Maternal–Newborn Nursing Comprehensive Review

Ante-Partum Assessment & Care

Weight & nutrition
- Recommended total gain for a normo-weight client: $25\text{–}35\,\text{lb}$
- Additional caloric need in 2nd/3rd trimester: $\approx 300\,\text{kcal\,day}^{-1}$
- Key micronutrient: folic acid (prevents NTDs)
Fundal-height Landmarks (single-ton, head-down)
- $12\,\text{wk}$ – just above symphysis pubis
- $20\,\text{wk}$ – at umbilicus
- $36\,\text{wk}$ – at xiphoid process, then drops at $40\,\text{wk}$ ("lightening")
Pregnancy signs
- Presumptive (felt by client): nausea-vomiting, breast tenderness, fatigue, quickening
- Probable (observed by examiner): Chadwick, Hegar, positive urine $hCG$ , cervical changes
- Positive (diagnostic): ① ultrasound visualization, ② fetal heartbeat auscultated/doppler, ③ fetal movement palpated by examiner
Routine fetal surveillance
- Non-stress test (NST) reactive = $\ge 2$ accelerations of $\ge 15\,\text{bpm}$ lasting $\ge 15\,\text{s}$ in $20\,\text{min}$
- Biophysical profile = NST $+$ U/S (tone, gross movement, breathing, AFI); score $10/10$ ideal; low score → repeat, vibroacoustic stimulation or juice, possible delivery
Genetic / lab testing
- Triple screen (maternal serum $AFP$ , estriol $E_3$ , $hCG$ ) – 2°-trimester screen for trisomies & NTDs
- Amniocentesis (diagnostic) ≈ $15\text{–}18\,\text{wk}$ ; empty bladder; continuous FHR; Rh-neg client receives RhoGAM
- Chorionic-villi sampling – 1° tri; full bladder
Rh incompatibility
- RhoGAM $300\,\mu\text{g}$ at $28\,\text{wk}$ , within $72\,\text{h}$ postpartum, and after any invasive procedure or bleeding episode if mom $Rh^-$ /baby $Rh^+$
Common ante-partum conditions
- STIs screened: chlamydia, gonorrhea (ophthalmia), HIV, syphilis, HSV-2, hepatitis B, GBS
- HSV-2 with active lesions → antiviral + elective C-section to avoid neonatal sepsis
- Gestational diabetes: start with diet/exercise → insulin; risks – macrosomia, shoulder dystocia, uterine atony, cesarean
- Ectopic pregnancy (tube) – unilateral pain ± bleed; emergency surgery ± methotrexate
- Gestational trophoblastic (hydatidiform mole) – sky-high $hCG$ , no viable fetus; hCG surveillance $\ge 6\,\text{mo}$ , avoid pregnancy
- Cervical insufficiency – painless dilation; prophylactic cerclage removed $36\text{–}37\,\text{wk}$

Intra-Partum (Labor & Delivery)

4 P’s of labor: Passage (pelvis), Passenger (fetus), Powers (contractions), Psyche (maternal emotional state)
Stages & phases
- Stage 1 dilation (latent $0\text{–}3$ cm, active $4\text{–}7$ cm, transition $8\text{–}10$ cm)
- Stage 2 – birth of neonate
- Stage 3 – placental expulsion; signs: gush of blood, lengthening cord
Normal contraction cycle: increment → acme → decrement with a rest period
FHR patterns (Veal-Chop)
- Variable = Cord compression → reposition, amnio-infusion
- Early = Head compression (OK)
- Late = Placental insufficiency → L-lateral, O2 via face mask, IV bolus, stop oxytocin, notify provider
Pharmacologic management
- Epidural (active labor) – preload with $\approx 500\text{–}1000\,\text{mL}$ LR to prevent hypotension; monitor BP, bladder, FHR; position side-lying or sit “C-curve”
- Spinal – rapid onset, typical for C-section; same hypotension risk
- Oxytocin infusion
  • Induction/augmentation labor; titrated IV
  • Stop for hyper-stimulation, fetal bradycardia, late d-cells
  • Post-partum: first-line for hemorrhage, given IV/IM
- Terbutaline $0.25\,\text{mg}$ SC q20 min × 3 (tocolytic) – max $48\,\text{h}$ ; contra in poorly-controlled asthma/cardiac disease; s/e ↑HR, tremor
- Magnesium sulfate (preeclampsia/seizure proph.) – therapeutic $4\text{–}7\,\text{mEq\,L}^{-1}$ ; monitor DTR, RR > $12$
Pre-term labor (< $37\,\text{wk}$ ) – tocolytics + steroids; goal = delay $\ge 48\,\text{h}$ for lung maturity
Third-trimester bleeding
- Placenta previa – painless bright red; placenta over os; plan C-section; no vaginal exam
- Placental abruption – painful dark bleeding, board-hard uterus; emergency delivery

Operative Birth & Perineal Management

Cesarean indications: prior classical scar, placenta previa, active HSV-2, breech, CPD, shoulder dystocia, uterine rupture, failure to progress, elective
Prep: consent, education, NPO > $8\,\text{h}$ if elective, abdominal clip, Foley, IV, spinal/epidural anesthesia (general only emergent)
Incisions: low transverse (pfannenstiel – VBAC possible) vs classical vertical (no VBAC)
Episiotomy vs physiologic tear – midline/mediolateral cut only if imminent 3°–4° tear or expedited birth

Post-Partum (Puerperium)

Uterine involution
- At umbilicus immediately PP, then ↓ $1\,\text{cm day}^{-1}$ ; non-palpable by $\approx 10–14\,\text{d}$
- Encourage voiding; fundal massage; prophylactic oxytocin IM
BUBBLE-HE assessment: Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy/Laceration, Homan’s/Extremities, Emotion
PP hemorrhage (blood loss > $500\,\text{mL}$ vag / $1000\,\text{mL}$ c-sec)
- 4 T’s: Tone (uterine atony ✓ most), Tissue (retained), Trauma, Thrombin
- Interventions: fundal massage → oxytocin → methylergonovine (hold if BP > $140/90$ ) → carboprost/misoprostol; ensure empty bladder, O2, IV fluids
Mood disorders
- Blues (< $2\,\text{wk}$ , self-limiting)
- Depression – anhedonia, guilt, lasts > $2\,\text{wk}$ ; treat talk therapy ± SSRIs
- Psychosis – hallucinations, SI/HI; psych emergency, 24-h supervision, antipsychotics, possible admission
Lactation & Breast Care
- Feeding frequency: q $2\text{–}3\,\text{h}$ (≈ $8\text{–}10$ feeds day)
- Colostrum first $2\text{–}3\,\text{d}$ – antibody-rich, high fat
- Effective feed indicators: audible swallow, content infant, $\ge 6$ wet diapers & $\ge 3$ yellow seedy stools day by day 4, pain-free latch
- Mastitis: unilateral redness, flu-like sx; continue breastfeeding, warm compress, analgesia, antibiotics PRN
Family planning
- Lactational amenorrhea effective only if exclusive BF, q ≤ $4\,\text{h}$ day/ $6\,\text{h}$ night, infant < $6\,\text{mo}$ ; no STI protection

Neonatal Adaptation & Assessment

Immediate care: Dry, warm, stimulate; airway suction PRN; APGAR $\times 1\,5\,10\,\text{min}$
Prophylaxis: Vitamin K IM, erythromycin eye ointment, Hep B vax
Bonding: Skin-to-skin within $\le 1\,\text{min}$ , room-in 24/7
Thermoregulation: neutral-thermal environment, hat, swaddle; avoid cold stress (↑O₂ consume, hypoglycemia, acidosis)
Elimination milestones
- First void & meconium within $24\,\text{h}$
- Stool sequence: meconium (black-tarry) → transition (green-brown) → milk stool (yellow-seedy BF / tan-pasty formula)
Weight categories & risks
- SGA/IUGR and LGA (macrosomia) both prone to $\text{hypoglycemia}$ – monitor serial BGL; early feeds IV D10 if needed
Respiratory Distress Syndrome (surfactant deficit)
- S/S: nasal flaring, grunting (expiratory), retractions, cyanosis, RR > $60\,/\text{min}$
- Initial management: suction → tactile stimulation → O₂ CPAP; definitive = endotracheal surfactant instillation

High-Yield Obstetric & Newborn Medications

Oxytocin – labor induction ( $0.5\text{–}2\,\text{mU min}^{-1}$ ) titrate q30–40 min; PP hemorrhage $10\,\text{U IM}$ or $20\,\text{U in 1000 mL}$ LR
Methylergonovine $0.2\,\text{mg IM}$ q2–4 h (max 5); hold for hypertension
Terbutaline $0.25\,\text{mg SC}$ q20 min ×3; max $48\,\text{h}$ ; side-effects ↑HR (≤ $120$ ) tremor; avoid in uncontrolled asthma/CV disease
Magnesium sulfate loading $4\,\text{g}$ over $20\,\text{min}$ then $1\text{–}2\,\text{g h}^{-1}$ ; antidote = calcium gluconate $1\,\text{g}$ IV push over $3\,\text{min}$

Universal “ROADIE” Intra-Partum Rescue Steps

R – Reposition (left-lateral)
O – Oxygen (non-rebreather $10\text{–}12\,\text{L min}^{-1}$ )
A – Administer IV fluid bolus
D – Discontinue oxytocin
I – Initiate tocolytic (terbutaline) if hyper-stimulation
E – Engage provider / escalate care

Exam Preparation Tips

Practice question source with highest fidelity to HESI: Evolve/HESI case studies & question banks
Expect focus on postpartum hemorrhage > pre-eclampsia; no fetal-monitor strips on exam but know interpretations
Dimensional-analysis IV-drip problems likely limited to simple unit conversion (remove grams → mL h)