Maternal and Newborn Care Flashcards

A client at 34 weeks gestation is admitted with severe preeclampsia and receiving IV magnesium sulfate. Her respirations drop to 10 breaths/minute and her patellar reflexes are absent. Which action is the nurse's FIRST priority?

Answer: Administer calcium gluconate 1 g IV slowly

Absent patellar reflexes and a respiratory rate below 12 breaths/minute are signs of magnesium sulfate toxicity. Calcium gluconate is the antidote and must be administered immediately to reverse toxicity and prevent respiratory arrest. Notifying the physician is important but not the first action when the client is in immediate danger. Oxygen alone will not reverse the toxicity, and decreasing the infusion rate is insufficient once toxicity has occurred.

A nurse is caring for a newborn at 2 hours of life whose blood glucose is 2.1 mmol/L. The infant is vigorous, rooting, and breastfeeding is initiated. A repeat glucose 30 minutes after the first feeding is 2.4 mmol/L. What is the most appropriate nursing action?

Answer: Apply dextrose gel to the buccal mucosa and recheck in 30 minutes

Buccal dextrose gel (40% gel, 200 mg/kg) is a current evidence-based first-line intervention for asymptomatic neonatal hypoglycemia that does not respond adequately to the first feeding. A glucose of 2.4 mmol/L after feeding remains below the acceptable threshold (typically ≥2.6 mmol/L), but the infant is asymptomatic. Dextrose gel supports glucose levels while maintaining breastfeeding. IV dextrose is reserved for symptomatic or refractory hypoglycemia. Formula supplementation alone would not act as quickly as buccal gel in the immediate term.

A multiparous client is in active labour at 8 cm dilation. The fetal monitor shows a normal baseline of 140 bpm with recurrent late decelerations and minimal variability for the past 20 minutes. Oxygen via mask is in place and the client is repositioned to a left lateral position. What is the next priority nursing intervention?

Answer: Increase the IV fluid rate and discontinue oxytocin if infusing

Recurrent late decelerations with minimal variability indicate uteroplacental insufficiency and potential fetal compromise. After repositioning and applying oxygen, discontinuing oxytocin (if infusing) removes the stimulus causing excessive uterine activity, and IV fluid bolus improves placental perfusion. These are standard NICHD Category II/III management steps. Cord prolapse is associated with variable decelerations, not late decelerations. Vacuum delivery is a physician/midwife decision and the client is only at 8 cm. Tocolytics require a physician order and are not a first-line independent nursing intervention in this context.

A newborn is delivered at 39 weeks to a mother with a positive Group B Streptococcus (GBS) culture. The mother received one dose of penicillin two hours before delivery. The newborn appears vigorous with Apgar scores of 8 and 9. What is the most appropriate management for this newborn?

Answer: Observe the newborn for a minimum of 48 hours and monitor for signs of early-onset sepsis

When a mother is GBS positive but receives intrapartum antibiotic prophylaxis (IAP) less than 4 hours before delivery, prophylaxis is considered inadequate. Current guidelines (e.g., CDC, SOGC) recommend enhanced observation for at least 48 hours for vigorous full-term newborns born to mothers with inadequate IAP. Empiric antibiotics are not indicated in an asymptomatic vigorous newborn without other risk factors. Early discharge at 24 hours is inappropriate given the risk period. Prophylactic antibiotics given to a vigorous, asymptomatic newborn is not standard practice without clinical signs or lab abnormalities.

On postpartum day 3, a breastfeeding client reports bilateral breast engorgement, a temperature of 37.9°C, and general flu-like myalgia. The breasts appear symmetrically full and firm without localized redness or a palpable mass. What should the nurse advise?

Answer: Increase the frequency of feedings or pumping and reassess in 24 hours

The presentation described — bilateral symmetric engorgement with low-grade temperature and myalgia on day 3 postpartum — is consistent with normal physiologic breast engorgement (milk 'coming in'), not mastitis. Mastitis typically presents as a unilateral wedge-shaped area of erythema, warmth, and induration, usually after the first week. The correct management for engorgement is frequent, effective milk removal (feeding or pumping), proper latch assessment, and symptom management. Antibiotics are not indicated. Discontinuing breastfeeding worsens engorgement. Misdiagnosing this as mastitis leads to unnecessary antibiotic use.

A nurse assesses a newborn at 24 hours of life and notes a firm, well-demarcated, non-pitting swelling over the right parietal bone that does not cross the suture lines. The newborn is alert, feeding well, and vital signs are stable. Which complication should the nurse monitor for over the next few days?

Answer: Jaundice secondary to breakdown of red blood cells in the hematoma

The described findings are classic for a cephalohematoma — a subperiosteal blood collection that respects suture lines. As the red blood cells in the hematoma break down, bilirubin is released, placing the newborn at increased risk for hyperbilirubinemia and jaundice in the days following birth. This is the most clinically relevant complication to monitor for. Subdural hemorrhage is a separate and more serious intracranial injury not associated with this presentation. While an underlying linear skull fracture can co-exist with cephalohematoma, it does not typically alter management in an asymptomatic newborn. Infection of cephalohematomas is rare.