Chapter-by-chapter chunked reference. Designed to replace the PDF for active study — every populated chapter has a TL;DR card, sectioned content, exercises, and abbreviation tooltips. Click a chapter to open it. Track your reading with the checkboxes — single tap = reviewed, double tap = complete.
Contraception choice = client autonomy + medical history. Highest effectiveness: LARCs (IUDs and implants) > sterilization > injectable > pill/patch/ring > barrier > natural. Only condoms protect against STIs. Hormonal methods carry thromboembolic, stroke, and hypertension risks — screen carefully. Smokers > 35 yo cannot take estrogen-containing methods.
Fertility-awareness based methods — no hormones, no devices. Effectiveness depends entirely on adherence and accurate cycle tracking. None protect against STIs.
Refraining from sexual intercourse eliminates the possibility of sperm entering the vagina. Eliminates STI risk if no genital contact.
Withdrawal of penis from vagina prior to ejaculation. Pre-ejaculatory fluid can contain sperm capable of fertilization.
Possible choice for monogamous couples without other contraception available.
Tracks menstrual cycles to estimate fertile days. Ovulation occurs ~14 days before the next menstrual period. To prevent pregnancy, abstain during the fertile window.
Modern calendar variant using a color-coded bead string: red bead = day 1, brown beads = nonfertile, white beads = fertile. Mobile apps available.
BBT drops slightly just before ovulation, then rises during ovulation. Symptom-based method.
After ovulation, cervical mucus becomes thin, slippery, and elastic under estrogen/progesterone influence — egg-white consistency. The ability to stretch mucus between fingers (spinnbarkeit sign) peaks during ovulation.
Daily check for vaginal secretions (no analysis required). After 2 days without secretions, the fertile period has passed.
Rule: If vaginal secretions are present 2 days in a row → avoid unprotected intercourse to prevent pregnancy. Simple but requires daily assessment.
To use the calendar method, the client tracks at least 6 menstrual cycles, recording the length of each. The fertile window is then calculated:
Example: Shortest cycle 26 days, longest 30 days → fertile period is days 8 through 19 (26 − 18 = 8; 30 − 11 = 19). Refrain from intercourse during these days to avoid conception.
Modernized calendar method using color-coded beads on a stringed necklace:
Advance one bead per day starting day 1. Unreliable for cycles < 26 days or > 32 days. Mobile app versions are also available.
Client examines cervical mucus daily from the vaginal introitus (no need to reach to cervix). Mucus characteristics indicate ovulation:
Combining cervical mucus method with calendar method increases effectiveness. Perform hand hygiene before and after examination.
Withdrawal of penis from vagina prior to ejaculation. Critical teaching point: Pre-ejaculatory fluid can leak from the penis prior to ejaculation and may contain sperm capable of fertilizing an ovum. One of the least effective contraceptive methods; offers no STI protection.
Physical or chemical barriers that block sperm from entering the cervix. Latex/polyurethane condoms are the only contraceptive method that protects against STIs.
Thin sheath worn over erect penis. Made of latex, polyurethane, or natural membrane (lamb cecum).
Nitrile vaginal sheath with flexible rings, pre-lubricated with spermicide.
Chemical barrier that destroys sperm before they enter the cervix and acidifies vaginal flora.
Dome-shaped silicone cup with a flexible rim, inserted over the cervix with spermicide. Requires fitting by a provider; available in different sizes.
TSS prevention: proper hand hygiene before insertion/removal AND removing the diaphragm promptly 6–8 hr after coitus reduces TSS risk.
Silicone rubber cap that fits tightly around the base of the cervix. Three sizes available; provider must fit. Use with spermicide increases effectiveness.
Small, round, concave-shaped polyurethane sponge containing spermicide. Fits over the cervix and acts as both a physical AND chemical barrier against sperm.
Male condom (latex/polyurethane):
Female condom (Nitrile/polyurethane):
Diaphragm:
Cervical cap:
Contraceptive sponge:
Spermicides (foam, gel, suppository, film):
Estrogen and/or progestin to suppress ovulation, thicken cervical mucus, and alter the uterine decidua. Effective and reversible — but with thromboembolic, stroke, hypertension, and cancer-history precautions.
The "pill." Suppresses ovulation, thickens cervical mucus, alters decidua. Requires daily intake at the same time.
Missed dose rules: 1 missed pill → take ASAP. 2–3 missed → follow manufacturer instructions; use backup method or abstain until regular dosing resumes. Take at bedtime if nausea is an issue.
Progestin only — fewer adverse effects, safer in breastfeeding. Less effective at suppressing ovulation than COCs.
Prevents fertilization by inhibiting ovulation and sperm transport. Does not terminate an established pregnancy.
Estrogen + progestin/progesterone delivered through skin. Avoids first-pass liver metabolism.
IM or subQ injection every 11–13 weeks. Inhibits ovulation and thickens cervical mucus.
Contraindications: breast cancer, current cardiovascular disease, abnormal liver function, liver tumors, unexplained vaginal bleeding. Can impair glucose tolerance in diabetic clients and increase diabetes risk in non-diabetic clients.
Flexible silicone ring releasing etonogestrel + ethinyl estradiol vaginally for 3 weeks at a time.
Small thin progestin rods implanted under the skin of the inner upper arm. Effective for up to 3 years. Reversible; immediate post-abortion or postpartum insertion possible.
Combined oral contraceptives (COCs):
Progestin-only pills (mini-pill):
Contraceptive patch (Ortho Evra):
Vaginal ring (NuvaRing):
Depo-Provera (DMPA) injection:
Etonogestrel implant (Nexplanon):
Long-acting reversible contraceptives (LARCs) — among the most effective methods. T-shaped device inserted through the cervix into the uterus by a provider. Two types: copper (no hormones) and hormonal (levonorgestrel).
Risks/contraindications: active pelvic infection, abnormal uterine bleeding, severe uterine distortion, increased risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy if pregnancy occurs. Best for clients in monogamous relationships (no STI protection). Bacterial vaginosis and PID risk.
Copper IUD (ParaGard):
Hormonal IUD (Mirena, Liletta, Kyleena, Skyla):
Insertion considerations:
Complications:
Permanent contraception. Decision should be made jointly with sexual partners since reversal is difficult and not always successful. Postpartum discharge teaching should include future contraceptive plans.
Cutting, burning, or blocking the fallopian tubes to prevent fertilization.
Small flexible agents inserted through the vagina/cervix into the fallopian tubes; resulting scar tissue blocks the tubes.
Ligation and severance of the vas deferens to prevent sperm from traveling.
Female: Tubal ligation
Male: Vasectomy
Post-procedure care (vasectomy):
From the book — uses the ATI Therapeutic Procedure template for vasectomy. Practice answering before reviewing the key.
A nurse is reviewing teaching with a client who is considering a vasectomy. Which of the following should be included in the teaching? Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.
Surgical procedure involving ligation and severance of the vas deferens.
Advantage: permanent; short, safe, simple procedure; sexual function not impaired.
Disadvantage: surgical procedure; considered irreversible.
4 NCLEX-style questions covering Ch 1 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching a client about combined oral contraceptives. Which of the following statements by the client indicates an understanding of the teaching?
Show rationale ▾A. CORRECT. Taking COCs at the same time daily maintains stable hormone levels and maximizes contraceptive effectiveness.
B. Skipping pills risks ovulation and pregnancy. Two pills the next day is not the recommended catch-up.
C. COCs do NOT protect against STIs — barrier methods like condoms are required.
D. Breast tenderness is a common, expected side effect that typically resolves; it is not a reason to stop the pill.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse is reviewing contraception options with a client. Which of the following are absolute contraindications to combined oral contraceptives? (Select all that apply.)
Show rationale ▾A. CORRECT. History of DVT/PE is an absolute contraindication — estrogen increases clotting risk.
B. CORRECT. Smoking after age 35 with COCs sharply increases cardiovascular risk.
C. Mild headaches alone are not a contraindication. Migraine with aura IS contraindicated.
D. CORRECT. Estrogen-receptor positive cancers can be stimulated by COCs.
E. CORRECT. Active liver disease/tumor is contraindicated since estrogen is hepatically metabolized.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA client asks the nurse about the typical effectiveness of emergency contraception. Which of the following responses is most accurate?
Show rationale ▾A. CORRECT. Emergency contraception is most effective within 24 hours, decreasing in efficacy up to 120 hours (5 days).
B. Emergency contraception prevents/delays ovulation; it is NOT an abortifacient. It will not terminate an established pregnancy.
C. Emergency contraception is for occasional use only — not for regular contraception (less effective, more side effects).
D. Levonorgestrel (Plan B) is available over-the-counter without prescription in the U.S.
NCLEX · Health Promotion & Maintenance · Health Promotion / Disease PreventionA nurse is teaching a client who is breastfeeding about contraception options at 6 weeks postpartum. Which of the following methods should the nurse recommend as most appropriate?
Show rationale ▾A. Combined hormonal contraceptives contain estrogen, which can decrease milk supply — not recommended in lactating clients.
B. CORRECT. Progestin-only methods (mini-pill, IUD, implant, DMPA) do NOT affect milk supply.
C. The estrogen patch is a combined hormonal method, contraindicated due to milk-supply effects.
D. The vaginal ring also contains estrogen and is contraindicated.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is counseling a client about levonorgestrel intrauterine devices (IUDs). Which of the following findings should the nurse identify as an indication to remove the IUD?
Show rationale ▾A. Spotting between menses is common in the first 3–6 months with IUDs and is expected.
B. Cramping during and immediately after placement is expected and typically resolves.
C. CORRECT. A change in string length (longer or shorter, or unable to palpate) suggests displacement, expulsion, or migration and requires evaluation and possible removal.
D. Decreased menstrual flow is an expected effect of levonorgestrel IUDs over time, not a reason for removal.
NCLEX · Health Promotion & Maintenance · Family PlanningA nurse is teaching a client about combined oral contraceptives (COCs). Which of the following findings should the client report immediately to the provider? (Select all that apply.)
Show rationale ▾A. CORRECT. Severe headache (the H in ACHES) may indicate stroke or thromboembolism.
B. CORRECT. Chest pain (the C in ACHES) may indicate myocardial infarction or pulmonary embolism.
C. Mild breast tenderness is an expected, transient side effect.
D. CORRECT. Sudden, severe leg pain (the S in ACHES) suggests DVT.
E. Breakthrough bleeding in the first 3 months is common and typically resolves.
F. CORRECT. Yellowing of skin/eyes suggests hepatic dysfunction — a contraindication to continued use.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsInfertility is a couple's diagnosis — both partners must be assessed. Semen analysis comes first (cheap, non-invasive, 40% of cases are male). Female workup is invasive (hormones, ultrasound, HSG, hysteroscopy, laparoscopy). Allergy to seafood/iodine = contraindication to HSG dye. Treatment ladder: lifestyle → medication → ART. Major complications: ectopic pregnancy and multiple gestations.
Both partners require thorough history-taking. Common categories overlap (sexual history, substance use, occupational exposure); some are gender-specific.
~40% of infertile couples have male-factor infertility. Semen analysis is cheaper and less invasive than female testing — eliminates a major cause early. May need to be repeated.
Female workup (after thorough history and pelvic exam):
Male workup:
Tests progress from low- to high-invasiveness. Most NCLEX-relevant: HSG (allergy/iodine screen), semen analysis (first step), and laparoscopy (most invasive).
Treatment progresses from lifestyle modification → medical therapy → assisted reproductive technologies (ART). All approaches address the couple as a unit; emotional support is essential.
Multiple-gestation warning: Use of medications to treat female infertility can increase the risk of multiple births by > 25%. Counsel before starting therapy.
Recommended when family or personal history suggests heritable risk. Identify candidates early and refer.
Not warranting referral: alopecia (non-hereditary), allergies (sulfa), recent rubella in non-pregnant client.
Ovum implants in the fallopian tube or abdominal cavity due to scarring from prior infection, surgery, or endometrial tissue. As the ovum grows, the tube can rupture → hemorrhage → emergency surgical removal of the damaged tube (salpingectomy).
ART is associated with an increased incidence of multiple gestations — twins, triplets, higher-order. Poses risks for the mother (preeclampsia, GDM, hemorrhage, preterm labor) and babies (prematurity, IUGR, twin-to-twin transfusion).
From the book — uses the ATI System Disorder template. Practice answering before reviewing the key.
A nurse in an infertility clinic is counseling a couple regarding infertility. Use the ATI Active Learning Template: System Disorder to complete this item.
Inability to conceive despite engaging in unprotected sexual intercourse for ≥ 12 months (≥ 6 months for clients > 35 yo or with a known risk factor).
4 NCLEX-style questions covering Ch 2 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is caring for a client who is scheduled for hysterosalpingography (HSG). The client asks why the procedure is performed in the follicular phase of her cycle. Which response by the nurse is most appropriate?
Show rationale ▾A. CORRECT. Performing HSG in the follicular phase (before ovulation) avoids the chance of a pregnancy being present and provides clearer imaging due to thinner endometrium.
B. Cervical dilation does not significantly change with cycle phase.
C. Estrogen rises during the follicular phase, but this is not the rationale for HSG timing.
D. Pain level isn't tied to cycle phase for HSG.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is reviewing risk factors for infertility with a client. Which of the following findings increase infertility risk? (Select all that apply.)
Show rationale ▾A. CORRECT. PCOS causes anovulation and is a leading cause of female infertility.
B. CORRECT. PID causes scarring of fallopian tubes, blocking ova transit.
C. CORRECT. Female fertility declines significantly after age 35 due to decreased oocyte quality.
D. Healthy BMI is protective. Both underweight (BMI < 18.5) and obesity (BMI > 30) impair fertility.
E. CORRECT. Endometriosis can cause adhesions and tubal obstruction.
NCLEX · Health Promotion & Maintenance · Health Promotion / Disease PreventionA nurse is teaching a couple about basal body temperature (BBT) tracking. Which finding indicates that ovulation has occurred?
Show rationale ▾A. A single-day drop is the pre-ovulatory dip, not confirmation of ovulation.
B. CORRECT. Progesterone after ovulation raises body temperature 0.4–1.0°F, and this rise must be sustained for at least 3 consecutive days to confirm ovulation occurred.
C. Random fluctuations do not indicate ovulation.
D. A single high reading is not sufficient — sustained rise is required.
NCLEX · Health Promotion & Maintenance · Health Promotion / Disease PreventionA nurse is preparing a client for in vitro fertilization (IVF). The client asks what to expect. Which statement should the nurse include in teaching?
Show rationale ▾A. CORRECT. IVF protocols suppress natural ovulation, then stimulate the ovaries to produce multiple oocytes for retrieval.
B. In IVF, fertilization occurs in vitro (lab); embryos are then transferred directly to the uterus, bypassing the tubes.
C. Embryo transfer is typically done with no anesthesia or light sedation, similar to a pelvic exam.
D. IVF success per cycle averages 20–40% depending on age, much lower than 90%.
NCLEX · Reduction of Risk Potential · Therapeutic ProceduresA nurse is preparing a client for hysterosalpingography (HSG). The client states, "I'm worried this will hurt." Which response by the nurse is appropriate?
Show rationale ▾A. HSG is generally not painless — clients often experience moderate cramping.
B. CORRECT. Most clients experience cramping similar to menstrual cramps during dye injection. Pre-procedure NSAIDs help manage discomfort.
C. HSG is an outpatient procedure performed without general anesthesia.
D. HSG is an outpatient procedure; clients go home the same day.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is reviewing assisted reproductive technology (ART) with a client. Which of the following statements should the nurse include about in vitro fertilization (IVF)? (Select all that apply.)
Show rationale ▾A. CORRECT. Oocyte retrieval is performed transvaginally using ultrasound guidance.
B. Fertilization in IVF occurs in vitro (in the lab), not in the fallopian tubes.
C. CORRECT. Multiple embryo transfer increases pregnancy chances but also risk of twins/triplets.
D. CORRECT. Injectable gonadotropins (FSH, LH) are used to stimulate multiple follicle development.
E. CORRECT. OHSS is a known complication of ovarian stimulation, ranging from mild to life-threatening.
NCLEX · Health Promotion & Maintenance · Family PlanningPregnancy signs ladder: presumptive (felt by client) → probable (seen by examiner) → positive (only pregnancy explains it). Only positive signs confirm: heart tones, fetal movement palpated by examiner, fetal visualization. Nägele's rule: LMP − 3 months + 7 days + 1 year. Supine hypotensive syndrome from vena caval compression — fix with left-lateral position.
Three-tier classification by source of evidence. Only positive signs definitively confirm pregnancy.
Changes the client experiences that suggest pregnancy. Can also be caused by stress, infections, peristalsis, or other physiological factors.
Findings observed by an examiner — primarily uterine/cervical changes. Can be caused by pelvic congestion or tumors.
Trick: a positive pregnancy test is a probable sign — not positive — because medications and other factors can cause false results.
PRESUMPTIVE signs (subjective, can have other causes):
PROBABLE signs (examiner-detected, primarily uterine changes):
POSITIVE signs (only explainable by pregnancy):
Human chorionic gonadotropin (hCG) is the marker. Detection in blood/urine begins ~7–8 days before expected menses; production starts at implantation.
Calculate due date with Nägele's rule, monitor fetal growth via fundal height, document obstetric history with GTPAL.
From the first day of LMP: subtract 3 months, add 7 days, add 1 year (adjusting the year as needed).
Example: LMP April 1, 2024 → −3 months = January 1, 2024 → +7 days = January 8, 2024 → +1 year = EDD January 8, 2025.
Measure in centimeters from the symphysis pubis to the top of the uterine fundus. Used between 18 and 30 weeks. Approximates gestational age ± 2 weeks.
Example: G3 T1 P0 A1 L1 → currently pregnant + 2 prior pregnancies, 1 delivered at term, 0 preterm, 1 miscarriage, 1 living child.
The point at which an infant has the capacity to survive outside the uterus. Not a fixed gestational age — infants born 22–25 weeks are considered on the threshold of viability.
To calculate Estimated Date of Birth (EDB):
Example: LMP April 1, 2024 → April − 3 mo = January → +7 days = January 8 → +1 year = EDB January 8, 2025.
Measured in centimeters from symphysis pubis to top of uterine fundus. Between 18 and 30 weeks of gestation, fundal height in centimeters approximates the gestational age in weeks (± 2 weeks).
Gravidity = total number of pregnancies (current pregnancy included):
Parity = number of pregnancies reaching 20 weeks of gestation (NOT the number of fetuses; not affected by stillborn vs alive):
GTPAL system documents pregnancies in 5 parts:
Every system adjusts to support the pregnancy. The placenta becomes the body's largest endocrine organ.
Pregnancy alters baseline vitals subtly but predictably. Position-dependent hypotension is a high-yield concept.
Weight of the gravid uterus on the vena cava in the supine position decreases venous return → ↓ cardiac output → maternal hypotension and fetal hypoxia.
Driven by increased estrogen and progesterone. Can affect self-perception — provide support and education.
Underlying principle: Increase in estrogen and progesterone occurring during pregnancy drives both the skin and breast changes.
From the book — uses the ATI Basic Concept template (skin/breast changes). Practice answering before reviewing the key.
A nurse is caring for a client who is in the fourth week of gestation. The client asks about skin and breast changes that can occur during pregnancy. What information should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item.
Increase in estrogen and progesterone occurring during pregnancy drives both the skin and breast changes.
NCLEX · Health Promotion and Maintenance · Ante/Intra/Postpartum and Newborn Care4 NCLEX-style questions covering Ch 3 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is performing a fundal height measurement at 24 weeks of gestation. Where should the nurse expect to palpate the fundus?
Show rationale ▾A. At 12 weeks, fundus is at the symphysis pubis.
B. CORRECT. At 20 weeks, the fundus reaches the umbilicus; at 24 weeks, fundal height is approximately at or just above the umbilicus (24 cm).
C. At 16 weeks, fundus is midway between symphysis pubis and umbilicus.
D. Fundus reaches the xiphoid at 36 weeks, then drops with lightening before delivery.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is classifying signs of pregnancy. Which of the following are positive (diagnostic) signs of pregnancy? (Select all that apply.)
Show rationale ▾A. CORRECT. Audible fetal heart tones are a positive (diagnostic) sign — only a fetus can produce them.
B. Positive hCG is a probable sign; rare false positives exist (e.g., trophoblastic disease).
C. CORRECT. Ultrasound visualization of the fetus is a positive (diagnostic) sign.
D. CORRECT. Fetal movement palpated by examiner is a positive sign (cannot be confused with other conditions).
E. Quickening (mother's perception of movement) is a presumptive sign — subjective and can be misinterpreted.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is teaching a pregnant client about expected skin changes. Which finding should the nurse identify as a normal physiologic change?
Show rationale ▾A. Sudden bright red rash can indicate herpes gestationis or other pathology — not normal.
B. CORRECT. Linea nigra (dark vertical line on abdomen) and chloasma (mask of pregnancy on face) are expected from increased melanocyte-stimulating hormone.
C. Yellow sclera suggests jaundice/cholestasis — abnormal in pregnancy.
D. Petechiae suggest a clotting disorder or platelet abnormality — abnormal.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is reviewing expected hematologic changes in pregnancy. Which finding is consistent with physiologic anemia of pregnancy?
Show rationale ▾A. CORRECT. Hgb 10.5 g/dL in the second trimester is consistent with physiologic anemia (plasma volume expanding faster than RBC mass). Thresholds: < 11 g/dL in 1st/3rd trimesters, < 10.5 in 2nd.
B. Hgb 8.0 g/dL is true anemia, not physiologic — needs evaluation and supplementation.
C. Hct 50% in pregnancy is elevated — could indicate hemoconcentration from dehydration or preeclampsia.
D. WBC 4,000 is low; pregnancy normally shows mild leukocytosis (up to 15,000).
NCLEX · Reduction of Risk Potential · Laboratory ValuesA nurse is assessing a client at 12 weeks gestation. Which of the following findings is considered a positive sign of pregnancy?
Show rationale ▾A. Amenorrhea is a presumptive sign — many causes besides pregnancy.
B. Positive pregnancy test is a probable sign — false positives possible.
C. Quickening (felt by mother) is a presumptive sign — can be confused with gas or peristalsis.
D. CORRECT. Fetal heart tones heard by the examiner is a positive sign of pregnancy (along with visualization of fetus on ultrasound and palpation of fetal movement by the examiner).
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CareA nurse is teaching a client about physiologic changes during pregnancy. Which of the following are expected findings? (Select all that apply.)
Show rationale ▾A. CORRECT. Blood volume increases 30–50% by term, peaking around 32 weeks.
B. Respiratory rate slightly increases or stays the same; tidal volume increases.
C. CORRECT. Hyperpigmentation including linea nigra and chloasma is normal.
D. CORRECT. HR rises 10–15 bpm by 32 weeks.
E. CORRECT. Progesterone slows GI motility, contributing to constipation and heartburn.
F. Fundal height decreases slightly with lightening (engagement) around 36–38 weeks, but this is not expected in all pregnancies — and a sudden decrease can suggest IUGR.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CareInitial visit ≤ 12 weeks. Visit schedule: monthly through 28w → q2w 29–36w → weekly 36w to delivery. Universal labs: blood type/Rh + Coombs, CBC, Hgb electrophoresis, rubella, Hep B, urinalysis, Pap, STI screen, HIV, MSAFP. OGTT screen at 24–28 weeks · GBS culture at 35–37 weeks · RhoGAM at 28 weeks if Rh-negative. Discomforts vs danger signs distinction is high-yield.
First visit captures a comprehensive baseline. Nonjudgmental tone is essential, especially around substance use, abuse, and psychosocial concerns.
Discuss birthing methods (Lamaze) and pain control options (epidural, natural childbirth). Verbal or written agreement of client's wishes for labor and delivery.
Each subsequent visit checks weight, BP, urine, FHR, fundal height, fetal movement, and elicits new concerns.
Birth defect critical window: The majority of birth defects occur between 2 and 8 weeks gestation (organogenesis). This is the rationale for preconception counseling and avoiding teratogenic exposures early.
A long but standardized list. Knowing why each is done is high-yield.
At each follow-up visit, assess:
Standard preconception/prenatal counseling. Many high-yield NCLEX cues come from these recommendations.
Tailor learning to the appropriate developmental stage. Use multiple methods (pamphlets, videos) and have client demonstrate or verbalize understanding.
Know which trimester each appears in and the specific intervention. These are textbook NCLEX items.
Wear a supportive bra.
Supine hypotension — gravid uterus on vena cava → ↓ blood to fetus, lightheadedness, faintness. Teach client to lie side-lying or semi-sitting with knees slightly flexed.
Common during pregnancy due to renal changes and alkaline vaginal flora. Decrease risk by:
FIRST TRIMESTER:
SECOND TRIMESTER:
THIRD TRIMESTER:
Differentiate from common discomforts. The decision to teach vs report is core nursing judgment.
1st trimester:
2nd trimester:
3rd trimester:
From the book — uses the ATI Basic Concept template (UTI prevention). Practice answering before reviewing the key.
A nurse is caring for a client at 14 weeks of gestation and is reviewing self-care concepts regarding the prevention of urinary tract infections (UTIs). What should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item.
UTIs are common during pregnancy because of renal changes during pregnancy and the vaginal flora becoming more alkaline.
4 NCLEX-style questions covering Ch 4 core content. Click each exercise to reveal rationales and NCLEX category.
A client at 32 weeks of gestation is scheduled for a routine prenatal visit. Based on standard prenatal care guidelines, when is the client expected to return next?
Show rationale ▾A. Monthly visits are standard until 28 weeks.
B. CORRECT. From 28 to 36 weeks gestation, prenatal visits occur every 2 weeks.
C. Weekly visits begin at 36 weeks until delivery.
D. Regular scheduled visits are essential — "as needed" is not standard prenatal care.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is reviewing danger signs of pregnancy with a client. Which of the following findings should the client report immediately? (Select all that apply.)
Show rationale ▾A. CORRECT. Any vaginal bleeding requires evaluation — could indicate previa, abruption, or pregnancy loss.
B. Mild dependent edema at end of day is expected from increased venous pressure — not a danger sign unless sudden, severe, or in the face.
C. CORRECT. Severe headache with visual changes is classic for severe preeclampsia.
D. CORRECT. Decreased fetal movement may indicate fetal distress — kick counts and NST needed.
E. CORRECT. Persistent vomiting can lead to hyperemesis gravidarum with dehydration and electrolyte imbalance.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is teaching a client at 8 weeks of gestation about common discomforts of pregnancy. Which intervention should the nurse recommend for morning sickness?
Show rationale ▾A. Large fatty meals worsen nausea due to delayed gastric emptying.
B. Antacids may help reflux but should not be used routinely without provider input.
C. CORRECT. Dry carbohydrates (crackers) before rising help raise blood sugar slowly and minimize nausea triggered by an empty stomach.
D. Large fluid volumes with meals distend the stomach and worsen nausea — fluids between meals are preferred.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is reviewing initial prenatal laboratory tests. Which of the following tests are routinely included? (Select all that apply.)
Show rationale ▾A. CORRECT. Determines need for Rho(D) immune globulin if Rh-negative.
B. CORRECT. Establishes baseline; identifies pre-existing anemia.
C. CORRECT. Identifies non-immune clients who need post-delivery vaccination (live vaccine; cannot give during pregnancy).
D. Karyotype is not routine — only ordered if specific genetic risk factors are identified.
E. CORRECT. Asymptomatic bacteriuria is common in pregnancy and increases pyelonephritis risk if untreated.
NCLEX · Reduction of Risk Potential · Laboratory ValuesA nurse is reviewing prenatal lab results for a client at 28 weeks gestation. Which of the following findings should the nurse report to the provider?
Show rationale ▾A. Hgb 11.2 is within the normal pregnancy range (11–12 g/dL); pregnancy causes physiologic hemodilution.
B. CORRECT. A 1-hour 50-g glucose challenge test > 140 mg/dL is abnormal and requires follow-up with the 3-hour OGTT to evaluate for gestational diabetes.
C. BP 118/74 is normal in pregnancy.
D. Urine specific gravity 1.020 is normal (1.003–1.030).
NCLEX · Reduction of Risk Potential · Laboratory ValuesA nurse is teaching a client at 8 weeks gestation about warning signs in pregnancy. Which of the following findings should be reported immediately? (Select all that apply.)
Show rationale ▾A. CORRECT. Any vaginal bleeding in pregnancy requires evaluation (miscarriage, ectopic, previa, abruption).
B. Mild morning nausea is an expected finding in early pregnancy.
C. CORRECT. Severe headache + visual changes suggests preeclampsia.
D. CORRECT. Sudden gush or steady leak suggests ROM.
E. Mild dependent edema late in the day is normal in late pregnancy.
F. CORRECT. Decreased fetal movement may indicate fetal compromise and requires immediate evaluation.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CareSingle-pregnancy goal: 1–2 kg total in 1st trimester, then ~0.5 kg/week through 2nd/3rd. Adjust for BMI (underweight: gain more; overweight: less). Critical supplements: folic acid 600 mcg (neural tube) · iron between meals + vitamin C (not with milk/caffeine) · calcium 1,000 mg/day (1,300 if < 19 yo). Caffeine ≤ 200 mg/day. PKU clients resume diet 3 months prior to pregnancy.
Targets are based on prepregnancy weight category. Pace matters as much as total — 1st trimester is slow, 2nd and 3rd are steady.
| Pre-Pregnancy BMI | Category | Total Gain (Single) | Weekly Gain (2nd–3rd Tri) | Total Gain (Twins) |
|---|---|---|---|---|
| < 18.5 | Underweight | 28–40 lb (12.7–18.1 kg) | 1.0–1.3 lb (0.5–0.6 kg) | 50–62 lb |
| 18.5–24.9 | Normal weight | 25–35 lb (11.3–15.9 kg) | 0.8–1.0 lb (0.4–0.5 kg) | 37–54 lb |
| 25.0–29.9 | Overweight | 15–25 lb (6.8–11.3 kg) | 0.5–0.7 lb (0.2–0.3 kg) | 31–50 lb |
| ≥ 30.0 | Obese | 11–20 lb (5.0–9.1 kg) | 0.4–0.6 lb (0.2–0.3 kg) | 25–42 lb |
First trimester gain: 1–4.4 lb (0.5–2 kg) total, regardless of pre-pregnancy BMI.
Build a complete dietary picture using both subjective journaling and objective data.
Client consumes recommended dietary allowances/nutrients during pregnancy.
Nursing actions: Assess journal at each prenatal visit · Provide education about nutritional benefits to mother and newborn · Encourage and answer questions · Weigh client and monitor for inadequate gain · Refer to dietitian or WIC as needed.
Specific numbers are high-yield. Each nutrient has a function, a target, and food sources.
Increased intake essential for basic growth — fetal/placental tissue, maternal blood volume expansion, breast tissue.
Crucial for neurologic development and prevention of fetal neural tube defects. Folate from food is converted to folic acid.
Supplements often added to prenatal plan to support increased maternal RBC mass.
Food sources: beef liver, red meats, fish, poultry, dried peas and beans, fortified cereals and breads.
Side effect tip: a stool softener may be needed to manage iron-related constipation.
Important for fetal bone and teeth formation.
| Nutrient | Pre-Pregnancy | Pregnancy | Lactation |
|---|---|---|---|
| Calories | ~2,000 / day | +340/day (2nd tri); +452/day (3rd tri) | +450–500/day |
| Protein | 46 g | 71 g | 71 g |
| Folic Acid | 400 mcg | 600 mcg | 500 mcg |
| Iron | 18 mg | 27 mg | 9 mg |
| Calcium | 1,000 mg (1,300 if < 19 yr) | 1,000 mg (1,300 if < 19 yr) | 1,000 mg (1,300 if < 19 yr) |
| Fluid | ~2 L/day | 2.3 L/day | 3.1 L/day |
| Caffeine | No limit | < 200 mg/day | < 200 mg/day |
Identify high-risk clients early. Age, culture, education, and socioeconomic status all influence nutrition; some specific conditions also inhibit adequate intake.
Maternal phenylketonuria (PKU) is a genetic disease in which high levels of phenylalanine pose danger to the fetus (intellectual disability, behavioral problems, microcephaly, cardiac defects).
Pica: craving and consumption of non-food substances such as dirt, clay, ice, starch, chalk, paper. May be related to iron-deficiency anemia. Risks include:
Screen for pica nonjudgmentally; refer to dietitian and treat underlying anemia.
Common issues like nausea/constipation get standard relief. Special conditions (PKU, diabetes) require focused dietary plans.
Maternal genetic disease in which high phenylalanine levels are dangerous to the fetus → intellectual disability, behavioral problems.
Tailored to whether the client is breastfeeding. Refer to financial assistance programs as needed.
Resume previously recommended well-balanced diet.
Refer to WIC (Women, Infants, and Children) — federally funded state program providing nutritional support to pregnant clients and their children up to 5 years old.
Lactating client:
Non-lactating client: resume a previously recommended well-balanced diet at pre-pregnancy caloric levels. Iron stores need time to replenish.
Refer clients needing financial nutrition support to the Women, Infants, and Children (WIC) program, a federally funded state program providing nutrition support for pregnant clients, postpartum clients, infants, and children up to 5 years old. Services include nutritious foods, nutrition education, breastfeeding support, and healthcare referrals.
From the book — uses the ATI Basic Concept template (risk factors for inadequate nutrition). Practice answering before reviewing the key.
A nurse manager in a prenatal clinic is preparing an in-service education program for a group of newly licensed nurses about risk factors preventing adequate nutrition during pregnancy. What information should the nurse include in this presentation? Use the ATI Active Learning Template: Basic Concept.
WIC (Women, Infants, and Children) is a federally funded state program that provides nutritional support to pregnant women and their children up to 5 years old.
4 NCLEX-style questions covering Ch 5 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching a client who is planning a pregnancy about folic acid intake. Which daily amount should the nurse recommend?
Show rationale ▾A. 100 mcg is insufficient to prevent neural tube defects.
B. CORRECT. 400 mcg/day is recommended for women of childbearing age before and during early pregnancy to prevent NTDs. The dose increases to 600 mcg during pregnancy.
C. 1,000 mcg is sometimes used during pregnancy but not the baseline preconception dose.
D. 4,000 mcg (4 mg) is reserved for women with a previous NTD-affected pregnancy.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is teaching a client of normal pre-pregnancy BMI about expected weight gain during pregnancy. Which total weight gain should the nurse recommend?
Show rationale ▾A. 5–10 lb is insufficient and risks low birth weight.
B. 11–20 lb is the recommended range for clients with obese pre-pregnancy BMI (≥ 30).
C. CORRECT. 25–35 lb total is recommended for women with normal pre-pregnancy BMI (18.5–24.9).
D. 40–50 lb exceeds the recommendation for any BMI category in singleton pregnancy.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is counseling a pregnant client who follows a strict vegan diet. Which nutrient deficiency should the nurse identify as the most urgent concern?
Show rationale ▾A. Vitamin C is abundant in plant-based diets; not a typical deficiency.
B. CORRECT. Vitamin B12 occurs naturally only in animal products. Deficiency in pregnancy can cause irreversible neurologic damage to the fetus. Supplementation is essential.
C. Magnesium is widely available in nuts, seeds, and leafy greens.
D. Sodium deficiency is rare in modern diets.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is teaching about nutrients important during pregnancy. Which of the following recommendations should the nurse include? (Select all that apply.)
Show rationale ▾A. CORRECT. 340 kcal/day in 2nd trimester, 452 kcal/day in 3rd trimester (singleton).
B. CORRECT. Protein increase from ~46 g to 71 g/day supports fetal growth.
C. CORRECT. 1,000 mg calcium daily (1,300 mg if under 19) supports fetal bone development.
D. Fish low in mercury (salmon, sardines) provides essential omega-3s. Avoid only high-mercury fish (shark, swordfish, tilefish, king mackerel).
E. CORRECT. Caffeine over 200 mg/day is linked to miscarriage and low birth weight.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is teaching a pregnant client with a pre-pregnancy BMI of 22 about expected weight gain. The nurse should recommend a total weight gain of:
Show rationale ▾A. 11–20 lb is recommended for obese clients (BMI ≥ 30).
B. 15–25 lb is recommended for overweight clients (BMI 25–29.9).
C. CORRECT. Normal-weight clients (BMI 18.5–24.9) should gain 25–35 lb (11.3–15.9 kg) total.
D. 28–40 lb is recommended for underweight clients (BMI < 18.5).
NCLEX · Health Promotion & Maintenance · Lifestyle ChoicesA nurse is teaching a pregnant client about dietary recommendations. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)
Show rationale ▾A. Correct understanding — 600 mcg of folic acid is recommended during pregnancy.
B. INDICATES NEED FOR TEACHING. Caffeine should be limited to < 200 mg/day (~1 cup of coffee). Excessive caffeine increases miscarriage risk.
C. INDICATES NEED FOR TEACHING. Milk and calcium inhibit iron absorption. Iron should be taken on an empty stomach with vitamin C (e.g., orange juice).
D. Correct understanding — 340 extra calories/day in 2nd trimester, 452 in 3rd.
E. Correct understanding — soft cheeses (listeria) and deli meats should be avoided.
NCLEX · Health Promotion & Maintenance · Lifestyle ChoicesBest NCLEX numbers: BPP = 5 variables × 0 or 2 (max 10) · NST reactive = ≥ 2 accelerations of ≥ 15/min × ≥ 15 sec in 20 min · CST positive = late decels with ≥ 50% of contractions · L/S ratio 2:1 = lung maturity (2.5:1 or 3:1 in DM). Amniocentesis after 14 weeks; CVS 10–13 weeks. MSAFP/Quad: HIGH = neural tube defect · LOW = Down syndrome.
A 20-minute, painless scan using high-frequency sound waves to visualize the fetus and maternal structures. Three types: external abdominal, transvaginal, Doppler.
Safe, noninvasive, painless. Transducer moved over the abdomen. More useful after the 1st trimester when the gravid uterus is larger.
Invasive — probe inserted vaginally for more accurate evaluation. Does NOT require a full bladder.
Noninvasive external method to study maternal-fetal blood flow — measures the velocity of RBCs in uterine and fetal vessels. Especially useful in IUGR, poor placental perfusion, and as adjunct in pregnancies at risk from HTN, DM, multiples, preterm labor.
Abdominal ultrasound:
Transvaginal ultrasound:
Combines real-time ultrasound and the NST to evaluate five variables. Each variable scores 0 (abnormal) or 2 (normal). Maximum total: 10.
| Test | What It Measures | Reassuring Result | Concerning Result |
|---|---|---|---|
| NST (Non-Stress Test) | FHR response to fetal movement | Reactive: 2+ accels in 20 min, ≥ 15 bpm × 15 sec | Nonreactive: no accelerations in 40 min |
| CST / OCT (Contraction Stress Test) | FHR response to oxytocin-induced contractions | Negative: no late decels with 3 contractions in 10 min | Positive: late decels with ≥ 50% of contractions |
| BPP (Biophysical Profile) | 5 parameters: NST, breathing, movement, tone, AFV | 8–10: normal | ≤ 4: deliver; 6: equivocal |
| Modified BPP | NST + Amniotic Fluid Index | Reactive NST + AFI > 5 cm | Nonreactive NST or AFI ≤ 5 cm |
| Amniocentesis | Genetic, lung maturity (L/S ratio), bilirubin | L/S ratio ≥ 2:1 = lung mature | L/S < 2:1; positive genetic findings |
| CVS (Chorionic Villus Sampling) | Fetal genetic disorders (10–13 wk) | Normal chromosomal analysis | Chromosomal abnormality |
Each variable scored 2 (normal) or 0 (abnormal). Max total = 10.
Score interpretation:
Most widely used antepartum test of fetal well-being. Performed in the 3rd trimester. Noninvasive; monitors FHR response to fetal movement.
Disadvantages: high rate of false nonreactive results — fetal sleep cycles, fetal immaturity, maternal medications, nicotine use can blunt the movement response.
Analyzes FHR response to contractions to determine how the fetus will tolerate the stress of labor. Need 3 contractions in 10 min, 40–60 sec each for assessment.
Within a 10-min period, with 3 uterine contractions, NO late decelerations of FHR.
Persistent and consistent late decelerations with ≥ 50% of contractions — suggests uteroplacental insufficiency. May lead to induction of labor or cesarean.
Other deceleration patterns: variable = cord compression · early = fetal head compression.
Aspiration of amniotic fluid via needle inserted transabdominally into the uterus and amniotic sac under direct ultrasound guidance. Performed after 14 weeks gestation.
Tested if < 37 weeks, ROM, preterm labor, or cesarean indication. Determines whether fetus can adapt to extrauterine life or needs more time + glucocorticoids.
Indications:
Timing:
Procedure:
Results timing:
Fetal lung maturity studies:
Complications (low overall risk):
Earlier alternative to amniocentesis for genetic testing.
Two approaches:
Pre/post-procedure:
Disadvantages of CVS vs amnio:
Reserved for high-risk pregnancies where standard tests don't provide sufficient information.
Most common method for fetal blood sampling and transfusion. Fine-gauge fiber-optic scope (fetoscope) passed into amniotic sac via amniocentesis technique; needle advanced into umbilical cord under ultrasound guidance; blood aspirated from umbilical vein.
Nursing: Educate client to count fetal movements after the procedure.
Aspiration of a portion of the developing placenta (chorionic villi) through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix, under ultrasound guidance. First-trimester alternative to amniocentesis.
Blood-based screening tests done between 16–18 weeks. Screen, don't diagnose — abnormal results require follow-up testing.
Screening tool to detect neural tube defects. Performed in all pregnant clients, preferably 16–18 weeks. Abnormal findings → quad marker screening, genetic counseling, ultrasound, and amniocentesis.
Important: MSAFP is only a screen. Abnormal results must be confirmed with further testing.
Blood test ascertaining likelihood of fetal birth defects (does not diagnose). Can be performed instead of MSAFP — yields more reliable findings. Preferred at 16–18 weeks.
Performed between 15–22 weeks gestation (optimally 16–18 weeks). Screens for:
Part of the Quad Screen (with hCG, estriol, inhibin A) for trisomy detection.
Maternal blood test performed as early as 10 weeks. Analyzes fetal DNA fragments in maternal circulation for chromosomal abnormalities. Higher sensitivity/specificity than the Quad Screen for trisomies 21, 18, and 13. Can determine fetal sex and Rh status.
From the book — uses the ATI Diagnostic Procedure template for the NST. Practice answering before reviewing the key.
A nurse in a prenatal clinic is orienting a newly licensed nurse about how to perform a nonstress test (NST). What should the nurse include in the teaching about the procedure? Use the ATI Active Learning Template: Diagnostic Procedure to complete this item.
Does NOT demonstrate ≥ 2 qualifying accelerations in a 20-min window. Further assessment with CST or BPP is indicated.
Preprocedure:
Intraprocedure: Instruct client to depress the event marker button each time they feel fetal movement.
NCLEX · Reduction of Risk Potential · Diagnostic Tests4 NCLEX-style questions covering Ch 6 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is performing a nonstress test (NST) on a client at 36 weeks of gestation. After 20 minutes, the tracing shows 2 accelerations of 15 bpm above baseline lasting 15 seconds each. How should the nurse interpret this result?
Show rationale ▾A. CORRECT. A reactive NST at ≥ 32 weeks requires ≥ 2 accelerations of 15 bpm × 15 seconds within 20 minutes. This is reassuring.
B. Nonreactive would mean fewer than 2 qualifying accelerations within 20 minutes (or extended testing).
C. CST (contraction stress test) is a different test; "positive" CST means late decelerations with contractions.
D. Equivocal is for CST, not NST.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is reviewing a biophysical profile (BPP) result of 4. Which action should the nurse anticipate?
Show rationale ▾A. BPP score ≥ 8 typically allows continued monitoring.
B. BPP ≤ 4 indicates fetal compromise and is not consistent with routine care.
C. CORRECT. BPP ≤ 4 is highly suggestive of fetal asphyxia — prompt delivery is indicated.
D. Amniocentesis is for genetic, lung maturity, or infection workup — not the priority for a BPP of 4.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is preparing a client for amniocentesis. Which of the following statements should be included in teaching? (Select all that apply.)
Show rationale ▾A. CORRECT. A full bladder helps before 20 weeks (lifts the uterus); after 20 weeks an empty bladder is preferred to avoid puncturing it.
B. CORRECT. Pressure and mild cramping are expected during needle insertion.
C. CORRECT. Fluid leakage, contractions, fever, or decreased fetal movement should be reported immediately.
D. Local anesthesia at the insertion site is used; general anesthesia is not required.
E. CORRECT. The needle can cause fetal-maternal blood mixing; Rho(D) is given to Rh-negative clients.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is performing a contraction stress test (CST). The fetus shows late decelerations with more than 50% of contractions. How should the nurse interpret this result?
Show rationale ▾A. Negative CST = no late decels with contractions; this is opposite.
B. CORRECT. Positive CST = late decels with > 50% of contractions, indicating uteroplacental insufficiency. Delivery is usually indicated.
C. Equivocal-suspicious is late decels with < 50% of contractions.
D. Reactive refers to NST acceleration patterns, not CST.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is interpreting a biophysical profile (BPP) result for a client at 36 weeks gestation. The score is 6. The nurse anticipates the provider will:
Show rationale ▾A. BPP score of 6 is equivocal and requires further evaluation, not reassurance.
B. Weekly retesting is appropriate for scores ≥ 8, not equivocal scores.
C. CORRECT. A BPP score of 6 is equivocal — provider will order additional testing (repeat BPP, NST, doppler studies) or consider delivery based on gestational age and clinical picture.
D. Emergency cesarean is indicated for a BPP of 0–4 with imminent fetal compromise, not for a score of 6.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is preparing a client for a nonstress test (NST). Which of the following actions should the nurse perform? (Select all that apply.)
Show rationale ▾A. CORRECT. Have the client void to enhance comfort during the 20–40 minute test.
B. Position semi-Fowler or left lateral — NOT supine — to prevent vena cava compression.
C. CORRECT. Juice or light snack with glucose can stimulate fetal activity.
D. CORRECT. Tocodynamometer and FHR transducer are applied externally.
E. CORRECT. Client presses event marker when fetal movement is felt — used to correlate with FHR accelerations.
NCLEX · Reduction of Risk Potential · Diagnostic TestsBleeding in pregnancy is always abnormal. Pattern of cause varies by trimester. Painless 3rd-trimester bleed = placenta previa. Painful 3rd-trimester bleed with rigid uterus = abruptio placentae. Sharp unilateral lower-quadrant pain ± referred shoulder pain = ectopic rupture.
ATI Figure 7.1 — pattern recognition by gestational age narrows the differential before workup.
Pregnancy ending from natural causes before 20 weeks of gestation, or fetus < 500 g. Use the lay term "miscarriage" with clients — "abortion" is misunderstood.
| Type | Cramps | Bleeding | Tissue passed | Cervical opening |
|---|---|---|---|---|
| Threatened | Possible mild | Slight spotting | None | Closed |
| Inevitable | Mild to moderate | Moderate | None | Usually dilated |
| Incomplete | Severe | Heavy, profuse | Yes | Dilated, tissue in canal |
| Complete | Mild | Minimal | Yes | Closed (after passage) |
| Missed | None | None / spotting | None — prolonged retention | Closed |
| Septic | Varies | Varies; malodorous | Varies | Usually dilated |
| Recurrent | Varies | Varies | Yes | Usually dilated |
Pregnancy loss before 20 weeks gestation. Occurs in ~15–20% of recognized pregnancies.
| Type | Cervix | Bleeding | Tissue Passed | Management |
|---|---|---|---|---|
| Threatened | Closed | Slight, spotting | None | Bed rest, observation, pelvic rest |
| Inevitable | Open (dilation) | Moderate | None yet | Expectant management or D&C |
| Incomplete | Open | Heavy, profuse | Some | D&C or D&E to remove retained tissue |
| Complete | Closed | Slight | All products expelled | Observation; no further intervention usually needed |
| Missed | Closed | None, brown discharge | None (fetus deceased, retained) | D&C or misoprostol |
| Septic | Open | Foul, malodorous | Variable | IV antibiotics, D&C, possible hysterectomy |
| Recurrent | — | — | — | ≥ 3 consecutive losses; investigate underlying causes |
Abnormal implantation outside the uterine cavity, usually fallopian tube. Tubal rupture causes fatal hemorrhage. Second most frequent cause of early-pregnancy bleeding and a leading cause of infertility.
Implantation of fertilized ovum outside the uterine cavity — most commonly in the fallopian tube (95%). Can result in tubal rupture causing fatal hemorrhage. Second most frequent cause of bleeding in early pregnancy and a leading cause of infertility.
Risk factors (anything that compromises tubal patency):
Hallmark findings:
Diagnostic: serial quantitative beta-hCG (rises abnormally slowly), transvaginal ultrasound (no intrauterine gestational sac), serum progesterone.
Proliferation and degeneration of trophoblastic villi — placenta becomes swollen, fluid-filled, takes on grape-like cluster appearance. Embryo fails to develop. Associated with choriocarcinoma, a rapidly metastasizing malignancy.
Benign proliferative growth of the placental trophoblast in which trophoblastic villi swell and form fluid-filled grape-like clusters. Two types:
Classic findings:
Management and critical follow-up:
Placenta implants in the lower uterine segment near or over the cervical os instead of the fundus. Bleeding occurs in the third trimester as the cervix begins to dilate and efface.
Cervical os is completely covered by placenta.
Cervical os is partially covered.
Placenta attaches in lower segment but does not reach the os.
Exact relationship to internal os not yet determined.
"Previa is painless — the placenta is in the way, not torn from the wall." If you can't feel it but you can see it, it's previa.
Premature separation of the placenta from the uterus — partial or complete detachment. Occurs after 20 weeks, usually 3rd trimester. Significant maternal and fetal morbidity/mortality. Leading cause of maternal death.
Coagulation defect (disseminated intravascular coagulopathy) is often associated with moderate-to-severe abruption. Watch coagulation factors closely.
"Abruption is agonizing — the placenta is being torn from the uterine wall." Sharp pain + rigid uterus + dark bleeding = abruption until proven otherwise.
| Feature | Placenta Previa | Abruptio Placentae |
|---|---|---|
| Definition | Placenta over/near cervical os | Premature separation of normally implanted placenta |
| Bleeding | Painless, bright red, often profuse | Painful, dark red, may be concealed |
| Pain | None | Sudden, sharp, severe abdominal/back pain |
| Uterus | Soft, relaxed, nontender | Rigid, board-like, tender |
| Onset | Usually 2nd or 3rd trimester | Usually 3rd trimester or labor |
| FHR | Usually normal initially | Often nonreassuring, bradycardia, late decels |
| Risk Factors | Prior cesarean, multiparity, smoking, age > 35 | HTN, trauma, cocaine, smoking, prior abruption |
| Vaginal Exam | CONTRAINDICATED (can cause hemorrhage) | OK with caution |
| Treatment | Bedrest, cesarean if complete previa | Emergent delivery; cesarean if fetal distress |
| Coagulopathy | Rare | Common — DIC risk |
Fetal umbilical vessels implant into the fetal membranes rather than the placenta — the vessels run between the fetus and the cervix unprotected by Wharton's jelly. Vessels rupture during labor, causing rapid fetal exsanguination.
From ATI Maternal Newborn (Ed 11), Chapter 7. Click each exercise to reveal the rationale and NCLEX connection.
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following?
Show rationale ▾A. Missed abortion presents with brownish discharge and no pain.
B. CORRECT. Unilateral lower-quadrant pain ± bleeding is classic for ectopic. IUD use is itself a risk factor for ectopic pregnancy.
C. Severe preeclampsia does not cause vaginal bleeding; presents with right upper quadrant epigastric pain.
D. Hydatidiform mole has dark brown 2nd-trimester bleeding without abdominal pain.
NCLEX · Physiological Adaptation · Alterations in Body SystemsA nurse is providing care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? (Select all that apply.)
Show rationale ▾A. Fetal position is not a risk factor for abruption.
B. CORRECT. Blunt abdominal trauma is a risk factor.
C. CORRECT. Cocaine causes vasoconstriction → abruption.
D. Maternal age is not specifically associated with abruption (it IS for previa).
E. CORRECT. Cigarette smoking is a risk factor.
NCLEX · Health Promotion & Maintenance · Health Promotion / Disease PreventionA nurse is caring for a client at 32 weeks of gestation with placenta previa, who is actively bleeding. Which medication should the nurse expect the provider will prescribe?
Show rationale ▾A. CORRECT. Betamethasone promotes fetal lung maturity if early delivery is anticipated.
B. Indomethacin — preterm labor (tocolytic).
C. Nifedipine — preterm labor (tocolytic).
D. Methylergonovine — postpartum hemorrhage.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse at an antepartum clinic is caring for a client at 4 months of gestation. The client reports continued nausea, vomiting, and scant prune-colored discharge. The client has experienced no weight loss and has fundal height larger than expected. Which complication should the nurse suspect?
Show rationale ▾A. Hyperemesis would have weight loss and dehydration.
B. Threatened abortion is 1st trimester with spotting/moderate bleeding, no enlarged uterus.
C. CORRECT. Hydatidiform mole shows increased fundal height inconsistent with gestational age, excessive nausea/vomiting from elevated hCG, and scant dark 2nd-trimester discharge — all classic.
D. Preterm labor is < 37 weeks with pink-stained discharge and regular contractions.
NCLEX · Physiological Adaptation · Unexpected Response to TherapiesA nurse is caring for a client experiencing a ruptured ectopic pregnancy. Which finding is expected with this condition?
Show rationale ▾A. Ruptured ectopic has delayed, scant, or irregular menses.
B. Transvaginal ultrasound shows an empty uterus in ectopic.
C. Progesterone is lower than expected in ectopic.
D. CORRECT. Severe shoulder pain = blood in the abdominal cavity irritating the diaphragm and phrenic nerve. Classic ectopic-rupture finding.
NCLEX · Physiological Adaptation · Unexpected Response to TherapiesATI Active Learning Scenario. A nurse manager is presenting an educational program on placenta previa for a group of nurses. What should the manager include? Use the ATI Active Learning Template: System Disorder to complete this item.
Alteration in health — types of placenta previa:
Risk factors (any three): previous placenta previa · uterine scarring (prior cesarean, curettage, endometritis) · maternal age 35–40 · multifetal gestation · multiple gestations · smoking
Diagnostic procedures (two):
Contraindicated nursing action: performing a vaginal exam (can exacerbate bleeding).
NCLEX · Physiological Adaptation · Unexpected Response to TherapiesA nurse is caring for a client at 32 weeks gestation who reports painless, bright red vaginal bleeding. The fundus is soft and nontender. Which of the following is the priority action?
Show rationale ▾A. Vaginal exam is CONTRAINDICATED in suspected placenta previa — can cause severe hemorrhage.
B. CORRECT. Painless bright red bleeding with soft uterus suggests placenta previa. Priority is fetal monitoring + maternal assessment. Ultrasound will confirm diagnosis.
C. Tocolysis is not the priority; assessment comes first.
D. Cesarean is indicated for complete previa or active bleeding with fetal compromise — but only after assessment.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is reviewing risk factors for placental abruption. Which of the following client conditions should the nurse identify as risk factors? (Select all that apply.)
Show rationale ▾A. CORRECT. Hypertensive disorders are the leading risk factor for abruption.
B. CORRECT. Cocaine causes vasospasm and is a strong risk factor.
C. Prior cesarean is a risk factor for placenta previa, not abruption.
D. CORRECT. Cigarette smoking causes placental insufficiency and abruption.
E. CORRECT. Blunt trauma (MVA, falls, intimate partner violence) is a major cause.
F. CORRECT. Advanced maternal age increases risk.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsHigh-yield NCLEX patterns: HIV — scheduled C-section at 38 wks if viral load > 1,000 copies/mL · zidovudine for mom and infant. GBS — vaginal/rectal culture at 35–37 weeks · intrapartum penicillin G if positive. TORCH crosses placenta (rubella vaccine postpartum only — avoid pregnancy 4 weeks). Erythromycin eye ointment to ALL newborns for chlamydia and gonorrhea prophylaxis (ophthalmia neonatorum). Avoid invasive procedures (amnio, episiotomy, internal monitors, vacuum/forceps) in HIV-positive clients.
Retrovirus that destroys T lymphocytes → immunosuppression. Severe immunosuppression = AIDS. Vertical transmission via placenta perinatally and via breast milk postnatally.
Universal screening: All pregnant clients should be screened for HIV at the initial prenatal visit using enzyme immunoassay (EIA). Confirmation is performed via Western blot or HIV-1/HIV-2 differentiation immunoassay. Third-trimester rescreening recommended for high-risk clients.
Antiretroviral therapy (ART): Initiated regardless of CD4 count to:
Mode of delivery decisions:
Newborn care:
Toxoplasmosis · Other (hepatitis A/B, syphilis, mumps, parvovirus B19, varicella-zoster) · Rubella · Cytomegalovirus · Herpes simplex virus. All cross the placenta with teratogenic effects on the fetus.
Bacterial infection passed to fetus during labor and delivery. Often part of normal vaginal flora. Can cause neonatal pneumonia, respiratory distress syndrome, sepsis, and meningitis.
Vaginal AND rectal cultures at 35–37 weeks of gestation for all pregnant clients.
Penicillin G or ampicillin are most commonly prescribed.
Client education: Notify the L&D nurse of GBS status. Decrease neonatal risks by being screened for GBS at 35–37 weeks.
Bacterial infection caused by Chlamydia trachomatis — most commonly reported STI in American women. Often asymptomatic, making screening crucial. Untreated → PID, infertility, ectopic pregnancy.
Bacterial infection caused by Neisseria gonorrhoeae. Spread genital-to-genital, anal-to-genital, or oral-to-genital. Transmissible to newborn during delivery. Often asymptomatic in females; untreated → tubal scarring, PID, infertility. Untreated neonate: ophthalmia neonatorum → blindness.
Same as chlamydia: yearly for sexually active females < 25 yo, those with risk factors, all pregnant clients at risk at first prenatal visit, rescreen 3rd trimester if continued high risk.
Caused by Treponema pallidum (spirochete). Transmitted through direct contact with chancres (sexual contact) or transplacentally. Crosses placenta — congenital syphilis is preventable through prenatal screening and treatment.
Note: This section's PDF source pages didn't extract cleanly. Content here is supplemented from standard maternal-newborn nursing references for completeness — verify with course materials.
Penicillin G benzathine IM — only effective treatment for syphilis in pregnancy. Penicillin-allergic clients must be desensitized — there is no acceptable alternative for congenital syphilis prevention.
Caused by Treponema pallidum. Crosses placenta; can cause stillbirth, preterm birth, and severe congenital infection.
Caused by HPV virus. Most common viral STI. Some strains cause cervical cancer; others cause genital warts (condyloma acuminata).
Note: This section's PDF source pages didn't extract cleanly. Content here is supplemented from standard maternal-newborn nursing references — verify with course materials.
Three common vaginal infections during pregnancy. Each has distinct discharge characteristics and treatment.
Note: This section's PDF source pages didn't extract cleanly. Content here is supplemented from standard maternal-newborn nursing references — verify with course materials.
Caused by Trichomonas vaginalis — a flagellated protozoan. Transmitted sexually.
Disruption of normal vaginal flora — overgrowth of Gardnerella vaginalis and other anaerobes. Reduced lactobacilli → ↑ vaginal pH.
Caused by Candida albicans (most common). Pregnancy ↑ susceptibility due to elevated estrogen and glycogen in vaginal epithelium.
Cross-cutting reference table for the full chapter.
4 NCLEX-style questions covering Ch 8 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is reviewing the timing of routine prenatal screenings. When is Group B Streptococcus (GBS) screening typically performed?
Show rationale ▾A. First-visit labs include initial cultures but not specifically the GBS screen.
B. 24–28 weeks is when the 1-hour GCT for gestational diabetes is performed.
C. CORRECT. GBS screening is performed via vaginal-rectal swab at 36 0/7 to 37 6/7 weeks. If positive, intrapartum IV penicillin prophylaxis is given.
D. Admission tests may include rapid GBS in some facilities, but routine screening is at 36–37 weeks.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA nurse is caring for an HIV-positive client in active labor with a viral load of 2,500 copies/mL. Which of the following interventions should the nurse anticipate? (Select all that apply.)
Show rationale ▾A. CORRECT. Cesarean delivery is recommended if viral load > 1,000 copies/mL to reduce vertical transmission.
B. CORRECT. IV zidovudine during labor reduces vertical transmission to less than 2%.
C. Internal fetal monitoring (scalp electrode) creates a portal of entry for HIV and is contraindicated.
D. CORRECT. Continue ART; interruption causes viral rebound and increases transmission.
E. CORRECT. AROM may increase exposure; avoid prolonged ROM.
NCLEX · Safety & Infection Control · Standard Precautions/Transmission-Based PrecautionsA nurse is reviewing the TORCH infections. Which of the following is NOT typically included in TORCH?
Show rationale ▾A. Toxoplasmosis is the "T" in TORCH.
B. Rubella is the "R" in TORCH.
C. CORRECT. Hepatitis B is NOT one of the classical TORCH infections. TORCH = Toxoplasmosis, Other (syphilis, varicella, parvovirus), Rubella, Cytomegalovirus, Herpes.
D. Cytomegalovirus is the "C" in TORCH.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is teaching a client diagnosed with chlamydia during pregnancy. Which medication should the nurse expect to be prescribed?
Show rationale ▾A. Doxycycline is contraindicated in pregnancy (affects fetal bone/tooth development).
B. CORRECT. Azithromycin is safe in pregnancy and is the recommended treatment for chlamydia. Single 1-g dose.
C. Ciprofloxacin is contraindicated in pregnancy (cartilage damage).
D. Tetracycline is contraindicated in pregnancy.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse is caring for a client at 38 weeks gestation with a positive group B streptococcus (GBS) culture. The client begins active labor. Which medication should the nurse anticipate administering?
Show rationale ▾A. Acyclovir is used for HSV infection, not GBS.
B. CORRECT. Penicillin G is first-line for intrapartum GBS prophylaxis — 5 million units IV initial dose, then 2.5–3 million units IV q4hr until birth.
C. Azithromycin is used for chlamydia treatment.
D. Metronidazole treats bacterial vaginosis and trichomoniasis, not GBS.
NCLEX · Pharmacological & Parenteral Therapies · Medication AdministrationA nurse is teaching a pregnant client with HIV about reducing the risk of perinatal transmission. Which of the following actions should the client be advised to take? (Select all that apply.)
Show rationale ▾A. CORRECT. ART throughout pregnancy reduces transmission risk to < 2%.
B. CORRECT. HIV is transmitted in breast milk; formula feeding is recommended in developed countries.
C. Mode of delivery depends on viral load. Cesarean recommended if > 1,000 copies/mL.
D. CORRECT. Scheduled cesarean at 38 weeks reduces transmission risk if viral load > 1,000 copies/mL.
E. CORRECT. Pumped breast milk is also contraindicated.
F. Skin-to-skin is generally OK and does not transmit HIV through intact skin, but breastfeeding is contraindicated.
NCLEX · Health Promotion & Maintenance · Health Promotion/Disease PreventionHigh-yield numbers: OGTT screen 24–28 wks · > 130–140 mg/dL → 3-hr OGTT. Hyperemesis: urinary ketones are key sign. Iron supplements: empty stomach + OJ, never milk. Gestational HTN: BP ≥ 140/90 on two readings 4+ hours apart. Severe: ≥ 160/110. Mag sulfate antidote = calcium gluconate. Cerclage placed 12–14 weeks, removed 36–38 weeks or at spontaneous labor.
Variable condition where products of conception are expelled because of tissue changes and shortened cervical length. Treated prophylactically with cervical cerclage at 12–14 weeks gestation.
Cervical insufficiency (formerly "incompetent cervix"): painless cervical dilation and effacement in the 2nd trimester leading to pregnancy loss without contractions. Common history: prior 2nd-trimester loss with rapid, painless dilation.
Diagnosis:
Cervical cerclage (McDonald or Shirodkar): surgical placement of a suture around the cervix.
Excessive nausea and vomiting (possibly related to elevated hCG) that persists past 16 weeks or causes weight loss, dehydration, nutritional deficiencies, electrolyte imbalances, and ketonuria. Risk to fetus: IUGR, SGA, preterm birth.
Most important initial test: urinalysis for ketones and acetones (breakdown of protein and fat). Elevated urine specific gravity confirms dehydration.
Clear liquids → bland foods → frequent small meals → soft diet → normal diet as tolerated. Start with dry toast, crackers, or cereal. Severe cases may need enteral nutrition or TPN.
Severe, persistent nausea and vomiting causing significant weight loss (> 5% pre-pregnancy weight), dehydration, electrolyte imbalance, ketosis, and acetonuria. Distinguishes from normal morning sickness by severity.
Lab findings:
Management:
Occurs during pregnancy due to inadequate maternal iron stores and insufficient dietary iron. Recommended iron intake during pregnancy: 27 mg/day (most prenatal vitamins contain 30 mg).
Most common medical disorder in pregnancy. Defined as:
Risk factors: adolescent pregnancy, vegan/vegetarian, multiple gestations, closely-spaced pregnancies, heavy menstruation prior to pregnancy.
Manifestations: fatigue, weakness, pallor, tachycardia, dyspnea on exertion, pica (especially craving ice — pagophagia).
Treatment:
Fetal/neonatal effects: IUGR, low birth weight, preterm birth, increased perinatal mortality, infant iron deficiency.
Impaired tolerance to glucose with first onset/recognition during pregnancy. Ideal glucose 60–99 mg/dL fasting/before meals · ≤ 120 mg/dL 2 hr after meals. ~50% develop type II DM later.
Hypertensive disease in pregnancy progresses along a continuum: GH → preeclampsia → severe preeclampsia → eclampsia. HELLP syndrome is a hematologic variant. Underlying mechanism: vasospasm → poor tissue perfusion.
Variant of GH with hematologic conditions coexisting with severe preeclampsia and hepatic dysfunction.
| Disorder | BP | Proteinuria | End-Organ Signs | Onset |
|---|---|---|---|---|
| Chronic HTN | ≥ 140/90 before 20 wk OR persists > 12 wk postpartum | None (initially) | None | Before pregnancy or before 20 wk |
| Gestational HTN | ≥ 140/90 after 20 wk × 2 readings, 4 hr apart | None | None | After 20 wk; resolves by 12 wk PP |
| Preeclampsia (without severe features) | ≥ 140/90 | ≥ 300 mg/24 hr OR P/C ratio ≥ 0.3 OR dipstick 1+ | None | After 20 wk |
| Preeclampsia (with severe features) | ≥ 160/110 | Present | Headache, visual changes, RUQ pain, plt < 100k, LFTs ×2 normal, Cr > 1.1, pulm edema | After 20 wk |
| HELLP Syndrome | May be normal | Variable | Hemolysis, Elevated Liver enzymes, Low Platelets < 100k | 3rd trimester or postpartum |
| Eclampsia | Severely elevated | Present | Tonic-clonic seizures | After 20 wk through 6 wk PP |
CNS depressant and smooth muscle relaxant. Medication of choice for seizure prophylaxis or treatment in eclampsia and severe preeclampsia. Among the most-tested medications in maternal-newborn nursing.
| Serum Level (mEq/L) | Clinical Effect | Action |
|---|---|---|
| 1.5–2.5 | Normal (non-pregnant) | Baseline |
| 4–7 | Therapeutic for tocolysis & seizure prophylaxis | Maintain infusion |
| 7–10 | Loss of DTRs (patellar reflex) | Decrease rate; notify provider |
| 10–12 | Respiratory depression (RR < 12); somnolence | STOP infusion; notify provider; calcium gluconate |
| 15–17 | Respiratory paralysis | Emergency: calcium gluconate 1 g IV, intubation |
| > 25 | Cardiac arrest | ACLS, calcium gluconate |
Antidote: Calcium gluconate 1 g IV over 3 minutes. Monitor RR, DTRs, urine output (> 30 mL/hr), and LOC q1hr during infusion.
From the book — uses the ATI Therapeutic Procedure template for cervical cerclage. Practice answering before reviewing the key.
A nurse is preparing to teach a client who is at 20 weeks of gestation and is scheduled to undergo a prophylactic cervical cerclage. What information should the nurse include in the teaching? Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.
Surgical reinforcement of the cervix with a heavy ligature (suture) placed submucosally around the cervix to strengthen it and prevent premature cervical dilation.
4 NCLEX-style questions covering Ch 9 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is caring for a client receiving magnesium sulfate infusion. Which of the following findings indicates magnesium toxicity? (Select all that apply.)
Show rationale ▾A. CORRECT. Loss of DTRs is the FIRST sign of toxicity — stop infusion immediately.
B. CORRECT. RR < 12/min indicates respiratory depression — toxic.
C. CORRECT. Urine output < 30 mL/hr risks toxicity since magnesium is renally excreted.
D. Therapeutic range is 4–7 mEq/L; toxicity begins > 7 mEq/L.
E. Elevated BP is the reason magnesium was given (in preeclampsia) — not a sign of toxicity itself.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is caring for a client with gestational diabetes. Which of the following dietary recommendations should be included in teaching?
Show rationale ▾A. Three large meals cause glucose spikes — small frequent meals are preferred.
B. CORRECT. 175 g of complex carbohydrates spread across 3 meals + 2–3 snacks prevents glucose excursions and maintains fetal glucose needs.
C. Eliminating carbs is unsafe; the fetus requires carbohydrate for brain development.
D. Fruit juice raises glucose more rapidly than whole fruit — whole fruit is preferred.
NCLEX · Health Promotion & Maintenance · Antepartum/Postpartum CareA nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the following lab findings should the nurse anticipate?
Show rationale ▾A. CORRECT. Hyperemesis causes starvation ketosis from prolonged inability to keep food down.
B. Hyperemesis can cause hypoglycemia, but ketonuria is the more specific finding.
C. Persistent vomiting causes hypokalemia (low potassium), not elevated.
D. Dehydration causes increased (not decreased) hematocrit from hemoconcentration.
NCLEX · Reduction of Risk Potential · Laboratory ValuesA nurse is providing post-procedure care to a client following cervical cerclage placement. Which finding should the nurse report to the provider?
Show rationale ▾A. Mild discomfort is expected post-procedure and usually resolves within 1–2 days.
B. Light pink discharge is expected.
C. CORRECT. Regular contractions suggest impending preterm labor — the cerclage may need urgent removal to prevent uterine rupture or fetal injury.
D. Light spotting within 24 hours is expected and usually resolves.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is caring for a client receiving IV magnesium sulfate for severe preeclampsia. Which assessment finding requires immediate intervention?
Show rationale ▾A. DTRs of 2+ are normal — would be concerning if absent (hyporeflexia indicates magnesium toxicity).
B. CORRECT. RR < 12/min is a sign of magnesium toxicity. Stop the infusion immediately, notify provider, and administer calcium gluconate (the antidote).
C. Urine output of 30+ mL/hr is acceptable.
D. BP 138/88 is improved from severe range — desired effect of treatment.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is providing education to a client newly diagnosed with gestational diabetes mellitus (GDM). Which of the following should the nurse include? (Select all that apply.)
Show rationale ▾A. CORRECT. Self-monitoring 4×/day (fasting + 1- or 2-hour postprandial).
B. CORRECT. Fasting glucose target is 60–95 mg/dL.
C. CORRECT. Glyburide and metformin are considered safe alternatives if diet/exercise is insufficient.
D. Insulin does NOT cross the placenta and is the safest option for tight glycemic control.
E. CORRECT. A 75-g, 2-hr OGTT at 6–12 weeks postpartum screens for persistent diabetes.
F. Daily exercise (e.g., walking after meals) is recommended for glucose control.
NCLEX · Health Promotion & Maintenance · Lifestyle ChoicesPreterm labor: uterine contractions + cervical changes between 20 and 36⁶/⁷ weeks. Tocolytic targets: nifedipine (CCB), mag sulfate (CNS depressant), terbutaline (β-agonist), indomethacin (NSAID, < 32 wks only). Betamethasone 12 mg IM × 2 doses 24 hr apart, between 24–34 weeks for fetal lung maturity. PPROM = ROM 20–37 wks; biggest complication is chorioamnionitis. Confirm ROM with positive nitrazine paper (blue, pH 6.5–7.5) or ferning test.
Uterine contractions and cervical changes occurring between 20 weeks and 36 weeks 6 days of gestation. Categorized as very preterm (< 32 wk), moderately preterm (32–34 wk), and late preterm (34–36 wk). Shorter gestation = higher neonatal risks.
Regular uterine contractions between 20 0/7 and 36 6/7 weeks that cause cervical changes. Affects ~10% of pregnancies; leading cause of neonatal morbidity/mortality.
Risk factors:
Screening tools:
Prevention in high-risk clients:
Used to suppress uterine contractions and delay delivery — buying time for betamethasone, transport, or maturation. Each agent has distinct mechanism, monitoring, and contraindications.
Suppresses contractions by inhibiting calcium from entering smooth muscle.
Relaxes smooth muscles via CNS depression. See Ch 9 § Magnesium Sulfate for full toxicity reference.
Adverse effects: hot flashes, diaphoresis, burning at IV site, nausea, vomiting, drowsiness, blurred vision, headache, nonreactive NST, reduced FHR variability.
Toxicity stop signs: loss of DTRs · urine < 30 mL/hr · RR < 12 · pulmonary edema · severe hypotension · chest pain. Antidote: calcium gluconate or calcium chloride.
Relaxes smooth muscle and inhibits uterine activity.
Dosing: 0.25 mg subcutaneous every 4 hr, for up to 24 hr. Discontinue if adverse effects intolerable.
Suppresses preterm labor by blocking prostaglandin production, which inhibits uterine contractions.
Can cause premature narrowing or closure of the ductus arteriosus in the fetus. Use only if < 32 weeks gestation; treatment ≤ 48 hr.
Medications used to suppress uterine contractions in preterm labor. Goal: delay delivery 48 hr to allow corticosteroids to work or transfer to higher-level facility. NOT used after 34 weeks (let labor progress) or with chorioamnionitis, fetal distress, or significant bleeding.
| Drug | Class | Dose | Maternal Effects | Avoid in |
|---|---|---|---|---|
| Magnesium sulfate | CNS depressant; smooth muscle relaxant | 4–6 g IV load over 20–30 min, then 1–3 g/hr | Flushing, warmth, lethargy, blurred vision, decreased DTRs, respiratory depression | Myasthenia gravis, renal impairment |
| Nifedipine (Procardia) | Calcium channel blocker | 20–30 mg PO load, then 10–20 mg PO q4–6hr | Hypotension, tachycardia, headache, dizziness, flushing | Maternal hypotension, cardiac disease; NEVER combine with magnesium (additive hypotension) |
| Indomethacin (Indocin) | NSAID / prostaglandin synthesis inhibitor | 50–100 mg loading PO/PR, then 25–50 mg q4–6hr | Nausea, heartburn, dizziness | > 32 weeks gestation (premature closure of fetal ductus arteriosus; oligohydramnios). Bleeding disorders, peptic ulcer disease, renal impairment |
| Terbutaline (Brethine) | Beta-2 adrenergic agonist | 0.25 mg SC q20–30 min (max 3 doses) | Maternal tachycardia, tremors, hyperglycemia, hypokalemia, pulmonary edema | Cardiac disease, hyperthyroidism, uncontrolled diabetes. FDA black box: not for > 48–72 hr use (maternal cardiac death) |
NEVER administer nifedipine and magnesium sulfate together — both cause maternal hypotension; combined effect can cause severe maternal hypotension, cardiac arrest, and fetal compromise. If switching from one to the other, allow adequate washout period.
Glucocorticoid given between 24 and 34 weeks of gestation to enhance fetal lung maturity and surfactant production. Reduces neonatal respiratory distress syndrome and other morbidities.
Client education: Report findings of pulmonary edema (chest pain, shortness of breath, crackles).
Given to accelerate fetal lung maturity in anticipated preterm delivery 24 0/7 to 33 6/7 weeks (consider down to 23 weeks; recent guidelines extend to 34 6/7 weeks for late preterm).
Standard regimens (choose one course):
Effects on fetus:
Maternal effects to monitor:
Single repeat course may be given if delivery doesn't occur within 7 days and continued risk of preterm delivery exists.
Admit if:
Home management may be appropriate if:
Distinct from tocolytic use: magnesium sulfate is also given specifically to reduce risk of cerebral palsy and severe neurologic dysfunction in surviving infants when preterm delivery is anticipated before 32 weeks.
Premature rupture of membranes (PROM): spontaneous rupture before onset of true labor. At term, often signifies labor onset. Preterm premature rupture of membranes (PPROM): spontaneous rupture after 20 wks but before 37 wks gestation.
Client reports a gush or leakage of clear fluid from the vagina.
| Gestational Age | Approach | Key Interventions |
|---|---|---|
| < 23 weeks | Counseling: expectant vs termination | Very poor prognosis (pulmonary hypoplasia, severe disability). Discuss options with the family. |
| 23–33 6/7 weeks | Expectant management (prolong pregnancy) | Hospital admission, broad-spectrum antibiotics, antenatal corticosteroids, GBS prophylaxis, no tocolytics, fetal surveillance |
| 34 0/7 – 36 6/7 weeks | Shared decision-making (delivery vs expectant) | Recent evidence supports either approach. Consider corticosteroids if not already given. |
| ≥ 37 weeks (term PROM) | Active management — proceed to delivery | Induction with oxytocin if labor doesn't begin spontaneously within 12–24 hr; GBS prophylaxis if applicable |
Prolongs the latency period and reduces neonatal morbidity:
Infection of the amniotic fluid, membranes, placenta, and/or decidua. Most common and most concerning complication of PPROM.
Classic findings (Gibbs criteria): Maternal temp ≥ 38°C (100.4°F) PLUS at least one of:
Management:
Generally NOT recommended once ROM occurs — the membranes have already ruptured, and prolonging pregnancy increases infection risk without proven benefit. Short-term tocolysis (≤ 48 hr) may be used only to:
If preterm delivery is anticipated before 32 weeks, administer magnesium sulfate to reduce risk of cerebral palsy and severe neurologic dysfunction in surviving infants.
Instillation of normal saline or LR into the uterine cavity via intrauterine pressure catheter (IUPC). Used in active labor for:
NOT used as routine prevention in PPROM management.
From the book — uses the ATI System Disorder template for preterm labor. Practice answering before reviewing the key.
A nurse in a prenatal clinic is reviewing preterm labor with a newly hired nurse. What should the nurse include in the discussion? Use the ATI Active Learning Template: System Disorder to complete this item.
Uterine contractions and cervical changes that occur between 20 and 37 weeks of gestation.
4 NCLEX-style questions covering Ch 10 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is assessing a client at 32 weeks of gestation. Which of the following findings would indicate preterm labor?
Show rationale ▾A. Irregular contractions resolving with hydration are typically Braxton-Hicks — not preterm labor.
B. CORRECT. Preterm labor is defined as regular contractions with cervical change between 20 0/7 and 36 6/7 weeks of gestation.
C. Back ache that improves with rest is a common discomfort, not labor.
D. Braxton-Hicks contractions are irregular, not associated with cervical change.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is administering betamethasone to a client at 30 weeks of gestation in preterm labor. Which is the primary purpose of this medication?
Show rationale ▾A. Tocolytics (terbutaline, nifedipine, indomethacin) stop contractions — not betamethasone.
B. Antibiotics prevent infection.
C. CORRECT. Betamethasone (corticosteroid) is given between 24–34 weeks to accelerate fetal lung surfactant production and reduce RDS risk. Maximum benefit occurs 24 hr after first dose.
D. Betamethasone does not improve maternal cardiac function.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse is caring for a client at 30 weeks of gestation with confirmed preterm premature rupture of membranes (PPROM). Which interventions should the nurse anticipate? (Select all that apply.)
Show rationale ▾A. CORRECT. Bed rest reduces leaking of amniotic fluid and stress on the cervix.
B. Vaginal exams should be MINIMIZED in PPROM to reduce infection risk; sterile speculum exam only when necessary.
C. CORRECT. Corticosteroids accelerate fetal lung maturity before potential preterm delivery.
D. CORRECT. Prophylactic antibiotics prolong latency and reduce neonatal infection.
E. CORRECT. Continuous FHR monitoring detects fetal compromise from cord compression or infection.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is administering terbutaline 0.25 mg subcutaneously for tocolysis. Which finding should the nurse report immediately?
Show rationale ▾A. HR 110 may be expected with beta-agonist tocolytics.
B. CORRECT. HR > 130/min is excessive and increases risk of maternal cardiac complications. Terbutaline should be held if HR exceeds this threshold.
C. Mild tremors are common, expected adverse effects.
D. Headache is a common adverse effect, generally manageable.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is caring for a client at 31 weeks gestation in preterm labor receiving terbutaline. Which assessment finding should be reported immediately?
Show rationale ▾A. Maternal HR up to ~120 bpm is expected with terbutaline.
B. CORRECT. Maternal HR > 120 bpm with chest pain may indicate pulmonary edema (a serious terbutaline complication). Stop infusion, notify provider, evaluate for cardiac/pulmonary toxicity. FDA black box warning.
C. Tremors and nervousness are common side effects.
D. Mild headache is expected and not concerning.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is teaching a client at 30 weeks gestation about preterm labor warning signs. Which of the following should be reported immediately? (Select all that apply.)
Show rationale ▾A. CORRECT. Pelvic pressure is a sign of preterm labor.
B. CORRECT. Regular contractions before 37 weeks are concerning.
C. CORRECT. Intermittent low back pain is a common preterm labor symptom.
D. CORRECT. Gush of fluid suggests PROM/PPROM.
E. Brown discharge is generally old blood and may not require immediate evaluation, though report at next visit.
F. CORRECT. Pink/red bleeding suggests cervical change or other complications.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum Care4 stages: 1st (onset → full dilation) · 2nd (full dilation → birth) · 3rd (birth → placenta) · 4th (recovery, ~1–2 hr). 1st stage phases by dilation: latent (0–3 cm) · active (4–7 cm) · transition (8–10 cm). Cord prolapse with ROM: first action is check FHR. Nitrazine paper: BLUE (pH 6.5–7.5) confirms amniotic fluid. Station 0: level of ischial spines. Negative = above; positive = below (descending).
A composite of cervical change, contraction characteristics, and maternal behavior. P = primigravida · M = multigravida.
Note: Some references recognize only two phases — latent (0–5 cm) and active (6–10 cm).
| Parameter | 0 points | 1 point | 2 points | 3 points |
|---|---|---|---|---|
| Dilation (cm) | Closed | 1–2 | 3–4 | ≥ 5 |
| Effacement (%) | 0–30 | 40–50 | 60–70 | ≥ 80 |
| Station | -3 | -2 | -1 / 0 | +1 / +2 |
| Consistency | Firm | Medium | Soft | — |
| Position | Posterior | Mid | Anterior | — |
Total score range: 0–13. Score ≥ 8: cervix favorable, induction likely successful. Score < 6: consider cervical ripening before induction.
| Stage | Phase | Cervix | Nulliparous Duration | Multiparous Duration |
|---|---|---|---|---|
| First Stage Onset of regular contractions to full dilation |
Latent | 0–6 cm | up to 20 hr | up to 14 hr |
| Active | 6–10 cm | 4–8 hr (1.2 cm/hr min) | 2–5 hr (1.5 cm/hr min) | |
| Transition | 8–10 cm | ~30 min–2 hr | ~10 min–1 hr | |
| Second Stage Full dilation to delivery of newborn |
— | 30 min–3 hr (up to 4 hr with epidural) | 5 min–2 hr (up to 3 hr with epidural) | |
| Third Stage Delivery of newborn to delivery of placenta |
— | 5–30 min | 5–30 min | |
| Fourth Stage Postpartum recovery |
— | 1–4 hr after delivery | 1–4 hr after delivery | |
Five factors that affect and define labor and birth: Passenger, Passageway, Powers, Position, Psychological response.
Size of fetal head, presentation, lie, attitude, and position affect the ability of the fetus to navigate the birth canal. The placenta is also a passenger.
Composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus. Bony pelvis must be adequate; cervix must dilate and efface in response to contractions and fetal descent.
Maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor. Support, education, and a calm environment promote effective labor.
Distinguishing characteristic: true labor leads to cervical dilation and effacement; false labor does not.
| True Labor | False Labor (Braxton-Hicks) | |
|---|---|---|
| Contractions | Regular, intensifying over time | Irregular, do not intensify |
| Discomfort location | Starts in lower back, radiates to abdomen | Abdomen only |
| Effect of activity | Intensifies with walking | Decreases or resolves with walking/rest |
| Effect of hydration/rest | Continues | Often resolves |
| Cervical change | Progressive effacement and dilation | No cervical change |
| Bloody show | Usually present | None |
If unclear, send the client home until contractions are more regular OR have her ambulate for 1–2 hours; reassess for cervical change.
Combines maternal vitals, fetal monitoring, contraction characteristics, vaginal examination, and labs.
Performed digitally by provider or qualified nurse. Assesses:
Adaptations the fetus makes as it progresses through the birth canal:
ROM can initiate labor or occur anytime during labor (most often during transition). Labor typically begins within 24 hours; ROM > 24 hr increases infection risk.
FIRST action: Assess FHR for abrupt decelerations — these indicate fetal distress and rule out umbilical cord prolapse. Other actions (drying client, assessing amniotic fluid, applying tocotransducer) come after FHR assessment.
Several methods to verify suspected ROM:
Document COAT: Color, Odor, Amount, Time of rupture.
Significance of fluid color:
The first 1–2 hours after placental delivery — focus on hemorrhage prevention, vital sign stabilization, and bonding.
Client education: Notify the nurse of increased vaginal bleeding or passage of blood clots.
From the book — uses the ATI Therapeutic Procedure template for vaginal examinations. Practice answering before reviewing the key.
A manager of a labor and delivery unit is reviewing the procedure for vaginal examinations with a group of newly hired nurses. Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.
4 NCLEX-style questions covering Ch 11 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching about the 5 P's affecting labor. Which combination correctly lists the 5 P's?
Show rationale ▾A. CORRECT. The 5 P's are: Powers (contractions + maternal effort), Passage (pelvic bones + soft tissue), Passenger (fetus), Position (maternal positioning), Psyche (psychological response).
B. Pelvis is part of Passage; Pulse is not one of the P's.
C. Pregnancy is not one of the 5 P's.
D. Pain is a manifestation, not one of the 5 P's.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is performing Leopold maneuvers on a client in labor. The fetal back is palpated on the left side of the maternal abdomen and the buttocks are at the fundus. Which position is the fetus in?
Show rationale ▾A. LOA = head is the presenting part, occiput on left side, anteriorly.
B. CORRECT. Buttocks at the fundus = breech presentation. Sacrum is the reference point in breech; on the left and anterior = Left Sacrum Anterior (LSA).
C. ROP = head presenting (occiput); positioning differs.
D. Transverse means fetal long axis is perpendicular to maternal long axis.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is differentiating true labor from false labor. Which of the following findings indicate true labor? (Select all that apply.)
Show rationale ▾A. CORRECT. True labor intensifies with activity; false labor resolves with activity or rest.
B. CORRECT. Bloody show (blood-tinged mucus) is a sign of cervical change.
C. Contractions that stop with rest are typical of false labor (Braxton-Hicks).
D. CORRECT. Progressive cervical change is the defining feature of true labor.
E. True labor pain typically starts in the lower back and radiates around to the abdomen; false labor pain is mainly anterior abdominal.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is assessing a client after rupture of membranes. Which finding should be reported immediately?
Show rationale ▾A. Clear, odorless fluid is expected for normal amniotic fluid.
B. CORRECT. Green-yellow fluid indicates meconium staining — possible fetal distress or post-term gestation. Notify provider; prepare for monitoring and possible suction at delivery.
C. Fluid is normally body temperature.
D. Volume varies but small leakage can occur with high-leak ROM and is not necessarily concerning.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is administering IV oxytocin for labor induction at 1.5 milliunits/min. The fetal monitor shows 7 contractions in 10 minutes lasting 90 seconds each, with late decelerations. Which action should the nurse take first?
Show rationale ▾A. Decreasing the rate is not sufficient when tachysystole + late decels are present.
B. Oxygen is part of intrauterine resuscitation but not the first action.
C. CORRECT. Tachysystole (> 5 contractions in 10 min) + nonreassuring FHR requires immediate discontinuation of oxytocin. Then reposition (left lateral), give O₂ 10 L/min, IV bolus, notify provider.
D. Notify provider AFTER stopping infusion and beginning intrauterine resuscitation.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsA nurse is assessing a client in early labor. Which of the following findings indicate true labor? (Select all that apply.)
Show rationale ▾A. False labor (Braxton-Hicks) typically decreases with activity. True labor intensifies.
B. CORRECT. Cervical change is the hallmark of true labor.
C. CORRECT. True labor pain begins in back and radiates to abdomen.
D. CORRECT. Regular pattern with progressive intensification is true labor.
E. Relief with rest/hydration is characteristic of false labor.
F. CORRECT. Bloody show (passage of mucus plug) suggests true labor onset.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CareSources by stage: 1st = visceral (back/leg) · 2nd = somatic (vaginal/perineal) · 3rd = like 1st · 4th = perineal stretch. Opioids = analgesia (perception). Pudendal/epidural/spinal = anesthesia (sensation blocked). Naloxone = opioid antidote. Epidural fluid bolus pre-administration to offset hypotension. Spinal headache → blood patch. Hyperventilation from breathing technique → numb fingers → oxygen mask or paper bag (let CO₂ rise).
Pain origin and quality differ by stage — guides selection of appropriate intervention.
Visceral pain — felt as back and leg pain.
Somatic pain — fetal descent and expulsion. Burning, splitting, tearing.
Similar to first stage.
Distention and stretching of vagina and perineum incurred during 2nd stage — splitting, burning, tearing sensation.
Pain level cannot always be assessed by outward expressions. Cultural beliefs, anxiety, and fear amplify pain experience.
Reduces anxiety, fear, and tension — the major contributors to pain in labor. Based on the gate-control theory of pain.
Sensory nerve pathways allow only a limited number of sensations to travel to the brain at any given time. By sending alternate signals (touch, sound, image) through these pathways, pain signals can be blocked from ascending → brain doesn't perceive pain.
Caused by low PCO₂ (blowing off too much CO₂). Manifestations: lightheadedness, tingling/numbness of fingers. Intervention: have client breathe into a paper bag or their cupped hands or place an oxygen mask over nose and mouth — letting them rebreathe CO₂.
Breathing techniques (taught in childbirth classes):
Counterpressure: sacral pressure with firm fist, tennis ball, or back of hand for back labor (OP positioning).
Effleurage: light circular stroking of the abdomen during contractions — promotes relaxation, distraction, gate control theory.
Hydrotherapy: warm shower or tub immersion (water 95–100°F / 35–37.8°C).
Position changes: side-lying, hands and knees, walking, squatting, birth ball.
Other techniques: TENS unit, acupressure, massage, music, guided imagery, hypnosis, focal point, doula support.
Alleviates pain sensations or raises the pain threshold. Verify labor is well-established with vaginal exam and contraction pattern before administering — to avoid slowing progress.
Secobarbital, pentobarbital, phenobarbital. Not typically used during birth — used in early/latent phase for anxiety relief and sleep induction.
Meperidine hydrochloride, fentanyl, butorphanol, nalbuphine. Act in CNS to decrease pain perception without loss of consciousness. IV preferred over IM during labor (faster). Usually given during early active labor.
Butorphanol & nalbuphine: provide pain relief WITHOUT significant maternal or fetal respiratory depression. Both IM and IV.
Short-acting opioids (fentanyl, sufentanil) administered as a motor block into the epidural or intrathecal space without anesthesia. Provides rapid pain relief while still allowing client to sense contractions and maintain ability to bear down.
Eliminates pain perception by interrupting nerve impulses to the brain. Regional blocks are most common: pudendal, epidural, spinal, paracervical. General anesthesia reserved for emergencies.
Local anesthetic (lidocaine, bupivacaine) administered transvaginally into the space in front of the pudendal nerve. No maternal or fetal systemic effects. Provides local anesthesia to perineum, vulva, rectal areas during delivery, episiotomy, and repair.
Compromise of maternal bearing-down reflex — coach client about when to bear down.
Bupivacaine + morphine or fentanyl injected into epidural space at L4 or L5. Eliminates pain from umbilicus to thighs — uterine contractions, fetal descent, perineal stretching. May not remove pressure sensations. Administered when client is in active labor and dilated to at least 4 cm. Continuous infusion or intermittent injections via indwelling epidural catheter. Patient-controlled epidural analgesia (PCEA) is favored.
Local anesthetic injected into subarachnoid space at L3, L4, or L5 interspace. Can be alone or with fentanyl. Eliminates all sensation from nipples to feet. Most commonly used for cesarean. Low spinal can be used for vaginal birth (NOT for labor — late 2nd stage only).
Rarely used. Reserved for delivery complications/emergencies when there's a contraindication to nerve block analgesia/anesthesia. Produces unconsciousness.
Procedure: Local anesthetic (bupivacaine, ropivacaine) ± opioid (fentanyl, sufentanil) injected into epidural space at L3-L4 or L4-L5 via catheter.
Prerequisites:
Position for placement: sitting at edge of bed, leaning forward over pillow, OR lateral recumbent. Round shoulders, curl spine outward ("cat" or "mad cat" pose).
Adverse effects and management:
Spinal block: single injection into subarachnoid space; rapid onset; used for cesarean delivery (NOT for labor analgesia).
Pudendal block: anesthetic injected near pudendal nerve transvaginally; provides perineal anesthesia for 2nd stage and episiotomy/repair. No effect on labor pain.
Spinal block: single injection of anesthetic directly into subarachnoid space (CSF).
Hybrid technique providing rapid onset of spinal with continuous epidural infusion afterward.
Local anesthetic injected transvaginally to anesthetize the pudendal nerve (S2-S4 nerve roots), providing perineal anesthesia.
Direct injection of local anesthetic (1% lidocaine) into perineal tissue immediately before episiotomy or for laceration repair. Most basic form of anesthesia for OB/GYN procedures. Minimal systemic effects.
Quick-reference for which method is appropriate at which stage of labor or birth.
From the book — uses the ATI Basic Concept template for nonpharmacological pain management. Practice answering before reviewing the key.
A nurse in a prenatal clinic is teaching a childbirth education class on methods to promote relaxation and pain management to a group of clients in the third trimester. What nonpharmacological pain management strategies should the nurse include in the discussion? Use the ATI Active Learning Template: Basic Concept to complete this item.
Sensory nerve pathways that pain sensations use to travel to the brain will allow only a limited number of sensations to travel at any given time. By sending alternate signals through these pathways, pain signals can be blocked from ascending the neurologic pathway, inhibiting the brain's perception and sensation of pain.
4 NCLEX-style questions covering Ch 12 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is monitoring a client 10 minutes after epidural placement. Maternal BP drops from 124/82 to 88/55. Which is the priority action?
Show rationale ▾A. Supine position worsens aortocaval compression and hypotension.
B. CORRECT. Left lateral position relieves aortocaval compression and IV fluid bolus increases preload. These are the FIRST actions before pharmacologic intervention.
C. Discontinuing the epidural is not the first action; positioning and fluids are.
D. Notifying anesthesia and giving vasopressor are appropriate next steps if positioning and fluids don't correct BP.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is teaching a client about non-pharmacologic pain management for labor. Which of the following techniques should be included? (Select all that apply.)
Show rationale ▾A. CORRECT. Breathing techniques reduce pain perception and prevent hyperventilation.
B. CORRECT. Effleurage stimulates gate-control pain inhibition.
C. CORRECT. Hydrotherapy reduces pain perception and may facilitate labor progress.
D. CORRECT. Position changes (especially upright) use gravity, relieve back pain, and aid descent.
E. Continuous supine bed rest causes aortocaval compression and may slow labor — not recommended.
NCLEX · Basic Care & Comfort · Non-Pharmacological Comfort InterventionsA nurse is administering butorphanol IV to a laboring client. Which assessment is most important after administration?
Show rationale ▾A. BP is monitored but is not the most important.
B. CORRECT. Butorphanol (opioid agonist-antagonist) can cause maternal and fetal respiratory depression — close monitoring of both is essential. Have naloxone available.
C. Cervical dilation is part of routine labor assessment but not specifically tied to butorphanol effects.
D. Hydration is important but not the priority post-medication.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is comparing spinal anesthesia and epidural anesthesia. Which characteristic is unique to spinal anesthesia?
Show rationale ▾A. Spinal is used for cesarean and some operative vaginal deliveries — true but not unique alone.
B. Single injection into subarachnoid space (vs continuous catheter in epidural space) is unique to spinal.
C. Risk of post-dural-puncture headache is much higher with spinal than epidural.
D. CORRECT. All three characteristics are features unique to spinal anesthesia compared with epidural.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse is caring for a client who received an epidural 15 minutes ago. The client's BP drops from 124/78 to 88/52 mm Hg, and the FHR shows late decelerations. Which action should the nurse perform first?
Show rationale ▾A. Notification follows initial interventions.
B. Ephedrine may be needed but only after positioning and fluid bolus.
C. CORRECT. Maternal hypotension after epidural is common (sympathectomy). Priority actions: position left lateral (relieves vena cava compression), IV fluid bolus, and oxygen if persistent. If BP not improving, then ephedrine.
D. Discontinuing the epidural is not the first action.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is reviewing nonpharmacologic pain management techniques with a client in labor. Which of the following are appropriate interventions? (Select all that apply.)
Show rationale ▾A. CORRECT. Effleurage promotes relaxation and distraction.
B. CORRECT. Hydrotherapy reduces pain perception and promotes relaxation.
C. Hyperventilation causes respiratory alkalosis and fetal acidosis. Slow, controlled breathing is appropriate.
D. CORRECT. Counterpressure is effective for back labor (e.g., OP position).
E. CORRECT. Position changes promote progress and comfort.
F. CORRECT. Music and imagery reduce anxiety and pain perception.
NCLEX · Basic Care & Comfort · Nonpharmacological Comfort InterventionsNormal FHR baseline at term is 110–160/min with moderate variability. Categorize tracings using the three-tier system. Late and variable decelerations require nursing intervention; early decelerations do not.
For each FHR pattern (top), think of the cause (bottom):
Bonus mnemonic for late decel response: "LION" — Left side · IV fluids · Oxygen · Notify provider (and stop oxytocin).
External palpations of the maternal uterus through the abdominal wall to determine fetal positioning before fetal monitoring is performed.
Palpate the fetal part occupying the fundus. Head feels round, firm, moves freely. Breech feels irregular and soft. Identifies fetal lie (longitudinal vs transverse) and presenting part (cephalic vs breech).
Locate and palpate the smooth contour of the fetal back with one hand; the irregular small parts (hands, feet, elbows) with the other. Validates the presenting part.
Gently grasp the lower uterine segment between thumb and fingers. Determines descent into the pelvis. If head is presenting and not engaged, determines whether head is flexed or extended.
Face the client's feet; outline the fetal head with the palmar surface of the fingertips on both hands to palpate the cephalic prominence. Identifies fetal attitude.
Systematic palpation of the maternal abdomen to determine fetal position. Performed after 32–36 weeks.
Preparation:
The four maneuvers (in order):
Document position and where to auscultate FHR. Listen at the fetal back — for cephalic vertex, lower abdomen; for breech, upper abdomen.
Intermittent auscultation of FHR using a hand-held Doppler, ultrasound stethoscope, or fetoscope, combined with palpation of contractions at the fundus for frequency, intensity, duration, and resting tone.
For low-risk labor, this method allows the client freedom of movement and can be done at home or in a birthing center.
Applies to both intermittent auscultation and continuous electronic fetal monitoring.
Auscultate FHR at these specific moments:
Securing an ultrasound transducer over the client's abdomen to record the FHR pattern, plus a tocotransducer on the fundus to record uterine contractions.
Noninvasive continuous FHR and uterine activity monitoring using two abdominal transducers.
Advantages over internal monitoring: noninvasive, no risk of infection, doesn't require ROM, suitable for any cervical dilation.
Limitations:
Intermittent auscultation with Doppler/fetoscope is an alternative for low-risk clients:
Normal baseline at term is 110–160/min, excluding accelerations, decelerations, and periods of marked variability — measured within a 10-minute window.
Fluctuations in the FHR baseline that are irregular in frequency and amplitude. Moderate variability is the goal.
Reference · Moderate variability — the healthy baseline pattern (compare to Fig 13.4 minimal)
These changes include accelerations and decelerations.
Associated with fetal hypoxia. Recognize these as signals to act:
Baseline FHR: average FHR over a 10-min window, excluding accelerations/decelerations and periods of marked variability.
Variability (fluctuations in baseline) — the most important indicator of fetal oxygenation/CNS integrity:
Causes of decreased variability: fetal sleep (cycles 20–40 min), maternal sedatives/opioids/magnesium, fetal hypoxia/acidosis, prematurity, congenital anomalies.
Accelerations:
All of the following must be present.
Examples include any of the following.
Either of the following.
| Category | Interpretation | Features | Action |
|---|---|---|---|
| Category I (Normal) |
Strongly predictive of normal acid-base balance | Baseline 110–160; moderate variability; no late or variable decels; accelerations present or absent; early decels OK | Routine monitoring; continue current care |
| Category II (Indeterminate) |
Not predictive of abnormal status but requires evaluation | Includes any tracing not Cat I or Cat III (most common); minimal variability without recurrent decels; recurrent variables with moderate variability; etc. | Continued surveillance, intrauterine resuscitation, reassess |
| Category III (Abnormal) |
Predictive of abnormal fetal acid-base balance | ABSENT variability with: recurrent late decels OR recurrent variable decels OR bradycardia; OR sinusoidal pattern | Urgent intervention or delivery if not resolving with resuscitation |
Variable transitory increase in FHR above baseline.
FHR <110/min for 10 minutes or more.
FHR >160/min for 10 minutes or more.
Decrease or loss of irregular fluctuations in the baseline FHR.
Fig 13.4 · Nearly flat baseline — fluctuations ≤ 5/min. Compare to expected moderate variability of 6–25/min.
Slowing of FHR at the start of contraction with return to baseline at end of contraction. Mirrors the contraction.
Fig 13.1 · FHR dip mirrors contraction — onset, nadir, and recovery align with the contraction
Slowing of FHR after contraction has started, returning to baseline well after contraction ends.
Fig 13.2 · FHR dip lags behind contraction — uteroplacental insufficiency means oxygenation drops after contraction stress
Transitory, abrupt slowing of FHR ≥15/min below baseline for ≥15 sec — variable in duration, intensity, and timing relative to contractions.
Fig 13.3 · Sharp V-shaped drops, irregular in timing and depth — classic for cord compression
| VEAL | CHOP | MINE | Pattern Description |
|---|---|---|---|
| Variable decels | Cord compression | Move (reposition mother) | Abrupt decrease > 15 bpm, > 15 sec, < 2 min; variable timing |
| Early decels | Head compression | Identify labor progress (benign) | Gradual; mirrors contraction; nadir at peak |
| Accelerations | Okay (well-oxygenated) | No intervention (reassuring) | Increase > 15 bpm × 15 sec (term) |
| Late decels | Placental insufficiency | Execute interventions (LION) | Gradual; nadir AFTER contraction peak; ominous |
LION intrauterine resuscitation: Lateral position · IV fluid bolus · Oxygen 10 L/min · Notify provider & stop oxytocin.
A small spiral electrode (FSE) is attached to the presenting part of the fetus to monitor FHR directly. Wires connect to a leg plate on the client's thigh, then to the fetal monitor.
Used in conjunction with an intrauterine pressure catheter (IUPC) — a solid or fluid-filled transducer placed inside the uterine cavity to monitor contraction frequency, duration, and intensity (which external monitoring cannot measure).
A nurse in labor and delivery is reviewing intermittent fetal auscultation and uterine contraction palpation with a newly licensed nurse. What information should the nurse include? Use the ATI Active Learning Template: Therapeutic Procedure.
Indications (any 4)
Outcomes / evaluation
Nursing interventions — devices & timing
A. Moderate variability — variability of 20/min falls in the 6–25/min reference range.
B. FHR accelerations — increases up to 150–155/min lasting 25 seconds.
C. No FHR decelerations — the FHR does not slow.
D. Normal baseline — 115–125/min is within 110–160/min reference range.
E. No fetal tachycardia — FHR is within reference range.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA. Internal monitoring is invasive, not noninvasive.
B. Detects abnormal fetal heart tones early.
C. Cannot determine amount of amniotic fluid.
D. Allows accurate readings with maternal movement — external monitoring requires adjusting when client moves.
E. Measures uterine contraction intensity (via IUPC) — external monitoring cannot.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA. At peak (acme), uteroplacental arteries are most compressed — fetal circulation/oxygenation decreases.
B. Moderate variability indicates FHR fluctuations, not increased oxygen.
C. Accelerations indicate intact fetal CNS, not increased oxygen delivery.
D. Fetus is most oxygenated during relaxation between contractions — uteroplacental arteries are not compressed, allowing perfusion.
NCLEX · Reduction of Risk Potential · Diagnostic TestsA. Greatest risk during late decels is uteroplacental insufficiency. Left-lateral position increases uteroplacental perfusion — first action.
B. Scalp electrode assists assessment but isn't the first action.
C. Inserting IV is an intervention but not first.
D. Vaginal exam may be performed but isn't first.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum & Newborn CareA. Palms on sides of uterus identifies fetal back vs small parts — verifies presenting part.
B. Palpating the fundus identifies the fetal part presenting there → fetal lie (longitudinal vs transverse).
C. Grasping lower segment determines descent of presenting part.
D. Outlining cephalic prominence identifies fetal attitude.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum & Newborn CareA nurse is reviewing a fetal heart rate tracing showing a gradual decrease in FHR with the nadir occurring after the contraction peak. Each contraction is followed by this same pattern. The nurse identifies this as:
Show rationale ▾A. Early decels mirror the contraction; nadir occurs AT the peak (not after).
B. Variable decels are abrupt (not gradual) and may not be related to contractions.
C. CORRECT. Late decels are gradual decreases with the nadir AFTER the contraction peak — indicating uteroplacental insufficiency. Requires immediate intrauterine resuscitation (LION: Lateral position, IV fluids, Oxygen, Notify/stop oxytocin).
D. Prolonged decels last 2–10 minutes.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsA nurse is interpreting an FHR tracing. Which of the following findings would the nurse expect with a Category III (abnormal) tracing? (Select all that apply.)
Show rationale ▾A. Category I (normal) — reassuring.
B. CORRECT. Cat III includes absent variability with recurrent late decels.
C. CORRECT. Sinusoidal pattern is Cat III — concerning for severe fetal anemia.
D. Accelerations are reassuring (Cat I).
E. CORRECT. Absent variability with bradycardia is Cat III.
F. Early decels are benign (head compression) — Cat I.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsMonitoring frequencies tighten as labor advances. Latent: q30–60 min · Active: q15–30 min · Transition: q10–15 min · 2nd stage: q5–15 min FHR. Crowning = bulging perineum + appearance of fetal head. Bowel-movement urge in transition = full dilation = prepare for delivery. Vaginal bleeding = DEFER vaginal exam until previa/abruption ruled out. Full bladder reduces pelvic space → encourage voiding q2h.
Begins before admission. Continuous maternal/fetal assessment throughout labor and immediately after birth.
These are commonalities and not meant to overgeneralize. Provide culturally competent care that respects each client's individual preferences.
From onset of regular uterine contractions to full effacement and dilation. Longer than 2nd and 3rd stages combined.
Latent phase (0–6 cm):
Active phase (6–10 cm):
Transition (8–10 cm):
From full cervical dilation/effacement to birth of the fetus.
Through skin of perineum only. Does NOT involve muscles.
Through skin AND muscles into perineum. NOT through anal sphincter.
Through skin, muscles, perineum, AND external anal sphincter muscle.
Through skin, muscles, anal sphincter, AND anterior rectal wall.
Crowning = bulging of the perineum and the appearance of the fetal head. (NOT placental protrusion, NOT decreased contraction intensity, NOT decreased rectal pressure — those are post-birth or pre-active findings.)
Begins with full cervical dilation (10 cm); ends with delivery of newborn.
Duration limits (in absence of fetal distress):
Pushing techniques:
Positions for pushing: upright (squatting, sitting), side-lying, hands-knees, lithotomy. Avoid prolonged supine.
Assessment:
Imminent delivery signs: bulging perineum, increasing bloody show, anal dilation, "I have to push!" sensation, perineal pressure.
From birth of the fetus until delivery of the placenta. Lasts 5–30 min.
Begins with delivery of placenta; includes at least the first 2 hr after birth. Focus: maintain uterine tone and prevent hemorrhage.
From the book — uses the ATI Basic Concept template for fourth-stage care. Practice answering before reviewing the key.
A nurse is caring for a client in the fourth stage of labor. What actions should the nurse take? Use the ATI Active Learning Template: Basic Concept to complete this item.
The focus of care in the fourth stage is to maintain uterine tone and prevent hemorrhage.
4 NCLEX-style questions covering Ch 14 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is providing care during the 4th stage of labor. Which assessment is the priority?
Show rationale ▾A. Cervical dilation is assessed during 1st stage, not 4th.
B. CORRECT. Fundal tone is the priority — uterine atony is the leading cause of postpartum hemorrhage in the immediate post-delivery period. Fundus should be firm, midline, at or just below umbilicus.
C. FHR is not relevant after delivery.
D. Temperature is monitored but is not the priority in the immediate post-delivery hour.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is documenting a third-degree perineal laceration. Which structures are involved?
Show rationale ▾A. 1st degree = skin and vaginal mucosa only.
B. 2nd degree = + perineal muscle.
C. CORRECT. 3rd degree extends through skin, muscle, AND external anal sphincter.
D. 4th degree extends THROUGH the anal sphincter into the rectal mucosa.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is monitoring a primigravida in active first-stage labor. The client is 7 cm dilated, contractions are 3 min apart lasting 60 seconds. Which interventions should the nurse implement? (Select all that apply.)
Show rationale ▾A. CORRECT. Position changes (upright, side-lying, hands and knees) aid fetal descent and reduce pain.
B. Pushing is contraindicated at 7 cm — full dilation (10 cm) is required to avoid cervical injury.
C. CORRECT. Hydration is important; offer per provider orders.
D. CORRECT. Patterned breathing helps cope with intensifying contractions.
E. CORRECT. AAP/ACOG: FHR assessment every 30 min in 1st-stage active labor for low-risk; every 15 min for high-risk.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is performing the immediate newborn assessment. Which is the priority intervention?
Show rationale ▾A. Vitamin K is given within the first hour but is not the priority immediate after birth.
B. CORRECT. Airway/breathing is always the priority. Suction mouth then nose with bulb syringe if needed; dry the newborn.
C. Cord clamping has shifted to delayed clamping (30–60 seconds) for term newborns to improve iron stores.
D. Apgar is calculated at 1 and 5 minutes but is not the priority intervention.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is assessing a client 30 minutes after vaginal delivery. The fundus is palpated at the umbilicus, deviated to the right, and boggy. Which action should the nurse take first?
Show rationale ▾A. Massage will help, but the displaced/boggy fundus is most likely due to a full bladder.
B. CORRECT. A deviated fundus suggests a full bladder, which displaces the uterus and prevents involution. Have the client void first (or catheterize if unable). Then reassess fundus.
C. Medications are not the first step for displaced fundus.
D. Provider notification is not the priority — implement standard nursing interventions first.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsA nurse is caring for a client in the fourth stage of labor. Which of the following are priorities for nursing assessment? (Select all that apply.)
Show rationale ▾A. CORRECT. VS q15 min × 4 in first hour, then q30 min × 2.
B. CORRECT. Fundus should be firm, midline, at umbilicus — prevent atony.
C. CORRECT. Heavy bleeding may indicate hemorrhage.
D. CORRECT. Full bladder displaces uterus and impairs involution.
E. Newborn assessment is performed but is not the priority during 4th-stage maternal assessment.
F. CORRECT. Visible bulging, severe pain → suspect hematoma.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsExternal version: 37–38 wks, breech/transverse, give Rho(D) IG if Rh-negative. Bishop ≥ 8 = successful induction at 39 wks. Oxytocin tachysystole = STOP infusion: contractions q<2 min, > 90 sec, > 90 mm Hg, resting tone > 20. Amniotomy: ensure fetal engagement first (cord prolapse risk); FHR before AND after. Amnioinfusion: for cord compression / oligohydramnios; membranes must be ruptured. Tocolytic for tachysystole/distress: terbutaline 0.25 mg SQ.
Ultrasound-guided hands-on procedure to externally manipulate the fetus into a cephalic lie. Performed at 37–38 weeks gestation, inpatient setting. High risk of placental abruption, umbilical cord compression, and emergent cesarean birth.
Malpositioned fetus in breech or transverse position late in gestation.
External manipulation of the maternal abdomen to convert a breech (or transverse) fetus to a vertex presentation.
Indications: Breech presentation at 36–37 weeks, no contraindications, singleton pregnancy, reassuring fetal status, adequate amniotic fluid.
Contraindications: Multifetal gestation, placenta previa, prior cesarean (classical), uterine anomaly, oligohydramnios, ROM, fetal anomaly, abnormal fetal heart pattern, third-trimester bleeding.
Procedure:
Success rate: ~50–60%. Risks: cord entanglement, abruption, ROM, fetal distress, fetomaternal hemorrhage.
Bishop score evaluates cervical readiness for labor. Cervical ripening uses mechanical or chemical methods to enhance cervical softening, dilation, and effacement before induction.
Five factors evaluated, each scored 0–3:
Indication: any condition where augmentation or induction is indicated.
Client readiness: at 39 weeks, a Bishop score of 8 or more is indicative of a successful induction.
Soften and thin the cervix. Oral medication or vaginal suppositories/gels.
Ongoing care includes assessing for: urinary retention, ROM, uterine tenderness/pain, contractions, vaginal bleeding, fetal distress.
For Bishop Score < 6 (unfavorable cervix) when induction is needed.
Pharmacologic (prostaglandins):
Mechanical methods:
Induction: deliberate initiation of contractions before spontaneous labor. Augmentation: stimulation of hypotonic contractions when labor has begun but progress is inadequate. Same procedures, assessments, and complications.
Elective induction: must meet criteria of at least 39 weeks gestation. Inductions outside criteria → ↑ infection, premature delivery, longer labor, cesarean.
Two procedures involving the membranes/fluid: AROM accelerates labor; amnioinfusion supplements low fluid volume.
Artificial rupture of amniotic membranes by the provider using a hook, clamp, or other sharp instrument.
Normal saline or lactated Ringer's instilled into amniotic cavity through a transcervical catheter introduced into the uterus to supplement amniotic fluid. Reduces severity of variable decelerations from cord compression.
Three procedures used to assist delivery of the fetal head.
Cuplike suction device attached to fetal head. Traction applied during contractions to assist in descent and birth of head; cup released and removed before delivery of fetal body.
Instrument with two curved spoon-like blades assists delivery of fetal head. Traction applied during contractions.
Incision into the perineum to enlarge vaginal opening, facilitate birth, minimize soft tissue damage.
Ongoing care: encourage alternate labor positions to reduce perineal pressure and promote stretching → reduce episiotomy necessity.
Prerequisites (must ALL be met):
Forceps types:
Vacuum extraction — "3-3-3 rule": discontinue if any of these occur:
Application landmarks for vacuum: cup placed at flexion point — 3 cm anterior to posterior fontanelle (over sagittal suture). Suboptimal placement causes higher complication rates.
Types:
Current practice: Restrictive use only — not routine. ACOG no longer recommends routine episiotomy. Indications:
Repair: layered closure with absorbable suture; muscle, fascia, mucosa, skin.
Postpartum care: ice 12–24 hr; sitz baths after 12 hr; topical anesthetics; peri-bottle; analgesics; stool softeners; observe for hematoma, infection, dehiscence.
Delivery of fetus through a transabdominal incision of the uterus to preserve life or health when complications exist. Incisions made vertically or horizontally; horizontal is the optimal incision.
Immediate post-op (first 24 hr):
Discharge teaching:
Client delivers vaginally after a previous cesarean. Requires careful selection and immediate cesarean availability.
VBAC (Vaginal Birth After Cesarean): successful vaginal delivery after prior cesarean. TOLAC (Trial of Labor After Cesarean): the attempt at VBAC.
Success rate: 60–80% when prerequisites met.
Candidate criteria (favorable):
Absolute contraindications:
Uterine rupture (catastrophic complication):
TOLAC nursing care:
From the book — uses the ATI Therapeutic Procedure template for cesarean birth. Practice answering before reviewing the key.
A nurse is planning care for a client who experienced a cesarean birth. What should the nurse include in the plan of care? Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.
Delivery of the fetus through a transabdominal incision of the uterus to preserve the life or health of the client and fetus when there is evidence of complications. Incisions are made vertically or horizontally into the lower segment of the uterus, with horizontal being the optimal incision.
4 NCLEX-style questions covering Ch 15 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is reviewing a Bishop score for a client being considered for labor induction. The score is 4. Which interpretation is most accurate?
Show rationale ▾A. Score < 6 = unfavorable, not favorable.
B. CORRECT. Bishop < 6 indicates unfavorable cervix — cervical ripening (misoprostol or dinoprostone) should be used before oxytocin to reduce induction failure and cesarean rate.
C. Cervix is unfavorable — proceeding directly to oxytocin would have a high failure rate.
D. Bishop score is not assessed as "normal"; it predicts induction outcomes.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is monitoring a client receiving oxytocin induction. The contraction pattern shows 6 contractions in 10 minutes lasting 60 seconds with Category II FHR. Which is the priority action?
Show rationale ▾A. Increasing oxytocin would worsen tachysystole — the opposite of what's needed.
B. CORRECT. Tachysystole (> 5 contractions in 10 min averaged over 30 min) with Category II FHR requires immediate cessation of oxytocin. Position left lateral, IV fluids, O₂, consider terbutaline.
C. Internal monitoring is not the priority; resolving tachysystole is.
D. Notifying provider is appropriate but stopping oxytocin is the priority FIRST action.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is preparing a client for a cesarean delivery. Which of the following are appropriate preoperative interventions? (Select all that apply.)
Show rationale ▾A. CORRECT. Indwelling catheter empties the bladder and keeps it out of the surgical field.
B. CORRECT. Antibiotics within 60 minutes of incision reduce surgical site infection rates.
C. CORRECT. SCDs reduce DVT risk perioperatively.
D. Supine flat causes aortocaval compression. Use a 15° left lateral tilt under right hip.
E. CORRECT. NPO reduces aspiration risk.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsA nurse is providing teaching to a client about vaginal birth after cesarean (VBAC). Which of the following is an absolute contraindication to VBAC?
Show rationale ▾A. Low-transverse incision is generally a favorable indicator for VBAC.
B. CORRECT. Classical (vertical) uterine incision carries a high risk (4–9%) of uterine rupture during labor — absolute contraindication.
C. Adequate pelvis is supportive of VBAC success.
D. Singleton pregnancies are generally favorable VBAC candidates.
NCLEX · Health Promotion & Maintenance · Intrapartum CareA nurse is caring for a client 4 hours after cesarean delivery. Which finding requires immediate intervention?
Show rationale ▾A. CORRECT. A boggy fundus above the umbilicus suggests uterine atony with risk for postpartum hemorrhage. Requires immediate fundal massage, bladder assessment, and possibly uterotonic medications.
B. Pain 4/10 at the incision site is expected and manageable with analgesics.
C. A bloody dressing the size of a quarter is normal in the first 24 hours after C-section.
D. Urine output of 50 mL/hr is adequate (> 30 mL/hr).
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is evaluating a client's eligibility for trial of labor after cesarean (TOLAC). Which of the following are contraindications? (Select all that apply.)
Show rationale ▾A. CORRECT. Classical incision has high uterine rupture risk during labor.
B. Low-transverse is the preferred scar for VBAC eligibility.
C. CORRECT. Prior myomectomy entering uterine cavity weakens uterine wall.
D. Two prior cesareans is a relative consideration; some clients with 2 prior LT incisions are still candidates.
E. Singleton pregnancy at term is generally favorable for TOLAC.
F. CORRECT. Previous uterine rupture is an absolute contraindication.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsCord prolapse: elevate presenting part with sterile fingers, knee-chest/Trendelenburg, warm saline towel, O₂, prepare delivery. Meconium fluid: notify resus team, follow suction protocol. Fetal distress: left lateral, O₂ 8–10 L/min mask, stop oxytocin, ↑ IV. Uterine rupture: "ripping/tearing" pain, hypovolemic shock signs, immediate cesarean ± hysterectomy. AFE: sudden chest pain + dyspnea + DIC; CPR ready. Precipitous labor: ≤ 3 hr from onset to delivery — don't try to stop it.
Cord is displaced, preceding the presenting part, or protruding through the cervix. Results in cord compression and compromised fetal circulation — fetal hypoxia within minutes.
Client reports feeling "something coming through the vagina".
Fetus has had loss of sphincter control, allowing meconium passage into amniotic fluid. Antepartum meconium passage typically not associated with unfavorable outcome. Intrapartum meconium with abnormal FHR pattern is ominous.
Assess respiratory efforts, muscle tone, and heart rate first, then:
Defined by FHR abnormalities. FHR < 110/min or > 160/min · decreased or no variability · fetal hyperactivity or no fetal activity. Additional manifestations: late decelerations with absent/minimal variability, recurrent variables, prolonged decelerations.
Standardized interventions for non-reassuring FHR patterns:
Additional interventions if persistent:
Difficult or abnormal labor related to the 5 P's (passenger, passageway, powers, position, psychologic response). Atypical contraction patterns prevent normal labor progression.
Abnormally slow labor progression. Two main categories:
Protraction disorder: slower than expected progression
Arrest disorder: complete cessation of progress
Causes (4 P's revisited): ineffective Powers (hypotonic contractions), Passenger problems (malposition, macrosomia), Passageway issues (CPD, pelvis shape), Position (suboptimal maternal position), Psyche (fear, anxiety).
Management:
Labor that lasts 3 hr or less from onset of contractions to delivery.
Labor lasting < 3 hours from onset of contractions to delivery.
Risk factors: Multiparity, history of precipitous labor, large pelvis, small fetus, induction with oxytocin, cocaine use.
Complications:
Nursing actions if delivery imminent:
Rare but life-threatening obstetric injury. Complete rupture: uterine wall, peritoneal cavity, and/or broad ligament — internal bleeding present. Incomplete rupture: dehiscence at site of prior scar (cesarean, surgical) — internal bleeding might not be present.
Rupture in amniotic sac or maternal uterine veins + high intrauterine pressure → infiltration of amniotic fluid into maternal circulation. Fluid travels to and obstructs pulmonary vessels → respiratory distress + circulatory collapse. Can occur during labor, birth, or within 30 min after birth. Meconium-stained fluid clogs pulmonary veins completely. Serious coagulation problems (DIC) can occur.
Subjective: sudden chest pain and/or sudden shortness of breath
Rare (1 in 8,000–80,000) but catastrophic complication: amniotic fluid, fetal cells, or debris enters maternal circulation via uterine veins, causing anaphylactoid reaction. Maternal mortality 20–60%.
Risk factors: Advanced maternal age, multiparity, induced labor (especially with oxytocin), cesarean delivery, polyhydramnios, multifetal gestation, placental abruption, uterine rupture, trauma.
Classic triad of findings (rapidly progressive):
Other manifestations: seizures, altered mental status, fetal bradycardia/distress.
Management (supportive — no specific treatment):
Newborn outcomes: 70% survive if delivered promptly; significant risk of HIE.
From the book — uses the ATI System Disorder template for meconium-stained amniotic fluid. Practice answering before reviewing the key.
A nurse is caring for a client and observes meconium-stained amniotic fluid upon rupture of the client's membranes. What actions should the nurse take? Use the ATI Active Learning Template: System Disorder to complete this item.
4 NCLEX-style questions covering Ch 16 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse performs an artificial rupture of membranes (AROM) and immediately notes the fetal heart rate drops to 80/min with severe variable decelerations. Which action is the priority?
Show rationale ▾A. Increasing oxytocin would worsen the situation — contractions further compress the cord.
B. CORRECT. Sudden severe variable decels post-AROM strongly suggest cord prolapse. Perform sterile VE — if cord is palpable, manually elevate the presenting part OFF the cord and call for emergent cesarean.
C. Continuing routine monitoring delays a life-threatening emergency.
D. High Fowler position would worsen cord compression. Knee-chest or Trendelenburg is correct positioning.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is managing a client with postpartum hemorrhage from uterine atony. Place the following interventions in priority order:
Show rationale ▾A. FIRST. Fundal massage to firm the uterus stops atonic bleeding most quickly.
B. THIRD. Pharmacologic uterotonic if massage is insufficient.
C. SECOND. Full bladder displaces uterus and prevents adequate contraction.
D. LAST. Surgical management if medical measures fail (e.g., uterine artery ligation, hysterectomy).
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is assessing for shoulder dystocia after the fetal head delivers but the anterior shoulder does not. Which interventions should the nurse anticipate? (Select all that apply.)
Show rationale ▾A. CORRECT. Suprapubic pressure dislodges the anterior shoulder from above the symphysis.
B. Fundal pressure is CONTRAINDICATED — it can cause uterine rupture and worsen impaction.
C. CORRECT. McRoberts maneuver (hyperflex maternal hips toward chest) widens the pelvic outlet.
D. CORRECT. Time tracking is critical because of risk of cord compression and hypoxia.
E. Encouraging pushing may worsen impaction. Maneuvers are done by the team, not relying on harder pushing.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is caring for a client who develops sudden respiratory distress, hypotension, and seizures during labor. The provider suspects amniotic fluid embolism. Which intervention is the priority?
Show rationale ▾A. Magnesium is not indicated for AFE; it's used for preeclampsia/eclampsia.
B. CORRECT. AFE causes cardiopulmonary collapse — airway, breathing, and circulation are immediate priorities. Intubation and 100% O₂ are typically required; prepare for emergent cesarean.
C. Position should be supine with left lateral tilt for resuscitation, not semi-Fowler.
D. Encouraging deep breathing is inadequate in this emergency.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is caring for a client whose membranes have just ruptured. The nurse observes the umbilical cord protruding from the vagina. Which action should the nurse take first?
Show rationale ▾A. Oxygen is important but not the first action.
B. CORRECT. Cord prolapse is an obstetric emergency. The priority is to relieve cord compression by inserting a gloved hand into the vagina and manually elevating the presenting part off the cord. Maintain this position until emergency cesarean delivery.
C. Notification follows immediate intervention.
D. IV access is needed but only after relieving cord compression.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is assisting with management of shoulder dystocia. Which of the following interventions are appropriate? (Select all that apply.)
Show rationale ▾A. CORRECT. McRoberts is the first-line maneuver — hyperflex maternal hips to chest.
B. CORRECT. Suprapubic pressure (NOT fundal) dislodges the impacted shoulder.
C. NEVER apply fundal pressure — it worsens impaction and increases injury risk.
D. Excessive traction causes brachial plexus injury — apply only gentle traction.
E. CORRECT. Gaskin (all-fours position) may help dislodge.
F. CORRECT. Internal rotation maneuvers reposition the shoulders.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsFundus assessment: midline, firm, descending 1 cm/day. Boggy fundus → massage in circular motion. Fundus displaced laterally + uterine atony = full bladder → encourage voiding (within 6–8 hr post-delivery). Lochia amounts: scant < 2.5 cm · light 2.5–10 cm · moderate > 10 cm · heavy 1 pad/2 hr · excessive: 1 pad/15 min. Puerperal bradycardia (HR as low as 40) is normal first 2 days. Postpartum leukocytosis WBC 20,000–25,000 expected. Hypercoagulability persists → DVT risk.
Involution = uterus contracts back to prepregnant state. From 1,000 g at end of 3rd stage to 60–80 g at 6 weeks. Fundal height descends approximately 1 fingerbreadth (1 cm) per day.
Documentation: If above umbilicus → +1, U+1, or 1/U. If below → -1, U-1, or U/1.
Endogenous oxytocin: early breastfeeding stimulates natural oxytocin release → uterine contractions → prevents hemorrhage. Encourage emptying of the bladder to prevent uterine displacement and atony.
| Letter | Assessment | Normal Findings | Abnormal / Action |
|---|---|---|---|
| B | Breasts | Soft to filling day 1–2; firm with milk by day 3–5; nipples intact | Cracked nipples → latch correction; engorgement → empty fully; mastitis → antibiotics |
| U | Uterus (Fundus) | Firm, midline, at umbilicus immediately PP; descends 1 cm/day; non-palpable by day 10 | Boggy → massage; deviated → empty bladder; above umbilicus → assess bleeding |
| B | Bladder | Voiding > 150 mL within 6–8 hr; non-distended | Distended → catheterize if no void; displaces uterus → uterine atony risk |
| B | Bowel | Bowel sounds in all quadrants; first BM by day 2–3 | Constipation → fluids, fiber, stool softener; no BS → assess for ileus (post-C/S) |
| L | Lochia | Rubra → serosa → alba; no large clots; no foul odor | Heavy bleeding → fundal massage, assess source; foul → suspect endometritis |
| E | Episiotomy / Perineum | REEDA: minimal Redness, Edema, Ecchymosis, Discharge; Approximated edges | Abnormal REEDA → infection workup; ice/sitz baths |
| H | Homans Sign (Lower Extremities) | No calf pain on dorsiflexion; no warmth or swelling | + Homans, redness, swelling → assess for DVT; Doppler ultrasound |
| E | Emotional Status | Baby blues acceptable (transient); bonding with newborn | PP depression (Edinburgh score > 12) → referral; psychosis → emergency |
The uterus returns to pre-pregnancy state through involution — contractions of uterine smooth muscle.
Afterpains are uncomfortable uterine cramping caused by intermittent contractions during involution.
Post-birth uterine discharge containing blood, mucus, and uterine tissue. Similar to heavy menstrual period 2 hr after delivery, then decreases gradually.
| Stage | Days Postpartum | Color | Composition | Amount |
|---|---|---|---|---|
| Lochia Rubra | Days 1–3 | Bright/dark red | Blood, decidua, trophoblastic debris | Moderate; small clots OK |
| Lochia Serosa | Days 4–10 | Pink/brown | Old blood, serum, WBCs, decidua | Small to moderate |
| Lochia Alba | Days 10–14 (up to 6 wk) | White/yellow | WBCs, decidua, epithelial cells, mucus | Scant |
Abnormal: Saturating pad in < 1 hr; large clots (> egg-sized); foul odor; return of rubra after serosa/alba (suggests subinvolution).
Assess lochia amount by quantity of saturation on the perineal pad:
Volume estimates:
Report to provider immediately:
Soft directly after birth; can be edematous, bruised, with small lacerations. Cervical os shape changes from round dimple to slit-like after first vaginal birth. Initial healing 2–3 weeks; complete healing 4–6 months.
Cervix:
Vagina:
Perineum:
Striae gravidarum (stretch marks): fade from pink/red/purple during pregnancy to silvery-white postpartum; never disappear completely.
Hyperpigmentation (linea nigra, chloasma) fades over months but may not fully resolve.
Colostrum produced during pregnancy and 2–3 days after birth. Mature milk transitions in 3–5 days after delivery (the "milk coming in"). Engorgement results from lymphatic circulation, milk production, and temporary vein congestion — breasts tight, tender, warm, full.
Varying positions prevents nipple soreness.
| Engorgement | Plugged Duct | Mastitis | |
|---|---|---|---|
| Timing | Day 3–5 PP | Anytime | 2–4 wk PP typically |
| Distribution | Bilateral | Unilateral, localized | Unilateral, wedge-shaped |
| Fever | Low-grade or none | None | ≥ 38.4°C (101°F) |
| Systemic symptoms | None | None | Flu-like, malaise, body aches |
| Lump | Whole breast firm | Localized tender lump | Hard, red, painful area |
| Skin | Tight, shiny | Normal or slightly red | Red, warm, well-demarcated |
| Treatment | Empty fully, cold compresses between feeds | Massage during feed; warm before feed; nurse on affected side first | Antibiotics × 10–14 days; continue breastfeeding; rest; hydration |
Three systems with significant postpartum adaptation. Each has expected vs concerning findings nurses must distinguish.
Cardiovascular:
Urinary tract:
GI tract:
Postpartum vaccinations, MSK recovery, and emotional adjustment. Watch for postpartum blues vs depression.
Attachment (sometimes called bonding) is the development of a strong affectional tie between the parent and infant. Begins during pregnancy and intensifies after birth.
Reciprocal interaction: parents and infant exchange cues that promote attachment
Engrossment: father's (or partner's) intense preoccupation with and interest in the newborn — characterized by visualization, eye contact, tactile awareness, awareness of distinct features, perception of the infant as perfect, intense feelings of attraction.
Reva Rubin's maternal role attainment phases:
Postpartum blues:
From the book — uses the ATI Basic Concept template for perineal care education. Practice answering before reviewing the key.
A nurse on the postpartum unit is leading a discussion with a group of clients about perineal care after delivery. What education should the nurse include? Use the ATI Active Learning Template: Basic Concept to complete this item.
4 NCLEX-style questions covering Ch 17 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is assessing a postpartum client 24 hours after vaginal delivery. The fundus is firm, 2 cm above the umbilicus, and deviated to the right. Which is the priority action?
Show rationale ▾A. Fundus is already firm — massage is not indicated.
B. Ambulation is beneficial but doesn't address the immediate issue.
C. CORRECT. Bladder distention displaces the uterus and is the #1 cause of fundal deviation and uterine atony. Have the client void (or catheterize if unable), then reassess.
D. Methylergonovine is for atony — fundus is firm here, so it's not needed.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is teaching a postpartum client about expected lochia. Which of the following statements indicates correct understanding? (Select all that apply.)
Show rationale ▾A. CORRECT. Lochia rubra: days 1–3, dark red.
B. CORRECT. Lochia serosa: days 4–10, pinkish to brown.
C. Saturating a pad within 15 minutes indicates EXCESSIVE bleeding — not normal at any stage.
D. CORRECT. Lochia alba: days 11–14 up to 6 weeks, yellowish-white.
E. CORRECT. Foul odor suggests endometritis — must be reported.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is teaching an Rh-negative postpartum client whose newborn is Rh-positive. Which statement reflects correct understanding of Rho(D) immune globulin administration?
Show rationale ▾A. CORRECT. Rho(D) immune globulin is given IM within 72 hours of delivery to prevent maternal sensitization from any Rh-positive fetal RBCs that crossed during birth.
B. It is given IM, not orally, and is a single injection (not daily).
C. Required after every pregnancy (delivery, miscarriage, abortion, amniocentesis) if fetal Rh status is positive or unknown.
D. It protects FUTURE fetuses from hemolytic disease — it does not protect the mother from reactions.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse is teaching a postpartum client about postpartum diuresis. Which expected finding should the nurse describe?
Show rationale ▾A. Postpartum diuresis INCREASES urine output, not decreases.
B. CORRECT. Postpartum diuresis produces up to 3,000 mL/day during days 2–5 as the body excretes excess fluid accumulated during pregnancy.
C. Brown urine indicates dehydration or pathology — not expected in postpartum diuresis.
D. Postpartum diaphoresis (night sweats) and diuresis are both expected, working together.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is performing a postpartum assessment on day 5 after vaginal delivery. The lochia is pink-brown in color. The nurse identifies this finding as:
Show rationale ▾A. Lochia rubra is bright red, occurring days 1–3.
B. CORRECT. Lochia serosa is pink-brown, occurring days 4–10. Composed of old blood, serum, and WBCs.
C. Lochia alba is white/yellow, occurring days 10–14 through 6 weeks.
D. Pink-brown lochia on day 5 is normal progression.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CareA nurse is performing a BUBBLE-HE assessment on a postpartum client. Which of the following findings should the nurse identify as abnormal? (Select all that apply.)
Show rationale ▾A. Normal — fundus should be firm, midline, at the umbilicus on day 1.
B. ABNORMAL. A boggy fundus suggests atony; deviation suggests bladder distention.
C. ABNORMAL. Saturating a pad in < 1 hour suggests hemorrhage.
D. Normal — lochia serosa on day 5.
E. ABNORMAL. Positive Homans + redness suggests DVT.
F. Mild perineal swelling is expected in the first 24 hours.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsThree maternal phases: Taking-in (24–48 hr, dependent, talkative, reviews birth) → Taking-hold (day 2–3 to weeks, learning baby care, "baby blues" possible) → Letting-go (interdependent, family as unit). Priority bonding action at delivery: place neonate skin-to-skin in en face position on client's chest. Maternal identity achieved ~4 months postpartum. Sibling regression (toileting, sleep) = adverse sibling response.
Maternal psychosocial adaptation begins during pregnancy with commitment, attachment, and birth preparation. After birth, the client moves through three phases of role attainment. Phases can overlap and vary based on maternal, infant, and environmental factors.
Nursing implication: Recognize the client's need to retell the birth story. Allow them to verbalize feelings; complete assessments around their narrative rather than asking them to stop talking.
Nursing implication: Optimal time for teaching infant care, breastfeeding, and self-care. Provide supportive guidance and praise as competence builds.
Healthy attachment behaviors include:
Warning signs of impaired attachment:
Document objective findings; do not label attachment as "good" or "poor." Refer for support and follow-up if concerns.
Family condition (unwanted pregnancy, adolescent pregnancy, depression history, difficult birth) and newborn condition (prematurity, anomalies) can affect bonding. Culture, age, and socioeconomic status are also factors.
Co-parent adaptation occurs through bonding behaviors and a recognized series of transition phases. Provide guidance and equal participation opportunities.
Desires to be deeply and emotionally connected with the infant.
Understands reality does not always meet expectations. Common emotions: sadness, frustration, jealousy. Can feel unable to talk with the other parent (consumed with caregiving and own transition).
Decides to become actively involved in care of the infant.
Rewards include infant smiles and a sense of completeness and meaning.
Adding an infant affects everyone, including siblings, who may experience temporary separation from parents. Siblings notice changes in parental behavior because the infant requires more time.
Sibling response varies by age and may include regression, jealousy, attention-seeking, or excitement.
Toddlers (1–3 yr):
Preschoolers (3–5 yr):
School-age (6–12 yr):
Adolescents:
Universal tips for parents:
From the book — uses the ATI Basic Concept template for paternal adaptation. Practice answering before reviewing the key.
A nurse is leading a parenting class on paternal adaptation for expectant clients and their partners. What concepts on paternal adaptation should the nurse include in the presentation? Use ATI Active Learning Template: Basic Concept to complete this item.
4 NCLEX-style questions covering Ch 18 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is caring for a postpartum client in the first 24 hours after delivery. The client is talkative about her labor experience and asks to be cared for. Which phase of maternal adaptation is the client experiencing?
Show rationale ▾A. CORRECT. Taking-in (1–2 days postpartum): mother is dependent, passive, focused on her own needs, and frequently talks about the labor experience.
B. Taking-hold (day 2–3 onward): mother is more independent, learning newborn care.
C. Letting-go (later): adjustment to new role and integration of newborn into family life.
D. Maternal-attachment is not a phase but an ongoing process.
NCLEX · Psychosocial Integrity · Family DynamicsA nurse is observing for bonding cues between a postpartum mother and newborn. Which of the following findings indicate POSITIVE bonding? (Select all that apply.)
Show rationale ▾A. CORRECT. En face position (mother and infant faces parallel and 30 cm/12 in apart) facilitates eye contact and bonding.
B. CORRECT. Higher-pitched, gentle voice ("parentese") is a healthy bonding behavior.
C. Lack of eye contact may indicate impaired bonding — requires further assessment.
D. CORRECT. Using the newborn's name personalizes the relationship and indicates bonding.
E. Disinterest in feeding/caring suggests impaired bonding — requires intervention.
NCLEX · Psychosocial Integrity · Family DynamicsA nurse is teaching parents about helping a 4-year-old sibling adjust to a new baby. Which intervention should the nurse recommend?
Show rationale ▾A. Suppressing feelings increases adjustment difficulties.
B. CORRECT. Dedicated one-on-one time reassures the older sibling of their continued importance and reduces rivalry.
C. Encouraging age-appropriate helping (fetching diapers, etc.) builds connection and confidence.
D. Major changes (room moves, school start) should occur BEFORE the baby's arrival, not at the same time.
NCLEX · Psychosocial Integrity · Family DynamicsA nurse is teaching a new father about adjustment to the parental role. Which is one of the four engrossment behaviors a father may exhibit?
Show rationale ▾A. Detachment indicates impaired bonding — opposite of engrossment.
B. CORRECT. Engrossment is the father's intense preoccupation with the newborn — characterized by visual awareness, tactile awareness, recognition of distinct features, awareness of emotional response, sense of elation, and increased self-esteem.
C. Resentment is not typical and may indicate impaired adjustment.
D. Withdrawal indicates impaired adjustment, not engrossment.
NCLEX · Psychosocial Integrity · Family DynamicsA nurse is caring for a client 2 days postpartum who is hesitant to hold her newborn and tearfully expresses uncertainty about her ability to care for the baby. The nurse identifies this behavior as consistent with which phase of maternal role attainment?
Show rationale ▾A. CORRECT. Rubin's taking-in phase (first 1–2 days) is characterized by maternal dependence, passive behavior, focus on her own needs (food, sleep, recounting birth experience). Self-doubt about caregiving is common.
B. Taking-hold (days 2–10) involves increased independence and learning infant care.
C. Letting-go (1+ week) is when the mother integrates the newborn into family life.
D. Anticipatory phase occurs during pregnancy, not postpartum.
NCLEX · Psychosocial Integrity · Family DynamicsA nurse is teaching parents about promoting attachment and bonding with their newborn. Which of the following interventions should the nurse recommend? (Select all that apply.)
Show rationale ▾A. CORRECT. Skin-to-skin within the first hour promotes bonding and breastfeeding success.
B. Early breastfeeding initiation promotes bonding and successful lactation.
C. CORRECT. Face-to-face positioning ('en face') promotes bonding.
D. CORRECT. 'Parentese' (high-pitched, slow speech) elicits newborn attention.
E. Cluster nursing care; minimize parent-newborn separation.
F. CORRECT. Rooming-in promotes bonding and feeding cue recognition.
NCLEX · Psychosocial Integrity · Family DynamicsBF engorgement: warm shower BEFORE feedings (letdown), cold compresses AFTER. Non-BF engorgement: cold compresses 15 on/45 off, cabbage leaves, supportive bra × 72 hr, NO warm water/stimulation. Nutrition: nonlactating 1,800–2,200 kcal · lactating add 450–500 kcal/day. Sexual activity: resume 2nd–4th week. Pregnancy can occur while BF — contraception still needed. FU appointments: 4–6 wks vaginal · 2 wks cesarean.
Effective teaching starts with assessment. Discharge planning starts at admission.
Perineal hygiene is universal. Breast care diverges sharply between breastfeeding and nonlactating clients — directly opposite recommendations for engorgement.
Suppression of lactation is necessary.
Perineal care:
Breast care (lactating):
Breast care (non-lactating):
Activity and exercise progression differ between vaginal and cesarean births. Nutrition needs differ between lactating and nonlactating clients.
Pregnancy can occur while breastfeeding even though menses has not returned. Contraception is needed regardless.
Postpartum complications include hemorrhage, infection, and depression. The follow-up appointment must be scheduled and confirmed before discharge.
From the book — uses the ATI Basic Concept template for discharge teaching with a nonlactating client. Practice answering before reviewing the key.
A nurse is reviewing discharge teaching with a client who is not breastfeeding. What information should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item.
4 NCLEX-style questions covering Ch 19 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching a non-lactating postpartum client about breast care. Which of the following recommendations should be included? (Select all that apply.)
Show rationale ▾A. CORRECT. Cold compresses reduce engorgement without stimulating milk production.
B. CORRECT. A supportive bra reduces discomfort. (For non-lactating clients, a tight bra was once recommended but a supportive bra is current best practice.)
C. Warm compresses INCREASE milk production — opposite of the goal for non-lactating clients.
D. CORRECT. Stimulation triggers milk production via prolactin.
E. CORRECT. Cabbage leaves applied to the breasts have been shown to reduce engorgement.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is teaching a postpartum client about timing of postpartum follow-up. The client had a vaginal delivery with no complications. When should the routine postpartum visit be scheduled?
Show rationale ▾A. Earlier follow-up (1 week) is reserved for hypertensive disorders of pregnancy.
B. 2-week visit is for cesarean clients (incision check).
C. CORRECT. Routine vaginal delivery follow-up is at 4–6 weeks postpartum.
D. 12 weeks is too long to wait for a routine check.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is reviewing postpartum warning signs with a client at discharge. Which of the following should be reported to the provider? (Select all that apply.)
Show rationale ▾A. CORRECT. Fever > 100.4°F suggests infection (endometritis, mastitis, UTI, wound).
B. CORRECT. Foul lochia suggests endometritis.
C. CORRECT. Calf pain or redness suggests DVT — high-risk in postpartum due to hypercoagulability.
D. Lochia rubra on day 2 is expected (days 1–3).
E. CORRECT. Saturating a pad in < 15 min is excessive bleeding — possible hemorrhage.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is teaching a postpartum client about resuming sexual activity. Which recommendation is most appropriate?
Show rationale ▾A. 6 weeks is a common guideline but updated recommendations focus on physical readiness (bleeding stopped, perineum healed) which often occurs at 2–4 weeks.
B. CORRECT. Resume intercourse once bleeding has stopped and any perineal repair has healed (usually 2–4 weeks). Discuss contraception before resumption — ovulation can return as early as 3 weeks postpartum in non-lactating clients.
C. Resuming immediately risks infection and bleeding.
D. Lactation does NOT reliably prevent pregnancy — ovulation can occur before menses return.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is providing discharge teaching to a postpartum client. The client should be instructed to report which finding immediately?
Show rationale ▾A. Constipation is common postpartum due to slowed peristalsis and decreased mobility.
B. Fatigue is expected with newborn care.
C. CORRECT. Saturating a pad in < 1 hour suggests postpartum hemorrhage — late PPH can occur up to 12 weeks postpartum.
D. Mild breast tenderness is expected, especially in early breastfeeding.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CareA nurse is providing discharge teaching about postpartum activity and self-care. Which of the following instructions should the nurse include? (Select all that apply.)
Show rationale ▾A. CORRECT. Resume sex when comfortable, typically 4–6 weeks (bleeding stopped, perineum healed).
B. Iron is best absorbed on empty stomach with vitamin C; milk INHIBITS absorption.
C. CORRECT. Sitz baths 3–4×/day promote comfort and healing.
D. Gradually resume activity; avoid heavy lifting and high-impact for 6 weeks.
E. CORRECT. Lactational amenorrhea is not reliable contraception — ovulation can return before menses.
F. CORRECT. Fever ≥ 38°C (100.4°F) on 2 consecutive days suggests postpartum infection.
NCLEX · Health Promotion & Maintenance · Ante/Intra/Postpartum CarePPH thresholds: > 500 mL vaginal · > 1,000 mL cesarean. Earliest hypovolemia sign: rising pulse + decreasing BP. Heparin antidote: protamine sulfate. Warfarin antidote: phytonadione (vit K). DVT — DO NOT massage affected limb (embolus risk); warm compresses, NOT cold. Atony management: empty bladder → massage fundus → express clots ONLY after firm. Uterotonic + HTN profile: methylergonovine and carboprost cause HTN (avoid in HTN); oxytocin and misoprostol cause HoTN.
Postpartum clients are at greatest risk for DVT due to physiologic hypercoagulability. Cesarean birth doubles the risk. Most often femoral, saphenous, or popliteal veins. Acute pulmonary embolus is an emergent situation.
Initially IV continuous infusion for 3–5 days; doses adjusted by coagulation studies. Prevents formation of new clots and enlargement of existing clot.
Oral, used for treatment, continued ~3 months.
Embolus from DVT moves into pulmonary artery or branch and lodges in lung → occludes vessel → obstructs blood flow. Same risk factors as DVT.
Pregnancy and postpartum are hypercoagulable states. VTE risk is 5× higher in pregnancy and 20× higher in immediate postpartum compared to non-pregnant. Highest risk in first 6 weeks postpartum.
Risk factors:
Manifestations:
DVT: unilateral calf pain, warmth, redness, swelling; positive Homans sign (calf pain on dorsiflexion — note: nonspecific). Diagnosis: Doppler ultrasound.
PE: sudden dyspnea, tachypnea, chest pain, tachycardia, anxiety, syncope, hemoptysis, hypoxia. Medical emergency. Diagnosis: V/Q scan (preferred in pregnancy/postpartum due to lower fetal radiation) or CT pulmonary angiogram.
Treatment:
Prevention:
Suspected when usual measures to stimulate uterine contractions fail to stop vaginal bleeding.
Autoimmune disorder where life span of platelets is decreased by antiplatelet antibodies. Can result in severe hemorrhage following cesarean or lacerations.
Coagulopathy where clotting AND anticlotting mechanisms occur simultaneously. Risk for both internal and external bleeding + organ damage from microclot ischemia.
Pathophysiology: massive activation of clotting cascade → consumption of clotting factors and platelets → simultaneous clotting and bleeding throughout body.
OB triggers for DIC:
Clinical findings:
Laboratory findings (diagnostic):
Management:
PPH occurring 24 hours to 12 weeks postpartum. Often catches mothers off-guard at home.
Causes:
Management:
PPH = > 500 mL after vaginal birth OR > 1,000 mL after cesarean. Two complications: hypovolemic shock and anemia.
Rising pulse and decreasing blood pressure are the FIRST signs. Cool/clammy skin, dizziness, ↑ RR, altered mental status come LATER.
| Medication | Dose / Route | Use | Contraindication |
|---|---|---|---|
| Oxytocin (Pitocin) | 10–40 units in 1,000 mL IV; or 10 units IM | 1st-line; given prophylactically with placental delivery | Hypersensitivity (rare); watch for water intoxication, hypotension |
| Methylergonovine (Methergine) | 0.2 mg IM q2–4hr; PO option | 2nd-line for atony; rapid uterine contraction | HYPERTENSION, preeclampsia, cardiac disease; never IV (causes severe HTN) |
| Carboprost (Hemabate) | 250 mcg IM q15–90 min (max 8 doses / 2 mg) | Refractory atony; prostaglandin F2α | ASTHMA (causes bronchospasm); active cardiac/renal/hepatic disease |
| Misoprostol (Cytotec) | 600–1,000 mcg PR, SL, or PO | PGE1 analog; useful in resource-limited settings; effective | None specifically; common: fever, diarrhea, shivering |
| Tranexamic acid (TXA) | 1 g IV (may repeat in 30 min) | Antifibrinolytic adjunct for PPH; reduces blood loss | Active intravascular clotting; renal insufficiency (relative) |
Inflatable balloon inserted into the uterine cavity to apply pressure to atonic uterus. Filled with 300–500 mL saline. Left in place 12–24 hr. Used when uterotonics fail before surgical intervention. Monitor for ongoing bleeding from drainage port.
If pharmacologic and tamponade fail, surgical options include:
Three uterine disorders that can lead to or accompany PPH. Each requires distinct nursing focus.
Inability of uterine muscle to contract adequately after birth. Leads to PPH.
Uterus remains enlarged with continued lochial discharge → can result in PPH.
Turning inside out of the uterus — partial or complete. Emergency situation that can result in PPH; requires immediate intervention.
Retained placenta = not delivered within 30 min of birth → uterine atony or subinvolution. Lacerations and hematomas can also cause significant blood loss with characteristic findings.
Lacerations: tearing of soft tissues in birth canal (cervical, vaginal, vulvar, perineal, rectal). Episiotomy can extend into 3rd-/4th-degree laceration. Hematomas: collection of clotted blood within tissues, appears as bulging bluish mass; can occur in pelvic region, vagina, or broad ligament.
Pain, rather than noticeable bleeding, is the distinguishing finding of hematomas.
Perineal lacerations are classified by depth:
Other lacerations: Periurethral, labial, vaginal, cervical (suspect with continuous bright red bleeding despite firm fundus).
Risk factors: Nulliparity, large fetus (> 4,000 g), shoulder dystocia, operative delivery (forceps, vacuum), prolonged 2nd stage, OP position, midline episiotomy.
Management: Repair in delivery room. Postpartum care includes pain management, sitz baths, stool softeners (essential for 3rd/4th degree to prevent dehiscence), perineal hygiene. Avoid rectal medications and enemas after 3rd/4th degree.
Long-term complications (especially 3rd/4th degree): fecal/urinary incontinence, fistula formation, pelvic pain.
Failure of the uterus to return to its non-pregnant state. Usually identified at 4–6 week postpartum visit.
Causes: Retained placental fragments, infection (endometritis), uterine fibroids.
Findings:
Management:
From the book — uses the ATI System Disorder template for deep-vein thrombosis. Practice answering before reviewing the key.
A nurse is planning care for a client who has a deep-vein thrombosis (DVT). What interventions should the nurse include in the plan of care? Use the ATI Active Learning Template: System Disorder to complete this item.
DVT is a thrombus that is associated with inflammation. It can occur in a superficial or deep vein (femoral, saphenous, or popliteal).
4 NCLEX-style questions covering Ch 20 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is caring for a client 30 minutes postpartum. Vital signs show BP 90/50, pulse 122, fundus is boggy, and lochia is saturating a pad in 10 minutes. Which is the priority intervention?
Show rationale ▾A. CORRECT. Fundal massage is the FIRST action for atony-related hemorrhage — firming the uterus mechanically stops the bleeding. Then notify provider, ensure IV access, administer uterotonics per protocol.
B. IV access is needed but is not the first action — fundal massage is.
C. Pharmacologic uterotonics follow fundal massage and oxytocin.
D. Notify provider concurrently, but fundal massage is the immediate priority.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is preparing to administer methylergonovine to a client with postpartum hemorrhage. Which assessment finding is a contraindication?
Show rationale ▾A. Tachycardia is expected with hemorrhage and is not a contraindication.
B. Low Hgb is expected with hemorrhage; it does not contraindicate the medication.
C. CORRECT. Methylergonovine causes vasoconstriction — CONTRAINDICATED in hypertension. Risk of severe HTN, stroke, MI. Use misoprostol PR instead.
D. Mild temperature elevation is not a contraindication.
NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/ContraindicationsA nurse is assessing a postpartum client for deep-vein thrombosis (DVT). Which findings should be reported to the provider? (Select all that apply.)
Show rationale ▾A. CORRECT. Unilateral swelling suggests DVT.
B. CORRECT. Positive Homan sign (calf pain with dorsiflexion) was historically associated with DVT but is now considered unreliable; calf pain at rest or with palpation should be reported regardless.
C. Bilateral mild ankle edema is common postpartum and usually resolves with mobility — not specifically concerning.
D. CORRECT. Warmth and erythema of the affected calf suggest DVT.
E. Bilateral symmetric cramping is more typical of musculoskeletal causes or electrolyte imbalance.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is differentiating perineal hematoma from laceration. Which finding is most characteristic of a hematoma?
Show rationale ▾A. Lacerations cause visible external bleeding; hematomas are concealed.
B. CORRECT. Severe perineal pain without visible bleeding is the hallmark of hematoma — blood accumulates in tissue. The key finding: PAIN = HEMATOMA.
C. Foul-smelling discharge suggests infection (endometritis), not hematoma.
D. Boggy uterus suggests atony, not hematoma.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is caring for a client 24 hours postpartum who reports calf pain. On assessment, the calf is warm, reddened, and tender to palpation. Homans sign is positive. Which action should the nurse take first?
Show rationale ▾A. Avoid heat application until DVT ruled out.
B. NEVER massage a suspected DVT — can dislodge a thrombus, causing pulmonary embolism.
C. CORRECT. Findings suggest deep vein thrombosis (DVT). Maintain bed rest to prevent embolus dislodgment, notify provider, expect doppler ultrasound and likely anticoagulation.
D. Ambulation could dislodge a thrombus — maintain bed rest until DVT is ruled out.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is assessing risk factors for postpartum hemorrhage. Which of the following should the nurse identify as risk factors? (Select all that apply.)
Show rationale ▾A. CORRECT. Uterine fatigue → atony.
B. CORRECT. Overdistention from macrosomia → atony.
C. Vaginal birth itself is not a risk; it's the lower-risk mode compared to cesarean. (Risk factors are conditions, not the mode itself.)
D. CORRECT. Grand multiparity (≥ 5) → uterine muscle wear.
E. CORRECT. Magnesium causes uterine relaxation.
F. CORRECT. Prolonged oxytocin desensitizes receptors → atony after discontinuation.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsFever criteria: ≥ 38°C after first 24 hr OR for 2 days during first 10 days. Endometritis = most frequent puerperal infection; starts day 3–4 PP. Mastitis cause: Staphylococcus aureus; usually unilateral; continue breastfeeding on affected side. UTI: increase fluids to 3,000 mL/day, front-to-back wiping. Greatest infection risk: premature ROM with prolonged labor (open canal × time = pathogen entry).
The immediate postpartum period is a time of increased risk for all clients due to micro-organisms entering the reproductive tract and migrating to blood and other body parts → can result in life-threatening septicemia.
Puerperal infection: any infection of the reproductive tract that occurs during the puerperium (delivery through 6 weeks postpartum).
Standard definition of postpartum fever: Temperature ≥ 38°C (100.4°F) on any 2 of the first 10 days postpartum, excluding the first 24 hours.
Universal risk factors:
Infection of the uterine lining or endometrium. Most frequently occurring puerperal infection. Usually begins on the 3rd to 4th postpartum day, generally starting as a localized infection at the placental attachment site and spreading to include the entire uterine endometrium.
Infection of the breast involving the interlobular connective tissue, usually unilateral. Can progress to abscess if untreated. Can occur as early as the 7th postpartum day; usually during the first 6 weeks of breastfeeding but can occur any time. Staphylococcus aureus is usually the infecting organism (also E. coli and streptococcus).
Administer antibiotics. Breast hygiene can prevent and manage mastitis.
Infection of breast tissue, typically unilateral, most commonly occurring 2–4 weeks postpartum. Most common organism: Staphylococcus aureus.
Risk factors:
Clinical findings (often "flu-like"):
Treatment:
Complications:
Sites: cesarean incisions, episiotomies, lacerations, any trauma wounds in the birth canal.
Provider may need to open and drain the wound or perform wound debridement if indicated.
Risk factors: Diabetes, obesity, immunosuppression, chorioamnionitis, prolonged ROM, prolonged labor, emergency cesarean, hematoma formation, poor hygiene.
Cesarean wound infection findings:
Management:
Episiotomy infection findings: Same REEDA assessment; significant edema, drainage, pain disproportionate to time since delivery, dehiscence.
Management: Antibiotics, sitz baths, debridement if necrotic tissue, possible re-suturing once infection clears.
Common postpartum infection secondary to bladder trauma during delivery or break in aseptic technique during catheterization. Potential complication: progression to pyelonephritis with permanent kidney damage → kidney failure.
Urinalysis for WBCs, RBCs, protein, bacteria.
Bladder hypotonia and overdistention, catheterization, and frequent vaginal exams increase risk in postpartum period.
Findings:
Diagnosis:
Treatment:
From the book — uses the ATI System Disorder template for endometritis. Practice answering before reviewing the key.
A nurse educator is reviewing care of a client who has endometritis with a group of newly hired nurses. What information should the nurse educator include in the teaching? Use the ATI Active Learning Template: System Disorder to complete this item.
Endometritis is an infection of the uterine lining or endometrium. It usually begins on the second to fifth postpartum day as a localized infection at the placental attachment site and spreads to include the entire endometrium. It is the most frequently occurring puerperal infection.
4 NCLEX-style questions covering Ch 21 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is caring for a postpartum client on day 3 with a fever of 38.6°C (101.5°F), uterine tenderness, and foul-smelling lochia. Which condition is most likely?
Show rationale ▾A. Mastitis presents on day 7+ with breast tenderness, redness, and warmth in a localized breast area.
B. CORRECT. Endometritis presents on day 3–4 with fever, uterine tenderness, and foul-smelling/dark/profuse lochia. Treatment: IV broad-spectrum antibiotics until afebrile × 48 hours.
C. UTI presents with dysuria, frequency, suprapubic pain, not uterine tenderness.
D. Wound infection presents with localized incisional pain, redness, drainage.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is teaching a breastfeeding client diagnosed with mastitis. Which of the following should the nurse include? (Select all that apply.)
Show rationale ▾A. CORRECT. Continuing BF, starting on the affected breast, helps drain the infected milk and resolve infection more quickly.
B. Weaning during mastitis worsens engorgement and can lead to abscess formation.
C. CORRECT. Warm compresses before feeding facilitate let-down and drainage.
D. CORRECT. Adequate hydration (3,000 mL/day) supports milk production and infection clearance.
E. Tight or underwire bras can worsen mastitis. A loose-fitting, supportive bra is best.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is assessing a postpartum cesarean client on day 5 for signs of wound infection. Which findings should be reported? (Select all that apply.)
Show rationale ▾A. CORRECT. Erythema and warmth indicate inflammation/infection.
B. CORRECT. Purulent drainage indicates infection.
C. Well-approximated edges are expected healing.
D. CORRECT. Increasing (rather than decreasing) pain suggests complication.
E. Mild ecchymosis is expected and not concerning.
NCLEX · Reduction of Risk Potential · Potential for ComplicationsA nurse is teaching a postpartum client about preventing urinary tract infection. Which instruction should be included?
Show rationale ▾A. Holding urine allows bacteria to multiply — frequent voiding is preferred.
B. Wipe FRONT TO BACK to avoid spreading rectal bacteria to the urethra.
C. CORRECT. Frequent voiding (q 2–3 hr) and voiding after intercourse reduces UTI risk.
D. Increased fluid intake (not decreased) helps flush the urinary tract.
NCLEX · Health Promotion & Maintenance · Postpartum CareA nurse is caring for a client 5 days postpartum who reports unilateral breast pain, redness, and a fever of 101.2°F (38.4°C). Which intervention should the nurse anticipate?
Show rationale ▾A. Continued breastfeeding from the affected side is important — milk stasis worsens mastitis.
B. CORRECT. Mastitis treatment: antibiotics (dicloxacillin first-line) + continued breastfeeding from affected side + warm compresses before feeds + cold packs between feeds + adequate rest and hydration. Milk is NOT contaminated.
C. Warm compresses BEFORE feeds, cold AFTER — alternating is appropriate, not continuous ice.
D. Weaning is not necessary and is contraindicated — milk stasis worsens mastitis.
NCLEX · Pharmacological & Parenteral Therapies · Medication AdministrationA nurse is teaching a postpartum client about preventing postpartum infection. Which of the following instructions should the nurse include? (Select all that apply.)
Show rationale ▾A. Wipe from front to back to avoid introducing bacteria into the urethra/vagina.
B. CORRECT. Frequent pad changes reduce bacterial growth.
C. CORRECT. Hand hygiene reduces infection risk.
D. Avoid scented products — they can cause irritation and disrupt normal flora.
E. CORRECT. Postpartum fever ≥ 38°C suggests infection.
F. CORRECT. Complete the full course even if symptoms improve.
NCLEX · Safety & Infection Control · Standard PrecautionsThree conditions on a spectrum: Blues (tearful, self-limiting in 10 days, no intervention) → Depression (persistent ≥ 12 mo, 10–15%, needs treatment, similar to nonpostpartum mood disorders) → Psychosis (within 2–3 weeks, severe, hallucinations/delusions/paranoia, bipolar history = risk). Priority safety action with psychosis or significant depression: directly ask about thoughts of harming self or infant. Antidepressants for depression · antipsychotics + mood stabilizers for psychosis.
Distinguishing the three conditions is the central clinical reasoning task — same population, very different responses needed.
| Feature | Postpartum Blues | Postpartum Depression | Postpartum Psychosis |
|---|---|---|---|
| Incidence | 50–80% | 10–20% | 1–2 per 1,000 |
| Onset | Day 2–3 postpartum | Within 1st year (peak 4 wk) | Within first 2 wk (peak 3–10 days) |
| Duration | 2 wk or less | Weeks to months without treatment | Days to weeks (with treatment) |
| Symptoms | Mood lability, tearfulness, mild anxiety, sleep difficulty | Persistent sad mood, fatigue, anhedonia, guilt, sleep/appetite changes, suicidal thoughts possible | Hallucinations, delusions, disorganized thinking, severe mood lability, infanticide/suicide ideation |
| Reality testing | Intact | Intact | Impaired |
| Functioning | Generally intact | Impaired ability to care for self/infant | Severely impaired; safety concern |
| Treatment | Reassurance, support, rest | Therapy, SSRIs, support groups | Psychiatric emergency: hospitalization, antipsychotics, mood stabilizers, ECT |
| Risk to baby | Minimal | Bonding issues; rare harm | High (infanticide 4%) |
Edinburgh Postnatal Depression Scale (EPDS): 10-item screening tool; score ≥ 12 suggests PPD; any positive on Q10 (self-harm) requires immediate evaluation.
A normal, self-limiting adjustment reaction in the first days after birth. Affects up to 85% of clients. Generally resolves in 10 days.
Persistent feelings of sadness and intense mood swings within 12 months of delivery. Occurs in 10–15% of new parents and does NOT resolve without intervention. Similar to nonpostpartum mood disorders. Requires clinical evaluation and treatment.
Per the practice exercises, depression-specific risks include:
Paranoia, by contrast, points toward postpartum psychosis, not depression.
Affects 10–20% of new mothers. Onset typically within first 4 weeks postpartum but can present any time in the first year.
Risk factors:
Edinburgh Postnatal Depression Scale (EPDS): 10-item self-report; each item 0–3 (max 30). Score ≥ 12 suggests probable depression. Item #10 asks about thoughts of self-harm — ANY positive response requires immediate evaluation. Routinely administered at postpartum visits.
Treatment:
Develops within the first 2–3 weeks of the postpartum period. Clients with a history of bipolar disorder are at higher risk. Clinical findings are severe. The client might attempt to harm themselves or their infant — safety is the priority.
Priority action: directly ask the client whether they have thoughts of self-harm, suicide, or harming the infant. The greatest risk to client and infant is harm; identifying that risk takes precedence over reinforcing medication adherence, monitoring infant for failure to thrive, or reviewing the medical record for bipolar history.
Provide for the safety of the infant and client as the priority of care.
Universal nursing care across all three conditions; medications differ by severity.
None typically required — self-limiting.
Antidepressants as prescribed by provider.
Antipsychotics and mood stabilizers; antidepressants may also be prescribed.
From the book — uses the ATI System Disorder template for postpartum depression. Practice answering before reviewing the key.
A nurse manager is reviewing the facility's protocol for the care of a client who has postpartum depression. What information should the nurse manager include in the protocol? Use the ATI Active Learning Template: System Disorder to complete this item.
Postpartum depression occurs within 6 months of delivery (book content elsewhere notes within 12 months). It is characterized by persistent feelings of sadness and intense mood swings. It occurs in 10–15% of new parents and usually does not resolve without intervention. It is similar to nonpostpartum mood disorders.
Antidepressants.
4 NCLEX-style questions covering Ch 22 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is differentiating postpartum blues, depression, and psychosis. Which finding is characteristic of postpartum PSYCHOSIS?
Show rationale ▾A. Postpartum BLUES (85% of women): self-limiting sadness within 10 days, no functional impairment.
B. Postpartum DEPRESSION (10–15%): persistent symptoms over 2+ weeks within first year, but NO break with reality.
C. CORRECT. Postpartum PSYCHOSIS (1–2/1000): onset 2–3 weeks postpartum with hallucinations, delusions, paranoia. Often linked to bipolar history. High risk of harm to self/infant. Hospitalization required.
D. Mild irritability is more consistent with blues, not psychosis.
NCLEX · Psychosocial Integrity · Mental Health ConceptsA nurse is caring for a postpartum client at 3 weeks who reports thoughts of harming her infant. Which is the priority nursing action?
Show rationale ▾A. Reassurance minimizes a potentially life-threatening situation.
B. CORRECT. Thoughts of harming the infant are a safety emergency. Do not leave the mother alone with the infant. Notify provider immediately for psychiatric evaluation. Assess for specific plan, means, and timing.
C. Support groups are appropriate later but not the immediate priority.
D. Rest may help fatigue but does not address the safety risk.
NCLEX · Safety & Infection Control · Use of Restraints/Safety DevicesA nurse is reviewing risk factors for postpartum depression. Which of the following increase risk? (Select all that apply.)
Show rationale ▾A. CORRECT. Previous psychiatric history is the strongest risk factor.
B. CORRECT. Lack of support increases stress and risk.
C. CORRECT. Stressful events (financial, relationship, loss) increase risk.
D. Previous uncomplicated postpartum experiences are protective, not a risk factor.
E. CORRECT. Unplanned/unwanted pregnancy increases risk.
NCLEX · Psychosocial Integrity · Mental Health ConceptsA nurse is teaching a breastfeeding mother who has been prescribed sertraline (Zoloft) for postpartum depression. Which statement requires further teaching?
Show rationale ▾A. Accurate — SSRIs take 4–6 weeks for therapeutic effect.
B. INCORRECT — requires teaching. Sertraline is the preferred SSRI in breastfeeding because of very low transfer into breast milk. Most BF clients can continue safely. Stopping BF could worsen depressive symptoms.
C. Accurate — abrupt cessation can cause discontinuation syndrome.
D. Accurate — monitor infant for unusual sedation, irritability, or poor feeding.
NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/OutcomesA nurse is assessing a client 10 days postpartum who reports being unable to sleep, having racing thoughts about the baby being possessed by demons, and believing she has special powers to communicate with God. Which action should the nurse take first?
Show rationale ▾A. These symptoms are NOT normal postpartum experiences — they suggest psychosis.
B. CORRECT. Delusions, paranoia, and impaired reality testing in the postpartum period indicate postpartum psychosis — a psychiatric emergency. Risk of suicide (4%) and infanticide (4%). Immediate provider notification, infant safety/supervision, and psychiatric hospitalization required.
C. Outpatient follow-up is insufficient for psychosis — emergency intervention is needed.
D. Journaling is inappropriate for someone with psychosis.
NCLEX · Psychosocial Integrity · Mental Health ConceptsA nurse is assessing a client 4 weeks postpartum. Which of the following findings would suggest postpartum depression rather than postpartum blues? (Select all that apply.)
Show rationale ▾A. CORRECT. PP blues resolves within 2 weeks; persistent symptoms suggest PPD.
B. CORRECT. Impaired functioning is consistent with PPD, not blues.
C. CORRECT. Anhedonia is a hallmark of depression.
D. Mild tearfulness that resolves with reassurance is consistent with postpartum blues.
E. CORRECT. Suicidal ideation requires immediate evaluation and intervention.
F. Mood lability that improves with rest/support is consistent with blues.
NCLEX · Psychosocial Integrity · Mental Health ConceptsApgar scoring: 1 and 5 min. 0–3 severe distress · 4–6 moderate · 7–10 minimal/none. Vital sign sequence: respirations FIRST (before disturbing), HR, BP, temp. Normal vitals: RR 30–60, HR 110–160, BP 60–80/40–50, temp 36.5–37.5°C. Apnea < 15 sec OK; > 15 sec needs evaluation. Mouth before nose for suction (prevents aspiration). Birth weight classification: SGA < 10th, AGA 10th–90th, LGA > 90th, LBW ≤ 2,500 g. Term: 37–42 wk · Preterm: < 37 · Postterm: > 42.
Apgar scoring + brief physical exam done immediately after birth to rule out abnormalities. The score is assigned at 1 and 5 min of life based on a quick review of systems.
| Sign | 0 points | 1 point | 2 points |
|---|---|---|---|
| Appearance (Skin Color) |
Blue, pale | Body pink, extremities blue (acrocyanosis) |
Completely pink |
| Pulse (Heart Rate) |
Absent | < 100 bpm | ≥ 100 bpm |
| Grimace (Reflex irritability) |
No response | Grimace, weak cry | Cough, sneeze, vigorous cry |
| Activity (Muscle tone) |
Limp, flaccid | Some flexion of extremities | Active motion, well flexed |
| Respirations | Absent | Slow, weak, irregular cry | Strong vigorous cry |
Interpretation: 7–10 = good condition (routine care) · 4–6 = moderate distress (stimulation, O₂) · 0–3 = severe distress (full resuscitation). Resuscitation does NOT wait for Apgar score.
Vital sign sequence: respirations FIRST (before disturbing the newborn), then HR, BP, temperature. Gestational age assessment within first 48 hr using New Ballard Score.
Newborn maturity rating to assess neuromuscular and physical maturity. Each parameter ranges from -1 to 5; totals give maturity rating in weeks gestation.
Ballard scoring (New Ballard Score): Postnatal assessment combining neuromuscular maturity (6 criteria) and physical maturity (6 criteria) to estimate gestational age. Most accurate at 12–20 hr of life.
More extensive physical exam within 24 hr of birth. Vital signs, head-to-toe assessment, neurologic and behavioral assessments by eliciting reflexes.
Small raised pearly white spots on nose, chin, forehead. Disappear spontaneously. Parents should NOT squeeze.
Spots of pigmentation (blue, gray, brown, black) on back/buttocks. More common in newborns with dark skin; linked to genetics. Document presence/location.
Flat pink/red marks that easily blanch. Found on back of neck, nose, upper eyelids, mid forehead. Usually fade by year 2.
Pink "newborn rash" appearing suddenly anywhere on body during first 3 weeks. No treatment required.
| Parameter | Normal Range | Abnormal / Notify |
|---|---|---|
| Heart rate | 110–160 bpm (awake); 80–100 (sleeping) | < 100 or > 180 sustained |
| Respiratory rate | 30–60 breaths/min (counted full 60 sec) | < 30 or > 60 sustained; retractions; grunting; nasal flaring |
| Blood pressure | 60–80 / 40–50 mm Hg | Not routinely measured unless concern |
| Temperature (axillary) | 36.5–37.5 °C (97.7–99.5 °F) | < 36.5 (cold stress) or > 37.5 (suspect sepsis) |
| SpO₂ | > 95% by 10 min of life | Pre/post-ductal difference > 3% concerning for CHD |
| Blood glucose | > 45 mg/dL (term, after first 4 hr) | < 40–45; treat with feeding or D10W |
| Birth weight | 2,500–4,000 g (5.5–8.8 lb) | SGA < 2,500 g; LGA > 4,000 g |
| Length | 45–55 cm (18–22 in) | — |
| Head circumference | 32–37 cm (13–14.5 in) | 2–3 cm larger than chest |
| Chest circumference | 30–35 cm (12–14 in) | — |
| Expected weight loss | 5–7% in first 3–4 days | > 10% loss is excessive |
| Regain birth weight | By 10–14 days | Not regained by 2 wk → FTT eval |
Head and face:
Chest and lungs:
Cardiovascular:
Abdomen:
Genitourinary:
Spine and extremities:
Eight key reflexes to elicit and document. Each has expected eliciting maneuver and expected age range for persistence.
Elicit: stroke cheek or edge of mouth. Response: turns head toward touch, starts to suck.
Age: usually disappears 3–4 months; can persist up to 1 year.
Elicit: place finger in palm. Response: fingers curl around examiner's finger.
Age: lessens by 3–4 months.
Elicit: place finger at base of toes. Response: toes curl downward.
Age: birth to 8 months.
Elicit: hold newborn in semi-sitting position; allow head and trunk to fall backward to angle ≥ 30°. Response: arms symmetrically extend, then abduct at elbows; fingers spread to form "C".
Age: complete response until 8 weeks; body jerk only until 8–18 weeks; absent by 6 months.
Elicit: with newborn supine, neutral; turn head quickly to one side. Response: arm and leg on that side extend; opposing arm and leg flex.
Age: birth to 3–4 months.
Elicit: stroke outer edge of sole of foot, moving up toward toes. Response: toes fan upward and out.
Age: birth to 1 year.
Elicit: hold newborn upright with feet touching flat surface. Response: stepping movements.
Age: birth to 4 weeks.
Differentiate elicitation: Moro (head trunk drop), stepping (vertical with feet on table), Babinski (outer sole stroke), palmar grasp (palm pressure).
| Reflex | How to Elicit | Normal Response | Disappears |
|---|---|---|---|
| Sucking | Stroke lips; insert nipple/finger | Rhythmic sucking | 3–4 months |
| Rooting | Stroke cheek/corner of mouth | Turns head toward stimulus, opens mouth | 3–4 months |
| Palmar grasp | Place finger in palm | Grasps tightly | 3–4 months |
| Plantar grasp | Place finger at base of toes | Toes curl downward | 8 months |
| Moro (startle) | Sudden movement or loud sound | Symmetric abduction/extension of arms; hands open; then flexion ('hugging') | 3–4 months |
| Babinski | Stroke lateral sole heel-to-toe | Toes fan and dorsiflex (POSITIVE = normal in infant) | 12 months |
| Tonic neck (fencing) | Turn head to side while supine | Same-side arm extends; opposite arm flexes | 3–4 months |
| Step / dance | Hold upright, feet touch surface | Stepping motions | 3–4 weeks |
| Galant (truncal incurvation) | Stroke one side of back along spine | Trunk curves toward stimulated side | 4 weeks |
| Crawling | Place prone on flat surface | Crawling motions | 6 weeks |
Asymmetric reflexes may indicate brachial plexus injury, fracture, or hemiparesis. Persistent reflexes beyond expected disappearance may indicate neurological dysfunction (cerebral palsy).
Five senses present at birth, with developmental specificity. Pain assessment uses behavioral observation + physiological findings + validated scales.
Protective mechanism — newborn becomes accustomed to environmental stimuli; response to constant or repetitive stimulus decreases. Allows selection of stimuli that promote learning, avoiding overload.
Newborns DO feel pain. Repeated unmanaged pain has lasting neurodevelopmental effects.
Pain assessment tools: NIPS (max 7), CRIES (max 10), N-PASS, PIPP (for preterm with GA adjustment).
Non-pharmacologic interventions (preferred for procedural pain):
Pharmacologic: Acetaminophen (10–15 mg/kg PO/PR/IV); opioids for moderate-severe; local anesthetics for circumcision (EMLA, DPNB).
Routine lab values + recognition and management of three major complications.
Related to obstructed airway, poorly functioning cardiopulmonary system, or hypothermia.
Provide reassurance about expected findings parents may worry about: milia, Epstein's pearls, caput succedaneum, Mongolian spots, telangiectatic nevi, erythema toxicum.
| Lab | Normal (Term Newborn) |
|---|---|
| Hemoglobin | 14–24 g/dL |
| Hematocrit | 44–64% |
| WBC | 9,000–30,000/mm³ |
| Platelets | 150,000–300,000/mm³ |
| Bilirubin (total, day 1) | < 6 mg/dL |
| Glucose | 40–60 mg/dL initially; > 45 by 4 hr |
| Sodium | 134–144 mEq/L |
| Potassium | 3.7–5.9 mEq/L |
| Calcium (total) | 7.8–11.0 mg/dL |
| Coombs test | Negative (positive = Rh/ABO incompatibility) |
From the book — uses the ATI Growth and Development template (first use of this template). Practice answering before reviewing the key.
A nurse in the nursery is admitting a newborn 2 hr following birth. What nursing actions should the nurse use to evaluate newborn physical development? Use the ATI Active Learning Template: Growth and Development to complete this item.
4 NCLEX-style questions covering Ch 23 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is calculating an Apgar score on a newborn at 1 minute. Heart rate 130, respirations strong cry, muscle tone well-flexed, reflex irritability cry, color pink body with blue extremities. What is the Apgar score?
Show rationale ▾A. Score 7 would reflect more deficits than seen here.
B. Score 8 would reflect 2 areas lacking a point.
C. CORRECT. HR > 100 (2) + good cry (2) + well-flexed (2) + cry (2) + acrocyanosis (1) = 9. Score 7–10 = minimal/no difficulty.
D. Score 10 requires completely pink body and extremities — acrocyanosis is normal in newborns.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is performing newborn head assessment. Which finding distinguishes a CEPHALOHEMATOMA from caput succedaneum?
Show rationale ▾A. Caput succedaneum (scalp edema) DOES cross suture lines.
B. CORRECT. Cephalohematoma (subperiosteal blood) is bounded by sutures and does NOT cross them. Caput crosses sutures. Cephalohematoma resolves in 2–8 weeks; carries higher hyperbilirubinemia risk.
C. Caput resolves in 3–4 days; cephalohematoma takes weeks.
D. Caput is present at birth; cephalohematoma may not be apparent until day 1–2.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is teaching parents about normal newborn skin findings. Which of the following are EXPECTED findings? (Select all that apply.)
Show rationale ▾A. CORRECT. Milia are blocked sebaceous glands — resolve spontaneously. Do NOT squeeze.
B. CORRECT. Mongolian spots are common in newborns with darker skin tones — pigmentation, not bruising.
C. Port wine stain (nevus flammeus) is NOT a normal variant — capillary malformation that persists.
D. CORRECT. Erythema toxicum appears in first 3 weeks and resolves without treatment.
E. CORRECT. Stork bites (telangiectatic nevi) on nape of neck, eyelids, forehead — fade by age 2.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is assessing newborn reflexes. Which technique correctly elicits the Moro reflex?
Show rationale ▾A. This elicits the ROOTING reflex (turns head toward stroke).
B. This elicits the PALMAR GRASP reflex (fingers curl around).
C. CORRECT. Moro is elicited by simulating loss of support — newborn arms symmetrically extend then abduct at elbows, fingers spread forming a 'C'. Disappears by 3–6 months.
D. This elicits the BABINSKI reflex (toes fan upward and out).
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is performing an Apgar assessment at 1 minute of life. The newborn has acrocyanosis, heart rate 110, vigorous cry, active motion with flexion, and grimaces to stimulation. What is the Apgar score?
Show rationale ▾A. Score is higher than 6.
B. Score is higher than 7.
C. Score is higher than 8.
D. CORRECT. Appearance: acrocyanosis = 1; Pulse: > 100 = 2; Grimace: grimaces to stimulus = 1; Activity: active motion = 2; Respirations: vigorous cry = 2. Total = 9.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsA nurse is assessing newborn reflexes. Which of the following are expected normal findings in a full-term newborn? (Select all that apply.)
Show rationale ▾A. CORRECT. Positive Babinski (toes fanning) is normal in infants; abnormal in adults.
B. Asymmetric Moro suggests brachial plexus injury or fracture — abnormal.
C. CORRECT. Sucking reflex is expected and disappears by 3–4 months.
D. CORRECT. Tonic neck (fencing) is normal; disappears by 3–4 months.
E. CORRECT. Crawling reflex is normal; disappears by 6 weeks.
F. Absent palmar grasp is abnormal — suggests neurologic dysfunction.
NCLEX · Reduction of Risk Potential · System-Specific AssessmentsVital signs: admission/birth → q30 min × 2 → q1 hr × 2 → q8 hr. Heel stick PKU: after 24 hr of feeds (formula or breast milk); use outer aspect of heel, lancet ≤ 2.4 mm. Heat loss mechanisms: Conduction · Convection · Evaporation · Radiation. Priority for newborn immediately after birth: prevent heat loss (cover head with cap). Three meds at birth: erythromycin (eye prophylaxis), vitamin K (hemorrhage prevention), hep B (immunization). Don't give vit K and hep B in same thigh. Suction mouth FIRST, then nose.
Routine physical assessment + lab tests + state-mandated newborn genetic screening.
Newborn hearing screening required in most states — early detection and treatment of hearing impairments.
Surgical removal of the foreskin of the penis. Family decision based on health, hygiene, religion (Jewish male on 8th day after birth), tradition, culture. Not performed immediately at birth — vitamin K is at low point → hemorrhage risk; cold stress risk. Usually within first few days of life.
Anesthesia is required. Types: ring block, dorsal-penile nerve block, topical (eutectic mixture of local anesthetics — EMLA), concentrated oral sucrose. Nonpharmacologic methods (swaddling, nonnutritive sucking) enhance pain management.
Provider applies clamp, loosens foreskin, inserts cone for cutting surface. Reduces blood loss. Wound covered with sterile petroleum gauze to prevent infection and control bleeding.
Slides between foreskin and glans. Suture tied tightly around foreskin at coronal edge. Pressure removes excess foreskin. Drops off after 5–7 days. NO petroleum used.
Pre-procedure:
Procedure techniques:
Post-procedure care (general):
Plastibell-specific care:
Discharge teaching:
Three foundational nursing care areas immediately after birth.
Monitor for clinical findings of respiratory complications:
Newborn has large surface-to-weight ratio, reduced metabolism per unit area, blood vessels close to surface, small amounts of insulation. Keeps warm by metabolizing brown fat (unique to newborns) within narrow temp range. Cold stress → ↑ O₂ demand, rapidly uses brown fat reserves.
Loss from direct contact with cooler surface.
Flow from body surface to cooler air.
Heat lost as surface liquid → vapor.
Loss from body surface to cooler solid surface that is close to but not in contact.
Newborns lose heat 4× faster than adults (large surface-to-mass ratio, thin subcutaneous fat).
Non-shivering thermogenesis (NST): newborns generate heat by metabolizing brown adipose tissue (BAT) in neck, scapula, axillae, kidneys, adrenals. Requires oxygen and glucose — cold stress causes hypoxia, hypoglycemia, metabolic acidosis.
Signs of cold stress: Temp < 36.5°C (97.7°F), peripheral cyanosis, tachypnea, hypoglycemia, lethargy, poor feeding.
Interventions:
Daily nursing care and family education topics.
Immediate care (delivery room):
Transitional care (first 1–4 hours):
Ongoing newborn nursery care:
Voiding and stooling expectations:
Prophylactic medications routinely given to all newborns: erythromycin (eye prophylaxis), vitamin K (prevents hemorrhagic disease), hepatitis B vaccine.
Mandatory antibiotic ointment to prevent ophthalmia neonatorum — caused by Neisseria gonorrhoeae or Chlamydia trachomatis transmitted during birth canal descent → can cause blindness.
Prevents hemorrhagic disorders. Vitamin K is NOT produced in newborn GI tract until ~day 7; produced by colonic bacteria once formula or breast milk is introduced.
It is important NOT to give the vitamin K and the hepatitis B injections in the same thigh.
Rationale: Newborns are vitamin K-deficient (gut not colonized; low placental transfer). Prevents Vitamin K Deficiency Bleeding (VKDB) — formerly HDN.
Parental refusal education: VKDB can cause life-threatening intracranial hemorrhage; late-onset VKDB (2 wk – 6 mo) especially serious; standard care since 1961 with excellent safety record.
Rationale: Prophylaxis against ophthalmia neonatorum (gonococcal, chlamydial conjunctivitis) — can cause blindness.
Three major complications of newborn nursing care that require active monitoring and intervention.
Ineffective thermoregulation → hypoxia, acidosis, hypoglycemia. Newborns with respiratory distress at higher risk.
Initial drop in blood glucose after birth common (cessation of maternal glucose supply). Healthy term newborn can tolerate initial drop as low as 30 mg/dL.
Due to improper cord care or placement of clamp.
From the book — uses the ATI Basic Concept template for newborn airway clearance. Practice answering before reviewing the key.
A nurse is conducting a class for parents on care of the newborn. What should the nurse include in this class? Use the ATI Active Learning Template: Basic Concept to complete this item.
4 NCLEX-style questions covering Ch 24 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching parents to use a bulb syringe to suction a newborn's airway. Which technique is correct?
Show rationale ▾A. Inserting without compressing first pushes air into the airway.
B. CORRECT. Compress the bulb BEFORE inserting, then release inside to draw out secretions. Suction MOUTH FIRST, then nose (mouth-before-nose prevents aspiration if nose suction triggers a gasp).
C. Reverse order — mouth first, then nose.
D. Avoid the center of the mouth (stimulates gag reflex); suction the sides of the cheeks.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is preventing heat loss in a newborn after birth. Which interventions address EACH heat-loss mechanism? (Select all that apply.)
Show rationale ▾A. CORRECT. Pre-warming surfaces (warmer, blankets, scale, hands, stethoscope) prevents conduction heat loss.
B. CORRECT. Distance from cold surfaces (windows, walls, drafts) prevents radiation heat loss.
C. CORRECT. Drying prevents evaporative heat loss from moisture on the skin.
D. Open doors create drafts that INCREASE convection heat loss — keep the room draft-free.
E. CORRECT. A hat covers a large surface area (head = ~25% of body in newborns), reducing radiation and convection loss.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is performing a heel stick on a newborn. Which technique is correct?
Show rationale ▾A. Center of heel can hit bone and cause necrotizing osteochondritis. Depth > 2.4 mm risks bone injury.
B. CORRECT. Outer aspect of the heel, no deeper than 2.4 mm, avoids bone penetration and the medial arch (where major vessels and nerves run).
C. Inside (medial) of the heel risks vascular and nerve injury.
D. Apply pressure with dry gauze (NOT alcohol — alcohol can cause continued bleeding and increases pain).
NCLEX · Safety & Infection Control · Safe Use of EquipmentA nurse is providing post-circumcision care for a newborn with a Plastibell device. Which client teaching is correct?
Show rationale ▾A. Petroleum jelly is used with Gomco/Yellen/Mogen clamps, NOT Plastibell. Petroleum can interfere with Plastibell drying.
B. CORRECT. Plastibell drops off in 5–7 days, leaving a clean healed excision. No petroleum is used.
C. Small amount of bleeding/oozing is expected. Frank bleeding (blood-soaked diaper, persistent dripping) requires evaluation.
D. Sponge baths until cord falls off; tub bathing after circumcision is healed.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is preparing to administer vitamin K to a newborn within the first hour after birth. The correct route and site are:
Show rationale ▾A. Vitamin K is not given IV in newborns due to risk of severe reactions.
B. Oral vitamin K is not the standard in the U.S. (multiple doses needed).
C. CORRECT. Phytonadione (vitamin K) is given IM in the vastus lateralis (middle one-third of anterolateral thigh) using a 5/8-inch, 25-gauge needle. Dose: 0.5–1 mg.
D. Vitamin K is given IM, not SC.
NCLEX · Pharmacological & Parenteral Therapies · Medication AdministrationA nurse is providing newborn umbilical cord care education to new parents. Which of the following instructions should the nurse include? (Select all that apply.)
Show rationale ▾A. CORRECT. Dry cord care is the current standard.
B. CORRECT. Folding diaper below the cord prevents soiling and exposes to air.
C. Alcohol is no longer recommended (delays separation).
D. Sponge baths only until cord falls off and area is healed.
E. CORRECT. Signs of omphalitis require immediate evaluation.
F. CORRECT. Cord separation typically occurs 7–14 days postpartum.
NCLEX · Health Promotion & Maintenance · Health ScreeningCaloric requirement: 110 kcal/kg/day first 3 mo · 100 kcal/kg/day 3–6 mo. Fluid: 60–80 mL/kg/24 hr first 2 days · 100–150 mL/kg/24 hr days 3–7. Both BF and formula: 20 kcal/oz. Vitamin D: 400 IU daily for all breastfed infants from first days of life. Iron supplements: exclusive BF at 4 mo · iron-fortified formula until 12 mo. Solids at 6 months (earlier → allergies). Adequate feeding indicators: 6–8 wet diapers/day · weight gain · content between feedings. Loose pale yellow stools normal in BF.
Desirable growth and development is enhanced by good nutrition. Feeding provides nutrition AND parent-newborn bonding opportunity. Education and support apply equally to BF, donor milk, and formula.
Solids are not introduced until 6 months of age. If introduced too early, food allergies can develop.
Optimal nutrition source. AAP recommends exclusive BF for first 6 months. Continue BF through first 12 months of life. Provide factual nonjudgmental information about both BF and bottle feeding during pregnancy when possible.
Secreted from postpartum client's breasts during postpartum days 1–3. Contains immunoglobulin A (IgA), which provides passive immunity to the newborn.
Over-the-shoulder and chin-supported positions are for BURPING, not breastfeeding. Supine is for sleeping, NOT BF or bottle.
| Letter / Parameter | 0 points | 1 point | 2 points |
|---|---|---|---|
| Latch | Too sleepy; no sustained latch | Repeated attempts; sucks & releases | Grasps; rhythmic sucking; audible swallow |
| Audible swallowing | None | Few with stimulation | Spontaneous & intermittent (< 24 hr); spontaneous & frequent (> 24 hr) |
| Type of nipple | Inverted | Flat | Everted (after stimulation) |
| Comfort (breast/nipple) | Engorged; cracked, bleeding, large blisters; severe discomfort | Filling; reddened/small blisters; mild-moderate pain | Soft; non-tender |
| Hold (positioning) | Full assist (staff holds infant at breast) | Minimal assist; teach positioning | No assist needed; mother able to position/hold independently |
Stirring/mouth opening/rooting → stretching/hand-to-mouth → crying (late — feed before this)
Breast milk can be expressed by hand or pump for bottle feeding or supplemental device.
Pumped directly into a bottle or freezer bag. One or both breasts can be pumped. Suction is adjustable for comfort.
| Location | Duration (Fresh) |
|---|---|
| Room temperature (≤ 77°F / 25°C) | Up to 4 hours |
| Insulated cooler with ice packs | Up to 24 hours |
| Refrigerator (≤ 40°F / 4°C) | Up to 4 days |
| Freezer compartment (single door) | 2 weeks |
| Freezer (separate door) | Up to 6 months |
| Deep freezer (≤ 0°F / -18°C) | Up to 12 months |
Once thawed:
Preparation:
If BF not possible, recommended alternative is pasteurized donor milk from a milk bank (informed consent required). If donor milk not accessible, commercial infant formula is used.
Types:
Forms: Ready-to-feed (sterile); concentrated liquid (mix with equal water); powdered (NOT sterile — use sterile water for < 2 months old or immunocompromised).
Preparation safety:
Feeding technique:
Standard formula is iron-fortified; most contain vitamin D — no extra supplementation needed.
Daily monitoring of growth + recognition of risk factors for impaired nutrition + interventions for sleepy/fussy/FTT newborns.
Educate parent to begin feeding upon cues rather than waiting until newborn is crying:
Spitting up clear mucus is airway clearance, NOT readiness. Turning toward sounds is sensory response, NOT readiness. Lying quietly with eyes open is alerting behavior, NOT readiness.
Failure to thrive = slow weight gain; newborn usually falls below the 5th percentile on growth chart.
From the book — uses the ATI Basic Concept template for breast pump use and milk storage. Practice answering before reviewing the key.
A nurse is teaching about the use of a breast pump and storing breast milk with a group of new parents. What information should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item.
Pumping of one or both breasts using adjustable suction for comfort to obtain breast milk for storage in a bottle or freezer bag.
4 NCLEX-style questions covering Ch 25 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching a new breastfeeding mother about expected output indicating adequate intake. Which finding suggests effective breastfeeding in a 1-week-old infant?
Show rationale ▾A. 2–3 wet diapers is inadequate — suggests insufficient intake.
B. CORRECT. ≥ 6 wet diapers/24 hr after day 4 indicates adequate hydration. Additional indicators: 3+ yellow seedy stools/day, weight gain ≥ 110 g/week (after initial 5–10% loss regained by 10–14 days), audible swallowing, content between feeds.
C. Pale white stools indicate biliary obstruction — abnormal. BF stools are yellow and seedy.
D. Newborns feed every 2–3 hours; 6-hour sleeps without feeding may indicate inadequate intake.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is teaching about breast milk storage. Which of the following statements indicate correct understanding? (Select all that apply.)
Show rationale ▾A. CORRECT. Fresh expressed milk: 8 hours at room temperature.
B. CORRECT. Refrigerated: 8 days in sterile container.
C. NEVER microwave — destroys immunoglobulins and creates hot spots that can burn the infant.
D. CORRECT. Freezer compartment: 6 months. Deep freezer: 12 months.
E. Thawed milk should NOT be refrozen. Use within 24 hours of thawing.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is teaching a parent about formula preparation. Which of the following are correct guidelines? (Select all that apply.)
Show rationale ▾A. CORRECT. Tap water is acceptable (boil first if water source is questionable).
B. CORRECT. Prepared formula stored in refrigerator: max 48 hours.
C. Microwaving creates hot spots that can burn the infant. Warm by placing bottle in warm water.
D. CORRECT. Discard leftover formula — bacterial contamination from infant's mouth.
E. NEVER prop a bottle — risk of choking, aspiration, and dental caries. Always hold the infant.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is teaching parents about introducing solid foods. When should the first solid food be introduced?
Show rationale ▾A. Too early — digestive enzymes immature; increases allergy and obesity risk.
B. Some pediatricians may introduce at 4 months if infant shows readiness, but 6 months is the AAP recommendation for most infants.
C. CORRECT. AAP recommends introducing solid foods at 6 months — exclusive breastfeeding (or formula) until then. Infant should be able to sit with support and show interest in food.
D. Waiting too long delays exposure to varied foods and texture progression.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is observing a first-time mother breastfeeding her 2-day-old newborn. Which finding indicates an effective latch?
Show rationale ▾A. Inverted lips indicate a shallow latch and ineffective milk transfer.
B. Dimpled cheeks suggest insufficient suction — poor latch.
C. CORRECT. Effective latch: wide-open mouth, lips flanged outward ('fish lips'), more areola covered below than above, chin and nose touching breast, audible swallowing.
D. Clicking/smacking sounds indicate poor latch with air intake.
NCLEX · Basic Care & Comfort · Nutrition & Oral HydrationA nurse is teaching a breastfeeding mother about expressed breast milk storage. Which of the following statements should the nurse include? (Select all that apply.)
Show rationale ▾A. CORRECT. Room temp up to 4 hours (CDC recommendation).
B. CORRECT. Refrigerated milk within 4 days (some sources allow up to 5–7).
C. CORRECT. Frozen milk (chest/deep freezer) 6–12 months.
D. Microwave creates hot spots, destroys antibodies. Thaw in refrigerator or under warm running water.
E. Once thawed, breast milk should NEVER be refrozen.
F. CORRECT. Use thawed milk within 24 hours.
NCLEX · Basic Care & Comfort · Nutrition & Oral HydrationDischarge timing: 48 hr vaginal, 72 hr cesarean. 1st well visit: 72 hr (2–3 days) after discharge. Car seat: rear-facing, back seat (preferably middle), until age 2 OR max height/weight. Bath water: 38°C (100.4°F); test with elbow. Hot water heater max: 49°C (120.2°F). Sleep position: SUPINE (decreases SIDS); never on parents' bed. Bathe BEFORE bedtime to soothe. Shake the newborn = NEVER. Bathing order: cleanest to dirtiest — eyes/face/head → chest/arms/legs → groin LAST.
Anticipatory guidance starts with assessing family readiness, then teaches expected newborn behaviors and how to respond.
Foundational handling skills parents must learn before discharge.
Review correct bulb syringe technique with parents (see Ch 24): compress before insertion, side of mouth, mouth first then nostrils. Have family return-demonstrate.
Cradle newborn's head in bend of elbow. Permits eye-to-eye contact; good for feeding.
Hold newborn upright facing the holder; support head, upper back, buttocks.
Half of newborn's body in holder's forearm; head and neck rest in palm. Good for breastfeeding and shampooing hair.
To reduce risk of SIDS, suffocation, and sleep-related infant death:
After initial bath, the face, diaper area, and skin folds are cleansed daily; complete bathing 2–3 times per week using mild soap. Demonstrate technique to parents and have them return-demonstrate.
Wash with soap and water; rinse. Foreskin should NOT be forced back — constriction can result.
Use warm water. Do NOT use soap until circumcision is healed.
Wash by wiping from front to back to prevent contamination of vagina/urethra from rectal bacteria.
Daily care topics. Cord care details and circumcision care reinforce earlier teaching from Ch 24.
Environmental safety education for the home + car seat positioning.
Schedule of follow-up + recognition of illness manifestations + family CPR training.
Review schedule with parents; protect against:
Encourage parents to seek CPR training.
Stem from improper understanding of discharge instructions:
Educate parents to call immediately for:
From the book — uses the ATI Basic Concept template for newborn bathing. Practice answering before reviewing the key.
A nurse is leading a discussion with a group of parents on bathing a newborn. What information should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item.
4 NCLEX-style questions covering Ch 26 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is teaching parents about umbilical cord care. Which instruction is correct?
Show rationale ▾A. Alcohol is no longer recommended — current evidence shows dry cord care promotes faster healing.
B. Covering the cord traps moisture and increases infection risk.
C. CORRECT. Keep the cord dry; fold the diaper down/below the cord to prevent urine contamination and promote drying. Cord typically falls off in 10–14 days.
D. 2 days is too soon. Average 10–14 days.
NCLEX · Health Promotion & Maintenance · Newborn CareA nurse is teaching parents about safe bathing of a newborn. Which is the correct water temperature?
Show rationale ▾A. Too cool — risk of cold stress.
B. CORRECT. Bath water 38°C (100.4°F). Test with elbow or inner wrist before bathing. Hot water heater should be set max 49°C (120.2°F).
C. Too hot — risk of burns.
D. 49°C is the hot water heater maximum — NOT bath water temperature.
NCLEX · Safety & Infection Control · Safe Use of EquipmentA nurse is reviewing safe sleep practices with new parents. Which of the following recommendations should be included? (Select all that apply.)
Show rationale ▾A. CORRECT. Supine (back) sleeping reduces SIDS risk.
B. CORRECT. Firm mattress in a safety-approved crib.
C. CORRECT. No soft objects, bumpers, blankets, or toys in the sleep area.
D. AAP recommends ROOM-sharing (not BED-sharing) for the first 6 months. Bed-sharing significantly increases SIDS and suffocation risk.
E. CORRECT. Avoid overdressing — room temperature 68–72°F (20–22°C); no more than one extra layer.
NCLEX · Safety & Infection Control · Accident/Error/Injury PreventionA nurse is teaching new parents about car seat safety. Which is the correct positioning for a newborn?
Show rationale ▾A. Forward-facing is for older children (typically 2+ years).
B. Front seat with active airbag is dangerous — airbag deployment can be fatal to infants.
C. CORRECT. Rear-facing in the back seat is safest. Keep infants rear-facing as long as possible — at least until age 2 or until they exceed seat weight/height limits.
D. Newborns must be REAR-facing, not forward-facing.
NCLEX · Safety & Infection Control · Accident/Error/Injury PreventionA nurse is providing discharge teaching to new parents about safe sleep practices for their newborn. Which statement by a parent indicates understanding?
Show rationale ▾A. Prone (stomach) sleeping increases SIDS risk — back is best.
B. Soft items in the crib (blankets, pillows, toys) increase suffocation risk.
C. CORRECT. AAP safe sleep: 'Back is best' — back position, firm flat surface, no soft items in crib, room-sharing without bed-sharing, no overheating.
D. Bed-sharing increases SIDS and suffocation risk. Room-share (separate sleep surface) instead.
NCLEX · Safety & Infection Control · Accident/Injury PreventionA nurse is providing car seat safety education to parents preparing for discharge. Which of the following are correct? (Select all that apply.)
Show rationale ▾A. CORRECT. Rear-facing in the back seat is safest for infants.
B. CORRECT. Rear-facing seat: harness at or below shoulders.
C. NEVER place in front seat with active airbag — fatal injury risk.
D. CORRECT. Chest clip at armpit level positions the harness over collarbones.
E. Aftermarket padding interferes with safety; use only manufacturer-provided inserts.
F. Children should remain rear-facing until at least age 2 (per AAP).
NCLEX · Safety & Infection Control · Accident/Injury PreventionHypoglycemia threshold: intervene at < 40–45 mg/dL · healthy term tolerates 30 mg/dL × first 2 hr. Apnea: preterm = ≥ 20 sec; periodic breathing = 5–10 sec pause + 10–15 sec compensation (NORMAL). RDS surfactant meds: beractant, calfactant, lucinactant — no ET tube suction × 1 hr after. NAS meds: morphine sulfate (opioid), phenobarbital (anticonvulsant). LGA delivery prep: McRoberts position + suprapubic pressure for shoulder dystocia. Postmature: > 42 wk, leathery cracked skin, meconium-stained nails/cord. Phototherapy priority finding: sunken fontanels (dehydration). Pathologic jaundice: < 24 hr OR > day 14 OR rises > 0.5 mg/dL/hr.
Maternal substance use during pregnancy → anomalies, neurobehavioral changes, withdrawal in neonate. Severity depends on drug, dose, route, metabolism, timing, and length of exposure.
From chronic or periodic alcohol intake during pregnancy. Alcohol is teratogenic.
Classification: Opioid
For opioid withdrawal management.
Classification: Anticonvulsant
Intended effect: Decrease CNS irritability and control seizures for newborns with alcohol or opioid withdrawal.
| Category | Sign | Points |
|---|---|---|
| CNS Disturbances | Excessive high-pitched cry / continuous | 2 / 3 |
| Sleeps < 1 hr / 2 hr / 3 hr after feeding | 3 / 2 / 1 | |
| Hyperactive Moro reflex / markedly hyperactive | 2 / 3 | |
| Mild / moderate-severe tremors disturbed | 1 / 2 | |
| Increased muscle tone | 2 | |
| Generalized convulsions | 5 | |
| Metabolic / Vasomotor / Respiratory | Sweating | 1 |
| Fever (37.2–38.3°C / 38.4–39°C+) | 1 / 2 | |
| Frequent yawning (> 3–4 / interval) | 1 | |
| Mottling | 1 | |
| Nasal stuffiness; sneezing (> 3–4 / interval) | 1 | |
| Respiratory rate > 60 (no/with retractions) | 1 / 2 | |
| GI Disturbances | Excessive sucking | 1 |
| Poor feeding | 2 | |
| Regurgitation / projectile vomiting | 2 / 3 | |
| Loose / watery stools | 2 / 3 |
Score q3–4hr. Pharmacologic intervention (morphine first-line) indicated for scores > 8 on 3 consecutive evaluations OR average score ≥ 8 on any 2 consecutive. Many institutions now use the ESC (Eat, Sleep, Console) approach as an alternative functional assessment.
Glucose source stops when umbilical cord is clamped. Healthy term newborns can tolerate as low as 30 mg/dL within first 2 hr. Intervene when < 40–45 mg/dL. Untreated → seizures and neurologic injury.
Definition: Plasma glucose < 40–45 mg/dL (definitions vary by age and source).
At-risk newborns (screening indicated):
Manifestations (often subtle, may be asymptomatic):
Screening: Heel-stick glucose at 30–60 min of life, then before next feed × 12–24 hr, depending on risk and protocol.
Management:
RDS = surfactant deficiency → poor gas exchange and ventilatory failure. Surfactant is a phospholipid that keeps alveoli open. Atelectasis → ↑ work of breathing → respiratory acidosis and hypoxemia. Birth weight alone is NOT an indicator of fetal lung maturity.
Classification: Lung surfactant
Intended effect: Restores surfactant and improves respiratory compliance for preterm newborns with RDS.
Factors that accelerate fetal lung maturation in utero: ↑ gestational age, intrauterine stress, exogenous steroid use, ruptured membranes.
Birth after 20 weeks but before 37 weeks of gestation. Late preterm = 34 to 36 6/7 wk. Risk for many complications due to immature organ systems. Main priority: support cardiac and respiratory systems. Most cared for in NICU until they can take oral feeds, maintain temperature, and weigh ~2 kg (4.4 lb).
Three size/maturity-related complications with overlapping risks (hypoglycemia, polycythemia, asphyxia, meconium aspiration).
Birth weight at or below 10th percentile with intrauterine growth restriction.
Can be preterm, postmature, or full-term. Uncontrolled hyperglycemia during pregnancy is the leading risk factor → congenital defects (CHD, TEF, CNS anomalies).
Born after completion of 42 weeks gestation. Two patterns:
Uteroplacental insufficiency → chronic fetal hypoxia and distress in utero. Fetal response: polycythemia, meconium aspiration, neonatal respiratory problems. Perinatal mortality is higher when postmature placenta fails to meet ↑ O₂ demands during labor.
Newborn becomes LGA at birth → difficult delivery, cephalopelvic disproportion, high insulin reserves, insufficient glucose. Response: birth trauma, asphyxia, clavicle fracture, seizures, hypoglycemia, temperature instability (cold stress).
Postmature can be EITHER SGA or LGA. Persistent pulmonary hypertension (persistent fetal circulation) can result from meconium aspiration — interferes with fetal-to-neonatal circulation transition; ductus arteriosus and foramen ovale remain open.
Two infection/injury complications. Sepsis = micro-organisms or toxins in blood/tissues during first month after birth. Newborns more susceptible due to limited immunity and inability to localize infection. Birth trauma can be minor, intervention-required, or fatal.
Prevention starts perinatally: maternal screening, prophylactic interventions, sterile/aseptic delivery, prophylactic eye antibiotics, appropriate cord care.
Early-onset sepsis (EOS): within first 7 days of life (most often first 24 hr).
Late-onset sepsis (LOS): 7–90 days of life.
Manifestations (non-specific):
Workup:
Empiric treatment:
Elevation of serum bilirubin → jaundice. Appears on head (sclera, mucous membranes), then progresses down thorax, abdomen, extremities. Two types: physiologic (benign) and pathologic.
Bilirubin deposited in brain when all binding sites are used → necrosis of neurons. Bilirubin levels > 25 mg/dL place newborn at risk. Permanent damage: dystonia, athetosis, upward gaze, hearing loss, cognitive impairment.
Irreversible, chronic result of bilirubin toxicity. Same manifestations as acute bilirubin encephalopathy plus: hypotonia, severe cognitive impairment, spastic quadriplegia.
Hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can result from hyperbilirubinemia and ↑ brain damage risk.
Bilirubin should start to decrease within 4–6 hr after starting phototherapy.
Physiologic jaundice (60% of newborns):
Pathologic jaundice (concerning):
Breastfeeding jaundice (early-onset):
Breast milk jaundice (late-onset):
Kernicterus (acute bilirubin encephalopathy):
Phototherapy management:
Exchange transfusion: for severe hyperbilirubinemia not responding to intensive phototherapy, or if signs of acute bilirubin encephalopathy. Rapidly removes bilirubin and antibodies.
TEF can occur with esophageal atresia (EA). Congenital anomalies involve all systems and are often diagnosed prenatally.
GI anomaly that can occur independently or with EA. TEF + EA = blind esophagus pouch and/or abnormal connection between esophagus and trachea. Risk for aspiration and respiratory complications. Detected on prenatal ultrasound.
From the book — uses the ATI System Disorder template for hyperbilirubinemia. Practice answering before reviewing the key.
A nurse educator is reviewing hyperbilirubinemia with a newly hired nurse. What should the nurse educator include in this review? Use the ATI Active Learning Template: System Disorder to complete this item.
Press the newborn's skin on the cheek or abdomen lightly with one finger. Then release pressure, and observe for a yellowish tint to the skin as the skin is blanched.
4 NCLEX-style questions covering Ch 27 core content. Click each exercise to reveal rationales and NCLEX category.
A nurse is caring for a newborn at 3 hours of life with a blood glucose of 35 mg/dL. The newborn is jittery and feeding poorly. Which is the priority intervention?
Show rationale ▾A. Observation is inadequate — symptomatic hypoglycemia requires treatment.
B. CORRECT. Newborn glucose < 40–45 mg/dL beyond 2 hours of life with symptoms requires intervention. Initiate feeding (breast or formula). If unstable or unable to feed: IV glucose. Recheck in 30 minutes.
C. Warming addresses hypothermia, which can WORSEN hypoglycemia, but feeding is the priority intervention.
D. Skin-to-skin alone is insufficient when symptomatic.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is using the Neonatal Abstinence Scoring System (NAS) to assess a newborn whose mother had opioid use during pregnancy. Which CNS findings indicate withdrawal? (Select all that apply.)
Show rationale ▾A. CORRECT. High-pitched/shrill/inconsolable cry is a classic NAS sign.
B. CORRECT. Hypertonicity and tremors are key CNS findings.
C. CORRECT. Hyperactive Moro and increased DTRs are typical.
D. Loose stools and excessive sucking are GI/autonomic findings of NAS — not CNS findings.
E. CORRECT. Convulsions occur in severe NAS.
NCLEX · Physiological Adaptation · PathophysiologyA nurse is assessing a preterm newborn for respiratory distress syndrome. Which finding indicates worsening RDS?
Show rationale ▾A. RR 50 is at upper-normal range for a newborn (normal 30–60).
B. CORRECT. Worsened RDS: unresponsiveness, flaccidity, and apnea with decreased breath sounds. This indicates progression to respiratory failure.
C. Mild flaring resolving with stimulation suggests transient or mild distress — not worsening.
D. Acrocyanosis (bluish hands and feet) is normal in newborns.
NCLEX · Physiological Adaptation · Medical EmergenciesA nurse is caring for a newborn receiving phototherapy for hyperbilirubinemia. Which intervention is correct?
Show rationale ▾A. Lotions absorb heat and can cause burns under phototherapy — avoid.
B. CORRECT. Eye covers protect corneas and retinas from light damage. Remove every 4 hours to check eyes. Keep newborn undressed (cover male genitalia with bikini mask, removing metal strip).
C. Newborn must be UNDRESSED to maximize skin exposure to light. Cover only the genitalia for male newborns.
D. Brief breaks for feeding and bonding are encouraged, but the goal is maximum light exposure — keep on lights as much as possible while ensuring safety.
NCLEX · Physiological Adaptation · Illness ManagementA nurse is caring for a newborn whose mother used opioids during pregnancy. The newborn is irritable, has a high-pitched cry, tremors, and frequent yawning. The Finnegan score is 11. Which intervention should the nurse anticipate?
Show rationale ▾A. Discharge is not appropriate with active withdrawal symptoms requiring treatment.
B. CORRECT. Finnegan score > 8 on consecutive scores indicates pharmacologic intervention needed. Oral morphine is first-line for opioid withdrawal in newborns, with gradual weaning over 1–4 weeks.
C. Naloxone is CONTRAINDICATED in newborns of opioid-dependent mothers — it precipitates severe withdrawal and seizures.
D. Decrease environmental stimulation (quiet, dim lights, swaddling) — overstimulation worsens NAS.
NCLEX · Pharmacological & Parenteral Therapies · Medication AdministrationA nurse is assessing a newborn whose mother has gestational diabetes. The newborn has jitteriness, lethargy, and poor feeding. Which of the following actions should the nurse take? (Select all that apply.)
Show rationale ▾A. CORRECT. Symptoms of hypoglycemia require immediate glucose check.
B. CORRECT. Skin-to-skin promotes warmth and bonding — reduces glucose use for thermoregulation.
C. CORRECT. Asymptomatic borderline glucose: feed and recheck. Symptomatic or very low: IV dextrose.
D. NEVER use D50W in newborns — causes rebound hypoglycemia and vessel damage. Use D10W bolus 2 mL/kg.
E. CORRECT. Cold stress increases glucose consumption, worsening hypoglycemia.
F. Symptomatic hypoglycemia requires immediate intervention, NOT delayed reassessment.
NCLEX · Pharmacological & Parenteral Therapies · Medication Administration