NCLEX: Caring for the Maternal/Infant Client

Terms you’ll need to understand:
Abortion
Alpha-fetoprotein
Amenorrhea
Braxton Hicks contractions
Caput succedaneum
Cervix
Cesarean section
Chadwick’s sign
Colostrum
Condylomata acuminate
Contraception
Decelerations
Disseminated intravascular coagulation
Dystocia
Ectopic pregnancy
Epidural anesthesia
Estriol
Fetal monitoring
Fundus
Goodell’s sign
Gravida
Hegar’s sign
HELLP
Herpes
Human papillomavirus (HPV)
Hydatidiform mole
Hyperbilirubinemia
Hyperemesis gravidarum
Isoimmunization
Leopold’s maneuvers
Linea nigra
McDonald’s sign
Multigravida
Nagel’s rule
Nullipara
Oligohydramnios
Oxytocin
Papanicolaou smear
Para
Pica
Polyhydramnios
Preeclampsia
Premature rupture of membranes
Preterm labor
Prostaglandin
Pulmonary surfactants
Rubella
Sexually transmitted infections
TORCH
Toxic Shock Syndrome
Toxoplasmosis
Ultrasonography
Wharton’s jelly

Nursing skills you’ll need to master:
Performing pediatric dextrostix
Checking for cervical dilation
Performing fetal monitoring

This guide focuses on the health needs of the obstetric client and newborn infant. Methods of birth control, prenatal care, and diseases affecting women are also discussed. After reviewing this chapter, the nurse should be able to answer commonly asked questions and provide teaching for the client and family.

Signs of Pregnancy
Signs of pregnancy include presumptive signs, probable signs, and positive signs. Presumptive signs are subjective and can be associated with some other gynecological alteration. Probable signs can be documented and are more conclusive; however, these signs can also be associated with conditions other than pregnancy. Only three physical findings establish the diagnosis of pregnancy, and these are known as positive signs of pregnancy.

Presumptive Signs
Presumptive signs of pregnancy are those signs and symptoms that lead the client to believe she is pregnant but that are not conclusive. Symptoms make the client suspect pregnancy. These include
- Amenorrhea
- Breast sensitivity
- Chadwick’s sign
- Fatigue
- Fingernail changes
- Linea nigra
- Quickening
- Urinary frequency
- Weight gain

Probable Signs
Probable signs of pregnancy are more conclusive but are still not definitive.
Even though the client believes she is pregnant, more tests should be done to conclude that a pregnancy exists. The probable signs of pregnancy are
- Balottement
- Chadwick’s sign
- Goodell’s sign
- Hegar’s sign
- Positive pregnancy test
- Uterine enlargement

Positive Signs
There are only three definite signs of pregnancy. These tell the client she is positively having a baby. These signs are
- Fetal heart tones
- Leopold’s maneuver
- Ultrasound of the fetal outline

Prenatal Care
Early prenatal care provides the nurse the opportunity to teach the client and family members. A systematic physical exam and health history give the healthcare provider information needed to treat and prevent fetal anomalies.
Screening tests can also be performed during the prenatal visit to detect diseases that affect the mother and fetus. It has been found that the earlier the pregnant client begins to visit the doctor, the better the outcome for the infant and mother. In this section, you will discover prenatal topics and information that might be tested on the NCLEX® exam.

Prenatal Diet and Weight Maintenance
During the prenatal period, the nurse should encourage the client to eat foods high in vitamins and minerals. A weight gain of approximately 36 pounds is allowable, and weight reduction during pregnancy is discouraged.
Prior to pregnancy, the client should be encouraged to increase the intake of foods high in vitamins such as B9 (folic acid). The ingestion of folic acid has been linked to a reduction of neural tube defects such as spina bifida and myelomeningocele. Prenatal diagnostic studies can be performed to detect neural tube defects.

Alpha-Fetoprotein Screening
Alpha-fetoprotein levels can be done between 16 and 20 weeks gestation.
Alpha-fetoprotein levels are considered a screening tool and are not diagnostic.
This level can be tested by obtaining a blood sample from the mother. Alphafetoprotein is a glucoprotein produced by the fetal yolk sac, gastrointestinal tract, and liver. This protein passes through the placenta to the maternal circulation and is excreted through fetal circulation and into the mother’s circulation.
Normal ranges for each week of pregnancy are measured.
When abnormal levels are detected, an amniocentesis should be performed. An amniocentesis can be done as early as 16 weeks; this allows adequate time for amniotic fluid to accumulate. An ultrasound exam of the uterus is performed prior to the amniocentesis to locate the placenta and the pockets of amniotic fluid. The client is instructed to drink large amounts of fluids to fill the bladder and not to void until after the exam. When the fetus is visualized and pockets of amniotic fluid are found, the client is instructed to void. A sample of amniotic fluid is then removed using a large bore needle. The client is instructed to remain in the clinic for approximately 2 hours and to report any bleeding or cramping.
Prior to 20 weeks gestation, leave the bladder full for amniocenthesis. After 20 weeks the bladder should be empty.

Other Prenatal Diagnostic Tests
Many other diagnostic studies can also be done from examination of amniotic fluid. Although amniocentesis is an invasive procedure with risk, the benefits of early diagnosis are many. Following the amniocentesis, the client should be told to report any cramping or bleeding and avoid lifting objects heavier than 5 pounds for several days. Some of the tests that can be performed on the amniotic fluid are lecithin/sphingomyelin (L/S) ratios, which detect lung maturity; estriol levels, which indicate fetal distress; and creatinine levels, which indicate renal function. Teratogenic effects of drugs and disease can also be detected by checking the amniotic fluid. Some examples of teratogenic agents are
- Accutane
- Alcohol
- Cytomegalovirus
- Herpes
- LSD
- Rubella virus
- Syphilis
- Tetracycline
- Toxoplasmosis
TORCHS is a syndrome that includes toxoplasmosis, rubella, cytomegalovirus, herpes, and syphilis.

Measuring Fetal Heart Tones
The fetal heart tone should be checked frequently to measure the viability and status of circulating blood to the fetus. This noninvasive technique can be obtained by use of a fetoscope or tocomonitor.
Fetal heart tones can be heard with a fetoscope at approximately 18–20 weeks and with a Doppler ultrasound at approximately 12 weeks.

Signs of Complications of Pregnancy
There are many complications of pregnancy. The nurse should instruct the client to report to a doctor if she has any of the following symptoms:
- Persistent vomiting—Hyperemesis gravidarum (nausea and vomiting after the first trimester) can lead to fluid and electrolyte imbalances.
- Vaginal bleeding—Can be an indication of placenta previa (placenta over cervix, which produces painless bleeding), abruptio placenta (separation of the placenta before the third stage of labor, which produces painful bleeding), or a threatened abortion.
- Abdominal pain—Can indicate a threatened abortion, an ectopic preg- nancy (pregnancy outside the body of the uterus; if it ruptures, peritonitis results), or abruptio placenta.
- Incompetent cervix—Causes a spontaneous abortion. This problem is corrected by performing a McDonalds’, cerclage or Shirodkar procedure to close the cervix.
- Vertigo, headache, or edema of the hands and face—Can indicate preeclampsia.
- Premature rupture of membranes—Can indicate premature labor and lead to infections.
- Chills and fever—Can be an indication of a urinary tract infection or sepsis.
- Excessively rapid uterine enlargement—Can indicate a hydatidiform mole.

A hydatidiform mole is a rapid proliferation of cells within the uterus due to trophoblastic disease. A complete molar pregnancy results from fertilization of an egg whose nucleus has been lost. The rapid cell growth can be associated with chorionic carcinoma. The client with a hydatidiform mole is treated by performing a dilation and curettage. The client should be instructed not to become pregnant for at least a year following a hydatidiform mole because a rising human chorionic gonadatropin (HCG) level will stimulate cancer cell growth.

Types of Abortions
Several types of abortions can be experienced by the client:
- Elective abortion—Evacuation of the fetus. There are several types of elective abortions, but all of them require early diagnosis of the pregnancy.
- Threatened—Produces spotting. The treatment is bed rest. If bleeding or cramping continues, the client should contact the physician immediately because the doctor might order tocolytic medications such as magnesium sulfate, bethrine, or yutopar.
- Inevitable—If there are no fetal heart tones and parts of the fetus are passed, the client is said to be experiencing an inevitable abortion. This type of abortion produces bleeding and passage of fetal parts. The treatment is a dilation and curettage (D & C).
- Incomplete—In an incomplete abortion, fetal demise exists but part of the conception is not passed. The treatment is a dilation and evacuation (D & E).
- Complete—In a complete abortion, all parts of the conception are passed. There is no treatment.
- Septic—A septic abortion includes the presence of infection. The treat- ment is administering antibiotics.
- Missed—In a missed abortion, there is fetal demise but there is no expulsion of the fetus. The treatment is an induction of labor or a surgical removal of the fetus.

Complications of all types of abortion include bleeding and infection. The client should be taught to report to the doctor any bleeding, lethargy, or elevated temperature.

Abnormalities Effecting Pregnancy
Several complications are commonly encountered by obstetric clients. This section covers diabetes in pregnancy, problems with elevated blood pressure, bleeding disorders, cord prolapse, abruption placenta, sexually transmitted infections, and premature labor.

Diabetes in Pregnancy
Clients with diabetes, and their infants, are at risk for complications during pregnancy. Infants of diabetic mothers tend to be large for gestational age.
Because glucose crosses the placenta, whereas insulin does not, these infants tend to gain weight. At birth they appear pudgy, ruddy, and lethargic. The high glucose environment impedes lung development and, although they are large for gestational age, they are often premature. Complications of maternal diabetes include
- Patent ductus arteriosus
- Polyhydramnios
- Premature delivery
- Respiratory distress syndrome

Fluctuations in maternal blood sugar can result in fetal brain damage or sudden fetal death due to ketosis. Clients with diabetes should be taught to check their blood glucose levels frequently during the day. Levels over 120 mg/dl should be reported to the doctor.
The best diagnostic test for diabetes is a glucose tolerance test, which should be performed early in the pregnancy. Infants born to diabetic mothers might be delivered by Cesarean section due to their large sizes. They should be assessed immediately after delivery for hypoglycemia by performing a dextrostix. The blood is usually obtained by performing a heel stick. The infant should be stuck on the lateral aspect of the heel. Blood tests should be performed to detect hypocalcemia, hypokalemia, and acidosis.

Preeclampsia
Preeclampsia is an abnormality found only in pregnancy. The diagnostic criteria are an elevated blood pressure above 140/90, facial edema, and proteinuria. Clients with preeclamsia tend to have infants that are small in birth weight for gestational age. These infants can also suffer from respiratory distress syndrome and congenital heart defects such as patent ductus arteriosus.
Clients with mild preeclampsia are treated with bed rest and a low-sodium diet. Severe preeclampsia is diagnosed when
- The blood pressure is equal to or greater than 160/110 on two occasions at least 6 hours apart with the woman at bed rest.
- Proteinuria is found to be greater than or equal to 5 grams in a 24-hour urine specimen.
- Oliguria equal to or less than 400ml in 24 hours is found.
- Cerebral or visual disturbances are reported.
- The client complains of epigastric pain.
- Pulmonary edema or cyanosis is reported.
- HELLP syndrome is diagnosed.
HELLP syndrome is hemolysis, elevated liver enzymes, and low platelets. This syndrome results in an enlarged liver and associated bleeding. If it’s not treated, the client can die as a result of bleeding. The treatment for this problem is early delivery of the fetus.

Management of severe preeclampsia consists of
- Complete bed rest
- Low-sodium diet
- Magnesium sulfate

Magnesium sulfate, or magnesium gluconate, is the treatment of choice. A therapeutic level of 4.8–9.6 mg/dl is achieved by intravenous administration of the medication. Magnesium sulfate is a vasodilator and rapidly lowers the blood pressure.

Complications common to use of MgSO4 include maternal hypotension, oliguria, and apnea. A Foley catheter should be inserted to monitor hourly urinary output.
Safe administration requires the use of an IV pump or a controller. Common side effects of MgSO4 are drowsiness and hot flashes. Every effort should be made to prevent seizures. A quiet, dark environment must be maintained and visitors should be restricted. The client should be assessed for signs of toxicity, which include hyporeflexia, oliguria, and decreased respirations.
Magnesium levels should be checked approximately every 6 hours and the results reported to the doctor.
The treatment for magnesium sulfate toxicity is calcium gluconate. This medication should be kept at the bedside along with an airway and tracheotomy set.

Disseminated Intravascular Coagulation
Disseminated intravascular coagulation (DIC) can occur in many disorders; however, pregnancy is a high risk time for the development of DIC. This bleeding disorder is caused when clotting factor is consumed, causing widespread external and internal bleeding. Bleeding can be evident from the gastrointestinal trait, kidneys, and vagina. The diagnostic tool for DIC is the presence of fibrin split compound. Treatment includes heparin administration to treat clotting, Amicar to stabilize bleeding, electrolyte and blood replacement, and oxygen. Hourly intake and output should also be monitored carefully. Early diagnosis is imperative if the prognosis is to be improved.

Cord Prolapse
Umbilical cord prolapse occurs when the umbilical cord is expelled with rupture of the membranes. If pressure is exerted on the cord by the presenting fetal part, fetal hypoxia results. Treatments include Trendelenberg position or knee-chest position, rapid IV infusion of normal saline or Lactated Ringer’s solution, and oxygen administration. Vital signs and fetal heart tones are evaluated, and the client is readied for a Cesarean section. If the cord remains outside the uterus, drying will occur, causing loss of oxygencarrying capacity. Treatment with sterile saline soaks is recommended until a
Cesarean section can be performed.

Maternal Infections
Infections during pregnancy are responsible for significant mortality and morbidity. Sexually transmitted infections are detrimental to the mother and fetus and should be treated promptly.

Some infections you should be aware of:

Sexually Transmitted Infections










Preterm Labor
Premature labor can be managed with hypnotics or sedatives. Several medications stop contractions, including
- Yutopar (ritodrine)—This is contraindicated in client with maternal cardiovascular disease because a side effect of this drug is tachycardia.
- Brethine (terbutaline sulfate)—This is a commonly used bronchodila- tor that is contraindicated in cardiovascular disease because it causes tachycardia and in diabetes because it elevates the blood glucose levels.
- Magnesium sulfate—This is a drug used to treat preeclampsia, It can also help to decrease uterine contractions. If this drug is given to treat premature contractions, the client should be monitored for magnesium toxicity. A Foley catheter should be inserted to monitor the output hourly. The client should be assessed for hypotension and respiratory distress.

Prematurity is defined as a delivery that occurs prior to 37 weeks gestation.
These infants exhibit several characteristics, including low birth weight (less than 1500 gms), lack of lanugo, absence of sucking pads, and in males undescended testes. Premature infants are prone to rapid heat loss through conduction, convection, radiation, and evaporation. Additional complications include respiratory distress syndrome, pneumothorax, necrotizing enterocolitis, bronchopulmonary dysplasia, and bleeding disorders. Careful management of the infant during bathing and drying should be taken because intracranial bleeding is a potential danger. Premature infants are best managed in neonatal intensive care units where respiratory status is supported through mechanical ventilation and treatment with applied surfactant.

Intrapartal Care
Labor is defined as the process by which the fetus is expelled from the uterus and the time period immediately after. Five factors influence the labor process:
- Passageway—The birth canal, which consists of the uterus, bony pelvis, and vagina.
- Passenger—The baby. This consideration during the intrapartal period involves evaluation and management of distress.
- Powers—The mother’s body’s power to expel the fetus; it consists of the uterine contractions.
- Position—The position the mother assumes during labor; it can make a difference in the decent of the fetus and the mother’s comfort.
- Psychological response—The psychological response of the mother makes a difference in the labor experience. If the mother is prepared and in control, it is much more likely that the labor process will proceed smoothly.

The intrapartal period is divided into stages and phases of labor, as covered in the following sections.

Stages of Labor
The stages of labor describe the process of dilation and decent of the baby.
The four stages of labor are
- Stage 1—1–10 centimeters dilation of the cervix
- Stage 2—From complete dilation to delivery of the baby
- Stage 3—From delivery of the baby to delivery of the placenta
- Stage 4—From delivery of the placenta until completion of the recovery period

Phases of Labor
The first stage of labor is divided into three phases of labor:
- Phase 1—Early labor or prodromal (1–3 cm dilation)
- Phase 2—Active labor (4–7 cm dilation)
- Phase 3—Transition (8–10 cm dilation)

Important Terms You Should Know
Several terms associated with labor and delivery are listed here. You should know these for the exam:
- Presentation—The part of the fetus that engages and presents first at delivery (cephalic presentation, or head presentation, is the most common type of presentation).
- Position—The relationship of the presenting part to the mother’s pelvis. For example, left occiput anterior (LOA) means that the back of the baby’s head is anterior to the pelvis and tilted to the left side. Right occiput anterior (ROA) means that the back of the baby’s head is anterior and tilted to the right side; occiput anterior (OA) means that the back of the baby’s head is directly to the front of the mother’s pelvis. See

A diagram of the fetal positions.


- Fetal lie—The relationship of the fetus to the long axis of the mother.

This can be determined by performing Leopold’s maneuvers. Leopold’s maneuver is a technique performed by the healthcare provider by palpating the maternal abdomen to determine where the fetal back, legs, head, and so on are located. This technique is a noninvasive way of estimating the fetal lie and whether the baby is engaged or in the true pelvis.
- Dystocia—This term is associated with a difficult or extremely painful labor and delivery.
- Effacement—This is the thinning of the cervix.
- Dilation—This is the opening of the cervix.
- Precipitate delivery—This term is associated with a rapid labor and delivery. The client with precipitate delivery is at risk for uterine rupture, vaginal laceratons, amniotic emboli, and postpartal hemorrhage.

Fetal complications include hypoxia and intracranial hemorrhage.
- Station—This refers to the relationship of the presenting part to the maternal ischial spines (0 station is at the ischial spines).

Prelabor Testing
Several tests can be performed to predict possible complications to the fetus and mother:
- Non-stress test—This test is used to determine fetal response to cycli- cal periods of rest and activity. A fetal monitor is applied for approximately 90 minutes. During this time, the client is instructed to press the response button each time the baby moves. Normal fetal response is an increase in fetal heart rate of 15 beats per minute. A reassuring or positive reading indicates a positive fetal outcome.
- Oxytocin challenge test (contraction stress test)—This test is used to determine fetal response to contractions. The length of time for an OCT is generally 90–120 minutes. Contractions are stimulated by beginning an infusion of Pitocin. Ten units of Pitocin are diluted in
1000ml of IV fluid, begun at 3 milliunits per minute, and increased every 15 minutes until three contractions in 10 minutes are observed. If fetal bradycardia (FHT is less than 120 bpm) or tachycardia (FHT is above 160 bpm) is observed or if the blood pressure of the mother rises above normal, the test is considered positive or abnormal. A positive reading can indicate that labor might not be advisable. After the exam, the Pitocin is discontinued.
If the physician decides to induce labor, the Pitocin can be continued and prostaglandin gel can be used to ripen or soften the cervix.

Pitocin should always be infused using a pump or controller.

Fetal Monitoring
Fetal monitoring can be done continuously by using an external tocodynamometer monitor. External monitoring is a noninvasive procedure that allows the nurse to observe the fetal heart tones and uterine contractions.
Internal fetal monitoring is recommended if fetal heart tones and contractions cannot be evaluated externally. The duration of a contraction is evaluated by measuring from the beginning of a contraction to the end of the same contraction. The frequency of a contraction is evaluated by measuring from the beginning of one contraction to the beginning of the next contraction or from the peak of one contraction to the peak of the next.
Bradycardia is a deceleration of fetal heart tones. Decelerations are associated with fetal hypoxia. The three types of decelerations are
- Early decelerations—Transitory drops in the fetal heart rate caused by head compression. If the client is complete and pushing and the baby is in a cephalic presentation, this finding is relatively benign. An early deceleration mirrors in depth and length the contraction. If there is a rapid return to the baseline fetal heart rate and the fetal heart rate is within normal range, no treatment is necessary.

Graphs of early decelerations.


Note the drop in the fetal heart tones prior to the peak of the contraction. If good variability and return to normal baseline fetal heart tones no treatment is necessary.
- Variable deceleration—V-shaped transitory decreases in the fetal heart tones that occur anytime during the contraction. They can also occur when no contractions are present. Variable decelerations are caused by cord compression. Two possible causes of variable decelerations are a prolapsed cord and a cord that is entangled or around the baby’s neck (nuchal cord). Because hypoxia can result from the cord being compressed, intervention is required. Treatment includes Trendelenburg position, oxygen administration, IV fluids, and notification of the physician. If fetal distress continues, the client should be prepared for a C-section. Figure 16.3 shows graphs of variable decelerations.

Variable decelerations:


Note the drop in the fetal heart tones that are V-shaped and do not correlate to the contractions. These decelerations are caused by cord compression. The treatment is to turn the client to the side, turn off pitocin, and apply oxygen. Contact the doctor if these continue after treatment.
- Late decelerations—Drops in the fetal heart tones late in the contrac- tion are caused by utero-placental insufficiency. These decelerations are U-shaped and mirror the contractions. Late decelerations are ominous because they result in fetal hypoxia. Treatment for these decelerations include discontining Pitocin, applying oxygen, and changing the mother’s position. The recommended position is left side-lying. If late decelerations continue despite interventions, the physician should be notified to expedite delivery.

Graphs of late decelerations.


Note the drop in the fetal heart tones after the peak of the contraction caused by utero-placental insufficiency. The treatment is to turn off pitocin if infusing, administer oxygen, and turn the client on her side or change position. Left side lying is best. If this pattern continues, contact the doctor.

Pharmacologic Management of Labor
Several methods are used to relieve the pain of labor, including
- Sedatives—Examples include barbiturates, narcotics, and agonist- antagonist compounds. Stadol (butorphanol) and Nubain (nalbuphine) are two agonist medications commonly used in labor. These drugs provide pain relief with little suppression of fetal heart tones. To decrease the amount of medication crossing the placental barrier, the medication should slowly be administered via IV push during a contraction.
Ataractics such as Phenergan (promethezine) can also be used to relieve pain and prevent nausea associated with labor.
- Nerve blocks—Several types of nerve blocks are useful in labor. The following six items are examples of nerve blocks:
- Local infiltration—This uses xylocaine for an episiotomy.
- Pudendal block—Useful for the second stage of labor, episiotomy, and birth, this blocks nerve impulses to the perineum, cervix, and vagina.
- Subarachnoid (spinal) anesthesia—This is injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space.

It is useful in relieving uterine pain. Because complete anesthesia is achieved, the client should be observed for hypotension and bradycardia. She will probably be unable to assist with pushing during the third stage of labor.
Leakage of spinal fluid can result in a headache. The client should be maintained supine following delivery for 8 hours, and fluids should be encouraged. If a spinal headache occurs following spinal anesthesia, the doctor might perform a blood patch.
A blood patch is done by injecting maternal blood into the space where spinal fluid is being lost. This allows for quicker replenishing of spinal fluid and restoration of equilibrium.

- Epidural block—This is useful for uterine labor pain. This type of anesthesia is commonly used in laboring clients because it does not suppress fetal heart tones and does not result in complete anesthesia. The client is able to assist with pushing but is relatively free of pain. Maternal hypotension is a complication. Two thousand milliliters of IV fluid should be given immediately prior to an epidural or spinal anesthesia to prevent hypotension. This increase in the amount of circulating volume helps prevent the associated hypotension. If hypotension occurs, the nurse should increase the IV infusion, apply oxygen, and reposition the client on her left side. Platelet counts should be monitored. Obstetric clients having epidural anesthesia often complain of shivering; explain to the client that this is expected and provide extra blankets.
- Spinal/epidural narcotics—Narcotics can be administered into the spinal or epidural space. Fentanyl or morphine is commonly used.
Side effects include nausea, itching, urinary retention, and respiratory distress.
- General anesthesia—This is rarely used for the laboring client and is reserved for Cesarean section deliveries.

Postpartum Care
To reduce bleeding and improve uterine tone, the nurse should massage the fundus often. Lochia rubra, or bright red bleeding, occurs after delivery and lasts approximately 3 days. Lochia serosa, or blood and serous fluid, is usually noted on the third or fourth postpartum day. Lochia alba, or the white or clear discharge, can last several weeks following delivery. Allowing breast feeding immediately after delivery is encouraged because it stimulates oxytocin release and uterine contractions. Another advantage of early breast feeding is the production of colostrum. Colostrum, the first liquid secreted from the breast, contains antibodies and nutrients that are needed by the infant.
Urinary retention often increases postpartal bleeding and is a problem during the early postpartal period, especially in clients who have epidural or spinal anesthesia for relief of labor pain. If the nurse notes that the fundus is deviated to the side, the bladder is probably distended. Encourage the client to void, or insert a French or Foley catheter to empty the bladder and enhance uterine contractions.

Terms Associated with the Normal Newborn
The following terms are associated with normal newborns. You should be familiar with these terms for the exam:

- Acrocyanosis—This is a bluish discoloration of the hands and feet of the newborn.
- APGAR scoring—This permits a rapid assessment of the need for resuscitation based on five signs. This survey is done at 1 and 5 minutes.
- Caput succedaneum—This is an edema that crosses the suture line on the baby’s scalp.
- Cephalohematoma—This is blood that does not cross the suture line on the baby’s scalp.
- Hyperbilirubinemia—An elevation in the infant’s bilirubin level caused by an immature liver. Although the baby will become jaundice, no treatment is necessary. The mother should be taught to place the baby in the sunshine to help with breakdown of the bilirubin.
- Milia—These are tiny, white bumps that occur across the newborn’s nose.
- Mongolian spots—These are darkened discolorations that occur on the sacral area of dark-skinned infants.

APGAR Scoring


Rh Incompatibility
Problems with hemolysis occur if the mother is Rh negative and the fetus is Rh positive. Maternal and fetal blood do not mix in-utero until the third stage of labor when the placenta separates from the wall of the uterus. At that time, a fetal-maternal transfusion can occur. This mixing of incompatible blood types causes isoimmunization and a transfusion reaction.
Usually no problems are seen in the first pregnancy. If, however, the mother becomes pregnant with another Rh positive fetus, her body will react as if the fetus were a foreign object and destroy the baby’s red blood cells. This destruction is known as erythroblastosis fetalis.
To prevent isoimmunization, the mother should be given Rhogam during pregnancy as early as 20 weeks or postpartally within the first 48–72 hours.

Kernictertus is the condition that results when unconjugated bilirubin crosses the blood-brain barrier. This often results in conditions such as cerebral palsy. Infants with pathologic jaundice should be assessed for alertness, presence of a high-pitched cry, a decreased sucking reflex, hydrops fetalis, and seizure activity. Treatment for pathological jaundice involves exchange transfusion either in-utero or immediately after delivery.
Physiologic jaundice is a benign condition resulting from an immature liver. As the amount of conjugated bilirubin builds in the baby’s blood, the infant becomes jaundice. This jaundice does not become evident until 48–72 hours and, although it does cause the infant to be irritable, it does not cause brain damage. Treatment of physiological jaundice includes placing the baby under a bili-light. Clothing should be removed and the eyes and genitals covered to prevent damage to fragile tissue. Feedings and fluids should be increased to promote defecation and urination. The infant should be turned often and vital signs should be monitored frequently. When the baby is ready for discharge, the mother should be instructed to place the baby’s crib in the sunlight.

Contraception
Contraception is the voluntary prevention of pregnancy. This can be accomplished using several methods.

Contraception Methods

(contd.)


Diagnostic Tests for Review
The following are diagnostic tests you should review before taking the
NCLEX® exam. These tests are performed to determine potential problems in the obstetric client and the fetus:
- 24-hour urine to determine renal disease
- Alpha feto-protein to determine nural tube defects
- CBC to indicate anemia or infections
- Creatinine to determine renal disease
- Estriol levels to determine fetal well-being
- Ferning test/nitrozine testing to confirm amniotic fluid
- Glucose tolerance test to determine whether an elevated blood glucose exists, and possibly diabetes
- L/S ratio to determine lung maturity
- Pap smear to detect cervical cancer
- Ultrasound/amniocentesis to determine fetal anomalies
- Urinalysis to detect kidney infections

Pharmacology Categories for Review
Several pharmacological agents are used to treat the pregnant client. You will need to review these prior to taking the NCLEX® exam:
- Analgesics
- Anesthetics
- Antibiotics
- Antihypertensives
- Antivirals
- Hormonal preparations
- Insulin
- Narcotics
- Surfactants
- Tocolytics
- Vasodilators