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What are presumptive signs of pregnancy?
Answer: Subjective symptoms reported by the woman that suggest but do not confirm pregnancy (other conditions can cause them).
Examples: amenorrhea, nausea/vomiting, breast tenderness, urinary frequency, fatigue, quickening (first fetal movement felt by mother, ~16-20 wks), skin changes (chloasma, linea nigra, striae).
What are probable signs of pregnancy?
Answer: Objective findings noted by an examiner that strongly suggest pregnancy but are still not conclusive proof.
Examples: Chadwick's sign (bluish cervix/vagina), Goodell's sign (softened cervix), Hegar's sign (softened lower uterine segment), Braxton Hicks contractions, ballottement, positive urine/serum hCG test, uterine enlargement.
What are positive signs of pregnancy?
Answer: Objective findings that can only be explained by the presence of a fetus — these confirm pregnancy definitively.
Examples: fetal heart tones auscultated by Doppler (~10-12 wks), fetal movement palpated by the examiner, visualization of the fetus on ultrasound.
Why are probable signs not used alone to confirm pregnancy?
Answer: Because other conditions (uterine tumors, pelvic congestion, hormonal issues) can mimic them, and false-positive hCG results can occur.
Only positive signs (fetal heart tones, fetal movement felt by examiner, ultrasound visualization) are diagnostic.
State Naegele's rule for calculating the estimated due date (EDD).
Answer: EDD = LMP (first day of last menstrual period) − 3 months + 7 days (adjust the year as needed).
Assumes a regular 28-day cycle. Example: LMP = March 10 → subtract 3 months = December 10 → add 7 days = December 17 of the appropriate year.
A patient's LMP is June 15. Using Naegele's rule, what is her EDD?
Answer: March 22 (of the following year).
June 15 − 3 months = March 15 → + 7 days = March 22.
What does each letter in GTPAL stand for?
Answer: G = Gravida (total pregnancies, including current); T = Term births (≥37 weeks); P = Preterm births (20-36 6/7 weeks); A = Abortions/miscarriages (before 20 weeks); L = Living children.
Multiples (e.g., twins) count as one birth event for T/P but add to L for each living child.
A woman is pregnant now, has one prior term birth, one preterm birth, one miscarriage, and has 2 living children. Write her GTPAL.
Answer: G4 T1 P1 A1 L2
Current pregnancy counts in Gravida only; each prior outcome is tallied in the corresponding category.
What is McDonald's rule for estimating gestational age by fundal height?
Answer: Fundal height in cm ≈ weeks of gestation, accurate between approximately 20 and 34 weeks.
Measured in cm from the top of the symphysis pubis to the top of the uterine fundus.
At what gestational age is the fundus typically palpated at the level of the umbilicus?
Answer: 20 weeks.
This is a key landmark used for quick gestational age estimation along with fundal height measurement.
At what gestational age is the fundus typically palpated at the xiphoid process?
Answer: 36 weeks (near term, before lightening causes the fundus to descend).
After lightening (fetal head engages in pelvis), fundal height may decrease slightly even though gestation continues.
What does the VEAL CHOP mnemonic teach about fetal heart rate (FHR) patterns?
Answer: V-ariable decelerations = C-ord compression; E-arly decelerations = H-ead compression; A-ccelerations = O-kay (reassuring); L-ate decelerations = P-lacental insufficiency.
Pairs each FHR pattern with its underlying cause so the nurse can choose the correct intervention.
Identify this FHR pattern and name its cause.
Answer: Early decelerations — caused by fetal head compression during contractions; they are benign and require no intervention.
The dip in FHR mirrors the contraction exactly — onset, nadir, and recovery coincide with the start, peak, and end of the contraction.
Identify this FHR pattern and give the priority nursing action.
Answer: Late decelerations — caused by uteroplacental insufficiency; priority: stop oxytocin, reposition mother to left lateral, give O2 via mask, increase IV fluids, and notify the provider.
The dip begins after the contraction peak and recovers after the contraction ends — a delayed, non-reassuring pattern.
Identify this FHR pattern and give the priority nursing action.
Answer: Variable decelerations — caused by umbilical cord compression; priority: reposition the mother (side-to-side or knee-chest), check for cord prolapse, give O2, and consider amnioinfusion.
Abrupt, V- or U-shaped drops that are not consistently timed with contractions.
A nurse is monitoring a laboring patient and sees recurrent late decelerations. What is the priority action?
Answer: Stop the oxytocin infusion, reposition the mother to left lateral, administer O2 via facemask, increase IV fluid rate, and notify the provider.
These steps aim to improve uteroplacental perfusion immediately; oxytocin worsens contractions and must be stopped first if infusing.
On vaginal exam, the nurse palpates a pulsating cord ahead of the fetal presenting part. What is the priority action?
Answer: Relieve pressure on the cord by keeping a gloved hand in the vagina to lift the presenting part off the cord, position the mother in knee-chest or Trendelenburg, call for help, give O2, and prepare for emergency cesarean birth.
Cord prolapse is an obstetric emergency causing cord compression and fetal hypoxia.
What are the four stages of labor?
Answer: Stage 1: onset of true labor to full cervical dilation (10 cm). Stage 2: full dilation to birth of the baby. Stage 3: birth of baby to delivery of the placenta. Stage 4: recovery, first 1-4 hours postpartum.
Each stage has distinct nursing priorities (comfort/monitoring in stage 1, pushing/delivery in stage 2, placental separation signs in stage 3, hemorrhage watch in stage 4).
What are the three phases of the first stage of labor and their dilation ranges?
Answer: Latent phase: 0-3 cm dilation (mild contractions, excited/talkative); Active phase: 4-7 cm (stronger contractions, increasing focus); Transition phase: 8-10 cm (intense contractions, urge to push, irritability).
Nursing support shifts from education/encouragement in latent phase to intensive coaching and pain management by transition.
What defines preeclampsia?
Answer: New-onset hypertension (≥140/90 mmHg) plus proteinuria (or other end-organ dysfunction) after 20 weeks of gestation.
It results from abnormal placental vascular development leading to vasospasm and endothelial damage.
What are severe features of preeclampsia?
Answer: BP ≥160/110 mmHg, severe headache, visual disturbances, epigastric/RUQ pain, thrombocytopenia, elevated liver enzymes, pulmonary edema, or oliguria.
Presence of severe features increases risk of progression to eclampsia (seizures) and warrants urgent delivery planning.
Why is magnesium sulfate given to patients with preeclampsia, and what is the therapeutic serum level?
Answer: It is a CNS depressant given to prevent/treat eclamptic seizures; therapeutic range is approximately 4-7 mEq/L.
It also has a mild tocolytic and vasodilatory effect but is primarily used for seizure prophylaxis.
What are the signs of magnesium sulfate toxicity?
Answer: Loss of deep tendon reflexes (DTRs), respiratory depression (RR <12/min), decreased urine output (<30 mL/hr), and hypotension.
DTR loss typically precedes respiratory depression, so DTRs are checked frequently during infusion.
A patient on magnesium sulfate has absent patellar reflexes and a respiratory rate of 10/min. What is the priority action?
Answer: Stop the magnesium sulfate infusion immediately and prepare to administer calcium gluconate (the antidote); monitor respiratory status closely.
Calcium gluconate directly antagonizes magnesium's effects on neuromuscular transmission.
What is the antidote for magnesium sulfate toxicity?
Answer: Calcium gluconate.
Kept at the bedside whenever a patient is receiving a magnesium sulfate infusion.
How is postpartum hemorrhage (PPH) defined?
Answer: Blood loss greater than 500 mL after a vaginal birth or greater than 1000 mL after a cesarean birth.
PPH can also be defined as any blood loss causing hemodynamic instability.
A postpartum nurse palpates a soft, boggy fundus with increased vaginal bleeding. What is the priority action?
Answer: Perform fundal massage immediately to stimulate uterine contraction; notify the provider if bleeding continues.
Uterine atony (failure of the uterus to contract) is the most common cause of early PPH.
What does the BUBBLE-HE mnemonic assess in the postpartum patient?
Answer: Breasts, Uterus (fundus), Bladder, Bowel, Lochia, Episiotomy/perineum, Homans sign/extremities (now assessed as DVT risk rather than via the Homans test), Emotional status.
A systematic head-to-toe postpartum assessment used every shift (or more often in the early recovery period).
Describe the progression of lochia after birth.
Answer: Lochia rubra: days 1-3, red/bloody. Lochia serosa: days 4-10, pink-brown, serous. Lochia alba: day 10-14+, white/yellowish.
A return to rubra-colored bleeding after serosa/alba has begun, or foul odor, suggests a complication (retained tissue/infection).
Explain the mechanism of Rh incompatibility in pregnancy.
Answer: An Rh-negative mother carrying an Rh-positive fetus can be exposed to fetal Rh-positive blood (e.g., at delivery, trauma, or miscarriage), causing her immune system to form anti-Rh antibodies that can attack Rh-positive fetal red blood cells in a subsequent pregnancy.
This can lead to hemolytic disease of the newborn (erythroblastosis fetalis) in future Rh-positive pregnancies.
When is RhoGAM given and why?
Answer: At approximately 28 weeks of gestation and again within 72 hours after delivery (if the newborn is Rh-positive); also after any event with potential fetomaternal hemorrhage (miscarriage, amniocentesis, trauma).
RhoGAM (Rh immune globulin) prevents maternal antibody formation against Rh antigen by destroying fetal Rh-positive cells in the mother's circulation before she can mount an immune response — it must be given before sensitization occurs.
What does the APGAR score assess, and when is it performed?
Answer: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), Respiration — each scored 0-2, assessed at 1 minute and 5 minutes after birth.
Total possible score is 10; it is a rapid snapshot of newborn transition to extrauterine life, not a diagnostic or long-term predictive tool.
How are APGAR score ranges interpreted?
Answer: 7-10 = normal/reassuring; 4-6 = moderately depressed, needs some resuscitative measures; 0-3 = severely depressed, needs immediate resuscitation.
A low 1-minute score with improvement by 5 minutes is reassuring; persistently low scores warrant further evaluation.
A newborn's 1-minute APGAR score is 3. What is the priority nursing action?
Answer: Begin immediate resuscitation: stimulate the infant, clear/suction the airway, provide warmth, and give positive-pressure ventilation/oxygen as needed — do not wait for the 5-minute score.
APGAR scoring should never delay necessary resuscitative interventions.
What are normal newborn vital sign ranges for heart rate, respiratory rate, and temperature?
Answer: Heart rate: 110-160 bpm; Respiratory rate: 30-60 breaths/min; Temperature: 97.7-99.5°F (36.5-37.5°C) axillary.
Newborns are prone to heat loss (evaporation, conduction, convection, radiation), so temperature stability is closely monitored.
Describe the Moro (startle) reflex and when it should disappear.
Answer: When startled (e.g., loud noise or sudden movement), the newborn symmetrically abducts and extends the arms then brings them back to the midline in an embrace-like motion. Disappears by about 4-6 months.
Asymmetric response may indicate a brachial plexus injury or fracture.
Describe the rooting and sucking reflexes.
Answer: Rooting: the newborn turns the head toward a stimulus that touches the cheek or corner of the mouth, searching for a nipple. Sucking: rhythmic sucking occurs when the palate is touched.
Both are essential for successful breastfeeding and typically disappear around 3-4 months (rooting) as they become voluntary.
Describe the Babinski reflex in a newborn.
Answer: Stroking the sole of the foot from heel toward the toes causes the toes to fan outward and the big toe to dorsiflex.
This is a normal finding in infants (unlike in adults, where it indicates a CNS lesion) and disappears by about 12 months.
Differentiate physiologic jaundice from pathologic jaundice in the newborn.
Answer: Physiologic jaundice: appears after 24 hours of life, peaks around day 3-5, due to normal breakdown of excess fetal RBCs with an immature liver. Pathologic jaundice: appears within the first 24 hours of life — always abnormal and requires immediate workup (e.g., hemolytic disease, sepsis).
Early-onset jaundice (<24 hrs) is a red flag that must be reported and investigated promptly to prevent kernicterus.
What nursing care is involved in newborn phototherapy for jaundice?
Answer: Keep the infant undressed except for a diaper, cover the eyes with protective shields, monitor temperature for hyper/hypothermia, ensure adequate hydration/feeding, and monitor bilirubin levels and skin integrity.
Phototherapy converts unconjugated bilirubin into water-soluble forms that can be excreted; untreated severe hyperbilirubinemia risks kernicterus (bilirubin-induced brain damage).
What are key teaching points for a proper breastfeeding latch?
Answer: The infant's mouth should cover most of the areola (not just the nipple), lips flanged outward, chin touching the breast, and audible/visible swallowing with minimal clicking or pain.
A shallow latch causes nipple trauma and ineffective milk transfer; the mother should bring the baby to the breast, not lean forward to the baby.
What signs indicate a breastfed newborn is getting adequate intake?
Answer: At least 6-8 wet diapers and 3-4 stools per day by day 4-5, regaining birth weight by about 2 weeks (after an initial loss of up to 7-10%), and audible swallowing during feeds.
Weight should be tracked at follow-up visits; excessive weight loss or dehydration signs warrant lactation consultation.
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