Maternal & Newborn NCLEX-RN Study Guide

Overview

This study guide covers essential maternal and newborn nursing concepts tested on the NCLEX-RN, including antepartum, intrapartum, postpartum, and newborn care. Mastery of these topics requires understanding normal versus abnormal findings, priority nursing interventions, and pharmacological considerations. Focus on recognizing clinical presentations and applying the nursing process to maternal-newborn scenarios.

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Antepartum Care

Gestational Age & Dating

Terminology for Gestational Age at Birth:

Nagele's Rule Formula:

> First day of LMP − 3 months + 7 days + 1 year = EDD (Estimated Date of Delivery)

Fundal Height Assessment:

#### Key Terms

> Watch Out For: Students often confuse Nagele's Rule direction — you subtract 3 months and add 7 days, not the reverse. Also remember that gestational age is counted from the LMP, not conception.

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Hypertensive Disorders of Pregnancy

#### Preeclampsia

#### Eclampsia

1. Ensure patent airway (first priority)

2. Protect client from injury

3. Position on left lateral side after seizure

4. Administer magnesium sulfate as ordered

5. Notify provider

#### Magnesium Sulfate — Key Points

| Assessment | Therapeutic Range | Toxicity |

|------------|------------------|---------|

| DTRs | Present and normal | Absent DTRs = FIRST sign of toxicity |

| Respirations | 12–16 breaths/min | <12 breaths/min |

| Urine output | ≥30 mL/hr | <30 mL/hr |

| Serum Mg²⁺ | 4–7 mEq/L | >7 mEq/L |

#### Key Terms

> Watch Out For: The earliest sign of magnesium toxicity is loss of DTRs, not respiratory depression. Always assess DTRs before each dose or continuously during infusion.

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Complications: Hydatidiform Mole

Classic Signs of Molar Pregnancy:

> Watch Out For: Molar pregnancy is associated with extremely high hCG, which can also cause hyperemesis gravidarum. After evacuation, serial hCG levels must be monitored to rule out gestational trophoblastic disease (choriocarcinoma).

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Intrapartum Care

Fetal Heart Rate Monitoring

| Deceleration Type | Cause | Shape | Priority Action |

|-------------------|-------|-------|----------------|

| Early | Head compression (normal) | Mirror contraction | Continue monitoring |

| Late | Uteroplacental insufficiency / fetal hypoxia | After peak of contraction | Reposition left lateral, ↑IV fluids, O₂ via face mask, notify provider |

| Variable | Umbilical cord compression | Abrupt, V-shaped | Change position (side-to-side, knee-chest, Trendelenburg) |

Late Deceleration Priority Actions (VEAL CHOP Mnemonic):

> Variable = Cord compression | Early = Head compression | Acceleration = Okay | Late = Placental insufficiency

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Labor Complications

#### Active Phase Arrest

- No change for ≥4 hours with adequate contractions

- No change for ≥6 hours with inadequate contractions

#### Umbilical Cord Prolapse — EMERGENCY

Priority nursing actions in order:

1. Manually push the presenting part off the cord with a gloved hand (FIRST action)

2. Maintain this hand position continuously

3. Call for help

4. Administer oxygen

5. Prepare for emergency cesarean delivery

#### Oxytocin (Pitocin) — Tachysystole

#### Placental Abruption — Four Classic Signs

1. Sudden onset of dark red or absent vaginal bleeding

2. Rigid, board-like abdomen

3. Severe abdominal/back pain

4. Uterine tenderness

#### Key Terms

> Watch Out For: Differentiate between placenta previa (painless, bright red bleeding) and placental abruption (painful, dark red/absent bleeding, board-like abdomen). The pain is the key distinguishing feature.

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Spontaneous Rupture of Membranes (SROM)

Priority Assessment Order:

1. Assess fetal heart rate FIRST (to detect cord prolapse)

2. Assess color, odor, and amount of amniotic fluid

3. Document time of rupture

Normal amniotic fluid: Clear to slightly cloudy, no foul odor

Concerning findings: Green (meconium), foul odor (infection), bloody

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Postpartum Care

BUBBLE-HE Assessment Framework

| Letter | Assessment Area |

|--------|----------------|

| B | Breasts (engorgement, nipple condition, lactation) |

| U | Uterus (fundal height, firmness, position) |

| B | Bladder (voiding, distension) |

| B | Bowel (function, hemorrhoids) |

| L | Lochia (color, amount, odor) |

| E | Episiotomy/Perineum (REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation) |

| H | Homan's sign/Lower extremities (DVT assessment) |

| E | Emotional status (bonding, postpartum mood) |

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Uterine Involution

Fundal Height Progression:

#### Boggy Uterus — Clinical Priority

| Finding | Most Likely Cause | Priority Action |

|---------|------------------|----------------|

| Boggy uterus displaced to the right | Full bladder | Have client void; catheterize if unable |

| Boggy uterus midline | Uterine atony | Fundal massage, oxytocin |

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Postpartum Hemorrhage (PPH)

The 4 T's of PPH:

Risk Factors for Uterine Atony:

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Contraception & Breastfeeding

- Progestin-only pills (mini-pill)

- IUD (after 6 weeks)

- Barrier methods

- Depo-Provera (after 6 weeks)

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RhoGAM Administration

> Watch Out For: RhoGAM must be given within 72 hours — this is a strict window. It is not given if the infant is also Rh-negative. Also remember it is indicated after any pregnancy event (including miscarriage or ectopic), not just delivery.

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Lochia Progression

| Type | Timing | Color | Characteristics |

|------|--------|-------|----------------|

| Rubra | Days 1–3 | Red | Blood, decidua |

| Serosa | Days 4–10 | Pink/brown | Mixed fluids |

| Alba | Day 10–6 weeks | White/yellow | Leukocytes, mucus |

Abnormal lochia: Foul odor (infection), return to rubra after serosa/alba (hemorrhage), large clots

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Newborn Care

APGAR Scoring

| Criteria | 0 | 1 | 2 |

|----------|---|---|---|

| Appearance (color) | Blue/pale all over | Blue extremities, pink body | Completely pink |

| Pulse (heart rate) | Absent | <100 bpm | ≥100 bpm |

| Grimace (reflex) | No response | Grimace | Cough/sneeze/cry |

| Activity (muscle tone) | Limp | Some flexion | Active motion |

| Respirations | Absent | Weak/irregular | Strong cry |

Scoring Interpretation:

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Normal Newborn Vital Signs

| Parameter | Normal Range |

|-----------|-------------|

| Heart rate | 110–160 bpm |

| Respiratory rate | 30–60 breaths/min |

| Axillary temperature | 36.5–37.5°C (97.7–99.5°F) |

| Blood pressure | 60–80/40–50 mmHg |

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Newborn Hypoglycemia

> Watch Out For: Newborn hypoglycemia can be asymptomatic or present with jitteriness, poor feeding, high-pitched cry, or seizures. Screening is done based on risk factors, not just symptoms.

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Meconium-Stained Amniotic Fluid

| Newborn Status | Action |

|----------------|--------|

| Vigorous (good tone, strong cry, HR >100) | Routine suctioning at mouth and nose |

| Not vigorous (poor tone, weak/absent cry, HR <100) | Immediate intubation and suctioning |

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Neonatal Jaundice (Hyperbilirubinemia)

| Type | Onset | Cause | Classification |

|------|-------|-------|---------------|

| Pathological | <24 hours | Hemolytic disease (Rh/ABO incompatibility) | Abnormal — requires treatment |

| Physiological | Days 2–3 (term) | Normal RBC breakdown | Normal — resolves spontaneously |

Risk of untreated hyperbilirubinemia: Kernicterus (bilirubin deposits in brain → permanent neurological damage)

Treatment — Phototherapy:

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Newborn Reflexes

| Reflex | Stimulus | Normal Response | Disappears |

|--------|----------|----------------|------------|

| Babinski | Stroke lateral sole heel to toe | Toe fanning + dorsiflexion of big toe | ~2 years |

| Moro | Sudden movement/sound | Arms extend then flex (startle) | 4–6 months |

| Rooting | Stroke cheek | Turns toward stimulus | 4 months |

| Sucking | Object in mouth | Sucking motion | 12 months |

| Grasp | Finger in palm | Grasps finger | 4–6 months |

> Watch Out For: The Babinski reflex is normal in newborns but abnormal in adults (indicates upper motor neuron lesion). Don't confuse normal newborn reflexes with pathological adult findings.

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Newborn Medications

#### Erythromycin Ophthalmic Ointment

#### Vitamin K (Phytonadione)