Maternal and Newborn Care Flashcards

A nurse is caring for a client at 34 weeks gestation diagnosed with HELLP syndrome. Which laboratory finding would the nurse anticipate as the MOST clinically significant indicator of deteriorating condition?

Answer: Platelet count of 85,000/mm³ dropping to 42,000/mm³ over 6 hours

A rapidly falling platelet count — particularly dropping below 50,000/mm³ — signals accelerating hemolysis and severe thrombocytopenia in HELLP syndrome, indicating imminent risk of disseminated intravascular coagulation (DIC) and uncontrolled hemorrhage. This rate of decline over 6 hours is more alarming than isolated elevation of liver enzymes or modest creatinine rise, as it directly threatens clotting ability and maternal survival.

A nurse is monitoring a postpartum client who delivered 18 hours ago. The client has a firm fundus at the umbilicus, minimal lochia rubra, a temperature of 38.4°C, and reports bilateral breast engorgement. Which action is the nurse's PRIORITY?

Answer: Assess the perineum and uterine tenderness for signs of endometritis

While transient engorgement fever can occur around 24–48 hours postpartum, a temperature of 38.4°C at only 18 hours warrants ruling out endometritis before attributing it to engorgement. Endometritis typically presents within the first 24–48 hours post-delivery with uterine tenderness, foul-smelling lochia, and fever. The nurse must assess the uterus and perineum first to differentiate infection from a benign cause — missing early endometritis delays antibiotic therapy and risks sepsis.

A nurse is caring for a newborn at 2 hours of life whose mother received magnesium sulfate for 14 hours prior to delivery. The infant's respiratory rate is 38 breaths/min, tone is decreased, and the Moro reflex is absent. Which nursing intervention is MOST appropriate?

Answer: Prepare calcium gluconate 200 mg/kg IV and notify the neonatal team immediately

Neonatal hypermagnesemia from transplacental transfer can cause respiratory depression, hypotonia, and absent reflexes. The antidote for magnesium toxicity in neonates is calcium gluconate, not naloxone (which reverses opioids). Calcium gluconate 200 mg/kg IV slowly is the recommended treatment and must be prepared immediately while the neonatal team is notified for close respiratory monitoring and potential intubation support.

A nurse is reviewing the prenatal history of a client in active labour. The client has a BMI of 41, gestational diabetes controlled by insulin, and a previous caesarean section via low-transverse incision. She is requesting a trial of labour after caesarean (TOLAC). Which finding would be the STRONGEST contraindication to proceeding with TOLAC?

Answer: Previous uterine incision documented as low-vertical (classical) rather than low-transverse

A prior classical (low-vertical or fundal) uterine incision carries a uterine rupture risk of 4–9%, compared to approximately 0.5–1% for a low-transverse incision. This is an absolute contraindication to TOLAC. Macrosomia (≥4,000–4,500 g) is a relative contraindication, spontaneous labour onset actually improves TOLAC outcomes compared to induction, and epidural use is safe and does not mask uterine rupture warning signs reliably in either case.

A nurse is assessing a newborn at 36 hours of life. Total serum bilirubin is 195 µmol/L. The infant is 38 weeks gestational age, exclusively breastfed, and blood type A positive while the mother is O negative. Direct Coombs test is positive. Which complication is this newborn MOST at risk for if phototherapy is not initiated promptly?

Answer: Kernicterus leading to sensorineural hearing loss and choreoathetoid cerebral palsy

A positive direct Coombs test in a newborn with O-negative mother and A-positive infant confirms ABO incompatibility with active hemolysis. Rapidly rising unconjugated bilirubin crosses the blood-brain barrier and deposits in the basal ganglia and brainstem nuclei (kernicterus/bilirubin encephalopathy), causing irreversible sensorineural hearing loss, choreoathetoid cerebral palsy, upward gaze palsy, and intellectual disability. At 38 weeks gestation, the threshold for phototherapy is lower than term, making prompt intervention critical.

A nurse working in a postpartum unit is assessing a client 72 hours after an uncomplicated vaginal delivery. The client reports she has been unable to sleep, feels detached from her baby, and states 'I keep thinking something terrible is going to happen to him even though I know he is fine.' The client is tearful but oriented, and denies hallucinations or thoughts of harm. Which nursing response is MOST appropriate?

Answer: Screen using the Edinburgh Postnatal Depression Scale and arrange follow-up within 24–48 hours with her primary provider

The client's symptoms — intrusive anxious thoughts, emotional detachment, sleep disruption, and tearfulness at 72 hours — exceed normal postpartum blues (which present as milder mood lability) and suggest early postpartum anxiety or depression rather than psychosis (no hallucinations, delusions, or harm ideation). The EPDS is the validated screening tool recommended in Canadian perinatal guidelines. Immediate psychiatric referral is not warranted without psychotic symptoms, but symptoms require prompt follow-up rather than simple reassurance or sleep advice, as untreated perinatal anxiety/depression can escalate.