PEDS HESI Hints for Maternal Exam Graded A 2025

HESI Hints – Maternal The Menstraul Cycle • The menstrual phase varies in length in most women. • Ovulation occurs approximately 14 days before the next menstrual cycle. • To avoid pregnancy a woman should abstain from unprotected sexual intercourse during her fertile days. The most fertile days for pregnancy are the day before ovulation and the day of ovulation. The fertile period begins 4-5 days prior to ovulation and ends 24-48 hours after ovulation. A couple must avoid unprotected intercourse for several days before an anticipated ovulation and for 3 days after ovulation to prevent pregnancy because sperm can live in a woman’s body approximately 4 to 5 days and eggs live approximately 24-48 hours after being released. • Some women do not realize they are pregnant because they experience implantation bleeding and spotting Antepartum Nursing Care • Signs of healthy psychosocial maternal-fetal bonding include massaging the abdomen, nicknaming the fetus, and talking to the fetus in utero. • For many women, battering (emotional or physical abuse) begins during pregnancy. Women should be assessed for abuse in private, away from the partner, by a nurse who is familiar with local resources and knows how to determine the safety of the client. • Practice determining gravidity and parity. A woman who is 6 weeks pregnancy has the following maternal history o Has healthy 2-year old fraternal twins. o Miscarried at 22 weeks. o Had an elective abortion at 6 weeks, 5 years earlier. o With this pregnancy she is gravida 4, para 2, only 2 deliveries after 20 weeks’ gestation, and twins are two living o GTPAL is 4-1-1-1-2l (G-4 pregnancies (twin’s miscarriage, elective abortion, current pregnancy), T-1 (twins count as one birth), P-1 (22-week miscarriage); A-1 (elective abortion at 6 weeks); L-2 (twins) • Practice calculating EDB. If the first day of a woman’s last normal menstrual period was December 9, what is her EDB, using the Nagele rule? o Answer: September 16th. Count back 3 months and add 7 days. • At approximately 28-32 weeks’ gestation, a plasma volume increase of 25% to 40% occurs, resulting in normal hemodilation of pregnancy and Hct values above 38% or hemoglobin levels above 13g/dL are associated with gestational hypertension. High Hct values may look good, but in reality they represent a gestational hypertension disorder and a depleted vascular space. • Hgb and Hct data can be used to evaluate nutritional status. Example: a 22 year old primigravida at 12 weeks’ gestation has a Hgb of 9.6 g/dL and an Hct of 31%. She has gained 3 pounds during the first trimester. A weight gain of 907.18 to 1814.4 g. (2-4 lbs.) during the first trimester is recommended. Since the client is anemic supplemental iron and a diet higher in iron are needed. • Food high in iron: o Fish and red meats o Cereal and yellow vegetables o Green leafy vegetables and citrus fruits o Egg yolks and dried fruits lOMoAR cPSD| • As pregnancy advances, the uterus presses on abdominal vessels (vena cava and aorta). Teach the woman that a left side-lying position relieves supine hypotension and increases perfusion to uterus, placenta, and fetus. • The normal FHR is 110-160 bmp. Changes in FHR are the first and most important indicators of compromised blood flow to the fetus; these changes require action! Fetal well-being is determined by assessing fundal height, fetal heart tones and rate, fetal movement, and uterine activity (contractions). • Early intervention can optimize maternal and fetal outcome. Teach clients to report immediately any of the following danger signs. Possible indications of preeclampsia and eclampsia are: o Visual disturbances o Swelling of face, fingers or sacrum o Severe, continuous headache o Persistent vomiting o Epigastric pain o Infection: ▪ Chills ▪ Temperature over 38 degrees C ▪ Dysuria ▪ Pain in abdomen o Fluid discharge or bleeding from vagina (anything other than normal leukorrhea) o Change in fetal movement or increased FHR • Most providers prescribe prenatal vitamins to ensure that the client receives an adequate intake of vitamins. However only the health care provider can prescribe prenatal vitamins. It is the nurse’s responsibility to teach about proper diet and about taking prescribed vitamins as they have been prescribed to the health care provider. • It is recommended that pregnant women consume the equivalent of 3 cups of milk or yogurt per day. This will ensure that the daily calcium needs are met and help alleviate the occurrence of leg cramps. Fetal and Maternal Assessment Techniques • In some states, screening for neural tube defects by testing either maternal serum alpha fetoprotein (AFP) levels or amniotic fluid AFP levels is mandated by state law. This screening is highly associated with both false positives and false negatives. • Gestational age is determined by an early sonogram rather than a later one. • When an amniocentesis is done in early pregnancy, the bladder must be full to help support the uterus and to help push the uterus up in the abdomen for easy access. When an amniocentesis is performed in late pregnancy, the bladder must be empty so it will not be punctured. • Check for labor progress if early decelerations are noted. Early decelerations caused by head compression and fetal descent usually occur in the second stage of labor between 4 and 7 cm dilation. • If cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord (i.e., knee-chest position) or push the presenting part of the cord until immediate cesarean delivery can be accomplished. • Late decelerations indicate UPI and are associated with conditions such as post maturity, preeclampsia, diabetes mellitus, cardiac disease, and abruption placentae. • The situation is ominous (potentially dangerous) and requires immediate intervention and fetal assessment when deceleration patterns (late or variable) are associated with decreased or absent variability and tachycardia. lOMoAR cPSD| • A decrease in uteroplacental perfusion results in late decelerations; cord compression results in a pattern of variable decelerations. Nursing interventions should include changing maternal position, discontinuing oxytocin (Pitocin) infusion, administering oxygen, and notifying the health care provider. • With nipple stimulation there is no control of the “dose” of oxytocin delivered by the posterior pituitary. The change of hyper stimulation or tetany (contractions lasting over 90 seconds or contractions with less than 30 seconds in between) is increased. • Percutaneous umbilical blood sampling (PUBS) can be done during pregnancy under ultrasound for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis, and some genetic testing can be done using this method. • The most important determinant of fetal maturity for extra uterine survival is the lung maturity: lung surfactant (L/S) ratio (2:1 or higher). Intrapartum Nursing Care • True Labor o Pain in lower back that radiates to abdomen o Pain accompanied by regular rhythmic contractions o Contractions that intensify with ambulation o Progressive cervical dilation and effacement • False Labor o Discomfort localized in abdomen o No lower back pain o Contractions decrease in intensity or frequency with ambulation • It is important to know the normal findings for a client in labor: o Normal FHR in labor: 110-160 bpm o Normal maternal BP: <140/90 o Normal maternal pulse: <100 bpm o Normal maternal temperature: 38 degrees C o Slight elevation in temperature may occur because of dehydration and the work of labor. Anything higher indicated infection and must be reported immediately. • Watch for cord prolapse if the infants head is floating • Meconium-stained fluid is yellow-green or gold-yellow and may indicate fetal stress • Breathing techniques, such as deep chest, accelerated, and cued, and not prescribed by the stage and phase of labor but by the discomfort level of the laboring women. If coping is decreasing, switch to a new technique. • Hyperventilation results in respiratory alkalosis that is caused by blowing off too much CO2. o Symptoms include: ▪ Dizziness ▪ Tingling of fingers ▪ Stiff mouth o Have woman breathe into her cupped hands or a paper bag in order to rebreathe CO2. • Determine cervical dilation before allowing client to push. Cervix should be completely dilated (10cm) before the client begins pushing. If pushing starts too early, the cervix can become edematous and never fully dilate. • Give the oxytocin (Pitocin) after the placenta is delivered because the drug will cause the uterus to contract. If the oxytocin drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposes the client to hemorrhage and infection. lOMoAR cPSD| • Methylergonovine is NOT given to clients with hypertension because of its vasoconstrictive action. Pitocin is given with caution to those with hypertension. • Never give methylergonovine or carboprost to a client while she is in labor or before delivery of the placenta. • Application of Perineal Pads after Delivery o Place two on perineum o Do not touch inside of pad o Do apply from front to back, being careful not to drag pad across the anus. • Full bladder is one of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery. If the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus, what action should be taken first? o First perform fundal massage; then have the client empty her bladder. Recheck fundus every 15 minutes for 1 hour, then every 30 minutes for 2 hours. • If narcotic analgesics are given, raise side rails and place call light within reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about drowsiness as a side effect. • A first-degree tear involves only the epidermis. A second-degree tear involves dermis, muscle, and fascia. A third-degree tear extends into the anal sphincter. A fourth- degree tear extends up the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations. • Do not wait until a 1-minute Apgar is assigned to begin resuscitation of the compromised neonate. • Apgar scores of 6 or lower at 5 minutes require an additional Apgar assessment at 10 minutes • IV administration of analgesics is preferred to IM administration for a client in labor because the onset and peak occur more quickly and the duration of the drug is shorter. It is important to know the following: o IV administration ▪ Onset: 5 minutes ▪ Peak: 30 minutes ▪ Duration: 1 hour o IM administration ▪ Onset: within 30 minutes ▪ Peak: 1to 3 hours after injection ▪ Duration: 4 to 6 hours • Tranquilizers (ataractics and phenothiazines), such as promethazine and hydroxyzine, are used in labor as analgesic-potentiating drugs to decrease the amount of narcotic needed and to decrease maternal anxiety. • Agonist narcotic drugs (morphine) produce narcosis and have a higher risk for causing maternal and fetal respiratory depression. Antagonist drugs (butorphanol, nalbuphine) have less respiratory depression but must be used with caution in a mother with preexisting narcotic dependency because withdrawal symptoms occur immediately. • Pudendal block and subarachnoid (saddle) block are used only in the second stage of labor. Peridural and epidural blocks may be used during all stages of labor. • The first sign of a block’s effectiveness is usually warmth and tingling in the ball of the foot or the big toe. • Stop continuous infusion at end of stage I or during transition to increase effectiveness of pushing. • Regional Block Anesthesia and Fetal Presentation o Internal rotation is harder to achieve when the pelvic floor is relaxed by the anesthesia; this results in a persistent occiput-posterior position of fetus. lOMoAR cPSD| o Monitor fetal position. Remember, the mother cannot tell you she has back pain, which is the cardinal sign of persistent posterior fetal position. o Regional blocks, especially epidural and caudal blocks, commonly result in assisted (forceps or vacuum) delivery because of the inability to push effectively during the second stage. Normal Puerperium (Postpartum) • Assessments should be made before notifying the health care provider about any abnormal findings. Assess fundal height and firmness; assess perineal integrity; check for signs and symptoms of thromboembolism; assess pulse, respirations and BP; assess client’s subjective description of symptoms (e.g., burning on urination, pain in leg, excessive tenderness of uterus). • Normal leukocytosis of pregnancy averages 12,000 to 15,000 mm3. During the first 10 to 12 days postbirth, values of 25,000 mm3 are common. Elevated WBC and the normal elevated erythrocyte sedimentation rate (ESR) may confuse interpretation of acute postpartum infections. For example, if a client’s temperature is 38.2 degrees C on the second post-partum day, what assessment should be made? • Client and family teaching is a common subject of NCLEX. Remember that when teaching the first step is to assess the clients’ (parents’) level of knowledge and identify their readiness to learn. Client teaching regarding lochia changes, perineal care, breastfeeding, and sore nipples are subjects that are commonly tested. • After the first postpartum day, the most common cause of uterine atony is retained placental fragments. The nurse must check for the presence of fragments in lochial tissue. • Women can tolerate blood loss, even slightly excessive blood loss, in the postpartal period because of the 40% increase in plasma volume during pregnancy. In the postpartal period, a woman can void up to 3000 mL/day to reduce the volume increase that occurred during pregnancy. • Client should void within 4 hours of delivery. Monitor closely for uterine retention. Suspect retention if voiding is frequent and <100 mL per voiding. • Women often have a syncopal (fainting) spell on the first ambulation after delivery (usually related to vasomotor changes, orthostatic hypotension). The astute nurse will check the client’s Hgb and Hct for anemia and BP, sitting and lying down, to ascertain orthostatic hypotension. • Kegel exercises increase the integrity of the introits and improve urine retention. Teach client to alternate contraction and relaxation of the pubococcygeal muscles. • Remember, RhoGAM is given to an Rh-negative mother who delivers an Rh-positive fetus and has a negative direct Coombs test. If the mother has a positive Coombs test, there is no need to give RhoGAM because the mother is already sensitized. • Because Rh immune globulins suppress the immune system, the client who receives both RhoGAM and the rubella vaccine should be tested for rubella immunity at 3 months. • Assess for thromboembolism: examine legs of postpartum client daily for pain, warmth, and tenderness or a swollen vein that is tender to the touch • “Postpartum blues” are usually normal, especially 5 to 7 days after delivery (unexplained tearfulness, feeling down, and having a decreased appetite). Encourage use of support persons to help with housework for first 2 postpartum weeks. Refer to community resources. The Normal Newborn lOMoAR cPSD| • Suction the mouth first and then the nose. Stimulating the nares can initiate inspiration, which could cause aspiration of mucus in oral pharynx. • Circumcision has become controversial because there is no real medical indication for the procedure, and it does cause trauma and pain to the newborn. It was once thought to decrease the incidence of penile and cervical cancer, but some researchers say this is unfounded. • Hypothermia (heat loss/extreme cold) leads to depletion of glucose, therefore, to the use of brown fat (special fat deposits fetus develops in last trimester; they are important to thermoregulation) for energy. This results in ketoacidosis and possible shock. Prevent by keeping neonate warm! • A detailed physical assessment is performed by the nurse or physician. Regardless of who performs the physical assessment, the nurse must know normal versus abnormal variations in the newborn. Observations must be recorded and the physician notified regarding abnormalities. • It is difficult to differentiate between caput succedaneum (edema under the scalp) and cephalohematoma (blood under the periosteum). The caput crosses suture lines and is usually present at birth, whereas the cephalohematoma does not cross suture lines and manifests a few hours after birth. The danger of cephalohematoma is increased by hyperbilirubinemia due to excess RBC breakdown. • The umbilical cord should always be checked at birth. It should contain three vessels: one vein which carries oxygenated blood to the fetus, and two arteries, which carry unoxygenated blood back to the placenta. This is the opposite of normal circulation in the adult. Cord abnormalities usually indicate cardiovascular or renal anomalies. • Postnatally, the fetal structures of foramen ovale, ductus arteriosus, and ductus venosus should close. If they do not, cardiac and pulmonary compromise will develop. • These neurologic reflexes are transient and, as such, disappear usually within the first year of life. In the pediatric client, prolonged presence of these reflexes can indicate CNS defects. Anticipate NCLEX-RN questions regarding normal newborn reflexes. Physical assessment questions focus on normal characteristics of the newborn and the differentiation of conditions such as caput succedaneum and cephalohematoma. • Physiologic jaundice occurs at 2 to 3 days of life. If it occurs before 24 hours or persists beyond 7 days, it becomes pathologic. Typically, NCLEX-RN questions ask about the normal problem of physiologic jaundice, which occurs 2 to 3 days after birth due to the immature liver’s normal liability to keep up with RBC destruction and to bind bilirubin. Remember, unconjugated bilirubin is the culprit. • To evaluate exact urine output, weigh dry diaper before applying. Weigh the wet diaper after infant has voided. Calculate and record each gram of added weight as 1 mL urine. • Do NOT feed a newborn when the respiratory rate is OVER 60. Inform the physicial and anticipate gavage feedings in order to prevent further energy utilization and possible aspiration • A 7 lb 8 oz baby would need 50 calories x 7 pounds = 350 calories plus 25 calories (1/2 lb or 8 oz) = 375 calories per day. Most infant formulas contain 20 calories per oz. Dividing 375 by 20 = 18.75 oz of formula needed per day. • Teach parents to take infant’s temperature, both axillary and rectal. Axillary is recommended, but some pediatricians request a rectal (core) temperature. o Axillary: place thermometer under infant’s arm and hold thermometer in place for 5 minutes o Rectal: Use thermometer with BLUNT end. Insert thermometer ¼ to ½ inch and hold in place for 5 minutes. Hold feet and legs firmly.