyperemesis Gravidarum may be administered what
medication?
a. Metoclopramide
b. Methotrexate
c. Pyridoxine
d. Meperidine
e. Both A and C
2. Which mother should the nurse watch most closely for placenta previa?
a. Mrs. Williamson, who is a 22-year-old woman of European race
b. Mrs. Greer, age 28, who is a nullipara
c. Mrs. Moore, a 40-year-old in her second pregnancy
d. Mrs. Smith, age 30, who is having a female child
3. Mrs. Johnson has been diagnosed with complete placenta previa and is having continued
vaginal bleeding with a 39-week fetus. What nursing care would be appropriate? Select
All That Apply
a. Prepare Mrs. Daily for vaginal birth
b. Have oxygen equipment available in case of fetal distress
c. Administer IV fluids
d. Insert an IV into Mrs. Daily for induction of labor
e. Ambulate Mrs. Daily to the bathroom to empty her bladder
f. Perform preoperative teaching for cesarean delivery
4. A New Grad Nurse has a firm understanding by stating which of the following as a risk
factor for Abruptio Placenta?
a. Cocaine Use
b. Maternal Hypotension
c. A woman who is nullipara
d. African-America Woman
5. Which of the following should a nurse expect to observe for a client during the
transition phase of labor?
a. The client is calm and in minimal discomfort
b. The longest phase of the first stage of labor
c. Preparing the client for birth while encouraging “pant-pant-blow” breathing
patterns
d. Strong contractions occurring at a frequency of 4 to 5 minutes
6. What would be an appropriate nursing intervention for fetal care during labor?
a. Monitor FHR every 30 minutes for a high-risk pregnancy
b. Maintain the mother in a supine position to promote fetal circulation
c. report findings of FHR above 110 and below 160 beats per minute
d. Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask for
mother if FHR pattern show late decelerations
7. Which sign should cause the greatest concern if noted by the nurse?
a. Maternal irritability during the transition phase of labor
b. Amniotic fluid that is greenish brown in color
c. FHR that is variable and increased with contractions
d. Contractions with a duration of 50 seconds in the active labor phase
e. Urine Output 20 mL/hr
f. Both B and E
8. The nurse should instruct a pregnant client to report which symptom immediately?
a. Bleeding from the vagina
b. Swelling of the feet and ankles
c. Indigestion after meals
d. Breast swelling and tenderness
9. What statement by a pregnant woman would indicate the need for additional education?
a. “Consuming about 1,000mg of calcium per day is important for a developing
fetus”
b. “I need to eat dark green vegetables and increase my protein intake for basic
growth”
c. “I can decrease constipation by avoiding vegetables and fruit.”
d. “I should eat small meals every 2 to 3 hours to prevent nausea”
10. If an expectant woman is exhibiting hypertension, headache, decreased level of
consciousness, proteinuria at 4+ level, and hyperreflexia with intermittent seizures,
what condition should the nurse suspect according to the following signs and
symptoms?
a. Severe Preeclampsia
b. Eclampsia
c. Gestational Hypertension
d. Preeclampsia
11. Which of the Five P’s is representation of the fetal position and head size impacting
labor and delivery?
a. Passageway
b. Powers
c. Position (of the mother)
d. Psychological responses
e. Passenger
12. The new grad nurse has an understanding of postpartum when they’re able to recognize
which of the following as an important nursing intervention for Phototherapy?
a.
b.
c.
d.
Applying lotion to the skin to protect the baby from burning
Keep child NPO during Phototherapy
Reposition the child every 30 minutes to prevent pressure sores
Assess axillary temperature and feed child every 3 to 4 hours
13. A patient is admitted with an ectopic pregnancy. What condition in the patient’s history
would be most significant to confirming her diagnosis?
a. Client prescribed Azithromycin three weeks ago for Chlamydia
b. Client gave birth to a child 3 years ago
c. Transvaginal ultrasound shows implantation of a fertilized ovum inside of the
uterine cavity
d. Client reports no signs of abnormal bleeding or no signs of pain
14. What symptoms are common in the second trimester of pregnancy?
a. Leg cramps
b. Breast Tenderness
c. Urinary urgency and frequency
d. Heartburn
15. What test would a couple be likely to receive if the mother is 35 years old with a close
relative diagnosed with Huntington’s Disease?
a. Serum sodium level measurement
b. Stress electrocardiography
c. Genetic Counseling
d. 24-hour fasting urinalysis
16. During the third trimester, what measures may be used to address discomforts of
pregnancy?
a. Wearing a bra that provides adequate support to help with Breast Tenderness
b. Weight-lifting exercises may strengthen back and abdominal muscles
c. Lie on back when sleeping to reduce renal blood flow and urinary frequency
d. Teaching client how to perform Kegel exercises to help reduce stress
incontinence
17. Which of the following women would be most likely to undergo chorionic villus
sampling?
a. Jennifer Lopez, age 38, first pregnancy
b. Arianna Grande, age 27, first pregnancy
c. Katy Perry, age 33, first pregnancy
d. Taylor Swift, age 18, first pregnancy
18. What condition is most likely to be noted in infants who are small for gestational age
(SGA) or Large for gestational age (LGA)?
a. Elevated respiratory rate
b. Hypoglycemia
c. Decreased subcutaneous fat
d. Large head
1. e
2. c
3. b, c, f
4. a
5. c
6. d
7. f
8. a
9. c
10. b
11. e
12. d
13. a
14. d
15. c
16. d
17. a
18. b