MATERNAL & CHILD NURSING BULLETS (NLE & NCLEX) Unlike false labor, true labor pr

oduces regular rhythmic contractions, abdominal

discomfort, progressive descent of the fetus, bloody show, and progressive
effacement and dilation of the cervix.
To help a mother break the suction of her breast-feeding infant, the nurse shoul
d teach her to insert a finger at the corner of the infant’s mouth. Administering
high levels of oxygen to a premature neonate can cause blindness as a result of
retrolental fibroplasia.
Amniotomy is artificial rupture of the amniotic membranes.
During pregnancy, weight gain averages 25 to 30 lb (11 to 13.5 kg).
Rubella has a teratogenic effect on the fetus during the first trimester. It
produces abnormalities in up to 40% of cases without interrupting the pregnancy.
Immunity to rubella can be measured by a hemagglutination inhibition test
(rubella titer). This test identifies exposure to rubella infection and determin
es
susceptibility in pregnant women. In a woman, a titer greater than 1:8 indicates
immunity.
When used to describe the degree of fetal descent during labor, floating means
the presenting part isn’t engaged in the pelvic inlet, but is freely movable
(ballotable) above the pelvic inlet.
When used to describe the degree of fetal descent, engagement means when the lar
gest diameter of the presenting part has passed through the pelvic inlet.
Fetal station indicates the location of the presenting part in relation to the i
schial spine. It’s described as –1, –2, –3, –4, or –5 to indicate the number of centimeters
above the level of the ischial spine; station –5 is at the pelvic inlet. Fetal sta
tion also is described as +1, +2, +3, +4, or +5 to indicate the number of centim
eters it is below the level of the ischial spine; station 0 is at the level of t
he ischial spine. During the first stage of labor, the side-lying position usual
ly provides the
greatest degree of comfort, although the patient may assume any comfortable
position.
During delivery, if the umbilical cord can’t be loosened and slipped from around
the neonate’s neck, it should be clamped with two clamps and cut between the
clamps.
An Apgar score of 7 to 10 indicates no immediate distress, 4 to 6 indicates mode
rate distress, and 0 to 3 indicates severe distress. To elicit Moro’s reflex, the
nurse holds the neonate in both hands and suddenly,
but gently, drops the neonate’s head backward. Normally, the neonate abducts and
extends all extremities bilaterally and symmetrically, forms a C shape with the
thumb and forefinger, and first adducts and then flexes the extremities.
Pregnancy-induced hypertension (preeclampsia) is an increase in blood pressure
of 30/15 mm Hg over baseline or blood pressure of 140/95 mm Hg on two occasions
at least 6 hours apart accompanied by edema and albuminuria after 20 weeks’
gestation.
Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and
fetal movement felt by the examiner (not usually present until 4 months’ gestation
Goodell’s sign is softening of the cervix. Quickening, a presumptive sign of pregn
ancy, occurs between 16 and 19 weeks’ gestation.
Ovulation ceases during pregnancy.
Any vaginal bleeding during pregnancy should be considered a complication until
proven otherwise. To estimate the date of delivery using Nägele’s rule, the nurse co
unts backward 3 months from the first day of the last menstrual period and then
adds 7 days to this date. At 12 weeks’ gestation, the fundus should be at the top
of the symphysis pubis. Cow’s milk shouldn’t be given to infants younger than age 1
because it has a low linoleic acid content and its protein is difficult for infa
nts to digest. If jaundice is suspected in a neonate, the nurse should examine t
he infant under natural window light. If natural light is unavailable, the nurse
should examine the infant under a white light. The three phases of a uterine co
ntraction are increment, acme, and decrement. The intensity of a labor contracti
on can be assessed by the indentability of the
uterine wall at the contraction’s peak. Intensity is graded as mild (uterine muscl
e is
somewhat tense), moderate (uterine muscle is moderately tense), or strong (uteri
ne
muscle is boardlike).