Memory tricks for maternal-newborn nursing

Most common cause: uterine atony (boggy uterus = not contracting). 4 Ts: Tone (70–80% — uterine atony), Trauma (lacerations), Tissue (retained placenta), Thrombin (coagulopathy). Assessment: fundus (boggy? midline? above umbilicus?), lochia (saturating pad in <1 hour = abnormal), vital signs (tachycardia first sign, then hypotension). Management of atony: massage fundus (never pummel), bimanual compression, oxytocin (Pitocin), methergine (not in HTN), carboprost (not in asthma), Bakri balloon, blood products. Monitor: I&O, H&H, coagulation studies.

CHOP BUGS covers the probable signs of pregnancy — signs that strongly suggest pregnancy but are not definitive proof. Positive signs (heartbeat on ultrasound, fetal movement felt by examiner, fetal parts on X-ray) confirm pregnancy. These probable signs point toward it.

Stop MOAN gives you the priority interventions when a fetus shows signs of distress during induction with uterine stimulants. Speed matters — follow this sequence immediately. Do NOT wait to notify the provider until after you have completed the other steps.

REEDA is your assessment tool for evaluating episiotomy, laceration, and C-section incision healing. Any of the first four findings may indicate infection or poor healing. Approximation (wound edges together) is the desired finding — report separation immediately.

Breasts: engorgement, nipple condition, signs of mastitis (red, warm, flu-like). Uterus: fundus firm (boggy = atony → massage), midline (deviated = full bladder), descends 1 cm/day, at umbilicus day 1. Bladder: void within 4–6 hrs of delivery, distension displaces uterus → hemorrhage risk. Bowel: bowel sounds present, first BM by day 2–3 (may be painful). Lochia: Rubra (red, days 1–3), Serosa (pink, days 4–10), Alba (white, days 11–14+). Report: foul odor, heavy saturation, large clots. Episiotomy: REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation). Homans sign: no longer used — check legs for unilateral swelling, warmth, redness, tenderness (DVT). Emotional: baby blues vs postpartum depression (>2 weeks, affects functioning).

LARA CROFT helps you remember the causes of abdominal pain in pregnancy — from normal labor to life-threatening emergencies. Quick recognition is critical for maternal and fetal safety.

HELLP syndrome is a severe variant of preeclampsia typically occurring in the third trimester. It involves breakdown of red blood cells, elevated liver enzymes, and dangerously low platelets. Requires immediate intervention — can be fatal to mother and baby.

APGAR assessed at 1 minute (status at birth — not used to decide on resuscitation) and 5 minutes (response to resuscitation). Each category scored 0–2: Appearance (color): 0=blue/pale all over, 1=pink body/blue extremities, 2=pink all over. Pulse: 0=absent, 1=<100, 2=≥100. Grimace (reflex irritability): 0=no response, 1=grimace, 2=cough/sneeze/cry. Activity (muscle tone): 0=limp, 1=some flexion, 2=active motion. Respiration: 0=absent, 1=weak/irregular, 2=strong cry. Score 7–10=normal, 4–6=moderate depression (stimulate, O2), 0–3=severe depression (resuscitation).

First stage: latent (0–6 cm, irregular contractions), active (6–10 cm, stronger/closer contractions), transition (8–10 cm, most intense). Assess: cervical dilation, effacement, station, fetal heart rate, contractions. Second stage: complete dilation to birth. Push with contractions (closed glottis). Monitor fetal heart rate. Third stage: placenta delivery — within 30 minutes. Signs of separation: gush of blood, lengthening of cord, uterine fundus rises and becomes firm. Fourth stage: first 1–4 hours after delivery. Assess: fundus (firm, midline, at umbilicus), lochia, perineum, BP, HR. Most common time for postpartum hemorrhage.

Early decelerations: mirror contractions (start and end together), caused by head compression, normal — no intervention needed. Variable decelerations: abrupt drop, variable timing, caused by cord compression. Intervention: change maternal position (left lateral, knee-chest), O2, stop oxytocin, fluid bolus — may need amnioinfusion. Late decelerations: begin AFTER peak of contraction, caused by uteroplacental insufficiency (placenta not delivering enough O2 to fetus). EMERGENCY — notify provider immediately. Interventions: left lateral position, O2 10 L nonrebreather, stop oxytocin, IV fluid bolus, prepare for delivery. Persistent late decels = C-section.

Placenta previa: placenta implants low, partially or fully covering the cervix. Painless, bright red bleeding, soft non-tender uterus. Diagnosed by ultrasound only — NEVER perform a vaginal/digital exam, which can trigger catastrophic hemorrhage. Risk factors: prior C-section, multiparity, advanced maternal age. C-section if the placenta covers the os. Placental abruption: premature separation of the placenta from the uterine wall. Painful, dark red bleeding (may be concealed), rigid board-like tender abdomen, frequent/hypertonic contractions. Risk factors: hypertension/preeclampsia, trauma, cocaine use. Fetal distress is common — an obstetric emergency that can progress to DIC and fetal death. Management depends on severity: emergency C-section if severe or fetal distress, close monitoring if mild and stable.

Preeclampsia: onset >20 weeks gestation. Criteria: BP ≥140/90 on two occasions 4 hrs apart, plus proteinuria or, without it, any severe feature. Severe features: BP ≥160/110, platelets <100,000, creatinine >1.1, LFTs 2× normal, pulmonary edema, severe headache, visual disturbances, RUQ pain. HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets. Nursing: quiet, dim room (reduce stimuli), magnesium sulfate (seizure prophylaxis AND treatment — monitor for toxicity: absent DTRs, RR <12, urine <30 mL/hr), antidote = calcium gluconate. Eclampsia: grand mal seizure — give magnesium, protect from injury, O2, notify provider immediately. Delivery is the only cure.

Normal vitals: HR 110–160 (tachycardia if >160, bradycardia if <110), RR 30–60 (normal is fast!), Temp 36.5–37.5°C (axillary). Acrocyanosis: blue hands/feet normal for first few hours (peripheral circulation immature) — central cyanosis (lips, trunk) = abnormal. Caput succedaneum: edema crossing suture lines, present at birth, resolves in days. Cephalohematoma: bleeding under periosteum, does NOT cross suture lines, appears 24–48 hrs, resolves in weeks (risk for jaundice). Vernix (white coating), lanugo (fine hair), milia (white dots on nose) = all normal. Meconium: first stool within 24–48 hrs. Void within 24 hrs.

Good latch: baby's mouth covers areola (not just nipple), lips flanged outward, chin touching breast, audible swallowing, no pain. Feed on demand — 8–12 times per 24 hours (every 2–3 hrs). Duration: untimed — let baby finish the first breast, then offer the second. Signs of adequate intake: 6+ wet diapers/day by day 4, weight regain by day 10–14 (lose up to 10% initially), yellow seedy stools by day 4. Colostrum: first 3–5 days — high in antibodies (IgA), thick yellow, small amounts normal. Engorgement: frequent feeding, warm compress before feeding, cold compress after, supportive bra. Mastitis: breast infection — continue breastfeeding, antibiotics if bacterial, ice/cold compress, NSAIDs, rest.

Immediate post-op: assess as for any surgical patient PLUS obstetric assessments. Fundus: firm, midline, at umbilicus. Lochia: rubra (red, first 3 days), serosa (pink, days 4–10), alba (white, days 11+). Incision: Pfannenstiel (bikini line — horizontal). Foley catheter: usually removed 12–24 hrs post-op. Pain: multimodal analgesia — IV opioids → oral NSAIDS + acetaminophen → wean opioids. Early ambulation: 12–24 hrs — prevents DVT, ileus, pneumonia. Sequential compression devices (SCDs) until ambulating. Patient teaching: no driving for about 2 weeks or while on opioids, lift nothing heavier than baby, incision care. Next delivery: VBAC possible for some.

GDM: glucose intolerance first recognized during pregnancy. Screening: 24–28 weeks (1-hr glucose challenge test). Diagnosis: 3-hr OGTT (or 1-step 75 g 2-hr OGTT). Pathophysiology: placental hormones → insulin resistance. Risks to baby: macrosomia (large baby → difficult delivery, shoulder dystocia), neonatal hypoglycemia (baby was compensating for mom's high glucose → baby's insulin remains high after birth — check newborn glucose at 1 hr). Risks to mother: UTIs, preeclampsia, C-section, future Type 2 DM (50% risk). Management: diet first (complex carbs, small meals), exercise, insulin if needed (insulin preferred; metformin or glyburide if insulin declined/not feasible). Resolves after delivery.

Jaundice: yellow skin from bilirubin (RBC breakdown). Physiologic (normal): appears day 2–3 (after 24 hrs), peaks day 3–5, resolves within 1–2 weeks. Cause: immature liver, polycythemia. Pathologic (abnormal): appears within first 24 hours — Rh or ABO incompatibility, infection. EMERGENCY — needs immediate treatment. Phototherapy (bili lights): converts bilirubin to water-soluble form excreted in urine/stool. Nursing: eye shields (protect from light), turn every 2 hrs, increase feeds (hydration promotes excretion), monitor skin color and bilirubin levels, remove briefly for feeds. Kernicterus: bilirubin deposits in brain → permanent neurological damage.

Effectiveness (best to least): Implant (Nexplanon, >99%), IUD (Mirena/Paraguard, >99%), Sterilization (>99%), Depo-Provera shot (94%), Combined pill (91% typical use), Patch/Ring, Male condom (85% typical), Diaphragm (83% typical), Spermicide (72% typical). Estrogen-containing contraceptives CONTRAINDICATED in: smokers ≥35 years (DVT/PE risk), uncontrolled HTN, history of DVT/PE/stroke, breast cancer, migraines with aura, breastfeeding <6 weeks. Progestin-only (mini-pill, Depo, Mirena, Nexplanon): safer alternatives. Copper IUD (Paraguard): no hormones, also emergency contraception within 5 days.

Placenta Previa: placenta implants over cervical os. Bleeding: bright red, painless, sudden onset (especially after 20 weeks). Risk factors: prior C-section, uterine surgery, multiparity, advanced maternal age. NEVER do vaginal exam — can cause massive hemorrhage. Management: bedrest, pelvic rest, monitor, C-section delivery. Placental Abruption: placenta separates prematurely. Bleeding: dark red, painful, rigid/board-like uterus, uterine tenderness. Concealed bleeding (no vaginal blood) possible but internal. Risk factors: HTN, cocaine, trauma, prior abruption, smoking. Can lead to DIC. Both: monitor FHR (fetal distress), large-bore IV access, type and crossmatch, O2, lateral positioning. NCLEX: painless bright red = previa; painful dark red + rigid uterus = abruption.

Cord prolapse = umbilical cord slips through cervix ahead of fetus — cord compression cuts off fetal blood supply. Risk factors: rupture of membranes with high presenting part, polyhydramnios, multiple gestation, preterm, abnormal fetal presentation (breech, transverse). Signs: sudden severe variable decelerations after ROM, visible/palpable cord at vaginal opening. IMMEDIATE actions: Call for help (emergency C-section needed), position patient knee-chest or Trendelenburg to relieve cord pressure, manually elevate presenting part off cord with gloved hand (do NOT remove hand until delivery), O2 by face mask, large-bore IV, prep for emergency C-section, keep cord moist if exposed (warm saline gauze — never push cord back). This is a true obstetric emergency — every second counts for fetal survival.

Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. If fetal Rh+ blood enters maternal circulation (delivery, miscarriage, amniocentesis, trauma), mother develops anti-Rh antibodies. In a subsequent Rh+ pregnancy, maternal antibodies cross placenta → hemolytic disease of newborn (HDN) = erythroblastosis fetalis — fetal anemia, hydrops, death. Prevention: RhoGAM (Rh immune globulin) — given to Rh- mothers: at 28 weeks gestation, within 72 hours of any pregnancy event (delivery, miscarriage, ectopic, amniocentesis, trauma). RhoGAM works by destroying fetal Rh+ cells before mother's immune system responds. NCLEX: mother is Rh-, baby Rh+ by cord blood typing, mom's indirect Coombs negative → give RhoGAM within 72h. If mother already sensitized (positive indirect Coombs) → RhoGAM will NOT help.

Postpartum Blues: onset days 1–5, resolves by 2 weeks. Tearfulness, mood swings, anxiety, irritability — normal hormonal adjustment. Nursing: reassurance, support, monitor. No treatment needed. Postpartum Depression (PPD): onset within 4 weeks (can be up to 1 year), lasts weeks to months. Persistent sadness, inability to bond, fatigue, appetite changes, thoughts of harming self or baby. Nursing: Edinburgh Postnatal Depression Scale screening, refer to provider, antidepressants (SSRIs safe with breastfeeding), therapy, support system. Postpartum Psychosis: RARE but EMERGENCY. Onset 1–4 weeks. Hallucinations, delusions (often about baby), confusion, rapid mood swings, command hallucinations to harm infant. Nursing: SAFETY FIRST — never leave mother alone with infant, psychiatric hospitalization, immediate provider notification. NCLEX: distinguish by timeline, severity, and infant safety risk.

Primitive reflexes are present at birth and disappear as cortex matures. Moro (startle): arms extend then flex in response to sudden stimulus — present birth to 4–6 months. Asymmetric = brachial plexus injury. Rooting: turn head toward cheek touch — facilitates feeding, disappears 3–4 months. Sucking: suck when anything touches lips — present until 3–4 months. Palmar grasp: fingers curl around object placed in palm — disappears 3–4 months. Plantar grasp: toes curl when sole pressed — disappears 9 months. Babinski: toes fan out when sole stroked — normal until about 1–2 years, abnormal in adults (UMN lesion). Tonic neck (fencing): head turned to side, same-side arm extends — disappears 4–6 months. NCLEX: absent Moro = possible neurological damage. Babinski in adult = abnormal. Asymmetric reflexes = assess for birth injury.

Jaundice (hyperbilirubinemia): yellow skin/sclera from bilirubin accumulation. Physiologic: appears after 24 hours, peaks days 3–5, resolves by 2 weeks. Due to normal RBC breakdown + immature liver. Pathologic: appears within first 24 hours — always abnormal — Rh incompatibility, ABO incompatibility, infection. Assessment: blanch skin over bony prominence — yellowness visible. Progresses head to toe (Kramer's zones). Treatment: phototherapy (bili lights). Nursing care during phototherapy: cover eyes with eye shields (corneal damage), leave skin exposed (maximum light exposure), remove for feedings (every 2–4 hours), monitor temperature (hyperthermia risk), adequate hydration (loose green stools normal — bilirubin excreted), monitor bilirubin levels. Exchange transfusion for severe cases. Kernicterus: bilirubin deposits in brain — irreversible — prevent with early treatment.

Ectopic pregnancy = fertilized egg implants outside uterus (95% in fallopian tube). Life-threatening if tube ruptures — internal hemorrhage. Risk factors: prior ectopic, PID/STI history, tubal surgery, IUD in place, infertility treatment. Classic presentation: missed period + unilateral sharp pelvic pain + vaginal spotting. Rupture signs: sudden severe abdominal pain, shoulder pain (referred from diaphragm — blood pooling), syncope, hypotension, tachycardia = hemorrhagic shock. Diagnosis: hCG positive but below expected for gestational age, no intrauterine pregnancy on ultrasound. Treatment: methotrexate (unruptured, stable) or surgical (salpingectomy). Nursing priorities: large-bore IV access, blood type and crossmatch, VS monitoring, prepare for emergency surgery, emotional support (pregnancy loss).

VEAL CHOP matches FHR pattern to cause: Variable decelerations = Cord compression (reposition, O2, fluid bolus, check for cord prolapse). Early decelerations = Head compression (fetal head compression during contraction — benign, mirrors contraction). Accelerations = OK (reassuring sign of fetal well-being). Late decelerations = Placental insufficiency (uteroplacental insufficiency — always non-reassuring, requires immediate intervention). Late deceleration interventions: reposition to left lateral, O2 10 L/min face mask, IV fluid bolus, stop oxytocin, notify provider, prepare for possible delivery. Sinusoidal pattern: smooth, undulating — associated with severe fetal anemia — emergency. Baseline FHR normal: 110–160 bpm. Tachycardia (>160): maternal fever, infection, medication, fetal anemia. Bradycardia (<110): cord compression, medication, prolonged late decel.

APGAR score is done at 1 minute (how did baby tolerate labor?) and 5 minutes (how is baby adapting?). Each category scored 0–2, max 10. Score 7–10 = normal. Score 4–6 = moderate distress. Score below 4 = severe depression. Resuscitation follows breathing and HR, not the score: PPV first; compressions if HR stays <60.

A patient who is currently pregnant with her 4th pregnancy, delivered 2 full-term babies, had 1 preterm, 0 abortions, and 2 living children = G4 T2 P1 A0 L2. Gravida = all pregnancies including current. Abortion includes elective AND spontaneous (miscarriages). Living = children currently alive.

TORCH infections can cross the placenta and cause serious fetal harm. Rubella in first trimester = highest risk (deafness, cataracts, heart defects). CMV is the most common congenital viral infection. Toxoplasmosis: avoid cat litter during pregnancy. Herpes: if active lesions at delivery → C-section.

Tocolytics: nifedipine (CCB), indomethacin (NSAID — avoid after 32 weeks, risk of fetal ductus arteriosus closure), terbutaline (beta-agonist), magnesium sulfate (also used for fetal neuroprotection against cerebral palsy). Magnesium toxicity: loss of deep tendon reflexes is the EARLIEST sign, before respiratory depression. Report RR <12/min, urine output <30 mL/hr, or absent reflexes immediately. Calcium gluconate is the antidote — keep at bedside during the entire infusion.

Monochorionic twins share a placenta and its blood vessels — risk of twin-to-twin transfusion syndrome (TTTS): donor twin becomes anemic/growth-restricted, recipient twin becomes volume-overloaded/polycythemic. Monochorionic twins need ultrasound monitoring roughly every 2 weeks. Identical twins can still be dichorionic depending on when the egg split — chorionicity must be confirmed by ultrasound, never assumed from zygosity. Multiples overall: higher risk of preterm labor, preeclampsia, anemia, and postpartum hemorrhage (uterine atony from overdistension).

PKU: can't metabolize phenylalanine — lifelong low-phenylalanine diet, avoid aspartame, untreated causes intellectual disability. Galactosemia: can't metabolize galactose — STOP breastfeeding, switch to soy-based lactose-free formula. Congenital hypothyroidism: often no symptoms at birth — levothyroxine started early prevents intellectual disability/poor growth. Refusal (usually religious) requires a signed written waiver, not just verbal decline.

Folic acid: start at least 1 month before conception, continue through first trimester — neural tube closure happens before pregnancy is often even confirmed. Iron: take at bedtime/between meals with vitamin C, not milk (impairs absorption). Weight gain by starting BMI: normal 25-35 lbs, overweight 15-25 lbs, underweight 28-40 lbs. Avoid: alcohol, high-mercury fish (swordfish, shark, king mackerel, tilefish), undercooked meat, unpasteurized dairy, raw fish. Maternal PKU requires strict phenylalanine control regardless of fetal PKU status.