Fetal monitoring without the confusion
Fetal heart rate interpretation is the most testable maternity skill because it produces clear right answers. Start with the baseline, which should be 110 to 160 beats per minute. Then look at variability, which reflects an intact nervous system; moderate variability is reassuring and its absence is the single most concerning finding on a strip.
Then classify the decelerations by their timing relative to contractions. Early decelerations mirror the contraction and reflect head compression; they are benign and require no intervention. Variable decelerations are abrupt and vary in timing, reflecting cord compression; reposition the client and consider amnioinfusion if ordered. Late decelerations begin after the contraction peaks and return to baseline after it ends; they reflect uteroplacental insufficiency and are the pattern requiring immediate intervention.
The intervention bundle is the same for any non-reassuring pattern, and memorising it in order gives you a ready-made answer for a whole family of questions: reposition to left lateral, discontinue oxytocin if infusing, administer oxygen by non-rebreather mask, increase the intravenous fluid rate, and notify the provider. If an option offers the earliest step in that sequence and another offers notification, choose the nursing action first unless the client is in extremis.
- •Baseline 110–160; moderate variability is reassuring
- •Early decelerations — head compression — no action needed
- •Variable decelerations — cord compression — reposition
- •Late decelerations — uteroplacental insufficiency — full intervention bundle
Postpartum priorities and haemorrhage
Postpartum haemorrhage is the leading maternal emergency on the exam, and uterine atony is by far its most common cause. Fundal assessment tells you almost everything: a firm fundus at the midline at the level of the umbilicus is reassuring. A boggy fundus means atony and the first action is massage. A fundus displaced to the right and elevated means a full bladder, so the next action is to have the client void or catheterise.
Quantify the bleeding rather than judging it subjectively. Saturating a perineal pad within fifteen minutes, or a continuous trickle of bright red blood with a firm fundus, suggests a laceration rather than atony and requires provider notification. Watch for the late signs of hypovolaemia — rising pulse, falling blood pressure, restlessness — and recognise that a young healthy mother compensates well until she suddenly does not.
Other postpartum items focus on infection, thromboembolism and mood. Fever above 38°C after the first twenty-four hours suggests endometritis. Unilateral calf pain with swelling suggests deep vein thrombosis. Distinguish postpartum blues, which are transient and self-limiting, from postpartum depression, which persists and impairs function, and from postpartum psychosis, which is an emergency requiring immediate safety measures for mother and infant.
| Finding | Likely cause | First nursing action |
|---|---|---|
| Boggy fundus, heavy lochia | Uterine atony | Massage the fundus |
| Fundus deviated right and high | Full bladder | Assist the client to void |
| Firm fundus, steady bright red trickle | Laceration | Notify the provider |
| Temperature above 38°C after 24 hours | Endometritis | Assess lochia and notify the provider |
| Unilateral calf swelling and pain | Deep vein thrombosis | Do not massage; notify the provider |
Hypertensive disorders and magnesium
Pre-eclampsia questions test your ability to spot progression. New hypertension after twenty weeks with proteinuria defines the condition, but the findings that signal severe disease are the ones the exam cares about: severe headache unrelieved by paracetamol, visual disturbances, right upper quadrant or epigastric pain, and brisk reflexes with clonus. Epigastric pain in particular signals hepatic involvement and impending seizure.
Magnesium sulfate is given for seizure prophylaxis, not for blood pressure control, and its monitoring parameters are heavily tested. Assess deep tendon reflexes, respiratory rate, level of consciousness and urine output before and during infusion. Loss of reflexes is the earliest reliable sign of toxicity, followed by a respiratory rate under twelve and urine output below thirty millilitres per hour. Stop the infusion and administer calcium gluconate.
Eclampsia — the onset of seizures — is managed by protecting the airway, turning the client to her side, ensuring safety without restraining, and calling for help. Do not insert anything into the mouth. After the seizure, assess the fetus, prepare for possible delivery, and continue magnesium therapy as ordered.
- •Severe features: headache, visual changes, epigastric pain, clonus
- •Magnesium monitoring: reflexes, respirations, urine output, consciousness
- •Calcium gluconate is the magnesium antidote
- •During a seizure: side-lying, protect, never restrain or insert anything orally
Newborn assessment essentials
Newborn items focus on transition. Apgar scoring at one and five minutes assesses heart rate, respiratory effort, muscle tone, reflex irritability and colour, with each scored zero to two. A score of seven or above is reassuring; four to six indicates moderate difficulty requiring stimulation and oxygen; three or below requires resuscitation.
Know the normal values so you can spot deviation: heart rate 110 to 160, respirations 30 to 60 and irregular, axillary temperature 36.5 to 37.5 degrees Celsius, and blood glucose above 40 milligrams per decilitre. Hypoglycaemia presents as jitteriness, poor feeding, lethargy and temperature instability, and is especially likely in infants of diabetic mothers and in large or small for gestational age babies.
Distinguish normal newborn variations from concerns. Acrocyanosis, milia, Mongolian spots, molding and pseudomenstruation are all normal. Central cyanosis, grunting, nasal flaring, sternal retractions, a bulging fontanelle and jaundice within the first twenty-four hours are not, and each requires prompt reporting.