Mark Klimek NCLEX Review: Maternity and Neonatology
Mark Klimek NCLEX Review: Maternity and Neonatology
Determining the estimated date of delivery
Use the Naegele’s rule—take first day of last menstrual period (LMP), add 7 days and subtract 3 months from it
- For instance, if the last menstrual period of a patient was between June 10 and 15
- The estimated date of delivery = March 17
Weight gained during pregnancy
- 1st trimester (12 weeks)
- 1 lb per month = Total of 3 lbs
- 2nd and 3rd trimesters
- Add 1 lb every week
- The ideal weight gained during pregnancy
- 28 lbs, plus or minus 3
- Between 25 to 31 lbs
Alternative method
A quick and dirty way to come up with the ideal weight gained during pregnancy is to
- Take the number of weeks gestation minus 9
Question
A woman is in her 28th week gestation. She gained 22 lbs, what is your impression?
Using the long method
- First trimester (12 weeks) … She gained 3 lbs
- 28 weeks minus 12 weeks = 16 weeks
- Therefore, she would add an extra 16 lbs on her weight
- 3 + 16 = 19 lbs … She has 3 lbs extra than her ideal weight
- Therefore, assess the patient
Alternatively, subtract 9 from the number of weeks gestation
- 28 – 9 = 19 lbs
Question
A pregnant woman at 31 weeks gestation gained 15 lbs. what is your impression?
Using the short method, this patient ideal weight should be
- 31 – 9 = 22 lbs
- However, 22 – 15 = 7 lbs less than the ideal
- Therefore, the nurse needs to assess the biophysical profile (BPP) on the fetus
Fundal Height
- Fundal height cannot be palpated until week 12
- That when the fundus is midway between the umbilicus and the pubic symphysis
- The fundus can be palpated at the umbilicus between 20 and 22 weeks
What is the significance of being able to palpable fundal height?
The examiner should be able to determine in what trimester the pregnancy is
- In case patient is unconscious, for instance
- It has diagnostic significance as well … A much bigger than normal fundus may indicate molar pregnancy
Positive Signs of Pregnancy
The Boards test positive signs and everything else
1. Fetal skeleton on x-ray
2. Presence of fetus on ultrasound
3. Auscultation of fetal heart (Doppler)
4. Examiner palpates fetal movement (outline)
- Not the mother but the examiner
Ranges of Values
In OB, there are 3 types of questions regarding range of values
For instance, the fetal HR can be heard first between 8 to 12 weeks gestation Quickening (baby Qicks) may be first felt between 16 to 20 weeks gestation Therefore, if the question asks:
• When would you first?
- Fetal Heart: 8 weeks
- Quickening: 16 weeks
- This is the earliest date
• When would you most likely?
- Fetal Heart: 10 weeks
- Quickening: 18 weeks
- This is the date midway in the range
• When should you __________ by?
- Fetal Heart: 12 weeks
- Quickening: 20 weeks
- This is the latest date
Maybe Signs of Pregnancy
1. Positive urine/blood hCG tests
- A positive pregnancy test may result from other conditions
- For instance, cancer
2. Chadwick sign—cervical color change to cyanosis (Cs)
- Bluish discoloration of the vulva, vagina and cervix
3. Goodell sign—good and soft
- Softening of the cervix
4. Hegar sign—uterine softening
- Softening of lower uterine segment
Chadwich à Goodells à Hegar
- All 3 signs are in alphabetical order and
- Move up from the vulva, vagina, cervix to the uterus
Patient Teaching for Prenatal Visit
During pregnancy, patient is advised to go for prenatal visits as follows
- Once a Month until week 28
- Every other week between 28 and 36
- Once a week after week 36 until delivery or week 42, whichever comes first
- At week 42, delivery can be induced or by C-section
Question
If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit?
A: Her next visit is at 16 weeks
Lab Values
Hemoglobin (Hb) level will fall during pregnancy
- Normally Hb in female = 12 – 16
- A pregnant woman can tolerate lower levels of Hb
- First Trimester: Hb can fall to 11 and be perfectly normal
- Second Trimester: Hb can fall to 10.5 and be perfectly normal
- Third Trimester: Hb can fall to 10 and be perfectly normal
Question
How do you treat morning sickness?
- Morning sickness is usually seen during the 1st trimester
- Treatment: Dry carbohydrates—not before breakfast but—before patient gets out of bed
Question
How do you deal with urinary incontinence?
- Urinary incontinence is seen in the 1st and 3rd trimesters
- Patient needs to void every 2 hours from the day she gets pregnant until 6 weeks postpartum
Question
A pregnant patient complains of difficulty breathing. What should you advise her to do?
- Difficulty breathing is a problem during the 2nd and 3rd trimesters
- Advise patient to assume to tripod position
- Tripod position is a physical stance often assumed by people experiencing respiratory distress
- The patient will be leaning forward with hands on knees or the surface of a desk or table
Question
A pregnant patient complains of back pain. What should you advise her to do?
- Back Pain is seen during the 2nd and 3rd trimester
- Advise pelvic tilt exercises to patient
Labor and Birth
What is the truest most valid sign that she is in labor?
- The truest most valid sign of labor is the onset of regular/progressive contractions
To Know
- Dilation is opening cervix from 0 to 10 cm
- Effacement is thinning of the cervix. It goes from thick to 100% efface (thin like paper)
- Station is the relation between fetal presenting part and the mother’s ischial spines (know this) - the narrowest part of the pelvis
- Positive numbers mean the baby has made it through this tight squeeze—good
to go.
- Positive numbers = Positive news.
- If a baby stays at a –3, –2, –1, it can’t get through vaginally. It needs C-
section for delivery.
- Engagement is station zero—this means the presenting part is at the ischial spines
Lie is relationship between the spine of the mother and spine of the baby
- You want a vertical lie—compatible with vaginal birth
- If the mother’s spine and the baby’s spine is parallel—we got a baby
- If lie is perpendicular—transverse lie = Trouble … C-section
- If we got them perpendicular, we’ve got trouble-T
Most common presentation is ROA or LOA - that’s the guess—don’t bother memorizing
- ROA (right occiput anterior)
- LOA (left occiput anterior)
- Pick ROA before LOA
Delivery of the Fetus and the Placenta
There are 4 stages of labor
Stage 1 Onset of Labor - It has 3 phases
• Latent - cervical dilation from 0 to 4 cm
- Phase 1
- Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds
- Mild intensity
• Active - cervical dilation from 5 to 7 cm
- Phase 2
- Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds
- Moderate intensity
• Transition - cervical dilation from 8 to 10 cm
- Phase 3
- Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds
- Strong intensity
Question
A pregnant woman comes into L&D (labor and delivery). She is 5 cm dilated, with contraction 5 minutes apart, lasting 45 seconds. What phase of labor is the pt in?
- The patient is in ACTIVE phase
One good studying strategy to use for memorizing the 3 phases of Stage 1 labor is to know everything about the Active (or Phase 2) of Stage 1
- Once you know the upper and lower limit values, you can deduce the values of Phase 1 and Phase 3
- Phase 2 — Contractions: 3 to 5 minutes and last 30 to 60 seconds
Stages and Phases of Labor
• Stage 1 - Onset of Labor à Cervical Dilation and Effacement
- Phase 1 - Latent
- Phase 2 - Active
- Phase 3 - Transition
• Stage 2 - Delivery of Baby
• Stage 3 - Delivery of Placenta
• Stage 4 - Recovery: 2 hours until bleeding stops
HESI Questions
What is purpose of uterine contraction in first stage?
- Dilation and effacement of the cervix
What is the purpose in 2nd stage?
- Delivery of baby
What is the purpose 3rd stage?
- Delivery of placenta
What is the purpose of 4th stage?
- Stop bleeding
When does postpartum technically begin?
- 2 hours after delivery of placenta
Pay attention to whether the question is asking about stages or phases
- There are 4 stages
- There are 3 phases, which are part of Stage 1
Questions
What is the #1 priority of second phase?
- Pain management
What is the #1 priority of second stage?
- Clearing baby’s airway
What is the #1 priority of third phase?
- Checking cervical dilation, Helping pregnant mother with breathing and pain management
What is the #1 priority of third stage?
- Assess the placenta for smoothness and intactness, and for 3-vessel (not 2) umbilical cord present
Memorize for the following 3 questions,
Uterine contraction should be no longer than 90 seconds and no closer than 2 minutes
Questions
What is a sign of uterine tetany?
- No longer than 90 seconds and no closer than 2 minutes.
What parameters regarding uterine contraction would make you stop Pitocin?
- No longer than 90 seconds and no closer than 2 minutes
What is uterine hyperstimulation?
- No longer than 90 seconds and no closer than 2 minutes
Know that phrase
No longer than 90 seconds and no closer than 2 minutes
Assessment of frequency of contraction
- Frequency is from the beginning of one contraction and beginning of the next
Assessment of duration of contraction
- Duration of contraction is from the beginning to end of one contraction
Intensity of labor
- Assessment of intensity of labor is purely subjective
- Teach her how to palpate with one hand over the fundus with the pads of the fingers
Complications of labor
- There are 18 complications
- Know them all
- But only 3 protocols—focus on the 3 protocols
Painful Back pain - “OP” = Oh Pain. What do you do?
- Position - Push
What position?
- KNEE-CHEST position
then
- PUSH with fist into sacrum to use counter pressure
Prolapsed Cord
- Push head in off cord and position knee-chest or
Trendelenburg
- Prep for C-section
- Think PUSH/POSTION
- Push head off the cord of fetus and position mother to knee-chest
Interventions for ALL other complications
- Tetany
- Maternal hypertension
- Vena cava syndrome
- Toxemia
- Uterine rupture
- All treated the same—with “LION”
- Left side (place mother on the left side)
- IV
- Oxygen
- Notify HCP
- Stop Pitocin (pit) if it was running—the first thing to do
Implement before “LION”
- In an OB crisis, if Pitocin is running, stop it first. Then, implement “LION”
When to administer systemic pain medication
- Do not administer a systemic pain medication to a woman in labor if the baby is likely to be born when the med is at its peak … For example
Questions
You have a primigravida at 5-cm dilated who wants her IV push pain med. What is the nursing intervention?
- Hold the pain medication
- This is because the patient is primigravida and will deliver in about 15 to 30
minutes when the medication peaks
You have a multigravida at 8-cm wants her IM pain med. What is the nursing intervention?
- Do not administer the pain medication