NCLEX-RN cheat sheet · Maternal and newborn

Postpartum and newborn care

Uterus and lochia, hemorrhage, mood, Apgar, first medicines, jaundice, low glucose, the high-risk newborn

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After birth, the danger isn't over: bleeding, infection, high blood pressure and depression show up in the weeks that follow.

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At a glance

Uterus and lochia

	Expect
Uterus	Hard and round near the navel shortly after birth; hard to feel within about a week. Breastfeeding helps it contract (afterpains)
Lochia	Red, with small clots when she first gets up; then pink, then yellow or white, up to 6 weeks. A brief red increase around days 7 to 14 can be normal
Not normal	Soaking more than 1 pad an hour, clots bigger than a golf ball, a foul odor. Bleeding that doesn't slow may mean retained placenta

Postpartum hemorrhage

WHO: 500 mL or more; act at 300 mL if vital signs are abnormal. U.S.: 1,000 mL or more, or any loss with low-volume signs.
Signs: soft uterus, heavy bleeding, rising pulse or falling pressure.
Uterine massage and an oxytocic, preferably oxytocin; then tranexamic acid, IV fluids, a genital tract exam, escalation. These steps happen together, so call for help at once.
Methylergonovine: contraindicated with hypertension or preeclampsia. Not given IV routinely.
Rh-negative mother (negative antibody screen), Rh-positive baby: Rho(D) immune globulin to her within 72 hours; route per label.

Recovery teaching

Perineum: ice packs for the first 24 hours, then warm baths.
Ibuprofen for pain; stool softeners, fiber and fluids; avoid enemas.
Wait 6 weeks for tampons, sex and impact exercise.
She can conceive as soon as 4 weeks after birth: discuss contraception before discharge.
Not breastfeeding: a supportive bra around the clock, no nipple stimulation, ice and ibuprofen.

Call: warning signs for a year

A fever that persists, heavier or foul-smelling discharge, increasing belly or perineal pain.
A tender, red, warm area on one breast: may be infection. A swollen, painful leg: a possible clot.
Postpartum preeclampsia: swelling of the hands or face, a lasting headache, vision changes, a gain over 2 lb in a week.
Trouble breathing, chest pain, a racing heart or fainting: urgent.

Baby blues or postpartum depression?

	Baby blues	Postpartum depression
When	Common in the first week or two; pass without treatment	Any time in the first year, usually within 3 months
Signs	Tearfulness, anxiety, irritability	More severe: loss of interest, guilt, sleep and appetite changes, trouble caring for herself or the baby
Care	Blues that last past 2 weeks: get help	Screen in pregnancy and after birth (Edinburgh scale). Talk therapy, medicine chosen with breastfeeding in mind

Right away: Thoughts of harming herself or the baby, or hallucinations: get help right away. She can call or text 988, or call 911.

Apgar score: at 1 and 5 minutes

Sign	0	1	2
Heart rate	None	Under 100 bpm	100 bpm or more
Breathing	None	Slow, irregular	Good cry
Tone	Floppy	Some tone	Active motion
Reflex response	None	Grimace	Grimace with a cough, sneeze or cry
Color	Pale blue	Pink body, blue hands and feet	All pink

Reading it: 7 to 9 is normal; blue hands and feet are normal at first. Under 7 needs close attention; any help with breathing follows the newborn resuscitation steps, not the score.

First medicines and screening

	Give or check
Vitamin K	One IM shot in the thigh just after birth: prevents vitamin K deficiency bleeding
Eyes	Erythromycin, once, soon after birth: prevents bacterial eye infection
Hepatitis B	Vaccine usually at birth; check the current schedule. Mother surface antigen positive: vaccine and immune globulin within 12 hours, separate sites
Heart	Pulse oximetry at 24 hours of age or later. Fails: evaluation, usually an echocardiogram
Hearing	1, 3, 6: screen before 1 month, diagnose by 3 months, intervention by 6

Daily care and safe sleep

Cord: falls off by 5 to 15 days. Gauze and water only; sponge-bathe; never pull it. Report foul yellow drainage, redness, bleeding.
Circumcision: petroleum jelly at each diaper change; some swelling and yellow crusting is normal; new bleeding, pus or severe pain is not.
Back to sleep, every sleep, until age 1. Only a fitted sheet. Share the room, not the bed, for at least the first 6 months.

Jaundice

Shows at 2 to 4 days, gone within 2 weeks; in the first 24 hours it isn't normal. Starts on the face, moves down to the soles.
Severe jaundice is more likely with an Rh or ABO mismatch, a cephalohematoma, infection or prematurity.
Feed often, 8 to 12 times a day, so stools carry bilirubin out.
Phototherapy: only a diaper and eye shades, in a warm bed. Keep breastfeeding; count wet and dirty diapers.
Jaundice with fever, listlessness or poor feeding is an emergency. Very high bilirubin can damage the brain (kernicterus).

Newborn low blood sugar

At risk: born early, infection, needing oxygen, a mother with diabetes, small or large for age.
Many have no symptoms: at-risk babies get heel-stick glucose checks until levels stay normal for 12 to 24 hours.
Signs: tremors, poor feeding, floppiness, trouble staying warm, apnea, grunting, seizures.
Treat: an extra feeding of breast milk or formula, oral glucose gel, or IV glucose if needed.

The high-risk newborn

	Look for	Care
Preterm, before 37 weeks	Apnea, lanugo, little body fat, low tone, soft ear cartilage, thin shiny skin. Trouble breathing and keeping warm	Warmer or incubator. Before 34 weeks most can't coordinate sucking and swallowing: fed by tube or vein
Respiratory distress syndrome	Too little surfactant; signs within minutes; the x-ray looks like ground glass	Oxygen, surfactant, continuous positive airway pressure or a ventilator. Prevention: steroids to the mother at 24 to 34 weeks
Transient tachypnea	Leftover lung fluid, often after a C-section without labor; fast breathing within 1 to 2 hours	Usually clears within 48 to 72 hours
Meconium	A stressed baby breathes in stool-stained fluid	Active, crying baby: no treatment. If not: warm, dry, stimulate
Withdrawal (neonatal abstinence)	Usually in 1 to 3 days: high-pitched cry, irritability, tremors, poor feeding. Watch up to a week	Low stimulation: low light and noise, swaddling, skin-to-skin. Small, frequent feeds
Sepsis	Subtle: temperature changes, poor sucking, less movement, breathing problems. Risks: group B strep, membranes ruptured over 18 hours	Under 4 weeks with fever or signs of infection: IV antibiotics right away, without waiting for results

Breathing: Normal newborn breathing is 40 to 60 a minute. All three breathing problems can bring cyanosis, fast breathing, grunting, nasal flaring and retractions.

Priority and safety calls

★ An hour after birth, a soft uterus and a pad soaked in 15 minutes: massage the uterus and call for help.
Question methylergonovine for a client with a blood pressure of 162/104 mmHg.
★ Infant of a mother with diabetes, jittery and feeding poorly: check the blood glucose with a heel stick first.
Unstable temperature, poor sucking, seems less active, but no fever: suspect sepsis.

How the NCLEX tests it

Expect a soft uterus with heavy bleeding, normal lochia, methylergonovine, Rho(D), and blues versus depression.
Traps: reassuring large clots, methylergonovine with high blood pressure, dismissing thoughts of harm.
Expect Apgar math, vitamin K, jaundice timing and phototherapy, hypoglycemia, cord care and safe sleep.
Traps: blankets in the crib, bed sharing, calling jitteriness normal in an infant of a diabetic mother.
Traps: waiting for fever to suspect sepsis, a bright, noisy room for withdrawal, bottle-feeding a baby who can't coordinate swallowing.

Practice it next

This sheet comes from Postpartum care and complications and Newborn care and The high-risk newborn 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

An Rh-negative mother with a negative antibody screen and an Rh-positive baby gets Rho(D) immune globulin within ___ hours.
Show answer
72
A normal Apgar score is 7 to ___.
Show answer
9
Vitamin K is one IM shot in the ___.
Show answer
thigh
Physiological jaundice shows at 2 to ___ days.
Show answer
4
Normal newborn breathing is 40 to ___ a minute.
Show answer
60

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