Comprehensive Nursing and Obstetric Signs, Calculations, and Interventions

How do you calculate estimated date of delivery (EDD)?

Naegele's Rule = First day of LMP + 7 days - 3 months (+1 year if needed)

What is normal pregnancy weight gain?

25-35 lb total (about 28 lb average)

What is the NCLEX shortcut for expected pregnancy weight gain?

Gestational weeks - 9 = expected pounds gained

What is the fundal height at 12 weeks?

Just above symphysis pubis

What is the fundal height at 20 weeks?

At the umbilicus

What is the fundal height at 36 weeks?

At the xiphoid process

What are positive signs of pregnancy?

Fetal heart tones, fetus seen on ultrasound, examiner palpates fetal movement, fetal skeleton on x-ray

What are presumptive signs of pregnancy?

Amenorrhea, nausea, fatigue, breast changes, quickening

What is the Goodell sign?

Softening of the cervix

What is the Chadwick sign?

Bluish discoloration of cervix and vagina

What is the Hegar sign?

Softening of lower uterine segment

What is the prenatal visit schedule?

Monthly until 28 weeks, every 2 weeks until 36 weeks, weekly until delivery

What is the normal hemoglobin during pregnancy?

1st trimester ≥11 g/dL, 2nd trimester ≥10.5 g/dL, 3rd trimester ≥11 g/dL

What is the teaching for morning sickness?

Eat dry crackers/carbohydrates before getting out of bed

What is the teaching for urinary frequency during pregnancy?

Void every 2 hours

What is the teaching for back pain during pregnancy?

Pelvic tilt exercises

What is the teaching for dyspnea during pregnancy?

Tripod position

What is the truest sign of labor?

Regular contractions causing cervical change

What is dilation?

Opening of cervix from 0-10 cm

What is effacement?

Thinning of cervix from 0-100%

What is station?

Relationship of presenting part to ischial spines

What is engagement?

Station 0

What is Stage 1 labor?

Cervical dilation and effacement

What is Stage 2 labor?

Delivery of baby

What is Stage 3 labor?

Delivery of placenta

What is Stage 4 labor?

Recovery period after placenta delivery

What is the latent phase of labor?

0-4 cm dilation

What is the active phase of labor?

5-7 cm dilation

What is the transition phase of labor?

8-10 cm dilation

When should Pitocin be stopped?

Contractions longer than 90 seconds or closer than every 2 minutes

What is uterine tachysystole?

Contractions >90 seconds or <2 minutes apart

What is the normal fetal heart rate?

110-160 bpm

What does the VEAL CHOP mnemonic stand for?

Variable=Cord compression, Early=Head compression, Accelerations=OK, Late=Placental insufficiency

What are early decelerations?

Head compression, expected finding

What are variable decelerations?

Cord compression

What are late decelerations?

Placental insufficiency

What is the intervention for late decelerations?

LION = Left side, IV fluids, Oxygen, Notify provider (stop Pitocin first)

What does low baseline variability indicate?

Bad sign, possible fetal hypoxia

What does high baseline variability indicate?

Reassuring sign

What is the delivery sequence after the head emerges?

Head, mouth suction, nose suction, check nuchal cord, shoulders, body

What is checked after placenta delivery?

Placenta intact and 3-vessel cord present

What are the three postpartum assessments most tested?

Fundus, lochia, thrombophlebitis

What is a normal postpartum fundus?

Firm, midline, at umbilicus

What is the intervention for a boggy fundus?

Massage fundus

What is the intervention for a boggy displaced fundus?

Empty bladder/catheterize

What is the lochia progression?

Rubra → Serosa → Alba

What is the best assessment for postpartum thrombophlebitis?

Bilateral calf circumference comparison

What is the most common cause of postpartum hemorrhage?

Uterine atony

What is the first intervention for uterine atony?

Massage fundus

What is the second intervention if fundus remains boggy?

Empty bladder

What are milia?

Small white facial papules, normal

What are Epstein pearls?

Small white cysts in mouth, normal

What are Mongolian spots?

Blue-gray sacral patches, normal

What is erythema toxicum?

Flea-bitten newborn rash, normal

What is acrocyanosis?

Blue hands and feet in newborn, normal first few days

What is caput succedaneum?

Edema that crosses suture lines

What is cephalohematoma?

Blood collection that does NOT cross suture lines

What is physiologic jaundice?

Appears after 24 hours of life

What is pathologic jaundice?

Appears within first 24 hours

What is the use of terbutaline?

Tocolytic to stop preterm labor

What is a major side effect of terbutaline?

Maternal tachycardia

What is the use of magnesium sulfate?

Prevent/treat seizures in preeclampsia

What are signs of magnesium toxicity?

Respiratory depression, absent reflexes, decreased LOC

What is the therapeutic magnesium sulfate assessment?

Respirations >12, urine output >30 mL/hr, reflexes present

What is the antidote for magnesium sulfate?

Calcium gluconate

What is a complication of Pitocin?

Uterine tachysystole/hyperstimulation

What is a major side effect of Methergine?

Hypertension

When should Methergine be avoided?

Hypertension or preeclampsia

What is the purpose of betamethasone?

Accelerates fetal lung maturity

What is the purpose of surfactant?

Treats/prevents neonatal respiratory distress syndrome

What are signs of preeclampsia?

Hypertension, proteinuria, edema, headache, hyperreflexia, visual changes

What are signs of severe preeclampsia?

BP ≥160/110, headache, RUQ pain, blurred vision, clonus

What is the priority intervention for severe preeclampsia?

Prevent seizures with magnesium sulfate

What is eclampsia?

Preeclampsia with seizures

What is placenta previa?

Painless bright red vaginal bleeding

What is the NCLEX rule for placenta previa?

No vaginal examinations

What is placental abruption?

Painful bleeding with rigid abdomen

What are the indications for Rhogam?

Rh-negative mother at 28 weeks and within 72 hours postpartum

What is the purpose of Rhogam?

Prevent maternal antibodies against Rh-positive fetus

What is the major complication of gestational diabetes?

Macrosomia

What is the most common newborn complication of diabetic mothers?

Hypoglycemia

What is shoulder dystocia?

Shoulder stuck after head delivers

What is the intervention for shoulder dystocia?

McRoberts maneuver and suprapubic pressure

What is oligohydramnios?

Too little amniotic fluid

What is polyhydramnios?

Too much amniotic fluid

What is the first nursing action after delivery?

Maintain airway and warmth

What are the four newborn heat loss mechanisms?

Evaporation, Conduction, Convection, Radiation

What are the APGAR components?

Appearance, Pulse, Grimace, Activity, Respirations

When is APGAR measured?

1 minute and 5 minutes

What is a normal APGAR score?

7-10

What are signs of neonatal hypoglycemia?

Jitteriness, tremors, irritability, lethargy, poor feeding

What are signs of newborn respiratory distress?

Grunting, retractions, nasal flaring, tachypnea

Why do newborns receive Vitamin K?

Prevent bleeding due to immature clotting factor production

Why do newborns receive erythromycin eye ointment?

Prevent gonococcal ophthalmia neonatorum

What is the age for the sensorimotor stage?

0-2 years

How do you teach a sensorimotor child?

Teach while procedure is occurring

What is the age for the preoperational stage?

3-6 years

How do you teach a preoperational child?

Use play and teach shortly before procedure

What is the age for the concrete operational stage?

7-11 years

How do you teach a concrete operational child?

Demonstrations and rules, 1-2 days before procedure