Maternal & Child Nursing Bullets (Nle & Nclex)
Maternal & Child Nursing Bullets (Nle & Nclex)
Maternal & Child Nursing Bullets (Nle & Nclex)
Unlike false labor, true labor produces regular rhythmic contractions, abdominal
discomfort, progressive descent of the fetus, bloody show, and progressive
effacement and dilation of the cervix.
To help a mother break the suction of her breast-feeding infant, the nurse should
teach her to insert a finger at the corner of the infant’s mouth.
Rubella has a teratogenic effect on the fetus during the first trimester. It
produces abnormalities in up to 40% of cases without interrupting the pregnancy.
When used to describe the degree of fetal descent during labor, floating means
the presenting part isn’t engaged in the pelvic inlet, but is freely movable
(ballotable) above the pelvic inlet.
When used to describe the degree of fetal descent, engagement means when the
largest diameter of the presenting part has passed through the pelvic inlet.
Fetal station indicates the location of the presenting part in relation to the ischial
spine. It’s described as –1, –2, –3, –4, or –5 to indicate the number of centimeters
above the level of the ischial spine; station –5 is at the pelvic inlet.
Fetal station also is described as +1, +2, +3, +4, or +5 to indicate the number of
centimeters it is below the level of the ischial spine; station 0 is at the level of the
ischial spine.
During the first stage of labor, the side-lying position usually provides the
greatest degree of comfort, although the patient may assume any comfortable
position.
During delivery, if the umbilical cord can’t be loosened and slipped from around
the neonate’s neck, it should be clamped with two clamps and cut between the
clamps.
To elicit Moro’s reflex, the nurse holds the neonate in both hands and suddenly,
but gently, drops the neonate’s head backward. Normally, the neonate abducts and
extends all extremities bilaterally and symmetrically, forms a C shape with the
thumb and forefinger, and first adducts and then flexes the extremities.
Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and
fetal movement felt by the examiner (not usually present until 4 months’ gestation
Goodell’s sign is softening of the cervix.
To estimate the date of delivery using Nägele’s rule, the nurse counts backward 3
months from the first day of the last menstrual period and then adds 7 days to this
date.
At 12 weeks’ gestation, the fundus should be at the top of the symphysis pubis.
Cow’s milk shouldn’t be given to infants younger than age 1 because it has a low
linoleic acid content and its protein is difficult for infants to digest.
If jaundice is suspected in a neonate, the nurse should examine the infant under
natural window light. If natural light is unavailable, the nurse should examine the
infant under a white light.
The three phases of a uterine contraction are increment, acme, and decrement.
The gynecoid pelvis is most ideal for delivery. Other types include platypelloid
(flat), anthropoid (apelike), and android (malelike).
Pregnant women should be advised that there is no safe level of alcohol intake.
Fetal alcohol syndrome presents in the first 24 hours after birth and produces
lethargy, seizures, poor sucking reflex, abdominal distention, and respiratory
difficulty.
Variability is any change in the fetal heart rate (FHR) from its normal rate of 120 to
160 beats/minute. Acceleration is increased FHR; deceleration is decreased FHR.
The nurse should provide a dark, quiet environment for a neonate who is
experiencing narcotic withdrawal.
Whenever an infant is being put down to sleep, the parent or caregiver should
position the infant on the back. (Remember back to sleep.)
After birth, the neonate’s umbilical cord is tied 1" (2.5 cm) from the abdominal
wall with a cotton cord, plastic clamp, or rubber band.
The first stage of labor begins with the onset of labor and ends with full cervical
dilation at 10 cm.
The second stage of labor begins with full cervical dilation and ends with the
neonate’s birth.
The third stage of labor begins after the neonate’s birth and ends with expulsion
of the placenta.
In a full-term neonate, skin creases appear over two-thirds of the neonate’s feet.
Preterm neonates have heel creases that cover less than two-thirds of the feet.
The fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the
placenta is delivered. This time is needed to stabilize the mother’s physical and
emotional state after the stress of childbirth.
At 20 weeks’ gestation, the fundus is at the level of the umbilicus.
At 36 weeks’ gestation, the fundus is at the lower border of the rib cage.
A premature neonate is one born before the end of the 37th week of gestation.
During the transition phase of the first stage of labor, the cervix is dilated 8 to 10
cm and contractions usually occur 2 to 3 minutes apart and last for 60 seconds.
A nonstress test is considered nonreactive (positive) if fewer than two fetal heart
rate accelerations of at least 15 beats/minute occur in 20 minutes.
A nonstress test is considered reactive (negative) if two or more fetal heart rate
accelerations of 15 beats/minute above baseline occur in 20 minutes.
A pregnant woman should drink at least eight 8-oz glasses (about 2,000 ml) of
water daily.
When both breasts are used for breast-feeding, the infant usually doesn’t empty
the second breast. Therefore, the second breast should be used first at the next
feeding.
When teaching parents to provide umbilical cord care, the nurse should teach
them to clean the umbilical area with a cotton ball saturated with alcohol after
every diaper change to prevent infection and promote drying.
Teenage mothers are more likely to have low-birth-weight neonates because they
seek prenatal care late in pregnancy (as a result of denial) and are more likely than
older mothers to have nutritional deficiencies.
Linea nigra, a dark line that extends from the umbilicus to the mons pubis,
commonly appears during pregnancy and disappears after pregnancy.
In complete (total) placenta previa, the placenta completely covers the cervical
os.
Ortolani’s sign (an audible click or palpable jerk that occurs with thigh abduction)
confirms congenital hip dislocation in a neonate.
If a patient who is taking an oral contraceptive misses a dose, she should take
the pill as soon as she remembers or take two at the next scheduled interval and
continue with the normal schedule.
In placenta previa, bleeding is painless and seldom fatal on the first occasion, but
it becomes heavier with each subsequent episode.
Infants with Down syndrome typically have marked hypotonia, floppiness, slanted
eyes, excess skin on the back of the neck, flattened bridge of the nose, flat facial
features, spadelike hands, short and broad feet, small male genitalia, absence of
Moro’s reflex, and a simian crease on the hands.
The chorion is the outermost extraembryonic membrane that gives rise to the
placenta.
From the 8th week of gestation through delivery, the developing cells are known
as a fetus.
In an incomplete abortion, the fetus is expelled, but parts of the placenta and
membrane remain in the uterus.
During the first hour after birth (the period of reactivity), the neonate is alert and
awake.
After delivery, the first nursing action is to establish the neonate’s airway.
Nursing interventions for a patient with placenta previa include positioning the
patient on her left side for maximum fetal perfusion, monitoring fetal heart tones,
and administering I.V. fluids and oxygen, as ordered.
The specific gravity of a neonate’s urine is 1.003 to 1.030. A lower specific gravity
suggests overhydration; a higher one suggests dehydration.
The neonatal period extends from birth to day 28. It’s also called the first 4
weeks or first month of life.
A woman who is breast-feeding should rub a mild emollient cream or a few drops
of breast milk (or colostrum) on the nipples after each feeding. She should let the
breasts air-dry to prevent them from cracking.
After feeding an infant with a cleft lip or palate, the nurse should rinse the
infant’s mouth with sterile water.
Human immunodeficiency virus (HIV) has been cultured in breast milk and can be
transmitted by an HIV-positive mother who breast-feeds her infant.
Lochia rubra is the vaginal discharge of almost pure blood that occurs during the
first few days after childbirth.
Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after
childbirth.
Lochia alba is the vaginal discharge of decreased blood and increased leukocytes
that’s the final stage of lochia. It occurs 7 to 10 days after childbirth.
Colostrum, the precursor of milk, is the first secretion from the breasts after
delivery.
The length of the uterus increases from 2½" (6.3 cm) before pregnancy to 12½"
(32 cm) at term.
To estimate the true conjugate (the smallest inlet measurement of the pelvis),
deduct 1.5 cm from the diagonal conjugate (usually 12 cm). A true conjugate of
10.5 cm enables the fetal head (usually 10 cm) to pass.
The nurse should suggest ambulation to a postpartum patient who has gas pain
and flatulence.
When a patient is admitted to the unit in active labor, the nurse’s first action is to
listen for fetal heart tones.
A mother should allow her infant to breast-feed until the infant is satisfied. The
time may vary from 5 to 20 minutes.
A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) during the first trimester
and slightly less than 1 lb (0.5 kg) per week during the last two trimesters.
Precipitate labor lasts for approximately 3 hours and ends with delivery of the
neonate.
Braxton Hicks contractions are usually felt in the abdomen and don’t cause
cervical change. True labor contractions are felt in the front of the abdomen and
back and lead to progressive cervical dilation and effacement.
The average birth weight of neonates born to mothers who smoke is 6 oz (170 g)
less than that of neonates born to nonsmoking mothers.
The nurse should teach a pregnant vegetarian to obtain protein from alternative
sources, such as nuts, soybeans, and legumes.
The nurse should instruct a pregnant patient to take only prescribed prenatal
vitamins because over-the-counter high-potency vitamins may harm the fetus.
If a fetus has late decelerations (a sign of fetal hypoxia), the nurse should
instruct the mother to lie on her left side and then administer 8 to 10 L of oxygen
per minute by mask or cannula. The nurse should notify the physician. The side-
lying position removes pressure on the inferior vena cava.
Lanugo covers the fetus’s body until about 20 weeks’ gestation. Then it begins to
disappear from the face, trunk, arms, and legs, in that order.
Neonates typically need to consume 50 to 55 cal per pound of body weight daily.
After a stillbirth, the mother should be allowed to hold the neonate to help her
come to terms with the death.
Molding is the process by which the fetal head changes shape to facilitate
movement through the birth canal.
If a woman receives a spinal block before delivery, the nurse should monitor the
patient’s blood pressure closely.
The best technique for assessing jaundice in a neonate is to blanch the tip of the
nose or the area just above the umbilicus.
During fetal heart monitoring, early deceleration is caused by compression of the
head during labor.
After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the
patient’s I.V. solution, as prescribed, to promote postpartum involution of the uterus
and stimulate lactation.
Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue, starch, or
hair. It may occur during pregnancy and can endanger the fetus.
A pregnant patient should take folic acid because this nutrient is required for
rapid cell division.
During the first trimester, a pregnant woman should avoid all drugs unless doing
so would adversely affect her health.
The Food and Drug Administration has established the following five categories of
drugs based on their potential for causing birth defects: A, no evidence of risk; B, no
risk found in animals, but no studies have been done in women; C, animal studies
have shown an adverse effect, but the drug may be beneficial to women despite the
potential risk; D, evidence of risk, but its benefits may outweigh its risks; and X,
fetal anomalies noted, and the risks clearly outweigh the potential benefits.
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the
lower abdomen, with spotting and cramping. She may have abdominal rigidity;
rapid, shallow respirations; tachycardia; and shock.
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the
lower abdomen, with spotting and cramping. She may have abdominal rigidity;
rapid, shallow respirations; tachycardia; and shock.
A pregnant woman’s partner should avoid introducing air into the vagina during
oral sex because of the possibility of air embolism.
Radiography isn’t usually used in a pregnant woman because it may harm the
developing fetus. If radiography is essential, it should be performed only after 36
weeks’ gestation.
The union of a male and a female gamete produces a zygote, which divides into
the fertilized ovum.
The first menstrual flow is called menarche and may be anovulatory (infertile).
Spermatozoa (or their fragments) remain in the vagina for 72 hours after sexual
intercourse.
A pregnant staff member shouldn’t be assigned to work with a patient who has
cytomegalovirus infection because the virus can be transmitted to the fetus.
The most common method of inducing labor after artificial rupture of the
membranes is oxytocin (Pitocin) infusion.
After the amniotic membranes rupture, the initial nursing action is to assess the
fetal heart rate.
The most common reasons for cesarean birth are malpresentation, fetal distress,
cephalopelvic disproportion, pregnancy-induced hypertension, previous cesarean
birth, and inadequate progress in labor.
If a pregnant patient’s test results are negative for glucose but positive for
acetone, the nurse should assess the patient’s diet for inadequate caloric intake.
If a pregnant patient’s test results are negative for glucose but positive for
acetone, the nurse should assess the patient’s diet for inadequate caloric intake.
Rubella infection in a pregnant patient, especially during the first trimester, can
lead to spontaneous abortion or stillbirth as well as fetal cardiac and other birth
defects.
Nausea and vomiting during the first trimester of pregnancy are caused by rising
levels of the hormone human chorionic gonadotropin.
Before discharging a patient who has had an abortion, the nurse should instruct
her to report bright red clots, bleeding that lasts longer than 7 days, or signs of
infection, such as a temperature of greater than 100° F (37.8° C), foul-smelling
vaginal discharge, severe uterine cramping, nausea, or vomiting.
When informed that a patient’s amniotic membrane has broken, the nurse should
check fetal heart tones and then maternal vital signs.
The initial weight loss for a healthy neonate is 5% to 10% of birth weight.
Crowning is the appearance of the fetus’s head when its largest diameter is
encircled by the vulvovaginal ring.
A multipara is a woman who has had two or more pregnancies that progressed to
viability, regardless of whether the offspring were alive at birth.
Skeletal system abnormalities and ventricular septal defects are the most
common disorders of infants who are born to diabetic women. The incidence of
congenital malformation is three times higher in these infants than in those born to
nondiabetic women.
Skeletal system abnormalities and ventricular septal defects are the most
common disorders of infants who are born to diabetic women. The incidence of
congenital malformation is three times higher in these infants than in those born to
nondiabetic women.
The patient with preeclampsia usually has puffiness around the eyes or edema in
the hands (for example, “I can’t put my wedding ring on.”).
Kegel exercises require contraction and relaxation of the perineal muscles. These
exercises help strengthen pelvic muscles and improve urine control in postpartum
patients.
Acrocyanosis (blueness and coolness of the arms and legs) is normal in neonates
because of their immature peripheral circulatory system.
The nurse may suction the neonate’s nose and mouth as needed with a bulb
syringe or suction trap.
To prevent heat loss, the nurse should place the neonate under a radiant warmer
during suctioning and initial delivery-room care, and then wrap the neonate in a
warmed blanket for transport to the nursery.
The umbilical cord normally has two arteries and one vein.
When providing care, the nurse should expose only one part of an infant’s body at
a time.
Lightening is settling of the fetal head into the brim of the pelvis.
If the neonate is stable, the mother should be allowed to breast-feed within the
neonate’s first hour of life.
The nurse should check the neonate’s temperature every 1 to 2 hours until it’s
maintained within normal limits.
In the neonate, temperature normally ranges from 98° to 99° F (36.7° to 37.2°
C), apical pulse rate averages 120 to 160 beats/minute, and respirations are 40 to
60 breaths/minute.
In the neonate, a straight spine is normal. A tuft of hair over the spine is an
abnormal finding.
Meconium is a material that collects in the fetus’s intestines and forms the
neonate’s first feces, which are black and tarry.
The presence of meconium in the amniotic fluid during labor indicates possible
fetal distress and the need to evaluate the neonate for meconium aspiration.
To assess a neonate’s rooting reflex, the nurse touches a finger to the cheek or
the corner of the mouth. Normally, the neonate turns his head toward the stimulus,
opens his mouth, and searches for the stimulus.
Harlequin sign is present when a neonate who is lying on his side appears red on
the dependent side and pale on the upper side.
Mongolian spots can range from brown to blue. Their color depends on how close
melanocytes are to the surface of the skin. They most commonly appear as patches
across the sacrum, buttocks, and legs.
Mongolian spots are common in non-white infants and usually disappear by age 2
to 3 years.
Vernix caseosa is a cheeselike substance that covers and protects the fetus’s
skin in utero. It may be rubbed into the neonate’s skin or washed away in one or
two baths.
Caput succedaneum is edema that develops in and under the fetal scalp during
labor and delivery. It resolves spontaneously and presents no danger to the
neonate. The edema doesn’t cross the suture line.
Nevus flammeus, or port-wine stain, is a diffuse pink to dark bluish red lesion on
a neonate’s face or neck.
The Guthrie test (a screening test for phenylketonuria) is most reliable if it’s done
between the second and sixth days after birth and is performed after the neonate
has ingested protein.
To assess coordination of sucking and swallowing, the nurse should observe the
neonate’s first breast-feeding or sterile water bottle-feeding.
To establish a milk supply pattern, the mother should breast-feed her infant at
least every 4 hours. During the first month, she should breast-feed 8 to 12 times
daily (demand feeding).
To avoid contact with blood and other body fluids, the nurse should wear gloves
when handling the neonate until after the first bath is given.
The hormone relaxin, which is secreted first by the corpus luteum and later by
the placenta, relaxes the connective tissue and cartilage of the symphysis pubis and
the sacroiliac joint to facilitate passage of the fetus during delivery.
Progesterone maintains the integrity of the pregnancy by inhibiting uterine
motility.
During pregnancy, the abdominal line from the symphysis pubis to the umbilicus
changes from linea alba to linea nigra.
o L: Number of children living (if a child has died, further explanation is needed to
clarify the discrepancy in numbers).
Parity doesn’t refer to the number of infants delivered, only the number of
deliveries.
Women who are carrying more than one fetus should be encouraged to gain 35
to 45 lb (15.5 to 20.5 kg) during pregnancy.
Two qualities of the myometrium are elasticity, which allows it to stretch yet
maintain its tone, and contractility, which allows it to shorten and lengthen in a
synchronized pattern.
During crowning, the presenting part of the fetus remains visible during the
interval between contractions.
Before feeding is initiated, an infant should be burped to expel air from the
stomach.
Neonates are nearsighted and focus on items that are held 10" to 12" (25 to 30.5
cm) away.
Meconium is usually passed in the first 24 hours; however, passage may take up
to 72 hours.
Boys who are born with hypospadias shouldn’t be circumcised at birth because
the foreskin may be needed for constructive surgery.
An arrest of descent occurs when the fetus doesn’t descend through the pelvic
cavity during labor. It’s commonly associated with cephalopelvic disproportion, and
cesarean delivery may be required.
In the patient with preeclampsia, blood pressure returns to normal during the
puerperal period.
An estriol level is used to assess fetal well-being and maternal renal functioning
as well as to monitor a pregnancy that’s complicated by diabetes.
In the early stages of pregnancy, the finding of glucose in the urine may be
related to the increased shunting of glucose to the developing placenta, without a
corresponding increase in the reabsorption capability of the kidneys.
A patient who has premature rupture of the membranes is at significant risk for
infection if labor doesn’t begin within 24 hours.
A patient who has a cesarean delivery is at greater risk for infection than the
patient who gives birth vaginally.
The occurrence of thrush in the neonate is probably caused by contact with the
organism during delivery through the birth canal.
The nurse should keep the sac of meningomyelocele moist with normal saline
solution.
If fundal height is at least 2 cm less than expected, the cause may be growth
retardation, missed abortion, transverse lie, or false pregnancy.
A major developmental task for a woman during the first trimester of pregnancy
is accepting the pregnancy.
Implantation occurs when the cellular walls of the blastocyte implants itself in
the endometrium, usually 7 to 9 days after fertilization.
Implantation occurs when the cellular walls of the blastocyte implants itself in the
endometrium, usually 7 to 9 days after fertilization.
The administration of folic acid during the early stages of gestation may prevent
neural tube defects.
In the early postpartum period, the fundus should be midline at the umbilicus.
After delivery, if the fundus is boggy and deviated to the right side, the patient
should empty her bladder.
Before providing a specimen for a sperm count, the patient should avoid
ejaculation for 48 to 72 hours.
Painless vaginal bleeding during the last trimester of pregnancy may indicate
placenta previa.
During the transition phase of labor, the woman usually is irritable and restless.
Because women with diabetes have a higher incidence of birth anomalies than
women without diabetes, an alpha-fetoprotein level may be ordered at 15 to 17
weeks’ gestation.
A mother who has a positive human immunodeficiency virus test result shouldn’t
breast-feed her infant.
If a pregnant patient’s rubella titer is less than 1:8, she should be immunized
after delivery.
For an extramural delivery (one that takes place outside of a normal delivery
center), the priorities for care of the neonate include maintaining a patent airway,
supporting efforts to breathe, monitoring vital signs, and maintaining adequate
body temperature.
Before performing a Leopold maneuver, the nurse should ask the patient to empty
her bladder.