NCLEX-RN maternal-newborn: antepartum, intrapartum, postpartum, and newborn care

Preeclampsia vs. eclampsia: Preeclampsia: BP ≥140/90 mmHg on two readings, proteinuria (>300 mg/24h or protein:creatinine ≥0.3), onset after 20 weeks. Severe features: BP ≥160/110, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary oedema, visual disturbances, new-onset headache unresponsive to analgesics. Eclampsia = seizure superimposed on preeclampsia. Magnesium sulfate is both the seizure prophylaxis and treatment — NCLEX always tests Mg toxicity signs (absent DTRs, RR <12, urine output <25 mL/hr) and the antidote (calcium gluconate).

Placenta praevia vs. abruptio placentae: Praevia: painless bright red bleeding, soft uterus — do NOT perform vaginal exam (risk of catastrophic haemorrhage). Abruption: painful dark red bleeding, rigid/board-like uterus, fetal distress — emergency. Nursing: assess maternal vital signs and fetal heart tones first, position in left lateral decubitus, IV access, notify provider stat.

Gestational diabetes (GDM): Screened at 24–28 weeks with 1-hour glucose challenge test (threshold 130–140 mg/dL depending on institution). Fasting glucose targets 60–95 mg/dL, 1-hour postprandial <140. Insulin is safe in pregnancy; metformin is sometimes used. Risks: macrosomia, shoulder dystocia, neonatal hypoglycaemia. Monitor neonatal glucose after delivery.

Electronic fetal monitoring (EFM) interpretation is a core NCLEX maternal-newborn skill. The goal is identifying reassuring vs. non-reassuring patterns.

Category I (reassuring): Baseline FHR 110–160 bpm, moderate variability (6–25 bpm), absent late/variable decelerations, present accelerations. No intervention needed beyond routine monitoring.

Category II (indeterminate): Requires continued assessment and evaluation. Examples: minimal variability, absent variability without decelerations, prolonged decelerations, recurrent late decelerations with moderate variability.

Category III (non-reassuring — requires immediate action): Sinusoidal pattern, or absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia. Nursing response: reposition mother (left lateral), discontinue oxytocin, administer O2 via non-rebreather at 8–10 L/min, increase IV fluid rate, notify provider, prepare for possible emergency delivery.

Decelerations: Early (head compression — benign, mirrors contraction), late (uteroplacental insufficiency — requires intervention), variable (cord compression — change position).

Postpartum haemorrhage (PPH): Blood loss >500 mL (vaginal delivery) or >1000 mL (caesarean). Primary PPH occurs within 24 hours — causes: uterine atony (most common; 4 Ts: Tone, Trauma, Tissue, Thrombin), retained placenta, lacerations, coagulopathy. Nursing: fundal massage, assess tone and lochia, bimanual compression if ordered, oxytocin administration, IV access × 2 with large-bore catheters, fluid resuscitation, type and crossmatch. Oxytocin is first-line uterotonic; methergine contraindicated in hypertension; carboprost (Hemabate) contraindicated in asthma.

Uterine assessment: Fundus should be firm, midline, and at the umbilicus at 1 hour post-delivery, descending approximately 1 cm/day. Boggy fundus = uterine atony — massage immediately. Deviated fundus (especially to right) = full bladder — assist with voiding first.

Postpartum infection: Endometritis most common. Signs: fever >38°C after 24 hours post-delivery (excluding first 24-hour fever), uterine tenderness, foul-smelling lochia. Urinary tract infection is also common (urinary retention, catheterisation during labour). DVT risk is elevated postpartum — LMWH prophylaxis, ambulation, compression devices.

Apgar score: Assessed at 1 and 5 minutes. Five components (0–2 each): Appearance (colour), Pulse (HR), Grimace (reflex irritability), Activity (muscle tone), Respiration. Total score: 7–10 normal, 4–6 moderate depression, 0–3 severe depression requiring resuscitation. Score guides immediate intervention, not discharge planning.

Newborn vital signs: Temperature 36.5–37.5°C (axillary preferred), HR 100–160 bpm, RR 30–60 breaths/min. Acrocyanosis (blue extremities) is normal in first hours. Central cyanosis (lips, mucous membranes) is always abnormal — assess SpO2, notify provider.

Neonatal hypoglycaemia: Glucose <45–50 mg/dL in term newborns. At-risk: large for gestational age (LGA), small for gestational age (SGA), infant of diabetic mother (IDM), prematurity. Signs: jitteriness, poor feeding, lethargy, high-pitched cry. Early breastfeeding/formula feeding, heel-stick glucose monitoring.

Hyperbilirubinaemia and jaundice: Physiologic jaundice (day 2–3, resolves by 1–2 weeks) vs. pathologic (within 24 hours — requires workup). Risk factors: ABO/Rh incompatibility, G6PD deficiency, bruising, prematurity. Phototherapy is the primary treatment; nursing care includes eye protection, hydration, turning the infant, and monitoring bilirubin levels.