Page 2 - Health Promotion and Maintenance Study Guide for the NCLEX-PN Exam
Ante/Intra/Postpartum and Newborn Care
When delivering care to a pregnant client, there are certain common tasks the nurse may be asked to perform and special considerations for this client population.
Assessing the Client
When assessing pregnant clients, in addition to the physical assessment, the nurse should assess for psychosocial aspects of the pregnancy. The nurse should gauge the client’s emotional preparedness for the new child along with what support systems are available and the perception of the pregnancy. This may or may not include the client’s partner.
Assisting with Tests
Pregnant clients undergo a number of tests during pregnancy, and the nurse may be asked to assist. In early pregnancy, the client will undergo tests to determine if she is likely to develop gestational diabetes. Further along in the pregnancy, the nurse may assist with non-stress tests along with fetal heart rate monitoring.
During labor, the nurse will continue to assess the client, ensuring that the blood pressure is stable and fluids are adequate. The nurse may also assist with fetal heart rate monitoring. Depending on the client’s preferences, the nurse may assist with pain interventions. The priority should always be on the safety of the mother and the baby.
Immediately after the delivery, the nurse will have a new client: the baby. The mother should continue to be assessed, and the baby will undergo assessments as well.
Immediately after the delivery of the baby, the mother’s labor will continue as the placenta is delivered. At this point, the mother is at risk for blood loss and hemorrhage and should be monitored closely. If the mother is stable, this is the ideal time to encourage skin-to-skin contact between the mother and baby.
Following labor, the mother should continue to be monitored to ensure she is stable. Vital signs will be taken regularly, pain assessments will be made, and medications and fluids will be administered as necessary. It is also very common for the mother to be extremely tired and request rest.
The nurse will be able to assist with the care of the mother after labor. This may include perineal care as needed, and the nurse should monitor for excess bleeding during this. The nurse may also provide the mother with assistance in feeding the infant, including discussing the mother’s preference of breastfeeding versus bottle feeding.
Immediately after birth, the infant will be routinely assessed to ensure there are no post-birth complications. The infant should be kept dry and warm to avoid hypothermia. APGAR scores are collected at 1 minute and 5 minutes after birth. If the score is less than 7 after 5 minutes, these will continue to be performed every 20 minutes.
Contribute to Plan of Care
The newborn’s assessment will determine the appropriate plan of care. If the newborn has low APGAR scores, he or she may require additional intervention and monitoring. As the nurse cares for the newborn, constant observation can assist in contributing to the plan of care.
Infant Care Skills
One of the most important areas of postnatal care is assisting the mother and her support system in infant care skills. The nurse can assist with reinforcing teaching of basic infant care and monitor the ability to care for the child.
Types of Data
As part of the nurse’s care, there are multiple types of data elements that will be collected, synthesized, and documented.
In the inpatient and outpatient setting, one of the first data elements collected is the client’s health history. This usually starts with the client’s medical history, such as illnesses, injuries, or conditions, along with their surgical history, allergies, and home medications. Additionally, it is helpful to gather the family’s medical history as well to be alert for any genetic predispositions.
A baseline physical exam will be performed in most scenarios. This will include the client’s height and weight and vital signs (heart rate, pulse oximetry, blood pressure, respiratory rate, temperature). The client’s condition may require a more focused physical exam in specific areas. When a client is admitted to the hospital, skin integrity should be assessed to ensure the baseline on admission is documented.
In the age of electronic medical records, data usage is of high importance. There are regulations around the appropriate use of clients’ private health information that must be followed at all times.
The nurse should document data in the client’s medical record when performing assessments and interventions. The nurse’s findings should be documented according to the facility’s policies. In some facilities, after the baseline for the client is established, the nurse can document by exception, only documenting the findings that deviate from normal.
The data should be reported to other members of the care team, including the primary healthcare provider. This may be performed at the end of shift when handing over care to another nurse or during rounds when the primary healthcare provider is present to review the client’s status. When reporting data, the client’s privacy should be respected and appropriate regulations adhered to.