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OB NCLEX Essentials

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Disclaimer

Medicine and nursing are continuously changing practices. The author and publisher have reviewed all information in this book with resources
believed to be reliable and accurate and have made every effort to provide information that is up to date with best practices at the time of
publication. Despite our best efforts we cannot disregard the possibility of human error and continual changes in best practices the author,
publisher, and any other party involved in the production of this work can warrant that the information contained herein is complete or fully
accurate. The author, publisher, and all other parties involved in this work disclaim all responsibility from any errors contained within this work
and from the results from the use of this information. Readers are encouraged to check all information in this book with institutional guidelines,
other sources, and up to date information. For up to date disclaimer information please visit: http://www.nrsng.com/about.

NCLEX®, NCLEX®-RN ®are registered trademarks of the National Council of State Boards of Nursing, INC. and hold no affiliation or support
of this product.

All Rights Reserved. No part of this publication may be reproduced in any form or by any means, including scanning, photocopying, or
otherwise without prior written permission of the copyright holder. This book is intended for entertainment purposes only and does not imply
legal, medical, financial or other professional advice. The reader should seek the help of a competent professional for all matters.

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©2016 and beyond TazKai LLC and NRSNG.com

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Contents
Introduction ................................................................................................................................................... 6
OB 01.01 Menstrual Cycle ........................................................................................................................... 7
OB 01.02 Family Planning ........................................................................................................................... 9
OB 02.01 Gestation..................................................................................................................................... 11
OB 02.02 Gravidity and Parity ................................................................................................................... 12
OB 02.03 Signs of Pregnancy ...................................................................................................................... 13
OB 02.04 Fundal Height .............................................................................................................................. 14
OB 02.05 Maternal Risk Factors .................................................................................................................. 15
OB 03.01 Physiological Maternal Changes.................................................................................................. 17
OB 03.03 Discomforts of Pregnancy ........................................................................................................... 18
OB 03.03 Antepartum Testing .................................................................................................................... 20
OB 03.04 Nutrition ...................................................................................................................................... 23
OB 04.01 Abortion ...................................................................................................................................... 25
OB 04.02 Anemia ........................................................................................................................................ 26
OB 04.03 Cardiac Disease ........................................................................................................................... 28
OB 04.04 Chorioamnionitis ......................................................................................................................... 29
OB 04.05 Diabetes Mellitus ........................................................................................................................ 32
OB 04.06 Disseminating Intravascular Coagulation (DIC) ........................................................................... 33
OB 04.07 Ectopic Pregnancy ....................................................................................................................... 34
OB 04.08 Hematoma................................................................................................................................... 36
OB 04.09 Hydatidiform Mole ...................................................................................................................... 37
OB 04.10 Hyperemesis Gravidarum ............................................................................................................ 39
OB 04.11 Gestational HTN .......................................................................................................................... 40
OB 04.12 Incompetent Cervix ..................................................................................................................... 42
OB 04.13 Infections ..................................................................................................................................... 43
OB 05.01 Fertilization and Implantation ..................................................................................................... 46
OB 05.02 Fetal Environment ....................................................................................................................... 50
OB 05.03 Fetal Development ...................................................................................................................... 53
OB05.04 Fetal Circulation ........................................................................................................................... 56

OB 06.01 Process of Labor .......................................................................................................................... 58

OB 06.02 Mechanisms of Labor .................................................................................................................. 62
OB 06.03 Leopold's ..................................................................................................................................... 65
OB 06.04 Fetal Monitoring.......................................................................................................................... 67
OB 06.05 Obstetrical Procedures ................................................................................................................ 71
OB 07.01 PROM .......................................................................................................................................... 76
OB 07.02 Prolapsed Umbilical Cord ............................................................................................................ 77
OB 07.03 Placenta Previa ............................................................................................................................ 80
OB 07.04 Abruptio Placenta........................................................................................................................ 82
OB 07.05 Preterm Labor ............................................................................................................................. 83
OB 07.06 Precipitous Labor......................................................................................................................... 84
OB 07.07 Dystocia ....................................................................................................................................... 85
OB 08.01 Postpartum Physiological Maternal Changes.............................................................................. 86
OB 08.02 Postpartum Interventions ........................................................................................................... 88
OB 08.03 Postpartum Discomforts ............................................................................................................. 89
OB 08.03 Breastfeeding .............................................................................................................................. 91
OB 09.01 Postpartum Hematoma ............................................................................................................... 93
OB 09.02 Postpartum Hemorrhage (PPH) .................................................................................................. 94
OB 09.03 Mastitis ........................................................................................................................................ 95
OB 09.04 Subinvolution .............................................................................................................................. 96
OB 09.05 Thrombophlebitis ........................................................................................................................ 97
OB 10.01 Initial Care of the Newborn ......................................................................................................... 99
OB 10.02 Newborn Physical Exam ............................................................................................................ 103
OB 10.03 Body System Assessments ........................................................................................................ 107
OB 10.04 Reflexes ..................................................................................................................................... 109
OB 11.01.01 Preterm ................................................................................................................................ 111
OB 11.01.02 Postterm ............................................................................................................................... 113
OB 11.01.03 Small for Gestational Age (SGA) ........................................................................................... 114
OB 11.01.04 Large for Gestational Age (LGA) ........................................................................................... 115
OB 11.02 Meconium Aspiration ................................................................................................................ 116

OB 11.03 Transient Tachypnea (TTN) ....................................................................................................... 118

OB 11.04 Retinopathy of Prematurity ...................................................................................................... 119
OB 11.05 Hyperbilirubinemia.................................................................................................................... 120
OB 11.06 Erythroblastosis fetalis .............................................................................................................. 123
OB 11.07 Addicted Newborn .................................................................................................................... 125
OB 11.08 Fetal Alcohol Syndrome ............................................................................................................ 126
OB 11.09 Newborn of HIV + Mother......................................................................................................... 128
OB 12.01 Tocolytics ................................................................................................................................... 129
OB 12.02 Betamethasone and Dexamethasone ....................................................................................... 131
OB 12.03 Magnesium Sulfate.................................................................................................................... 132
OB 12.04 Opioid Analgesics ...................................................................................................................... 133
OB 12.05 Prostaglandins ........................................................................................................................... 135
OB 12.06 Uterine Stimulants .................................................................................................................... 137
OB 12.07 Meds for PPH............................................................................................................................. 139
OB 12.08 Rh Immune Globulin.................................................................................................................. 140
OB 12.09 Lung Surfactant ......................................................................................................................... 141
OB 12.10 Eye Prophylaxis for Newborn .................................................................................................... 142
OB 12.11 Phytonadione ............................................................................................................................ 143
OB 12.12 Hb Vaccine ................................................................................................................................. 144

Introduction

Welcome to the OB NCLEX® Essentials book by NRSNG.com. This book is designed to give you
exactly what you need to know regarding the OB patient without the extra fluff. Our goal is to help make
the material "click".

The goal of everything we do is to provide you with the tools and the confidence that you need to succeed
in nursing school, on the NCLEX®, and in your life as a nurse.

This book is based on the OB Course found at NRSNG.com. To learn more about this and all the other
courses please visit us online at NRSNG.com.

Happy Nursing!

Jon Haws RN BSN BS CCRN

OB 01.01 Menstrual Cycle

Overview

○28-day cycles in which either a period or pregnancy occur

■ FSH, LH, estrogen, progesterone are the hormones
■ Your brain, ovaries, and uterus are all part of this
○ Timeline of the menstrual cycle is as follow:
■ Pituitary gland releases FSH and LH, which stimulates follicles (thousands
located in ovaries, each follicle contains one oocyte) to grow
■ Growing follicles secrete estrogen
■ When estrogen peaks, it tells the brain to stop producing FSH and increase LH
production
■ The most mature oocyte bursts out of its follicle and starts traveling towards the
uterus via the fallopian tube to potentially become fertilized by a sperm
● This is called ovulation!
● Its former follicular home stays in the ovary and is now called the corpus
luteum
■ Back in ovary, the now-empty follicle, the corpus luteum, secretes progesterone,
which tells the uterine lining (endometrium) to plump itself up with blood and
nutrients to prepare for implantation of a fertilized ovum
■ If an ovum gets fertilized, it implants itself into the plump wall of the uterus.
She’s pregnant!
■ If the ovum does not get fertilized, the progesterone and estrogen levels plummet.
This tells the uterine lining to shed, because it’s not needed to support a
pregnancy.
■ Blood, tissue, and the ovum are shed and leave the body via the vagina.
● This shedding/dispelling of unused contents can take up to 7 days. This
is a period.
■ So what are menstrual cramps?
● The uterus is a muscle, which contracts to release the unused contents.
Vasoconstriction occurs during these contractions of the uterine muscle.
This vasoconstriction causes temporary oxygen deprivation, which then
causes the pain (or dysmenorrheal) associated with their period.
● NCLEX® Points
○ Fertilization occurs when with the sperm and ovum unite
○ The fertilized ovum is now called a zygote
○ This zygote will implant approximately 6-8 days after ovulation
○ The zygote matures into a blastocyst
○ The blastocyst will cause the body to produce human chorionic gonadotropin (hCG).
This tells the corpus luteum to continue secreting progesterone to maintain the pregnancy
until the placenta takes over production when it develops fully, 2-3 months later.
○ Ovarian Changes
■ Preovulation phase: Starts FSH + LH secretion -> ends with follicular rupture
and release of ovum
■ Luteal phase: ovulation -> starts with declining estrogen and ends with
progesterone
○ Uterine Changes

■ Menstrual phase (4-6 days): Starts with menstruation -> ends with increasing
FSH, starting a new cycle
■ Proliferation phase (about 9 days): Starts with increase estrogen production,
which causes the decreasing FSH and increase of LH -> ends with ovulation,
high levels of estrogen, low levels of progesterone
■ Secretory phase (about 12 days): starts in response to increased LH -> corpus
luteum secreting progesterone

OB 01.02 Family Planning

● Overview
○ Family planning consists of multiple things, not just contraception
○ Assess their current lifestyle / habits
○ Identify their family planning goals
■ Pregnancy prevention
● Oral contraceptives, intrauterine devices
a. Please see maternal and newborn pharm module for details
on meds
■ Pregnancy and STI prevention
● Condoms
■ Trying to get pregnant
● Infertility
a. Meds, surgical procedures, in vitro, surrogates, embryo
hosts, adoption
■ Finished having children and want to permanently prevent future pregnancy
● Tubal ligation, vasectomy
○ Note: nothing of the above is 100% guaranteed (except abstinence to prevent
pregnancy and STI’s)
○ Make recommendations and educate appropriately, based on goals
● NCLEX® Points
○ Must remember her preferences are most important and the below factors may
influence choices of family planning
○ Goal-oriented in selection of method
○ Factors that may influence contraception selection
■ Religious, cultural, personal influences
■ Goals
■ Level of compliancy (for example, will she take an oral contraceptive every
day?)
■ Frequency of intercourse (for example, if someone is frequently having
intercourse, will they use a condom every time or would an oral
contraceptive or IUD be more appropriate?)
■ Age

Package of oral contraceptives

By Bryancalabro - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=21125607

OB 02.01 Gestation
● Overview
○ From time of conception to estimated date of delivery
○ Nägele’s Rule
● NCLEX® Points
○ To use Nägele’s Rule, the patient must have a normal 28-day menstrual cycle
○ – 3 months, + 7 days to the first day of the last period
○ + 7 days to the last period, then count ahead 9 days

OB 02.02 Gravidity and Parity

● Overview
○ Gravida = pregnant woman
○ Gravidity = number of pregnancies
○ Parity = the number of births carried to a viable gestation age (past 20 weeks)
■ Whether or not the fetus was born alive
■ The number of pregnancies/births is what is counted, so if the mother has had
twins, triplets, etc. that would be counted as 1
○ Nullipara = never given birth
○ Use of GTPAL acronym
■ Please note, this system explains parity in more depth than just saying number of
births carried to a viable gestational age. It’s not different, it’s just further
explaining parity

G Gravidity = Number of pregnancies,

including any current pregnancies
(regardless of current gestational age)

T Term births = number of children born at

37+ weeks gestation

P Preterm births = number of births between

20-37 weeks
(so twins, triplets, etc. count as 1 birth)

A Abortions = number of miscarriages,

abortion (include in gravidity if before 20
weeks, include in parity if past 20 weeks)

L Living children

○ Examples
■ A woman with a history of 5 pregnancies: 2 births at 39 and 40 weeks, and 3
miscarriages before 20 weeks
● G5 T2 P0 A3 L2
■ A woman currently pregnant with a history of 1 miscarriage (22 weeks)
● G2 T0 P0 A1 L0
■ A woman with twins born at 32 weeks, history of 2 miscarriages (11 and 9
weeks), and currently pregnant
● G4 T0 P1 A2 L2

● NCLEX® Points
○ Know GTPAL

OB 02.03 Signs of Pregnancy

● Overview
○ Signs of pregnancy are divided into 3 categories
■ Presumptive signs = “You might be pregnant”
■ Probable signs = “It’s highly likely you’re pregnant”
■ Positive signs = “Yea, you’re definitely pregnant”
● NCLEX® Points
○ Quickening: feeling the fetus move, the earliest usually around 16 weeks
○ Ballottement: examiner inserts finger into the vagina, pushes on uterus and feels
the return of the fetus to the finger
■ “Playing ball with the baby” – push on them, they float away and come
back.. ball-ottement
○ Chadwick’s sign is a purple/blue/violet discolorization of the cervix, labia and
vagina due to increased blood flow
■ My college library was the Chadwick Library and our school color was
purple
○ Hegar’s sign is a softening at the bottom of the uterus, usually around 4-6 weeks
■ “He guards my soft uterus”
○ Goodell’s sign is at approximately 4 weeks gestation, the vaginal portion of the
cervix gets softer due to increased vascularization
■ “Good hell, Goodell! That cervix is soft!”
Presumptive Amenorrhea, N/V, larger and fuller breasts,
urinary frequency, pronounced nipples,
fatigue, quickening, changes in the color of
vaginal mucosa
Probable Ballottement, Chadwick’s sign, Goddell’s
sign, Hegar’s sign, uterine enlargement,
Braxton Hick’s contractions, positive
pregnancy test
Positive Active fetal movement felt by practitioner,
visual confirmation of fetus on ultrasound,
fetal heart beat heard on ultrasound (10-12
weeks) or by a fetascope at 20 weeks

OB 02.04 Fundal Height

● Overview
○ Fundus definition: the part of a hollow organ farther from the opening
○ This measurement begins at the symphysis pubis and ends at the top of the uterus
○ Measurement is in centimeters
○ The fundal height helps the practitioner to evaluate the age of the fetus
○ During the 1st and 2nd trimesters, it is approximately equal to gestational age in
weeks (+/- 2 centimeters)
● NCLEX® Points
○ This is measured while the patient is lying supine (flat on their back)
i. Lying flat on your back while pregnant puts pressure on the inferior vena
cava and can cause a drop in blood pressure
ii. This is called supine hypotension and you must monitor for it

OB 02.05 Maternal Risk Factors

● Overview
○ These are the factors that can put a pregnancy at risk
○ Genetic issues, lack of access to healthcare, abuse and violence, age (less than 20,
over 35, nutritional deficiencies, substances abuse, cigarette smoking, various
medical conditions (diabetes, thyroid issues, hypertension, mental illness, etc.)
● NCLEX® Points
○ Women younger than 20 are at risk for higher blood pressure, anemia, and pre-
term labor. They may also underestimate the value of prenatal care as well as not
fully understand which medications they can and cannot use while pregnant
■ Note: no drug is 100% safe during pregnancy
○ Folic acid supplements are recommended to prevent tissues with the development
of neural tubes
○ German measles (rubella): if mother acquires this during the first 8 weeks, it
carries the highest rate of fetal infection
○ Many STI’s can be transmitted to the fetus during pregnancy or during delivery
■ Syphilis is especially detrimental, as it may cross the placenta and lead to
spontaneous abortions and mental/physical deformities
■ HIV may be transmitted to the fetus if there is repeated exposure during
pregnancy.
● Can be transmitted via breast milk
● Zidovudine (or azidothymidine), an antiretroviral med, can be
given during pregnancy to decrease the transmission risk. It
reduces replication of the virus.
■ Substance abuse is a MAJOR risk factor
● Many substances cross the placenta
● Cannot take any OTC meds without first clearing it with MD
● ETOH consumption may lead to fetal alcohol syndrome (FAS)
a. Studies are inconsistent to demonstrate if there is a safe
amount of ETOH during pregnancy, therefore it is best to
recommend complete abstinence from it

By Teresa Kellerman - http://www.come-over.to/FAS/fasbabyface.jpg, CC BY-SA 3.0,

https://commons.wikimedia.org/w/index.php?curid=4847497

OB 03.01 Physiological Maternal Changes

● Overview
● Wikipedia | Medscape | YouTube Explanation
○ Many physiological and psychological changes occur to all body systems
○ Many of these changes are due to an expanding uterus (and therefore pelvis), an increase
in oxygen consumption and circulating blood volume, and fluctuations in various
hormones
○ Scheduled of prenatal visits:
■ Q4 weeks from 28-32 weeks
■ Q2 weeks from 32-36 weeks
■ Q1 weeks from 36-40 weeks
● NCLEX® Points
○ Heart rate will typically increase approximately 10-15 BPM
○ Blood pressure decreases in the 2nd trimester
○ Hormones that are causing changes are: estrogen, progesterone, human chorionic
gonatropin, aldosterone
○ As the uterus grows, the pelvis tilts forward to accommodate. Educate patient on
maintaining correct posture to prevent musculoskeletal discomfort and back pain

OB 03.03 Discomforts of Pregnancy

● Overview
● Wikipedia | Medscape | PatientStory
○ Pregnancy can cause many different discomforts
○ Every pregnancy is different and dynamic, therefore one cannot predict the severity of
various potential discomforts or which ones they will experience
○ Most discomforts are due to the expanding uterus and pelvis, hormonal changes,
increased blood volume and increased oxygen consumption
● NCLEX® Points
○ Generalized discomforts
■ Syncope
■ Fatigue
■ Headache
■ Backache
■ Weight gain
■ Generalized edema
■ Gait changes (widening standing stance to improve balance)
○ Genitourinary / female reproductive discomforts
■ Urinary urgency and frequency
■ Vaginal discharge increases
■ Breast tenderness increases
○ Cardiovascular discomforts
■ Varicose veins
■ Edema in feet and ankles
■ Leg cramps
■ Shortness of breath
■ Nasal stuffiness
○ Gastrointestinal discomforts
■ Nausea and vomiting
■ Constipation
■ Hemorrhoids
■ Heartburn

OB 03.03 Antepartum Testing

● Overview
● Wikipedia | Medscape | PatientStory
○ Many routine diagnostic exams are done during prenatal visits during various stages
○ Baseline routine exams will be completed and if there are complications, there are many
other diagnostic exams that can be completed
○ All pregnancies are different and dynamic, therefore not every pregnant woman will have
the same experience every time
○ Basically seeing what issues/complications may be present to appropriately address and
support during and after pregnancy
○ Complete appropriate tests as they’re required, we do not want to perform procedures that
could potentially harm mother or baby if they are not necessary
● NCLEX® Points
○ Routine diagnostics
■ Blood type and Rh Factor
■ Rubella titer
● Cannot give rubella vaccine during pregnancy due to it potentially
crossing placenta
■ Complete blood count
● H/H
● Platelets
■ STI testing
● Mandated in some states
● Pap smear with cultures
● TB test (may be AFTER delivery) to see if baby needs a CXR after
delivery
● May test for: HIV, HPV, herpes, gonorrhea, syphilis, chlamydia,
trichomoniasis
■ Hep B screening
■ Glucose challenge
■ UA with culture
● Urine dip for glucose (diabetes) and protein (preeclampsia) at every
prenantal visit
■ Ultrasound
● Abdominal (may also be transvaginal to visualize all structures
appropriately)
● A full bladder pushes up the uterus, making structures easier to visualize
● Checking anatomy of baby and maternal structures (cervix, placenta)
● Helps confirm the estimated gestational age and that structures are
forming appropriately and at the appropriate rate
● Can also assess the blood flow of placenta and baby
■ Nonstress test (NST)
● Noninvasive, not painful, completed outpatient
● 2 transducers: one for baby, one for contractions

A: Fetal heartbeat; B: Movements felt by mother (from by pressing button); C: Fetal movement; D: Uterine
contractions

By -- PhantomSteve/talk|contribs\ (The original uploader was Phantomsteve at English Wikipedia) - I (--

PhantomSteve/talk|contribs\) created this work entirely by myself. (), CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=19780765

●Assess fetal well-being, changes in their heart rate with movement

(accelerates, decelerates), also how the placenta is functioning and its
oxygenation
● We want a reactive NST (when the fetus moves, the heart rate increases
appropriately, approx. 15 beats above baseline at least twice in 20 min)
● Baseline maternal BP and HR before
● Patient to press button when they feel fetal movement, examiner can note
if it correlates with tracing
● We DO NOT want a nonreactive NST. Further testing will be required if
this is noted.
■ Kick counts
● Mother counts number of kicks during 2 hour period while lying on side
● Notify if less than 10 in 2 hrs
○ Not routine (only done if previous diagnostics or physical exam warrants them)
■ Contraction stress (only performed if NST is nonreactive)
● Stress the baby by momentarily inducing contractions (with Pitocin), see
how they respond
■ Percutaneous umbilical blood sampling
■ Alpha-fetoprotein screening
● If Down’s Syndrome or spina bifida suspected
● Blood sample from mom btwn 16-18 weeks
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■ Chorionic villus sample

● Invasive!
● Checking genetic issues by sampling chorionic villus
■ Amniocentesis
● Invasive!
● Checking amniotic fluid for genetic and metabolic issues, fetal lung
issues
● After this and previous tests, mother must be instructed to call MD with
any sign of decreased fetal movement, uterine contractions, cramping,
fever, chills, fluid leaking from site
■ Nitrazine test
● Checking for amniotic fluid in vaginal secretions
● Water broke vs. urine
● Turns swab blue if it’s amniotic fluid
● Not 100% accurate, as blood and urine can turn it blue/purple also

OB 03.04 Nutrition
● Overview
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● Wikipedia | Medscape | PatientStory

○ Expected weight gain is 25-35 lbs for women with a normal prepregnancy weight
○ Promote healthy food and weight gain (increase of 300 calories/day)
○ Mother is NOT eating for two

○ Education is essential
○ Provide resources for further reading and reliable places to go with questions
● NCLEX® Points
○ Weight gain of 25-35 lbs for normal pre-pregnancy weight
○ Increase of 300 calories/day for pregnancy
○ Increase of 500 calories/day for lactation
○ Educate vegetarian or vegan clients about the importance of consumption of complete
proteins and vitamins (Vit D, calcium, zinc, B12, omega 3’s)
○ Some prenatal discomforts can be remedied with dietary changes
■ Eliminate chocolate or caffeine for heartburn
■ Increase carb intake for nausea
○ Monitor for pica
■ Eating non-food substances (clay, freezer starch)
■ May have cultural influences
○ Cultural considerations
■ Ensure you are assess for cultural needs or influences before making dietary
recommendations
■ In religions that routinely fast, pregnant women are typically exempt but they
may choose to limit or change intake during traditional fasting times
○ Foods to avoid
■ Seafood high in mercury (swordfish, shark, King mackerel, etc). May have foods
with small amounts of mercury, but limit servings to a few meals a week (shrimp,

trout, catfish). Limit tuna to less than 6oz/week due to inconsistent mercury
levels
■ All raw fish
■ Undercooked meat, eggs, poultry
● Encourage mother to heat lunchmeat until steaming to avoid listeria
■ Unpasteurized foods
■ Excessive caffeine
■ Alcohol
■ Unwashed fruits and veggies

OB 04.01 Abortion
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● Overview
● Wikipedia | Medscape | PatientStory
○ Definition: a pregnancy that ends (spontaneously or electively) before 20 weeks
gestation
● NCLEX® Points
○ Types of abortions
■ Spontaneous
■ Induced
■ Threatened
■ Inevitable
■ Incomplete
■ Complete
■ Missed
■ Habitual
○ If any parts of conception are still present, prepare client for a D&C (dilation and
curettage) to remove contents.
■ Must be performed because of risk of infection
■ Evaluate blood loss
● Count perineal pads
● Save expelled contents
● Replace IVF per orders
● Check blood type of mom (give RhoGAM) if she’s Rh-negative

OB 04.02 Anemia
● Overview
● PatientStory
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○ Definition: a deficiency of red blood cells

○ In pregnancy, this is typically due to an insufficient amount of iron
○ There is an increased need for iron in pregnant women due to the growing fetus and
placenta, and increased circulating blood volume

● NCLEX® Points
○ This predisposes pregnant patients to infection: this relationship is unclear
○ CBC’s must be monitored frequently (q2weeks) to watch H/H
○ Iron and folic acid supplements may be ordered; encourage dietary sources Nutritional
education is important
■ Iron supplements best absorbed between meals, with a Vitamin C source, but not
with any milk or tea products
○ Blood transfusions may be needed during delivery
○ Oxytocin can be given for postpartum hemorrhage
■ Drug of choice
■ Causes uterus to contract quicker and stronger, therefore decrease bleeding.
Placenta detaches and creates essentially a wound within the uterus. We need to
it to contract and get smaller ASAP to decrease this bleeding risk.

OB 04.03 Cardiac Disease

● Overview
● PatientStory
○ Definition: pregnant patients with underlying cardiac disease may not be able to
compensate appropriately for the increased blood volume / cardiac output

○Concerning cardiac issues include, but are not limited to, heart valve replacements (tissue
and mechanical), Marfan syndrome, cardiomyopathy, pulmonary HTN, congenital heart
issues
○ Heart failure is also a major concern (Classes I-IV)
● NCLEX® Points
○ Baseline assessment of hemodynamics of both mom and fetus important
○ Auscultate and note abnormal heart/lung sounds
○ Note any pain, discomfort with normal activity
○ Cardiac monitoring may be indicated during labor
○ Educate on appropriate weight gain. Baseline obesity will place the client at even greater
risk.

OB 04.04 Chorioamnionitis
● Overview
○ Definition: a bacterial infection of the amniotic cavity, typically caused by an
intrauterine procedure (amniocentesis) PROM, or vaginitis.
○ It can result in endometritis and sepsis
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○ It’s a really big deal

● NCLEX® Points
○ Assessment is crucial
■ Mother must have fever over 100.4 F + 2 of the following
● Leukocytosis
● Tachycardia
● Uterine tenderness
● Malodorous amniotic fluid
● Fetal tachycardia
○ May have nonspecific signs/symptoms of sepsis that don’t seem like a big deal at first,
but they really are
○ Monitor vitals of mom and baby
○ Draw blood cultures promptly if suspected - BEFORE antibiotics initiated
○ Amniocentesis may be indicated for Gram stain / leuk count
○ If delivery is imminent, obtaining cultures from baby post-delivery is essential

Cluster of blue dots are neutrophils, eosinophils, and lymphocytes (due to the inflammatory response)

By Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16158284

OB 04.05 Diabetes Mellitus

● Overview
● PatientStory
○ Patient may have DM at baseline or gestational DM
○ Gestational DM is diabetes that is diagnosed in pregnancy in someone who has never
been diagnosed with it otherwise. Basically the pancreas can’t respond to the increased
insulin requirements coupled with increased insulin resistance from hormone increases in
the placenta.
○ Changes in carb metabolism change insulin requirements
○ Baby makes own insulin but needs glucose, therefore pulls glucose from mom and can
make mom more likely to be hypoglycemic
● NCLEX® Points
○ Mother’s changes are as follows:
■ 1st trimester: insulin needs go down
■ 2nd and 3rd trimester: insulin resistance occurs when hormones increase in the
placenta
■ Right after delivery: after placenta is delivered, hormones and insulin
requirements decrease
○ Newborn changes/issues
■ The baby grows faster and larger, but their function is still reflective of age and
not size
○ Assessments
■ Screen for glucose and protein in urine at regular prenatal visits (glucosuria and
ketonuria)
■ Check blood sugar between 24-28 weeks
○ Interventions
■ Ideal to control with diet and exercise, but can be challenging to restrict enough
to control excessive glucose but not so much that we’re restricting nutrients
■ Monitor for typical DM complications (signs of infection, HTN, edema,
proteinuria)
■ Closely watch mother and newborn’s glucose during labor and delivery as labor
depletes glycogen
■ Make dietary recommendations based on what you note their glucose is and their
insulin requirements (if any)

OB 04.06 Disseminating Intravascular Coagulation (DIC)

● Overview
○ A very serious condition that is caused by a an issue with the clotting cascade.
○ Clots form rapidly and extensively, depleting clotting factors. Severe hemorrhage results
(eyes, ears, nares, rectum, and so forth.. Patients bleed from all orifices) and various
vascular occlusion of organs also result.
○ This is incredibly serious.
○ So, so serious.
● NCLEX® Points
○ Assessment findings
■ Presents like sepsis / shock
■ Lots of bleeding from literally everywhere
■ Labs
● Decreased: Hematocrit, fibrinogen, platelets
● Increased: PT, PTT, clotting time, fibrin degradation products (FDPs)
○ Interventions
■ Draw labs (CBC, coagulation studies, metabolic panels)
■ Watch for bleeding
■ Support hemodynamics
■ Administer fluid replacements, blood products, and heparin as ordered
● Monitor for complications with administering them
■ Monitor for kidney failure

OB 04.07 Ectopic Pregnancy

● Overview
● PatientStory
○ Definition: when a fertilized egg (ovum) implants itself outside of the uterine cavity
○ “Ectopic” means out of place
○ It could be in multiple different locations, however most are in fallopian tubes
○ Patient may have missed period/signs of pregnancy, but do not know that it is ectopic
○ Affects about 1-2% of live births, but as high as 4% in those that use infertility treatments
● NCLEX® Points
○ Assessment findings
■ Classic signs are vaginal bleeding and abdominal pain
■ Signs of rupture include an increase in pain, signs of shock, and pain referring to
the shoulder
● Referred pain is due to blood in the abdomen
○ This can be an emergency, especially if it has ruptured
○ Goals are to prevent rupture, bleeding, and shock
○ Therapeutic management:
■ Surgery may be necessary (laparoscopic)
■ Fallopian tube, or structure implanted may be compromised/need to be removed
■ Antibiotics
■ Rh immune globulin if mom is Rh negative
■ Methotrexate (folic acid antagonist) may be ordered
● Inhibits cellular division of embryo

By BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44897672

OB 04.08 Hematoma
● Overview
○ Definition: solid swelling of clotted blood within tissues - NOT where it is supposed to
be
○ As it relates to OB - blood that escapes into areas of mother’s tissues after delivery has
occurred
○ Rarely life-threatening
○ Most commonly associated with assisted delivery (forceps, vacuum) or episiotomy, and
also injured blood vessels (traumatic AV fistula, pseudoaneurysm)
● NCLEX® Points
○ Assessment findings
■ Perineal pressure (“I gotta poop!”) from the hematoma
■ Edematous and sensitive perineal area
■ Shock signs / changes in hemodynamics
■ Severe abdominal pain, different from labor pain
■ Cannot void
○ Therapeutic management
■ Monitor appropriately for shock and infection (VS, I&O, CBC)
■ Treat pain
■ Promote fluids to facilitate urination (may need cath)
■ Administer blood products as indicated
■ Administered antibiotics; infection risk increased with hematoma
■ May need hematoma evacuation if large enough

OB 04.09 Hydatidiform Mole

● Overview
● PatientStory
○ The developing cells outside of the fertilized egg (ovum) develop abnormally, creating a
nonviable pregnancy and noncancerous tumor
○ Doesn’t contain original maternal neucleus
○ Mole = clump of growing tissue
○ Grapeline appearance - caused by the distention of the chorionic villi
○ Almost always results in a miscarriage
○ Can develop into choriocarcinoma
● NCLEX® Points
○ Assessment findings
■ No fetal heart rate
■ Gestational HTN symptoms before it would be expected (after 20th weekish)
● Increased BP, edema, proteinuria
■ Vaginal bleeding - painless in 4th or 5th month
■ hCG levels higher than expected
■ Fundal height greater than expected
○ Therapeutic management
■ Pregnancy is nonviable and it can turn into a malignancy, therefore it must be
removed
■ Mole is removed via vacuum aspiration
■ Oxytocin is given to contract uterus after mole is removed
■ Monitor for hemorrhage and infection
■ Sending to lab for pathology is ESSENTIAL to see if there are any signs of
malignancy
■ Watch hCG levels (q1-2weeks until pre-pregnancy levels noted, then q1-2months
for 1 year total)

By Seans Potato Business (derivative of the source cited above) - Blastocyst.png, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=3306843

OB 04.10 Hyperemesis Gravidarum

● Overview
● PatientStory
○ Intractable N/V during 1st trimester
○ Exact cause unknown
■ More often seen in first pregnancies, when pregnant with multiple, history of an
eating disorder, family history, and/or history of pregnancy-related tumors
○ Can cause severe nutritional deficiencies and electrolyte imbalances
● NCLEX® Points
○ Typically worse when waking in am
○ Fluid and electrolyte imbalances can be severe
○ First try altering diet and eating habits to minimize N/V and maximize oral nutrition
■ Sit up right after meals
■ Eat before getting up in am (snacks at bedside)
■ Eat small portions of easily digestible carbs (rice, cereal, pasta)
■ Consume liquids between meals, not during
○ Then, give meds (Zofran, Phenergan, Diclegis, etc.) to achieve goal
■ Meds have risks, but at this point, risks outweigh benefits if mother/baby are not
getting adequate nutrition
○ If meds don’t work, then IVF and TPN may be initiated to prevent/address electrolyte
and fluid imbalances
○ Monitor vital signs, electrolytes (CMP/BMP, Mag, Phos lab draws) intake and output,
urine for ketones, weight, calorie counts

OB 04.11 Gestational HTN

● Overview
● PatientStories
○ Elevated BP after 20 weeks (without signs of preeclampsia)
○ Gestational HTN = BP greater than 140/90
○ Progression = gestational HTN -> preeclampsia -> eclampsia
■ Goal to monitor closely, prevent progression to eclampsia, deliver baby when
benefit outweighs risk (usually at 37 weeks they’ll induce if a woman is
preeclamptic)
○ Monitoring includes:
■ Labs (CBC, BMP, checking urine for protein, 24 hr urine for creatinine
clearance)
■ Monitor mother’s blood pressure
■ Frequent assessments of baby (NST’s, ultrasounds)
● High pressures can reduce the amniotic fluid volume and restrict growth
○ Other preeclampsia signs:
■ Low platelets
■ Elevated LFT’s
■ Kidney dysfunction
■ Edema
■ SOB
■ Visual disturbances
● NCLEX® Points
○ Assessment findings
■ Elevated BP (over 140/90) with no other signs/symptoms
■ Watch closely for progression
○ Interventions
■ Severe preeclampsia
● Bedrest may be ordered
● Administer meds
○ Magnesium sulfate
■ Watch for mag toxicity (flushing, sweating, hypotension,
CNS depression)
■ Have calcium gluconate on hand
○ Antihypertensives
● Communicate with MD about possible induction
○ Typically after 37 weeks they will induce because benefit of
keeping baby in utero 2 more weeks does not outweigh the risk
of progressing preeclampsia

○ Eclampsia
■ Maintain airway
■ Note duration of seizure and clinical presentation
■ Give O2 (8-10 L/min via face mask)
■ Turn patient on side
■ Monitor FHR
■ Administer antiepileptics as ordered
■ Suction airway once seizure is complete
■ Prepare for delivery once mother is stabilized

Hypertensive States of Pregnancy

Gestational HTN BP greater than 140/90

Mild Preeclampsia BP greater than 140/90

Proteinuria (more than 300 mg

protein in a 24 hour sample)

Severe Preeclampsia BP greater than 160/110 (2 readings,

6hr apart while resting)

Proteinuria

Elevated creatinine

Elevated LFT’s

Oliguria

Unrelenting HA, confusion

RUQ or epigastric pain

Visual changes

Fetal growth restriction

Eclampsia When a patient diagnosed with

preeclampsia has seizures

OB 04.12 Incompetent Cervix

● Overview
● PatientStory
○ When the cervix dilates prematurely
○ Dilation and effacement may occur without contractions
● NCLEX® Points
○ Assessment
■ Vaginal bleeding or discharge (progressing from clear/white to pink/tan)
■ Pelvic pressure
■ Cramping
■ Backache
○ Treatment
■ Prevent contractions
● Bed rest, fluids, meds (tocolytics)
■ Prepare for placement of a cervical cerclage (suture) at about 10-14 weeks if it
appears that the pregnancy has been threatened
● After placement, must monitor for infection, PROM, contractions
● Educate not to have sex or do much activity for a prescribed amount of
time
● May be monitored overnight for premature labor
● Educate to notify MD if contractions or bleeding
■ This reinforces the cervix, preventing further premature dilation
■ Considered successful if preterm labor is avoided after 37 weeks

OB 04.13 Infections
● Overview
● PatientStories - Cytomegalovirus
○ Specific infections during pregnancy are more concerning due potential transmission to
the baby (via placenta or during delivery), which can have detrimental effects on the
newborn
■ Cytomegalovirus
■ Group B strep (GBS)
■ Herpes simplex
■ Rubella
■ Toxoplasmosis
● NCLEX® Points
○ Cytomegalovirus (CMV)
■ A very common, asymptomatic virus transmitted through body fluids
■ Transmitted via placenta or during delivery
■ Both mom and baby may be asymptomatic (remains latent over long periods of
time)
■ Potential issues = IUGR, seizures, blindness, hepatomegaly, splenomegaly,
jaundice, hearing loss, microcephaly
■ Antivirals may be given if severe, but benefit may not outweigh risk (toxic)
○ GBS
■ All women screened for this during prenatal period by a vaginal / rectal culture at
approximately 35-37 weeks (done at this time because it could be negative earlier
in pregnancy and become positive, therefore they wait until this period of time to
know if they need to treat during labor)
■ Up to 30% of adults are naturally colonized with this
■ Main cause of bacterial infections in NB’s
■ Transmitted via vaginal delivery in birth canal
■ Potentially issues for NB = pneumonia, sepsis, meningitis
■ Prophylactic antibiotics (penicillin or ampicillin) given during labor to women
who screen positive
■ IV antibiotics given to infected newborns
○ Herpes Simplex
■ Transmitted during birth, if active lesions present
■ Acyclovir may be given around 36 weeks to prevent outbreak during labor and
delivery
■ Serious neonatal complications (death, neuro issues)
■ MD may strongly recommended c-section to prevent transmission if lesions
active when patient goes into labor
■ Very strict precautions are to be maintained if patient delivers vaginally

○ Rubella
■ AKA German Measles
■ Transmitted via placenta
■ Most dangerous/serious if mother acquires this infection in 1st trimester
■ Brain damage, hearing loss, miscarriage, stillbirth, and various congenital defects
may result
■ Assess mother’s immunity by drawing titer. If her titer is less than 1:8,
vaccinated right after delivery.
● Should not try to get pregnant for 1-3 months after vaccination
○ Toxoplasmosis
■ Parasitic disease transmitted to mother by handling cat litter, undercooked or raw
meat; transmitted to baby via placenta
■ Mother is typically asymptomatic, but may have rash or flu like symptoms for
anywhere from a few weeks to months
■ Fetal death, spontaneous abortion, and neuro complications may result for baby
■ Educate mom to never change cat litter
■ KATI ADD CAT PIC

Acyclovir

By No machine-readable author provided. Ragesoss assumed (based on copyright claims). - No machine-readable source provided. Own work
assumed (based on copyright claims)., Public Domain, https://commons.wikimedia.org/w/index.php?curid=1657934

OB 05.01 Fertilization and Implantation

● Overview
○ Fertilization: when ovum and sperm unite in fallopian tube
■ Once one sperm successfully fertilizes, the outer membrane of the ovum
polarizes and repels any other sperm from trying to fertilize
■ After successful implantation, it is now called a zygote
■ Before fertilization, the ovum has half genetic material that will fuse with the half
that the sperm brings (one set of chromosomes from the ovum + one set from the
sperm = baby!)
○ Implantation: when zygote travels from fallopian tube to uterus and implants itself into
the thickened uterine wall
● NCLEX® Points
○ Each reproductive cell contains 23 chromosomes
○ Blastocyst starts secreting hCG to tell the corpus luteum (where the oocyte came from in
the first place) to keep making estrogen and progesterone to support to baby for the first
2-3 months until the placenta has been formed and takes over

Unknown - http://www.pdimages.com/web9.htm

By Ttrue12 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19679961

By Seans Potato Business (derivative of the source cited above) - Blastocyst.png, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=3306843

By Mr. J. Conaghan - http://stemcells.nih.gov/info/scireport/pages/chapter3.aspx, Public Domain,

https://commons.wikimedia.org/w/index.php?curid=32289210

OB 05.02 Fetal Environment

● Overview
○ Important structures form the optimal fetal environment
■ Amnion
● Inner membrane that forms the amniotic sac that later surrounds the
embryo/fetus
■ Chorion
● Outer membrane that form the amniotic sac
● Eventually develops vascular structures
● Forms fetal structures of placenta
■ Amniotic fluid
● Cushions, protects
● Fetus will swallow amniotic fluid, urine it out, and move it through their
respiratory system
■ Placenta
● Fully formed at 12 weeks
● Provides exchange of nutrients and waste products between mom and
baby
● NCLEX® Points
○ Drugs, nutrients, ETOH, viruses, and antibodies can pass through placenta
○ Larger particles, like bacteria, cannot pass through placenta

By Gray38.png: User Magnus Manske on en.wikipediaderivative work: Amada44 talk to me - Gray38.png, Public Domain,
https://commons.wikimedia.org/w/index.php?curid=11650416

No machine-readable source provided. Own work assumed (based on copyright claims)., Public Domain,
https://commons.wikimedia.org/w/index.php?curid=408074

OB 05.03 Fetal Development

● Overview
○ Three stages
■ Preembryonic
■ Embryonic
■ Fetal
○ A developing human being is referred to as an embryo from weeks 3-8, and a fetus from
8 - birth
○ By end of embryonic phase, most organs are formed (not functional necessarily, but
formed)
○ After fertilization occurs, a lot of cellular division occurs as the free-floating ball of cells
makes its way to the uterus to implant itself into the wall
● NCLEX® Points
○ Pre-embryonic
■ First 2 weeks after conception
■ Free floating ball of cells making its way to the uterus
■ This stage ends with implantation
○ Embryonic
■ 2 weeks - 8 weeks after conception
■ Heartbeat present, circulation begins
■ All major brain structures in place
■ Bone begins to replace cartilage
■ Embryo is approximately 1.2 inches long
○ Fetal: 8 weeks - birth
■ Circulatory system and all organs present
■ Heartbeat able to be heard on US at 10-12 weeks
■ Able to hear at 24 weeks
■ Lungs developed enough to facilitate gas exchange and able to open and close
eyes at 28 weeks

Embryonic Phase: 8 weeks old

By Dr. Vilas Gayakwad - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9582575

Beginning of fetal phase, 10 weeks old

By drsuparna http://www.flickr.com/photos/74896762@N00/ - http://www.flickr.com/photos/74896762@N00/3167352760/, CC BY-SA 2.0,

https://commons.wikimedia.org/w/index.php?curid=5658338

OB05.04 Fetal Circulation

● Overview
○ Blood flow from mother goes to the placenta, then via the umbilical cord to and from
baby
○ Lungs and liver not fully functional; bypasses necessary to ensure adequate oxygenation
○ Gas exchange does not occur via alveoli like normal in fetal lungs, they are filled with
fluid. Because of this, there is high pressure and therefore high resistance in lungs, which
plays a role in these bypasses.
○ Oxygen and nutrient exchange occurs in the placenta
○ Blood is carried to and from the placenta via the umbilical cord
■ While it appears as 1 big vessel, there are 2 arteries and 1 vein within the
umbilical cord
● Mnemonic: mother has 2 areola and 1 vagina (2 arteries, 1 vein)
● NCLEX® Points
○ Bypasses
■ Ductus arteriosus: connects pulmonary artery and aorta, bypasses lungs
■ Foramen ovale: connects left and right atrium, bypasses lungs
■ Ductus venosus: umbilical vein and inferior vena cava, bypasses liver

By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY
3.0, https://commons.wikimedia.org/w/index.php?curid=30148606

OB 06.01 Process of Labor

● Overview
○ The process of labor is comprised of both mom and baby working together to have a
successful delivery
○ Mom’s part in the process (4 P’s)
■ Powers
■ Passageway
■ Passenger
■ Psyche
○ Baby’s part in the process
■ Attitude
■ Lie
■ Presentation
■ Presenting part
■ Position
■ Station
● NCLEX® Points
○ Mom’s part in the process
■ 4P’s: the 4P’s all work together and essential to facilitate a safe and successful
delivery
● Powers
○ The power the mother exerting push out the baby
■ Uterine power (contractions)
■ Cervical power (dilation and effacement)
● Passageway
○ The pathway the baby takes out of the mother’s body
○ Essentially, the pelvis and related structures
● Passenger
○ BABY!
○ Placenta
● Psyche
○ Mom’s emotional state
■ Supportive, therapeutic environment will facilitate a
smoother labor
■ Fearful, angry, tense emotions will make labor much more
○ Baby’s part in the process
■ Attitude: head position regarding spine
● Flexion: normal attitude, head flexed down with chin to chest
● Extension: abnormal attitude, less commonly seen, head extended back
■ Lie: where is the baby’s spine lying when compared to mom’s spine?
● Longitudinal / vertical: normal lie, both spines parallel
● Transverse: both spines form cross, c-section required
■ Presentation: This term is used to describe the way the baby is positioned while
coming down the birth canal
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● Cephalic: head
○ Vertex: most common, head fully flexed down
○ Military: head straight forward
○ Brow: head tipped back slightly, “eyebrows first”
○ Face: head tipped back fully, full face first
● Breech: butt
○ Frank: most common, hips flexed, knees extended
○ Full / complete: both knees bent, bottom of feet closest to birth
canal, cross-legged appearance
○ Footling: when a foot presents first
● Shoulder: shoulder, side, arm, back abdomen
■ Presenting part: This term is used to describe which part of the baby will lead the
way out of the birth canal
● Head, shoulder, side, foot, abdomen, etc.
■ Position: This term is used to describe the position of the baby in relation to mom’s
pelvis
● Must know landmark to know correct terminology
● Most common landmark is the occiput.. Lower portion of the back of the
head
● Landmark depends on baby’s presentation (most common is vertex)
● Look at where the landmark is in relation to mom’s pelvis
○ Right vs. left
○ Anterior vs. posterior
● Left occipito anterior is most common and where most babies naturally
face.. It allows the widest part of the baby’s head to correspond with the
widest part of mom’s pelvis
■ Station: how far down the baby is in the birth canal in relation to mom’s ischial
spine
● Mom’s ischial spine is the narrowest part of her pelvis, so when the baby is
there, they are at 0 station
● Negative numbers mean the baby is farther inside
● Positive numbers mean the baby is farther out
● Measured in centimeters

Note location of ischial spines - where station is 0.

By Anatomist90 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=23305500

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate
242, Public Domain, https://commons.wikimedia.org/w/index.php?curid=323669

Left occipitoanterior

By Mikael Häggström - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=8981957

Right occipitoposterior

By Mikael Häggström - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=8982009

OB 06.02 Mechanisms of Labor

● Overview
○ Specific movements the baby does, in this specific order, to exit mom successfully
○ This all happens fluidly during the process of delivery
○ Occasionally referred to as the Cardinal Movements
■ Engagement
■ Descent and flexion
■ Internal rotation
■ Extension
■ Restitution and external rotation
■ Expulsion
○ True labor vs. false labor
■ The uterus is a muscle and it contracts to prepare for childbirth. Mom can feel
this and believe she is in labor, when she may not be. It is important to be able to
differentiate between true vs. false labor.
● NCLEX® Points
○ Cardinal Movements explained
■ Engagement: where the presenting part descends through the pelvic inlet
● May be called lightening or dropping
● Occurs approximately 2 weeks before delivery
■ Descent and flexion: process of presenting part (typically the head) going
through mom’s pelvis, occur simultaneously as a fluid movement
● Baby flexes head down
● Descent is measured by station, continuous process until delivery
● 0 station = presenting part at ischial spine
■ Internal rotation: see diagram
● Baby’s face in line with mom’s rectum
■ Extension: see diagram
● Begins after crowning
● Complete when chin is out of perineum
■ Restitution and external rotation: occur simultaneously as a fluid movement
● baby re-aligning its head with body
■ Expulsion: baby’s entire body is out
○ True labor vs. false labor
■ True labor is progressive, regular, and becomes stronger
■ If mom changes activity (going from resting to walking) and the contractions
stop, it is FALSE labor
■ True labor produces dilation, effacement, engagement and descent
■ False labor does not do any of the above
○ Other events that occur just before labor occurs
■ Vaginal discharge increases
■ Brown/blood tinged cervical mucus passes
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■ Cervix gets ready by ripening, potentially dilating/effacing

■ Burst of energy can occur 24-48 hrs before (“nesting”)
■ Estrogen and progesterone levels fluctuate, causing a fluid shift and subsequent
weight loss of 2.2-6.6 kg approximately 24-48 hrs prior to labor
■ Rupture of membranes / amniorrhexis: rupture of amniotic sac
● Described as “water breaking”
● Absence of the buffer of the amniotic fluid in uterus will stimulate
uterine contractions and therefore labor
● Can be anywhere from 50-300 ml
● May need to perform Nitrazine test to determine if mother has urinated
or ruptured membranes
○ Tests pH of fluid
○ Amniotic fluid has a pH of 7-7.5 and will turn test strip blue
● PROM: premature rupture of membranes
○ Can be gush of fluid or steady leak
○ Greatest risk to baby occurs when this occurs before 37 weeks
● SPOM: spontaneous rupture of membranes at full term
● AROM: artificial rupture of membranes
○ Done with a tool or hand of physician

By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0,
https://commons.wikimedia.org/w/index.php?curid=30148612

OB 06.03 Leopold's
● Overview
○ Palpating the mother’s abdomen/uterus to determine the position of the fetus (essential!)
and assist examiner in estimating a location for fetal heart sounds
● NCLEX® Points
○ Fundal grip
■ Head will feel hard, round and moveable
■ Baby’s bottom will feel irregular
■ Should feel smooth back on one side
■ Should feel irregular bumps and lumps on the side to indicate fingers, toes, knees
○ Umbilical grip
○ 1st pelvic grip
○ 2nd pelvic grip

By Christian Gerhard Leopold - Leopold und Spörlin (1894) Die Leitung der regelmäßigen Geburt nur durch äußere Untersuchung. Arch
Gynäkol 45: 337–368 Reprinted in: Ludwig H. Christian Gerhard Leopold (1846–1911). Nicht nur der Lehrmeister der Geburtshilfe. Der
Gynäkologe. 37. 10: 961-966 (2004). doi:10.1007/s00129-004-1576-x., Public Domain,
https://commons.wikimedia.org/w/index.php?curid=6237483
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67

OB 06.04 Fetal Monitoring

● Overview
● PatientStory
○ Purpose: determine fetal well being by measuring FHR, fetal response to contractions.
Also measures intensity, length and frequency of uterine contractions.
○ Two kinds of monitoring
■ External: noninvasive
■ Internal: invasive, requires rupture of membranes and mother to be dilated 2-3
cm, electrode placed on baby’s scalp
○ Reassuring vs. nonreassuring
■ This is okay
■ This is not okay, I need to intervene, reassess, notify MD
○ What we’re looking at our monitor for
■ Variability
■ Accelerations
■ Early decelerations
● Associated with a contraction, causing compression and normal
■ Late decelerations
● Associated with a contraction, caused by fall in O2 level
■ Variable decelerations
● Abrupt decreases
○ Nonstress test: basically 20 minutes of noninvasive fetal monitoring
■ Reactive if there are 2+ accelerations in a 20 min period
■ Nonreactive if less than 2 accelerations in a 20 min period
● NCLEX® Points
○ FHR patterns to watch out for
■ Bradycardia (less than 110 for 10+ min)
■ Tachycardia (more than 160 for 10+ min)
■ Late decel’s (reflect issues with placenta)
■ Prolonged decel’s
■ Hypertonic uterine activity (uterus not resting in between contractions, which
decreases uterine circulation and therefore O2 supply to fetus)
■ Absent or decreasing variability
■ Variable decel’s lasting longer than 1 minute with a FHR less than 70
○ We want ACCELERATIONS and VARIABILITY
■ Means the fetus is responsive and nonacidodic
○ What to do when these FHR’s occur
■ ID cause (like checking to see if cord is prolapsed, checking mom’s vitals for
hyper/hypotension, fever)
■ Stop oxytocin, if infusing (this can worsen the nonreassuring pattern)
■ Change mother’s position (preferably to side-lying if not already there)
■ Give oxygen at 8-10 L via face mask
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■ Prepare to initiate appropriate monitoring (IE internal monitoring)

■ Notify provider of potential cause, interventions, mother and baby’s response and
prepare for further potential intervention

OB 06.05 Obstetrical Procedures

● Overview
● PatientStory - Induction
● PatientStory - Vacuum Extraction
● PatientStory - Cesarean Section
○ Various procedures are utilized to facilitate and assist the safe delivery of the fetus
○ This can include the use of medications or tools to facilitate and assist a vaginal delivery,
surgical procedures
● NCLEX® Points
○ Induction
■ Artificial initiation of labor by stimulating contractions
● Oxytocin (Pitocin) typically used
● D/C Pit if contractions are less than 2 min apart, longer than 1.5 minutes,
or if fetal distress is apparent
○ Amniotomy
■ When amniotic sac is intentionally ruptured to stimulate labor
● This is done either with a tool or the HCP’s hand
● Baby must be at 0+ station
● Watch for meconium stained amniotic fluid, which is associated with
fetal distress
● Note if amniotic fluid is malodorous, which can indicate infection
■ External version
● Moves baby from an abnormal position to a normal position, much more
favorable for a successful vaginal delivery
● Monitor appropriately
● If mom is Rh-negative, make sure she got RhoGAM at 28 weeks
○ Perform Kleihauer-Betke test (or acid elution test); measures
hemoglobin transferred from fetus to mother. Quantifies this to
let us know if we need to give additional RhoGAM
● IVF + tocolytics given facilitate procedure
○ Episiotomy
■ An incision made in the vagina to make the outlet larger for delivery
● Nurses are responsible for assessment and care
● Ice for first 24 hr, sitz bath after
● Blot perineal area after voiding
● Prevent infection, educate on s/s infection to watch for
● Apply pads without touching top side
● Shower, do not bathe
○ Forceps
■ Use of forceps to help delivery head
■ Check for injury, assist with repair of any lacerations on mom/baby
○ Vacuum
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■ Suction device applied to baby’s head to aid in delivery of head

■ Should not be left on longer than 25 minutes
■ Monitor FHR q5min
■ Assess newborn’s scalp immediately after birth and routinely after for signs of
trauma/hematoma and report as needed
■ Watch for caput succedaneum (edema of scalp from prolonged pressure from
cervix, vacuum)
● Typically resolves in 24 hours
○ Cesarean Section
■ Delivery via abdominal incision
● OBTAIN CONSENT
● Insert foley
● Ensure appropriate diagnostics were done (Rh factor)
● Monitor, administer meds as appropriate
● Provide emotional support
● Post op, watch for:
○ Mother with a productive cough or chills
○ Tender uterus, malodorous lochia (endometriosis)
○ Painful urination (bladder or urinary tract infection)
○ General signs of infection
○ Pain, edema, redness of an extremity (thrombophlebitis)

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OB 07.01 PROM
● Overview
● PatientStory
○ Premature of membranes (rupture of amniotic sac) before onset of labor
■ Normal progression is for the sac to rupture AFTER labor starts
■ Can be anywhere from 50-300 ml at once, or a slow leak
■ Frequently described as “water breaking,” but if it’s a slow leak, mother may
confuse it with urination
■ Absence of the buffer of the amniotic fluid in uterus will stimulate uterine
contractions and therefore labor
■ If membranes rupture before term labor, biggest concern is infection
● NCLEX® Points
○ Perform Nitrazine test to determine if it is urine vs. amniotic fluid
○ Assess and note color, amount and odor of fluid
○ Monitor temp, increased temp can indicate infection
○ Fetal monitoring will be indicated; watch FHR for tachycardia (infection indicator)
○ Avoid vaginal exams to decrease risk of infection
○ Antibiotics may be indicated

OB 07.02 Prolapsed Umbilical Cord

● Overview
○ Umbilical cord is lying alongside or below the presenting part (leg, shoulder, head, etc.)
and can be see/felt in the vagina
○ Umbilical cord is how fetus gets oxygenation. If pressure is applied from the fetus on the
displaced cord, then oxygenation is compromised.
○ This is an emergency
● NCLEX® Points
○ What to do when this occurs
■ Never try to push presenting part or cord back in
● Wrap cord loosely in sterile towel that’s saturated with warm sterile
saline
■ Elevate presenting part with your hand to relieve pressure
■ Have mother get into knee-chest or exaggerated Trendelenburg position
■ Give supplemental O2
■ Monitor FHR and signs of hypoxia (tachycardia, increased variability, and
significant hypoxia would present with bradycardia)
■ Prepare for immediate delivery (most likely c-section)

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OB 07.03 Placenta Previa

● Overview
● PatientStory
○ The placenta is improperly implanted and covering the cervix either totally, partially, or
marginally.
○ How it is managed depends on age of fetus, degree of placenta previa and if the fetus or
mother are in distress
■ If it’s very minor, vaginal delivery can be attempted
■ C-section may be indicated
● NCLEX® Points
○ Vaginal exams are contraindicated
○ Assessment findings
■ Painless, bright red vaginal bleeding typically around 32 weeks
■ Fundal height higher than expected

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OB 07.04 Abruptio Placenta

● Overview
● PatientStory (start at 7:20)
○ Also called placental abruption
○ When the placenta detaches from the uterine wall
■ After 20 weeks, before birth
● NCLEX® Points
○ Assessment findings
■ Dark red bleeding
■ Severe abdominal pain
■ Uterine rigidity and/or pain
■ Fetal distress
■ Shock, if extensive blood loss has occurred
○ Important to be able to distinguish from placenta previa
○ Therapeutic management
■ Monitor mother and baby (vitals, pain, vaginal bleeding, change in fundal height)
■ IVF, blood products, bed rest, may be ordered
■ Prepare for delivery (vaginal preferred, emergent c-section if fetal distress noted)
■ Monitor for DIC and PPH

OB 07.05 Preterm Labor

● Overview
● PatientStory
○ Labor that occurs between 20-37 weeks
○ Management goal is to stop labor
● NCLEX® Points
○ Assessment findings
■ Contractions and/or cramping
■ Change in vaginal discharge (maybe it was white and thick, now it is thin and
brown or bloody)
■ Pelvic pain
■ PROM (see section 07.01)
○ Therapeutic management
■ Attempt to stop labor
■ Administer tocolytics as ordered (see section 12.01 for descriptions of this class
of meds)
■ Monitor mom and baby
■ Bedrest
■ Fluids
■ Monitor for infection

OB 07.06 Precipitous Labor

● Overview
● PatientStory (start at 4:20)
○ Delivery of baby in 3 hours or less from the time labor began
○ Risk of infection is increased due to unexpected delivery lack of benefit of asepsis
● NCLEX® Points
○ Assessment findings
■ Rapidly progressing labor
○ Therapeutic management
■ Prepare to potentially deliver baby if MD or midwife will not arrive in time
■ Have supplies for delivery readily available
■ Stay with mother, provide emotional support as pain is typically more intense
and due to rapid progression and inability to administer pain meds so quickly

OB 07.07 Dystocia
● Overview
○ Difficult labor that may be prolonged or extraordinarily painful
○ Various reasons
■ Hypotonic contractions: too weak, ineffective
■ Hypertonic contractions: too strong, uncoordinated
■ Extremely large fetus
■ Fetus is awkward/bad position
■ Less than ideal maternal pelvic structure
● NCLEX® Points
○ Assessment findings
■ Excessive pain
■ Fetal distress
■ Uncoordinated/disorganized contractions
■ Labor not progressing
○ Therapeutic management
■ Assess mother and fetus frequently (vitals, amniotic fluid, I&O, note signs of
distress and notify MD as appropriate)
■ Administer IVF, antibiotics, pain meds, etc. as ordered
■ Promote rest
■ If hypotonic contractions are occurring, oxytocin (Pitocin) may be indicated.
Begin appropriate monitoring of mother and baby and titrate appropriately.

OB 08.01 Postpartum Physiological Maternal Changes

● Overview
● PatientStory: Afterpains
○ Postpartum definition: period of time immediately after delivery through 6 weeks after
when the maternal body returns to the nonpregnant state
○ Involution definition: shrinking of an organ when inactive (uterus, cervix)
○ Changes include:
■ Uterine and cervical involution
■ Presence of lochia
■ Vaginal changes
■ Resuming of menstrual cycle
■ Breast changes
■ Urinary changes
■ GI changes
● NCLEX® Points
○ Uterine changes
■ Rapid shrinking / involution
● Patients who are breastfeeding will experience more rapid shrinking due
to oxytocin release
● “Afterpains” are the painful postpartum uterine contractions due to the
release of oxytocin (again, more likely to be more painful in mothers
who are breastfeeding, typically feel like menstrual cramps)
■ Fundal height decreases approximately 1cm each day and should be midline
○ Lochia
■ Because fetus has occupied the uterus for 9 months, the lining has not shed as it
normally does with each menstrual cycle. The lining is no longer needed and
must be shed. Postpartum mothers will experience vaginal bleeding for up to 6
weeks as the uterine lining is shed. Lochia is shed in 3 stages:
● Rubra
● Serosa
● Alba
■ Most accurate way to determine amount of lochia: weigh pad before and after
use
● Heavy amount of lochia = saturating a pad in 1 hour
● Excessive amount of lochia = saturating a pad in 15 minutes
○ Cervix
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■ Involution occurs and returns to its normal state within 1 week

○ Vagina
■ Decreased tone: will never return to pre-pregnancy state
○ Menstruation
■ Return to normal cycle depends if mother is breastfeeding or not
● Breastfeeding moms will return in about 3-6 months
○ Breastfeeding moms may have amenorrhea but may still
ovulation. Education is important! Some may rationalize that if
they do not have their normal monthly bleeding that they cannot
get pregnant again
● Non-breastfeeding moms will return in 1-2 months
○ Breasts
■ Estrogen and progesterone levels plummet which stimulates prolactin levels and
therefore milk production
■ Colostrum is secreted for first 72 hours
■ Milk typically comes in on day 3 or 4
■ Mothers not breastfeeding will still have milk come in
● No nipple stimulation
● Wear tight bra
● Milk production typically stops after 5-7 days
● Mild pain meds may be needed to ease engorgement
○ Urinary changes
■ Excessive output / diuresis the first 12 hrs post delivery due to fluid shifts
■ Encourage regular emptying of the bladder to prevent urinary retention and
displacement of uterus
■ Note if urinary retention occurs as it can be common due to any trauma, meds,
anesthesia, etc.
○ GI changes
■ Hemorrhoids and constipation are common
■ Administer stool softeners as ordered

OB 08.02 Postpartum Interventions

● Overview
○ The nurse must thoroughly assess both mom and newborn during the postpartum period.
○ The nurse must also thoroughly educate mom (and dad and/or support system)
● NCLEX® Points
○ Frequently assess:
■ Pain
■ Fundus (patient should empty bladder prior to fundal assessment as this can
affect results)
■ Lochia
■ Incisions and laceration repairs (if c-section or episiotomy occurred)
■ Assess for thrombus
■ Thoroughly assess, observe and promote bonding with newborn
■ Thoroughly assess emotional status
○ Education is essential during this time
■ Assess and educate about feeding (breast or bottle)
■ Demonstrate and have patient participate in bathing newborn
■ Educate that intercourse should be avoided until lochia ceases, or otherwise
indicated by physician
● Once intercourse has been resumed, educate on importance of
contraception as women can still get pregnant while breastfeeding even if
no menstrual bleeding has resumed
■ Promote compliance with outpatient follow up visit in 4-6 weeks
■ Educate on when to notify MD after discharge
● Signs of infection
● Signs of postpartum depression
● Increasing lochia

OB 08.03 Postpartum Discomforts

● Overview
● PatientStory: Postpartum Depression
● PatientStory: Postpartum Psychosis
● PatientStory: Episiotomy
○ Due to the many physiological maternal changes during the postpartum period, various
pain and discomforts can occur. It is especially important to adequately address these
after mom and baby experienced labor and delivery, which is also uncomfortable and
painful.
○ Afterbirth pains, perineal discomfort, lacerations, breast discomfort, emotional changes,
and episiotomy pain all are common
○ Assess, provide comfort measures, educate, follow up
● NCLEX® Points
○ Afterbirth pains
■ Typically feel like painful menstrual cramping
■ Educate about these before they occur
■ They typically subside in a few days
■ Patients more likely to experience increased afterbirth pains:
● Breastfeeding mothers; nursing often triggers these pains
● Those who were given oxytocin
● Those with an overdistended uterus (carrying multiples)
○ Perineal pain/discomfort
■ Ice packs during first 24 hours and sitz baths thereafter relieve swelling provide
substantial pain relief
■ Sitz baths can be done in a small basin over the toilet or at home in a bath
○ Lacerations and episiotomies
■ Analgesic sprays may be helpful
■ Appropriately clean perineal area after every trip to the bathroom
■ Regularly assess for signs of infection
○ Constipation
■ Passing stool may be more difficult after delivery, especially if hemorrhoids
resulted
■ Provide stool softeners and other pharmacological interventions as ordered
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■ Promote hydration and ambulation

○ Emotional changes/discomforts
■ Encourage dialogue between yourself, mom and support system
■ Ask open-ended questions
■ Validate feelings
■ Assess for signs of PPD both before discharge and at follow up
■ Educate patient and support system about signs of PPD
■ Educate about the difference between postpartum blues, PPD, and postpartum
psychosis
■ Fathers do experience PPD as well - assess both

Postpartum blues Crying, occasionally unprovoked and randomly

Increased irritability

Feelings of sadness and confusion

Anxiety

Restlessness

Issues with sleeping (in addition to normal

postpartum sleep deprivation)

Labile emotions

Postpartum depression Feelings of guilt

Low energy levels

Suicidal thoughts

Not very responsive to newborn / feeling

disconnected

Problems concentrating

Anxiety

Loss of enjoyment in normal activities

Crying, unrelenting sadness

Extreme irritability

Postpartum psychosis Delirium

Disconnected from reality

Panic

Hallucinations

Delusions

Confusion

OB 08.03 Breastfeeding
● Overview
● PatientStory
○ Breastfeeding is extremely beneficial for both mom and baby
○ Breastfed babies have better clinical outcomes
■ They have lower risk of asthma, allergies, respiratory issues, diarrhea,
○ First feeding should occur within the first hour after birth
○ Many hospitals have lactation consultants available to reinforce and support nursing staff
with breastfeeding mothers
○ American Academy of Pediatrics recommends exclusive breastfeeding for the first 6
months of life, then recommends the introduction of solid foods, and weaning off at
approximately 12 months (per pediatrician recommends)
○ Breastfeeding is difficult to learn
■ 75% of mother start breastfeeding
■ Only 13% are still breastfeeding at 6 months
○ Demonstrate breast pump if needed (most women who are breastfeeding will utilize a
breast pump at some point)
○ This is an extensive topic
● NCLEX® Points
○ Promote initial feeding as soon as possible (within 1 hour of birth)
○ Educate, reinforce, encourage
○ Utilize lactation consultants
○ If engorgement occurs, apply warm packs before feedings and ice packs in between
○ Encourage appropriate latch, which prevents cracked sore nipples
○ Increase caloric intake up to 500 additional calories daily and continue prenatal vitamin
during breastfeeding
○ After meconium passes, breastfed baby's stools are seedy, yellow, watery and frequent
○ Encourage them when they become frustrated if the baby has a hard time latching
correctly
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○ Procedure
■ Hand hygiene
■ Position newborn transversely and flat across chest, with mouth near nipple
■ Stimulate newborn’s lip, chin or nose with nipple
■ Guide newborn’s mouth up and over nipple, getting as much of the areola into
the mouth as possible
■ Allow time to feed (in beginning they are not efficient and it can take as long as
20 minutes each side)
■ Listen for sucking and swallowing
■ If a bad latch occurs, detach and re-try
■ Release suction by inserting finger into the corner of the newborn’s mouth
■ Switch breasts
■ Follow same process
■ Burp
○ Encourage multiple positions if mother is comfortable

OB 09.01 Postpartum Hematoma

● Overview
○ Localized collection of blood in loose connective tissue beneath the skin of the genitalia
○ Occurs more often in assisted deliveries (vacuum, forceps)
● NCLEX® Points
○ Assessment
■ Pain, pressure
■ Apparent bulging area, skin discolored
■ Decreasing H/H due to bleeding
■ Signs and symptoms of hypovolemic shock
● Hypotension
● Tachycardia
● Febrile
● Pallor
■ Cannot void due to hematoma obstructing flow
○ Therapeutic Management
■ Prepare to administer IVF, pain meds, antibiotics (infection is common), blood
products
■ Monitor I&O, vitals
■ May need to insert foley if urinary obstruction has occurred

OB 09.02 Postpartum Hemorrhage (PPH)

● Overview
● PatientStory
○ 500 ml + blood loss after delivery
○ A major cause of maternal mortality
● NCLEX® Points
○ Assessment
■ Early: first 24 hours
■ Late: after the first 24 hours
○ Therapeutic management
■ Fundal massage is essential (q5-15min)
■ Assess appropriately
● LOC
● Vitals: tachycardia and restlessness are early signs, hypotension is late
● Estimated blood loss: make sure to turn patient and look under them to
qualify all of bleeding
● Labs: H/H
■ Meds (oxytocin) or blood products may be indicated, depending on severity
■ Most serious intervention is D&C or hysterectomy
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OB 09.03 Mastitis
● Overview
○ Inflammation of the breast due to infection
○ Most commonly occurs in breastfeeding mothers
■ Can occur at any time during lactation
■ Most commonly occurs 2-3 weeks after delivery
● NCLEX® Points
○ Assessment
■ Flulike symptoms
■ Pain, tenderness
■ Localized edema, redness
■ Febrile
○ Therapeutic Management
■ Continue to promote lactation despite mastitis - it is safe
■ Either manually express or utilize a breast pump at least q4hr
■ Administer pain meds and antibiotics if indicated

■ Support breasts with bra without underwire, which can irritate the already
inflamed breast and potentially clog ducts

OB 09.04 Subinvolution
● Overview
○ Failure of uterus to return to prepregnancy size, either complete or incomplete
● NCLEX® Points
○ Assessment
■ More uterine bleeding than expected
■ Fundal height not decreasing as expected
■ Uterus larger than expected
■ Cramp-like pain
■ Pain noted when palpating uterus
○ Therapeutic management
■ Assess appropriately
■ Elevate bilateral lower extremities to promote venous return

■ Prepare to give mthylergonovine maleate (Methergine), which will increase

duration of uterine contractions

OB 09.05 Thrombophlebitis
● Overview
○ When a clot is formed in a vessel wall due to inflammation of said vessel wall
○ Postpartum patients are at an increased risk due to the increase of clotting factors during
this time
○ 3 types are most common in postpartum patients: superficial, femoral, pelvic
○ Early ambulation after delivery is an important preventative measure
● NCLEX® Points
○ Assessment
■ Superficial

● Able to feel clot upon palpation

● Pain, tenderness
● Skin discoloration at site
■ Femoral
● Fever, chills, pallor
● Diminished popliteal and pedal pulses
● Pain, stiffness in affected leg
■ Pelvic (most serious)
● PE s/s
● Significant body temp changes
○ Interventions
■ Maintain bedrest/restrict activity as ordered
■ Watch closely for PE
■ Heat packs may relieve some pain
■ IV heparin may be ordered
○ Education
■ Avoid massaging the area, restrictive clothing, crossing legs, prolonged sitting or
standing
■ Educate about discharge meds (anticoagulants) and follow-up appts

OB 10.01 Initial Care of the Newborn

● Overview
○ Appropriate assessment of the newborn is crucial and can be completed while the baby is
skin to skin on the mother’s chest
○ The first hour of the baby’s life outside of the womb is crucial; unless the baby is
unstable, the newborn should be skin to skin with the mother and your assessment can be
completed while baby is on mother’s chest
○ APGAR scoring
● NCLEX® Points
○ APGAR score at 1 and 5 minutes (see mind map)
■ How Ready Is This Child
■ Heart rate Respiratory effort, Irritability, Tone, Color
○ Assessment
■ Observe respirations and assist (clear secretions) if needed
● Note and characterize any respiratory issues like grunting, retractions,
seesaw respirations (rise and fall of chest/abdomen don’t coincide)
■ Vitals, note any cyanosis and hyper/hypothermia

● Acrocyanosis = cyanosis of hands or feet

○ Interventions
■ Use a bulb syringe to suction mouth, then nares
■ The amniotic fluid on the baby can make them very cold; dry the baby quickly
while rubbing/stroking their back to stimulate their first cry if they are not
already doing so (this helps clear the lungs of fluid)
■ Grab a fresh blanket and cap, put baby against mom’s chest (skin to skin) and
place blanket around baby and mom and cap on head to maintain temp stability
■ Keep mom and baby skin to skin for at least an hour, if medically appropriate
■ If breastfeeding, encourage the first feeding during this hour
■ After the golden hour, complete appropriate newborn identification process,
meds (vitamin K, eye ointment, etc.), and any further assessment per hospital
policy
● Finger and foot prints
● ID bands for mom and baby

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OB 10.02 Newborn Physical Exam

● Overview
○ Imperative that we maintain temp stability - keep baby warm!
○ Observe, then complete least disruptive assessments, progressing to most disruptive
○ Intrauterine - extrauterine transition period
■ Going from the inside world to the outside world is traumatic for them
■ First 6-8 hours of life outside of the womb
■ 3 phases
● Reactivity
● Decreased responsiveness
● Reactivity
○ These are the first physical assessments - establishing a baseline is important!
■ Note ALL abnormalities
● NCLEX® Points
○ General observations
■ Flexed posture
■ Palpable pulses
■ Spine, trachea, head, nose midline
■ Coordinated movements
■ Count extremities, fingers, toes
■ Check for anus and urinary meatus on penis if male
■ Check for hip dysplasia
● Rotate thighs outward and listen (no click)
○ Vital signs
■ Assess as much as possible while sleeping
■ BP not routinely assessed in newborn patients
■ Some newborns may present with slight / subtle tremors
● Can be normal, can be due to drugs withdrawal, hypocalcemia,
hypoglycemia
■ Listen to apical pulse for 1 full min
● 120-160 BPM resting
● 80-100 BPM sleeping
● Up to 180 crying
● 4th intercostal space
■ Listen to respirations for 1 full min
● 30-60 RR
■ Axillary temp
● 96.8-99F
■ Measure head, weight, length
■ Fontanels - see image

● Eyes
● EOM’s weak; may be cross or have disconjugate gaze
○ Look in mouth for signs of Candida albicans (thrush)
■ White and patchy tongue
■ Potentially painful
■ Do not come off with wiping
○ Chest
■ Assess for clavicular fractures from birth
■ Diaphragmatic respirations may be observed, bronchial respirations may be heard
■ Breast tissue and nipple edema not uncommon
■ May note secretions from nipples
○ Skin
■ Document skin abnormalities thoroughly
■ See table for terminology and definitions
■ Assess for any skin trauma from labor and delivery, especially if assisted
○ Umbilical cord
■ Assess for 2 arteries, 1 vein
● Memory device: mother has 2 areolas and 1 vagina - 2 arteries and 1
vein
■ Notify if abnormal
■ Assess for meconium staining on cord
○ Female genitalia
■ Blood stained discharge may be present due to sudden decrease of estrogen

Potential Findings for Newborn Skin Assessment

Acrocyanosis Blue extremities

Normal for first 10 days if intermittent

Lanugo Fine body hair

Harlequin Sign Red/pink on one half of body

Other half normal or pallor

Indicative of cardiac issues or sepsis

Milia Small white sebaceous glands

Typically noted on face

Vernix caseosa White cheese-looking substance

Preterm: covered

Term: typically only in folds

Postterm: absent

Stork bites Telangiectatic nevi

Nevus simplex

Nape of neck, nose, eyelids

Dark red - pale pink

Port-wine stain Nevus vasculosus

Typically on face (Gorbatschow has one)

Flat

Red - purple

Technically a capillary angioma below skin

Strawberries Nevus vasculosus

On face / head

Raised

Capillary hemangioma

Mongolian spots On back, bottom

Black - blue

Flat, wavy borders and irregular shape

More common in various races (African, Asian,

Native American)

OB 10.03 Body System Assessments

● Overview
○ Various assessments and interventions are necessary during the newborn phase
○ Educate parents/support system about what you’re doing and why it is necessary, before
you do it
○ Always keep the newborn warm
○ Reinforce education and encourage parents
○ Observe, assess, then intervene
○ Assess systematically so you do not forget anything
○ Provide or facilitate appropriate screening
■ Hearing exam
■ PKU (phenylketonuria)
● Blood sample
● Must be eating successfully for 24 hrs before screening to appropriately
assess
● A build up of an amino acid that can result in seizures, mental disability,
and other serious issues
● NCLEX® Points - by system
○ Nervous
■ Keep newborn dry and warm
● Assess temp at least q4hrs during first 24
● Have a limited capacity to thermoregulate
○ Prevent cold stress: when they become cold they divert calories,
increasing O2 consumption, to try to increase their temp, which
can impair essential growth
○ Newborns cannot shiver to produce heat
■ Observe reaction to stimuli - is the appropriate response noted?
■ Check fontanels and head size - proportional?
■ Check reflexes (next section)
○ Cardiac
■ Auscultate heart sounds, note abnormalities
● Assess O2 sat if murmur noted to assess perfusion
● Check pulses
● Check heart rate (120-160 BPM at rest)
○ If abnormal, listen longer to see if it sustains
○ Respiratory
■ Observe respiratory pattern, effort, and rate before auscultation
■ Only suction as needed, not routinely
● Bulb syringe
● Mouth first, nares second
● Compress bulb, insert, slowly release as you remove it
○ Hepatic
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■ Jaundice
● When to expect it:
○ After 24 hours for term baby
○ After 48 hours for preterm
○ If noted before this time frame, notify MD. (Can indicate early
lysis of RBC’s)
■ Assess H/H, glucose, indirect bilirubin (if elevated, may order direct bili)
■ Vitamin K
● Necessary to prevent hemorrhagic issues
● Coags made in liver depend on this
● Not naturally made in liver until intestinal microflora present
○ Renal
■ 5-10% weight loss expected during week 1
■ Typically not an issue, but can present problems and require
supplementation/increase in nutritional requirements if started out underweight
■ Weight newborn regularly and diapers if necessary
● 1g diaper = 1mL urine
● Must know weight of dry diaper
■ Circumcision
● Check for urinary retention post-procedure
○ Integumentary
■ Assess thoroughly and document abnormalities
■ Provide appropriate cord care
● Clamp can only be removed if it dry, occluded and free from bleeding
(typically after 24 hours)
● Educate parents on appropriate care
○ Do not pull off, allow to fall off naturally
○ Only use soap and water to clean
○ Use clean gauze on it, not a dirty washcloth
○ Fold diaper down so it does not cover
○ Watch for signs of infection (odor, edema, discharge, fever,
lethargy, poor feeding)
○ Do not submerge in a bath until stump falls off
○ Stump typically falls off after 5-15 days on its own

OB 10.04 Reflexes
● Overview
● PatientExample
○ Newborns have various reflexes that are present at certain times and some eventually
disappear
○ Refer to below table and video
● NCLEX® Points
Newborn Reflexes from Head to Toe

Reflex Examiner Expected Time frame Additional notes

Action Newborn
Response

Sucking and rooting Touch cheek, Turns head that Disappears after 3- May persist up to
lip, corner of direction, opens 4 months 12 months
mouth with mouth, takes in
nipple nipple, sucks

Swallowing None Coordinated Permanent Concern noted if

sucking and persistent gagging,
swallowing coughing or
emesis observed

Palmar grasp Place a finger Curls hand fingers Lessens at 3-4 None
in their hand around examiners months

Plantar grasp Rub bottom of Toes curl Lessens at 8 None

foot downward months

Moro Gently slightly Symmetrical Disappears at 6 Believed to be

lift newborn up spreading of arms months only unlearned
from lying out (abducts), then fear in newborns
position and pulling of arms in If present past 6
allow to fall (adducts) months, can Can occur
back indicate neuro spontaneously
issues while sleeping

Swaddle newborn
while sleeping to
prevent disturbed

sleep

Startle Clap or make a Adducts arms with Disappears after Newborn should
loud, startling flexed elbows by 4 months be at least 1 day
noise old

Pull to sit Pull from Head will lag Disappears at 4-5

supine to behind months
sitting

Plantar/Babinski Stroke gently Toes fan Disappears at 12 If this is not

upward on months present, there
lateral side of could be neuro
foot issues

Walking/Stepping Hold newborn Simulates walking Disappears at 4-5

up in standing months
position

Crawling Place newborn Makes crawling Disappears at

on stomach movements with about 6 weeks
extremities

OB 11.01.01 Preterm
● Overview
○ Definition: a baby born before 37 weeks
○ Other names: premature baby, preemie, a premature birth
○ The earlier the birth, the more complications and risks
○ Will most likely spend time in the neonatal intensive care unit
○ Infection prevention is essential, as an infection could be catastrophic
● NCLEX® Points
○ Assessment
■ Hypothermia
● Increased risk for cold stress
■ Impaired ability to eat
● Poor suck/swallow reflexes
■ Immature genitalia
● Undescended testicles, narrow labia
■ Multiple integumentary issues
● Lanugo present
● Jaundice
● Visible vasculature
● Minimal subcut fat
■ Respiratory issues
● Periods of apnea may be observed
● Irregular breathing patterns
○ Therapeutic management
■ Maintain airway
■ Maintain and promote adequate perfusion
■ Frequent vitals (frequency dependent upon newborn’s stability and orders)
■ Keep baby warm!
■ Strict I&O, weights
■ Involve parents as much as medically appropriate
■ Provide therapeutic stimulation

OB 11.01.02 Postterm
● Overview
○ Definition: A baby born after 42 weeks
○ After 42 weeks, the placenta starts to age and eventually fails
○ Some postterm babies may not have below assessment findings
○ Major concerns include meconium aspiration and hypoglycemia
● NCLEX® Points
○ Assessment
■ Muscle and fat wasting
■ Large baby
■ Meconium noted on nails or cord
■ Overgrown nails
■ Hypoglycemia
■ Dry and cracked skin
■ More hair on scalp that usual
○ Interventions (depend on presenting symptoms)
■ Hypoglycemia is common; assess and treat appropriately
● Glucose stores all used up, therefore hypoglycemia results
■ Assess for respiratory issues related meconium aspiration
■ Always assess and regulate temperature

OB 11.01.03 Small for Gestational Age (SGA)

● Overview
○ Definition: newborns below 10th percentile for their gestational age
○ It is NOT the same as low birth weight, very low birth weight, or extremely low birth
weight
● NCLEX® Points
○ Assessment
■ Hypoglycemia
■ General signs of infection
● If sepsis suspected, collect appropriate labs (cultures!) ASAP
■ Meconium aspiration
■ Signs of fetal distress
■ Abnormal body temp
■ Polycythemia
○ Interventions
■ Stabilize infant
● ABC’s
● Body temp
■ Closely monitor blood sugar per protocol
■ Provide therapeutic stimulation
■ Assess, monitor and prevent sepsis

OB 11.01.04 Large for Gestational Age (LGA)

● Overview
○ Definition: a newborn at or above the 90th percentile for weight, length, or head
circumference
○ It is not only based upon weight
● NCLEX® Points
○ Assessment
■ Trauma from a difficult and/or assisted birth
■ Shoulder dysocia from squeezing through birth canal
■ Hypoglycemia
■ Respiratory issues
■ Jaundice
■ If sepsis is suspected, draw appropriate labs ASAP
○ Interventions
■ Assess and monitor for meconium aspiration
■ Monitor and treat hypoglycemia per protocols
■ Manage and prevent sepsis
■ Provide therapeutic touch, if condition allows

OB 11.02 Meconium Aspiration

● Overview
○ Definitions
■ Meconium: first stool from newborn, if expelled prior to delivery and therefore
present in amniotic fluid, it is a sign of fetal distress
■ Aspiration: breathing in
■ Meconium aspiration: when the meconium is released into the amniotic fluid.
The baby aspirates prior to delivery or with their first breath.
○ The presence of meconium can indicate fetal distress but it does not mean that all infants
who expel meconium early are in distress
○ Especially concerned because not only are we getting gunk in the lungs, it’s feces!
○ Etiology unknown
● NCLEX® Points
○ Assessment
■ Immediate respiratory issues
● General respiratory distress
● Cyanosis
● Grunting
● Abnormal breath sounds
● Increase RR
■ Green, yellow amniotic fluid
■ Discolored nails or cord
○ Therapeutic management
■ Quick intervention/action is essential
● Suction immediately after head is delivered BEFORE first breath
● Must visualize vocal cords before stimulating crying and therefore first
deep breaths in
■ ECMO may be necessary in severe cases

By BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44806372

OB 11.03 Transient Tachypnea (TTN)

● Overview
○ Tachypnea noted in the newborn
■ Normal RR is 30-60 breaths/min
○ Most common reason for respiratory distress in newborns
○ Believed to be due to retained lung fluid related to delayed absorption, which increases
airway resistance and decreases compliancy
○ Typically resolves itself within 24-48 hours
● NCLEX® Points
○ Assessment
■ All symptoms are respiratory
● Tachypnea
● Labored breathing (retractions, grunting)
● Nasal flaring
● General cyanosis
● Abnormal breath sounds
○ Interventions
■ Supplemental O2
■ Educate mother/support system
■ Monitor oxygen saturation and work of breathing
■ Provide emotional support

OB 11.04 Retinopathy of Prematurity

● Overview
● PatientStory
○ Disease of the eye of premature babies that received NICU care and supplemental
oxygen, most likely due to premature lungs
○ Believed to be caused by disorganized growth of blood vessels, that get replaced by
fibrous tissue or bleed into the eye
○ Typically newborn is less than 31 weeks
○ Screening will be complete by a qualified examiner to determine diagnosis
○ Treatment is surgery
● NCLEX® Points
○ Remember that it is due to supplemental oxygen given in NICU settings (typically greater
than 30 days)
○ Assessment
■ Vitreous hemorrhage (blood in the space between the lens and retina)
■ Red reflex (red reflection of light noted when assessing eyes with
ophthalmoscope)
■ Leukocoria (abnormal white reflection of the eye)
■ Misalignment of the eyes (strabismus)

Leukocoria
By J Morley-Smith (talk) - Own work (Original text: I created this work entirely by myself.), Public Domain,
https://commons.wikimedia.org/w/index.php?curid=6463697

OB 11.05 Hyperbilirubinemia
● Overview
○ Definition: an elevated total bilirubin over 12 mg/dL in the newborn
○ Bilirubin explanation
■ It is a substance that if formed in the liver when old RBC’s are broken down (a
natural, normal process) and then excreted into bile and urine
■ This bile goes to the gallbladder to be concentrated and stored so it can be used
by your body when it is needed in the small intestine to digest fats
■ When it’s needed, it is released from the gallbladder and goes to the small
intestines to get to work, helping digest fats
■ We then excrete it in our feces and it is what makes feces brown
○ Why is this commonly seen in newborns?
■ In utero, the placenta removes the bilirubin from the baby’s body because they’re
not excreting it in their feces yet like they will after they are born
■ After birth, it can take some time for the newborn’s liver to take over this task
and do so efficiently
○ Pathological vs. physiological
■ Some degree of jaundice at about the 3rd day of life can be expected as this
normal transition from placenta doing the work to the baby’s liver. That is
physiological jaundice.
■ Jaundice that appears within the first 24 hours of life indicates that there is a
pathological process going on.. Something else other than this normal process,
and requires further investigation/assessment.
○ Concern
■ If hyperbilirubinemia is sustained, brain damage can occur because bilirubin can
deposit in the basal ganglia and brainstem (kernicterus)
○ Different kinds of bilirubin levels
■ Indirect (or unconjugated): bilirubin attached to a protein
■ Direct (conjugated): free floating bilirubin
■ Total: direct + indirect
● Higher levels are expected in newborns, levels typically peak at 5 days
● NCLEX® Points
○ Assessment
■ Jaundice
● Definition: accumulation of unconjugated bilirubin, resulting in
yellowing of skin, sclera
● Assess skin in natural light
● Assess skin head to extremities, as it usually starts in forehead or face

●
Jaundice in first 24 hours is a red flag for PATHOLOGICAL issues -
notify MD!
■ Elevated bilirubin levels
● Total level greater than 12
● Critical result is greater than 15
■ Hepatomegaly
■ Lethargy
■ Difficulty/trouble feeding, sucking
■ Decreased muscular tone
○ Therapeutic management
■ Hydration and nutrition are key, as they maintain blood volume and facilitate the
excretion of excess bilirubin
■ Phototherapy may be needed

● Fluorescent light converts bilirubin and makes it easier for infant to

excrete it, therefore decreasing levels
● Expose as much skin as possible while protecting eyes and genitals
○ Make sure eyes are closed before placing shield
● Assess skin under patches per policy (typically qshift, during feedings to
decrease therapy interruptions and maximize time, allow family bonding
at this time)
● Assess rest of skin when light is off
● Notify MD for grayish/brown skin color change
● Reposition q2hrs to prevent skin breakdown
● If drawing bili labs, make sure light is off or level will be incorrect
because the light will break down of bilirubin in specimen
● Monitor skin temp, stools
● IVF may be ordered due to water loss from therapy
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122

● After D/Cing therapy, watch for rebound elevations

■ Exchange transfusions is another treatment option, but typically last option if
they are worried about kernicterus as phototherapy is highly effective

OB 11.06 Erythroblastosis fetalis

● Overview
○ Other name: hemolytic disease of the newborn (HDFN, HDN)
○ An immune response from the fetus, which attacks RBC’s, that occurs when antibodies
from the mother pass through the placenta - typically during the birth process when the
placenta separates
○ Name comes from all of the erythroblasts in fetal blood, which are immature RBC’s
○ Typically NOT an issue with the first pregnancy, but can be with subsequent pregnancies
○ RBC’s get destroyed and therefore cannot function, resulting in anemia (this would be
characterized as hemolytic anemia)
○ Remember: antibodies are NOT an issue for the mother, but an issue for the fetus
○ Hemolysis results which then elevates bilirubin levels (remember, bilirubin is a substance
that if formed in the liver when old RBC’s are broken down (a natural, normal process)
and then excreted into bile and urine. Bilirubin can’t be cleared adequately because
there’s so many destroyed RBC’s built up
■ Normally, jaundice can be seen in newborns around day 3
■ If jaundice is seen in first 24 hours after birth, then pathological
hyperbilirubinemia is suspected. Levels can be extremely high and infant is
unable to clear them, and then kernicterus can result.
○ Treatment is focused on the infant, while mom merely receives a dose of RhoGAM and
should not experience any further issue herself
● NCLEX® Points
○ Assessment
■ Quickly developing jaundice, within 24 hours of birth
■ Anemia, draw a CBC to assess
■ Elevated bilirubin levels
■ Positive direct and/or indirect Coomb’s test
○ Therapeutic Management
■ Depends on severity
■ After delivery, cord blood is sampled and if infant is Rh-negative, there is no
need for further intervention (we’re looking for those antibodies that attack their
RBC’s and if they’re not there, we’re good!)
■ If mom is Rh-negative and pregnant with an Rh-positive baby, she is given Rho-
GAM (Rh immune globin, RhIG) at 28, 34 weeks (called RhIG prophylaxis) and
within the first 72 hours of delivery to hopefully prevent her antibodies (that have
naturally crossed the placenta due to the delivery) from attacking the infant’s
RBC’s
■ Newborn may need a blood transfusion that replaces their blood with Rh-
negative blood to stop the destruction, and then they are gradually given their
own blood back

By OpenStax College - Anatomy & Physiology, Connexions Web site.

http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0,
https://commons.wikimedia.org/w/index.php?curid=30148179

OB 11.07 Addicted Newborn

● Overview
● PatientStory
○ Many drugs cross the placenta and when the infant is born, they are no longer receiving
the drug that they have grown getting and go into withdrawal
○ It is important, if possible, to identify the specific drug and the amount to anticipate
symptoms and complications, and also to plan the care
○ With increased usage of opioids, more newborns are being born addicted to prescription
pain meds in addition to illegal drugs (cocaine, heroin, etc.)
○ Neonatal withdrawal, neonatal abstinence syndrome
● NCLEX® Points
○ Assessment (this is general, as it may depend on various drugs)
■ Fever
■ Mottling
■ High-pitched cry
■ Respiratory issues/distress
■ Gastric issues: diarrhea, vomiting
■ Sneezing, stuffy nose
■ Sucking fists excessively
■ Diaphoresis
■ Seizures
■ Difficulty feeding
■ Tremors
■ Hyperactive reflexes
■ Irritability
○ Therapeutic management
■ This can vary, depending on drug that’s involved
■ Seizure precautions (including suction at bedside, padded crib rails)
■ Close monitoring and assessment of cardiac, respiratory, neuro systems
■ Typically more fussy, they should be held tightly during feedings and other
routine care
■ Decrease stimulation as much as possible (quieter isolette area)
■ Swaddle effectively
■ Skin precautions: prevent breakdown from seizures, tremors, excessive rubbing
or sucking
■ May require smaller, slower feedings
■ Involve social work to assist mother with resources

OB 11.08 Fetal Alcohol Syndrome

● Overview
● PatientStories
○ A group of conditions that can occur when a mother ingest alcohol while pregnant
○ Can be mild or very severe
● NCLEX® Points
○ Assessment
■ While you as the nurse in the newborn period may only note the physical
assessment issues, kids with FAS can grow to have issues with judgement,
behavior, problems hearing/seeing, or low intelligence
■ Various craniofacial abnormalities can be noted
● See diagram
■ Respiratory issues
■ Congenital heart issues
■ CNS issues
● Encephalopathy
● Increased sensitivity to stimuli
● Seizures
■ Growth deficiencies
○ Interventions
■ Monitor cardiac, respiratory and neuro closely, intervene PRN
■ Seizure precautions (including suction at bedside, padded crib rails, decrease
stimuli)
■ May need to measure head circumference and weight more than usual
■ May require smaller, slower, more frequent feedings
■ See 11.07 Addicted Newborn interventions for more

By NIH/National Institute on Alcohol Abuse and Alcoholism - http://www.niaaa.nih.gov/Resources/GraphicsGallery/FetalAlcoholSyndrome/,

Public Domain, https://commons.wikimedia.org/w/index.php?curid=5470170

OB 11.09 Newborn of HIV + Mother

● Overview
● PatientStory
○ Close monitoring of HIV+ pregnant women is essential
○ Ongoing assessment of the newborn up to 18 month after birth is necessary, as mother’s
antibodies persist that long
■ May be asymptomatic
○ All newborns of HIV+ moms will acquire the maternal antibody, but not all will get the
actual infection
○ HIV+ mothers should not breastfeed (WHO may change this recommendation due to new
research.. benefit of breast milk may outweigh risk of transmission)
○ Circumcision typically not performed until HIV status known
● NCLEX® Points
○ Modes of transmission
■ Across the placenta during pregnancy
■ During childbirth
■ Through breastmilk
○ Assessment
■ May be asymptomatic
■ Immunodeficiencies
■ CBC, blood test for HIV
○ Interventions
■ Prophylactic Pneumocystits jiroveci given (PCP) to newborn
■ Antiretrovirals
■ Watch for signs of immunocompromise (enlarged liver or spleen)
○ Follow-up
■ Appointments
● Newborns of HIV+ mothers will require more follow up visits (normal
well-child checks are 1 month, 2 months, 4 months, 6 months, etc.)
○ 1 week
○ 2 weeks
○ 1 month
○ 2 months
■ Immunizations
● No live vaccines until HIV status determined
● Do give vaccines that are not live
● If newborn does end up being HIV+, they should not receive live
vaccines

OB 12.01 Tocolytics
● Overview
○ Anti-contraction meds, labor represents
○ Tokos = Greek word for childbirth
○ Lytic = lysis = decline of disease/symptoms
○ Use: prevent premature labor by suppressing uterine contractions
■ Preterm = before 37 weeks
○ If preterm labor cannot be stopped, this class of meds will allow time for the
administration of betamethasone to attempt to quickly increase lung maturity over 24-48
hours
○ Different classes of drugs
○ Different meds with different level of success rates, potential adverse reactions, research
changing frequently. There is currently no first-line, go to med
● NCLEX® Points
○ General nursing interventions for patients receiving these meds
■ Side-lying (preferably left) if patient can tolerate it (pressure off of vena cava,
increases BP)
■ Most likely, fetal monitoring will be ordered
■ Follow your protocol/order set, which will indicate frequency of assessments,
vitals, adverse reactions, I&O, etc.
■ Always monitor for potential adverse reactions and notify MD when noted
■ Thoroughly educate mother and support system about what to expect
■ Please note: magnesium sulfate is also used as a tocolytic, however there are
more effective agents available. Current research does not support this as a
tocolytic, but you may run into some old school docs that still prefer to use this.
Please see module 12.02.

■ Table below (there are more tocolytics than what is listed here)
Med Class Mechanism of RN Route / Dose Notes
Action considerations

Terbutaline Beta 2 adrenergic- Cause smooth Most adverse IV, subcut; Also causes
agonist muscle relaxation effects are cardiac bronchodilation
(Brethine) related Start @ 2.5-5
mcg/min Watch beta
Can delay labor blocker video in
up to 48 hours, but Titrate q30 min pharm course
not longer due to
potential cardiac Typical
issues with NB therapeutic range
17.5-30 mcg/min

D/C 12 hrs after

contractions stop

Should not infuse

more than 48-72
hrs

Nifedipine Calcium channel Disrupts calcium Rapidly lowers PO; Don’t use with
blocker entry into the cell, BP, watch closely mag unless you
(Procardia) which reduce as you may need Multiple dosing really need to b/c
smooth muscle to give fluids or options and no it will lower BP
contractions other meds to clear gold dosing further
increase BP standard

Indomethacin NSAID Inhibits Same bleeding PO, PR; dosing Can prematurely
prostaglandins, precautions as varies. PR 100 close fetus’ ductus
(Indocin) which cause other NSAIDs, mg x1. PO 25 mg arteriosus; may
uterine don’t use if pt has q4-6 hrs, not to need to assess this
contractions ulcers exceed 48 hrs after D/Cing this
med.

Watch for
oligohydramnios
(deficiency of
amniotic fluid)

OB 12.02 Betamethasone and Dexamethasone

● Overview
○ Purpose: to accelerate fetal lung maturity and decrease severity of respiratory distress
○ Given IM, 2-4 doses over 48 hours
● NCLEX® Points
○ Given to mom’s that are in preterm labor at 28-32 (newer research shows benefits go up
to 34) weeks that are receiving tocolytics. Inhibit the labor, quickly mature the lungs,
then allow the labor to resume after 48 hours. Even 24 hours is helpful and allows time
for preparation to get the baby to NICU.
■ Note: benefits no longer justifiable at 35 weeks
○ Interventions
■ Assess mother’s blood sugar
● Steroids = hyperglycemia
■ Assess CBC, monitor WBC
● Steroids affect mother’s immune system, lowers response, and increases
susceptibility to infection
■ Assess lung sounds, BMP to check sodium level
● Sodium can become elevated and cause fluid retention, pulmonary
edema

OB 12.03 Magnesium Sulfate

● Overview
○ Used as an anticonvulsant in the pregnant patient
■ Decreases risk of preeclampsia from turning into eclampsia
○ Has been used as a tocolytic, but research shows there are other more effective options
○ May suppress uterine contractions (remember, it was/is used as a tocolytic!) in the
laboring patient
○ If given in an actively seizing patient, it is an emergency. IV bolus given, IM injections,
then continuous IV infusion.
○ May be given prophylactically in the laboring preeclamptic patient, as labor reduces the
seizure threshold so we use magnesium to raise it up and prevent the from occurring and
may be continued up to 24 hours postpartum as it takes that long for the seizure threshold
to go back up naturally after delivery.
○ Dosing depends on severity of situation
○ Normal serum mag level is 1.5-2.5 mEq/L
● NCLEX® Points
○ Therapeutic management
■ Calcium gluconate is the antidote - ALWAYS have on hand in the event of mag
toxicity
● Calcium gluconate antagonizes the effect of mag sulfate
● Mag toxicity: loss of deep tendon reflexes, heart blocks, respiratory
paralysis, cardiac arrest
■ Closely monitor mag levels
● Target therapeutic range for this indication is 2.5-7.5 mEq/L
● Mag over 12 mEq/L can be fatal
■ Closely monitor vitals per protocol/order set
● Hypotension
■ Closely monitor deep tendon reflexes, respiratory function, heart monitor
● Patellar reflex = legs hanging over bed, use reflex hammer to hit the
quadricep tendon, do it on both legs and rate. Suppressed reflex can be a
sign of impending respiratory arrest!
○ 0 - no response
○ 1 - sluggish
○ 2 - normal
○ 3 - more brisk, slightly hyperactive
○ 4 - brisk, hyperactive
● Call if RR is less than 12/min
● Check RR + reflex before IV doses. Reflex MUST be present and RR
greater than 16 before each IV dose (unless hospital policy reflects
otherwise).
■ Watch renal function on BMP or CMP and urinary output (med eliminated by
kidneys
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OB 12.04 Opioid Analgesics

● Overview
○ Opioids are given for moderate to severe pain
■ They will not provide the same relief as an epidural
○ They are fast-acting
○ Typically given IV or Im during labor
■ PO can be given, but takes much longer to work
○ Ideal to be given when needed for breakthrough/acute pain during labor, not chronically
throughout pregnancy (newborn can be born with withdrawal symptoms if taken
throughout course of pregnancy)
■ History taking is essential before administration to make sure they haven’t been
taking them during pregnancy. Some meds are contraindicated if someone is
already dependent on specific meds, as they may elicit withdrawal symptoms for
both baby and mom
● NCLEX® Points
○ Always know your antidote/reversal agent
■ Naloxone (Narcan) - when giving make sure you administer appropriately per
order
● More than 1 dose may be necessary, dilute appropriately
■ If you must give this in someone who has received too much, be prepared for
potential withdrawal symptoms in newborn
● Fever
● Mottling
● High-pitched cry
● Respiratory issues/distress
● Gastric issues: diarrhea, vomiting
● Sneezing, stuffy nose
● Sucking fists excessively
● Diaphoresis
● Seizures
● Difficulty feeding
● Tremors
● Hyperactive reflexes
● Irritability
○ Antimetics may be given concurrently to combat nausea that is a frequent side effect
■ Phenergan, Zofran
○ Monitor respirations and BP closely, these all can cause respiratory depression and
hypotension
■ RR less than 12/min is concerning - do not give med and notify MD
○ Common meds:
■ Meperidine hydrochloride (Demerol)
■ Hydromorphone (Dilaudid)
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■ Fentanyl
■ Morphine
■ Butorphanol tartrate (Stadol)
■ Nalbuphine (Nubain)

OB 12.05 Prostaglandins
● Overview
○ Two different kinds:
■ Prostaglandin E: Misoprostol (Cytotec)
■ Prostaglandin E2: Dinoprostone (Cervadil)
○ Given for two reasons
■ Stimulate uterine contractions
■ Cervical ripening (getting the cervix ready by helping it to dilate and efface)
○ Given as part of an induction of labor or abortion
○ It is given ahead of time - if an induction with oxytocin (Pitocin) is scheduled, they will
typically get a prostaglandin to ripen the cervix the night before
■ We’ve got to soften the cervix before artificially starting contractions
○ MD will check the mother’s cervix first to assess if any dilation or effacement has
already occurred, as it may not be indicated
○ This will not be given if it is known the patient will get a c-section
○ Route: vaginal suppository or gel
● NCLEX® Points
○ Contraindications
■ Acute PID
■ History of c-section, difficult or traumatic birth, major uterine surgery
■ If signs of infection are present
■ Any vaginal bleeding or placenta previa
■ If mom is already have contractions or dilated/effaced to the point where it is not
necessary
■ Other significant issues with mother’s health (cardiac, renal, hepatic, neuro,
pulmonary, etc.)
○ Adverse or Side Effects to be aware of and anticipate
■ Gastric upset
● Nausea, vomiting, diarrhea, stomach cramping
■ Overstimulation of uterine muscles
■ Meconium passage
■ Tachysystole: when there are more than 6 contractions in 10 minutes (or more
frequently than q2minutes)
○ Nursing Management
■ Baseline vitals on mom and baby
● Bishop score - see table
● Add numbers together
○ Score greater than 6 = time to induce!
● There is a modified Bishop score to account for specialized
circumstances, but you probably won’t be tested on it
■ Maintain bedrest for 30-60 min if it’s a gel, 2 hours if it’s a vaginal suppository
● Have patient void prior
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● Have supplies for gastric upset nearby, as patient cannot get up to go to

the bathroom
■ Follow protocol / order set
● Reassessments with Bishop score will be indicated
● Discontinuation will be based upon:
○ Bishop score (8+)
○ 3+ contractions in 10 min
○ Significant side effects
● Induction time will be based upon when prostaglandin therapy
discontinued (6-12 hrs later)

Bishop Scoring

Add together

Condition of 0 1 2 3
Cervix

Dilation 0 1-2 3-4 Greater than 5

Effacement 0-30 40-50 60-70 Greater than 80

Consistency Firm Medium Soft _

Position Posterior Midposition Anterior -

Station (of -3 -2 -1 +1, +2

presenting part)

OB 12.06 Uterine Stimulants

● Overview
○ Naturally occurring hormone in the body that is released during labor and delivery and
also breastfeeding
○ Oxytocin (Pitocin) is the medication
○ Stimulates uterine contractions and increases intensity, strength, and duration of
contractions
○ Given as a continuous infusion IV for labor induction (most common use)
○ What else we use it for
■ Help control PPH
■ Incomplete abortions
■ Breastfeeding moms having trouble (intranasal route stimulates letdown)
○ Should not be given in a patient who is going to have a c-section
○ Causes extremely painful uterine contractions - much more painful than a normal labor
■ Most women will have an epidural
● NCLEX® Points
○ Will most likely come with an order set - base monitoring, titrations, and interventions
based up on this protocol
○ Monitoring
■ Frequent monitoring of mom
● Q15min BP / HR
● Note LOC, pain level, lung and heart sounds
● Frequent I&O
■ Frequent fetal monitoring
● Continuous external fetal monitoring
● Q15min monitoring of baby
○ If membranes ruptured and changes occur, they may want
internal monitoring
● Q15 min monitoring of contractions
○ Monitor and chart frequency, duration, intensity
○ Watch for hypertonic contraction - a single contraction lasting
2+ minutes or 5+ in 10 minutes
■ Watch for hypotension
■ Watch uterine atony
● Loss of uterine tone. When the uterus contracts back down after labor,
vasoconstriction of the vessels in the uterus occur, which reduces blood
flow naturally, coagulation occurs and bleeding ceases. If these
contractions stop or are ineffective, hemorrhage is a concern.
○ If the baby isn’t doing so great..
■ STOP infusion
■ Turn mom on side
■ O2
50 Most Commonly Prescribed Med Free Cheatsheet: NRSNG.com/50meds | Nursing School Shouldn't be so DAMN Hard!
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138

■ Assess baby and mom to see if changes occurred

■ Notify MD

OB 12.07 Meds for PPH

● Overview
○ Ergot alkaloids
■ Ergonovine
■ Methergine
○ They stimulate a firm uterine contraction to cause vasoconstriction within the uterine
muscle and stop bleeding
■ They can also cause arterial and coronary artery vasoconstriction
○ They are NOT to be given before delivery of the placenta
○ They must be given only during the postpartum period - not while patient is still pregnant
○ Two other options: Oxytocin (Pitocin), or a prostaglandin F2alpha (Hemabate)
■ Both contract uterus
■ Hemabate contraindicated in asthmatic patients
● NCLEX® Points
○ Contraindications
■ Due to vasoconstriction, do not give to patients with HTN
■ Clarify with MD if patient has any cardiac history
○ Monitoring
■ Watch for s/s MI, HTN, bradycardia, nausea, dysrhythmias
■ Monitor VS per order set, especially BP
■ Monitor hemorrhage and note response to med
○ Therapeutic management
■ May need pain meds due to painful, yet necessary, uterine cramping
■ Hold and clarify if HTN develops
■ Get baseline vitals before starting

OB 12.08 Rh Immune Globulin

● Overview
○ RhoGAM, WinRho
○ See module 11.06 for explanation of pathophysiology of erythroblastosis
○ Indication: given to prevent the fetus from developing antibodies and subsequent
erythroblastosis
○ Given to moms - not baby - both prophylactically (at 28 weeks) and up to 72 hours after
potential exposure
○ IM injection
● NCLEX® Points
○ Contraindications
■ Allergies to any human immunoglobulins
■ If patient (mom) has a positive antibody titer to Rh antigen
○ Assessment
■ Must check temp before and after - report any elevation
■ Tenderness may be noted at injection site

OB 12.09 Lung Surfactant

● Overview
○ Given to newborns to replenish lung surface activity also for prevention/treatment of
respiratory distress
○ Lung surfactant makes it easier for O2 to get into the lining of the lungs and therefore
into blood/circulation easier
○ Given via ETT of newborn
● NCLEX® Points
○ Use in caution with newborns in fluid overload
○ Procedure
■ Newborn will have ETT
■ Get baseline for lung sounds, vitals prior to administering
■ Med administered into ETT
■ Watch for bradycardia and dropping O2 sat while administering
■ Assess lung sounds, vitals after and monitor response

OB 12.10 Eye Prophylaxis for Newborn

● Overview
○ Given to protect neonatal conjunctivitis or ophthalmia neonatorum
○ Required by law in US
○ These conditions are transmitted to newborn in birth canal by mother infected with
gonorrhea or chlamydia, can ultimately cause blindness
○ Exact name/brand will depend on hospital/facility
■ Typically an ophthalmic form of erythromycin or tetracycline
● NCLEX® Points
○ Clean eyes first, then apply ointment. Do not wipe off or flush eyes.
○ Educate mother/support system about this before you do it, also educate them not to wipe
it off
○ This can be delayed up to 1 hour after birth
■ Getting baby on mother’s chest, stabilized, and starting skin-to-skin is the
priority

By CDC/ J. Pledger - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with
identification number #3766.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content
providers.English | Slovenščina | +/−, Public Domain, https://commons.wikimedia.org/w/index.php?curid=901973

OB 12.11 Phytonadione
● Overview
○ Also known as Vitamin K
○ Why it’s routinely given: intestinal bacteria does not develop in newborns for the first 5-8
days of life and coagulation factors are not produced in liver until this occurs. This is
given to prevent any hemorrhagic disorders that may result, as newborns are deficient in
vitamin K at birth.
○ Only adverse concern is hyperbilirubinemia (see module 11.05) and rare
○ IM injection given shortly after birth
● NCLEX® Points
○ Given IM
■ Administer IM injection in thigh
■ Hold them tight because they’ll move!
○ Protect med from light
○ Given shortly after birth
■ Remember skin to skin time with mother is priority, this can be given shortly
after
○ Monitor for hyperbilirubinemia
○ Reassess injection site regularly as well as for any bleeding

OB 12.12 Hb Vaccine
● Overview
○ Hepatitis B vaccine
○ Abbreviated as Hb vaccine or HBV (not to be confused with HPV)
○ Recommended by CDC to be given in first 12 hours of life
○ IM injection
○ If mother already has Hepatitis B, then Hep B immune globulin also needs to be given
● NCLEX® Points
○ Procedure
■ Educate importance and need
■ If they want to refuse; follow hospital policy and document appropriately
■ Obtain consent
■ Give IM injection in lateral side of middle 3rd of vastus lateralis muscle
■ Document per policy
● Typically includes documenting in hospital chart and providing a card to
the parents for their records

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