NCLEX-RN cheat sheet · Maternal and newborn

Labor, birth and fetal monitoring

True vs false labor, stages, station, pain relief, oxytocin, emergencies, reading the tracing

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Labor is a normal process: support it, watch both patients, and recognize when it stops being normal.

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At a glance

False or true labor?

	False (Braxton Hicks)	True labor
Pattern	Irregular, usually short	Regular, about 5 to 10 minutes apart
Over time	Taper off	Longer, stronger, closer; spread to the back
With activity	Walking or lying down may stop it	Doesn't stop, whatever she does
Cervix	No change	Only true labor changes it

Timing: Time contractions from the start of one to the start of the next.

Signs labor is near, and when to call

Lightening: the baby drops into the pelvis. Bloody show: the cervix is starting to open, though labor may be days away.
Water breaks: she calls right away and notes the time, color and odor, because infection risk rises.
Also call for less fetal movement, bleeding beyond spotting, or painful contractions every 5 to 10 minutes for an hour.

Stages of labor

Stage	What, and how long
First	Start of labor to full dilation, 10 cm: the cervix effaces and dilates. Longest, often 12 to 19 hours; ends with transition
Second	Pushing and birth, usually 20 minutes to 2 hours. Crowning: the head appears
Third	Delivering the placenta: shortest, 5 to 30 minutes

Transition: Very strong contractions, little rest, shakiness, nausea. Help her relax between contractions: ice chips, a cool cloth, back rubs.

Station and position

	Means
Station	Presenting part compared with the ischial spines. Zero station: level with the spines; above them, minus 1 to minus 5
Occiput anterior or posterior	Anterior, facing the mother's back, is best. Posterior, facing her front, is harder, often with back labor
Breech, transverse	Breech: usually delivered by C-section; vaginal breech birth is only for selected cases. Transverse: a C-section unless the baby can be turned

Pain relief

	What it does, and what to watch
Comfort	Breathing and relaxation, warm showers, massage, heat on the lower back, position changes, ice chips, a supportive person
IV or IM opioids	Make pain bearable without affecting pushing; short-acting; drowsiness, nausea, itching. Not right before delivery: they may slow the baby's breathing and heart rate at birth
Epidural	Numbs the lower body; relief in 10 to 20 minutes. Main risk: her blood pressure drops, which can slow the baby's heart rate. IV fluids; if pressure falls, she turns on her side and may get medicine to raise it. Pushing can be harder
Other blocks	Spinal: one injection, fast relief for 1 to 2 hours. Pudendal: numbs the vaginal area just before birth

Induction and oxytocin

Reasons: ruptured membranes without labor, past the due date, high blood pressure or diabetes, fetal concerns.
Prostaglandins ripen the cervix, with the fetal heart monitored. Amniotomy needs a dilated cervix and the head down in the pelvis.
Oxytocin: IV by pump, slowly increased, piggybacked so it can be stopped without stopping the IV.
Watch the fetal heart and contraction strength. Too strong or too long: stop the oxytocin.

C-sections and emergencies

C-section: about 1 in 3 births. Risks: infection, more blood loss; later previa, uterine rupture or accreta. The baby has more breathing problems right after birth.
Cord prolapse: lift the presenting part off the cord while the team prepares; an emergency C-section is usually needed.
VBAC usually succeeds; its most serious risk is uterine rupture, so continuous monitoring, with a team ready.

Testing before labor

Test	How, and results
Nonstress test	Usually after 28 weeks; no risk; two belts, about 20 to 30 minutes. Reactive: the heart rate rose at least twice, reassuring. Nonreactive: the baby may be asleep; not proof of a problem, but more testing follows
Contraction stress test	Oxytocin or nipple stimulation causes mild contractions. Heart rate slows after them: the baby may struggle in labor
Biophysical profile	Nonstress test plus ultrasound: movement, tone, breathing, amniotic fluid. Often next after a nonreactive test

Reading the tracing

	Reading it
Baseline	Average rate over 10 minutes. Normal 110 to 160 bpm. Above 160: tachycardia (maternal fever or infection, terbutaline, cocaine, abruption). Below 110: bradycardia
Variability	Moderate, 6 to 25 beats, is normal. Minimal: 5 or less. Absent: flat. Marked: over 25
Accelerations	15 beats for 15 seconds after 32 weeks; 10 for 10 before. Moderate variability or accelerations strongly suggest the baby is well oxygenated

Decelerations

	Shape and timing	Means, and what to do
Early	Gradual dip that mirrors the contraction, lowest at its peak	Early decelerations fit a normal tracing: no action needed
Late	Gradual, but lowest after the contraction's peak	Poor blood flow through the placenta: side-lying, an IV bolus, check the contractions, and oxygen only as ordered. After an epidural, check her blood pressure
Variable	Abrupt drop that varies from one contraction to the next	Cord compression: reposition her first; amnioinfusion if they keep recurring. Occasional variables usually need no treatment
Prolonged; sinusoidal	Prolonged: 2 to 10 minutes. Sinusoidal: smooth sine wave, 20 minutes or more	Prolonged 10 minutes or more is a new baseline. Sinusoidal is Category 3

	Tracing, and response
1	Baseline 110 to 160 bpm, moderate variability, no late or variable decelerations. Routine care
2	Everything in between: evaluate, correct the cause, watch closely, reassess
3	Absent variability with recurrent lates, variables or bradycardia; or sinusoidal. Resuscitate in the uterus and prepare for delivery

Contractions and resuscitation

Normal: 5 or fewer contractions in 10 minutes, averaged over 30.
More than 5 is tachysystole: with a worrisome tracing, stop the oxytocin or ripening agent. A short-term tocolytic injection, such as terbutaline, may be ordered; watch her heart rate.
Resuscitation in the uterus combines side-lying (either side), fluids and fewer contractions, with oxygen only as ordered.
Scalp blood pH: below 7.20 is abnormal; 7.20 to 7.25 borderline.

Priority and safety calls

★ Blood pressure falls after an epidural: turn her onto her side first, then fluids, and call the provider about medicine to raise it.
★ On oxytocin with recurrent late decelerations and minimal variability: stop the oxytocin and turn her to her side, then fluids and oxygen as ordered, and notify the provider.
Head about to crown, and she asks for an IV opioid: question it, because it may slow the baby's breathing at birth.
The nurse feels the cord ahead of the head: lift the presenting part off the cord and expect an emergency C-section.

How the NCLEX tests it

Expect true versus false labor, station, the first action after an epidural, and oxytocin that's too strong.
Traps: an opioid just before birth, skipping fluids before an epidural, continuing oxytocin when contractions are too strong.
Expect reactive versus nonreactive, naming a deceleration, the first response to lates, and tachysystole on oxytocin.
Traps: treating early decelerations as an emergency, and raising oxytocin with late decelerations.
Category 3: prepare for delivery. Tachysystole: stop the oxytocin.

Practice it next

This sheet comes from Labor and birth and Fetal monitoring and internal monitoring in our NCLEX-RN course. Try free practice questions, or see the lessons it was written from.

Free NCLEX practice questions The NCLEX-RN course

Quick self-quiz

Full dilation is ___ cm.
Show answer
10
At zero station, the presenting part is level with the ___ spines.
Show answer
ischial
A normal fetal heart rate baseline is 110 to ___ bpm.
Show answer
160
A late deceleration is lowest after the contraction's ___.
Show answer
peak
More than 5 contractions in 10 minutes is called ___.
Show answer
tachysystole

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