# Page 1 Health Promotion and Maintenance Study Guide for the NCLEX-RN® exam

## How to Prepare for Health Promotion and Maintenance Questions on the NCLEX-RN® Exam

### General Information

Questions on this area of nursing competence are related to knowledge of developmental milestones and stages throughout the human life cycle. Knowing what is expected at various stages aids in the prevention and/or early detection of health problems and the provision of optimal healthcare.

### The Aging Process

The aging process begins in infancy and progresses slowly through time to the elderly years. Understanding the different stages of aging is essential as a nurse as you will need to use this knowledge to educate and care for patients of different ages through your career. These stages differ from those discussed in the Safety and Infection Control section. Please make sure you familiarize yourself with the specifics of each.

#### The Stages

Each stage of the aging process is different. While we will discuss each in greater detail later, be familiar with the age ranges of each and understand that each stage will have its own expected developmental milestones, warning signs of deviation(s) from normal, and special needs to consider when planning and communicating care.

Infancy— 0 to 12 months

• Preschool— 1 to 4 years

• School-age— 5 to 12 years

Adolescent— 13 to 18 years (beginning with puberty)

• Working years— 19 to 64 years

• Retirement years— 65 to 85 years

• Elderly— over 85 years

### The Birth Process

Pregnancies are now monitored from the time a mother first learns she is expecting until several weeks after the birth of the child. This type of care ensures the best health outcomes for both the mother and the new baby.

#### Antepartum Care

Also known as prenatal care, antepartum care consists of gathering information about the previous health history of the mother and her current state of health, health information, and counseling that can impact the outcome of her pregnancy as well as several important examinations of mother and baby. This care takes place prior to the birth of the child.

Delivery Date Calculation

One of the first questions that a woman will have once she learns that she is pregnant is when her baby is due. The estimated delivery date is calculated by using Naegele’s Rule. This calculation is based on the first day of the last menstrual period (LMP) and is performed as follows: add 9 months and 7 days to the first day of the LMP. Because the calculation is based on a 28-day menstrual cycle and a 40-week gestation (pregnancy) period, it truly is an estimate. Only $4\%$ of babies are born on their estimated due date.

Full-term pregnancy is defined as birth between 37 and 42 weeks. Premature is any birth before 37 weeks, and we say the baby is overdue when pregnancy lasts over 42 weeks.

Mother’s Health

Proper and complete documentation of the mother’s current and past health history is an important part of prenatal care. This should include information about: blood pressure, weight, lifestyle, family and genetic history, and medications. This includes all prescription, alternative, and over-the-counter medications. There are several medications that are considered Category X, or contraindicated, during pregnancy. They can be harmful to the proper development of a fetus or cause miscarriage. These include: birth control pills, isotretinoin (Accutane), some hyperlipidemia drugs, warfarin (Coumadin), and misoprostol (Cytotec). The vaccinations for measles, mumps, and smallpox can also be harmful to a developing fetus.

It is also helpful to ask about and document the mother’s perception of her pregnancy, her support systems and previous coping mechanisms. Nurses are frontline providers and may assist in making a referral for prenatal support or other counseling if appropriate.

Rh Factor

Rh factor testing is another important piece of proper prenatal care. If the mother is Rh positive (has the factor) or both parents are Rh negative (lack the factor), then further intervention is not necessary. However, if testing reveals that the mother is Rh negative and the father is Rh positive or if the Rh status of the father is unknown, then the mother will require a dose of Rho (D) immune globulin (RhoGAM) in the 28th week of pregnancy to prevent immune-mediated complications later in the pregnancy and at birth.

Tests

A number of tests may be done routinely during the prenatal period. Non-invasive testing includes ultrasound that can confirm pregnancy and fetal viability as well as gestational age, monitor fetal growth and fetal anatomy, and determine the location of the placenta.

Amniocentesis is an invasive prenatal test that can give detailed information on genetic/chromosomal abnormalities of the fetus. While not routinely performed, it is indicated if the mother is over the age of 35 (advanced maternal age) or if there is a positive family history of genetic or metabolic disorders.

Nutrition

Nutrition counseling is an essential part of prenatal care. Up to 50% of all pregnancies are unplanned. Nurses can ensure that mothers are getting the proper nutrients they need to ensure the development of healthy babies and reduce the risk of intrapartum and postpartum morbidity. Pregnant teenagers will require greater amounts of protein, calcium, and phosphorus as their bodies are still growing throughout the pregnancy.

A mother’s average weight gain should be between 22 and 27 pounds during pregnancy. Overweight mothers should gain less and underweight mothers more. Substantial weight gain over this amount can increase the risk of preeclampsia, which endangers both the mother and baby. If excess pregnancy weight is not lost after birth, a mother’s risk of developing hypertension and type II diabetes increases as well.

Fetal Health

Nurses provide valuable information to mothers on normal pregnancy events that help monitor the health of the baby. The first fetal movement or quickening should be felt around week 17 to 19. In some pregnancies, it may be as early as 15 weeks and, in others, as late as 25. Mothers should take note of fetal movement and count kicks as they may provide helpful information on fetal health in the later stages of pregnancy. At each prenatal visit, a fetal heart rate will be taken. Normal range is between 120 and 160 beats per minute.

Signs of Danger

As important as counseling a new mother on ways to take care of herself and baby during pregnancy is counseling her on what to look for if something is wrong is even more so. The following are examples of signs of serious problems or life-threatening conditions:

• Vaginal bleeding

• Severe, unrelenting abdominal pain

• Continuous headaches in the last trimester

• Sudden onset of swelling or severe swelling of the hands and feet in the last trimester

• Blurred or dimmed vision in the last trimester

• Decreased fetal movement past 24 weeks

Cultural Considerations

It is important to get to know the religious and cultural backgrounds and practices of your pregnant patients. Different cultures have very different views regarding pregnancy and the birthing process. Be familiar and accepting with any particular customs and accommodate patients and their families in any way that you can.

#### Intrapartum Care

Intrapartum care is defined as the nursing care that you will give from the onset of labor until birth of the newborn.

Labor Onset

Three main factors trigger the onset of labor: the effect of hormones, the distension of the uterus, and the effect of oxytocin. Two very recognizable signs that labor will begin in the near future are the loss of the cervical mucus plug and rupture of the amniotic membranes. For a patient’s first pregnancy, the entire process from the onset of labor to the birth of the baby may take anywhere between 12 and 14 hours. The time for the process tends to decrease with each subsequent pregnancy.

Stages of Labor

Nurses must be able to identify the stages of labor and properly provide interventions that are specific for each stage.

4 to 10 cm dilation— During this stage of labor, the cervix continues to dilate and soften/stretch/thin (efface). The main nursing interventions will be monitoring and documenting this process and assessing the need for analgesia.

Full dilation to delivery— As the baby descends down the birth canal, the nursing assessment may include changes in the perineum that signal birth is imminent (bulging, increase in bloody show, crowning or visibility of other body parts of the baby), mother’s and baby’s vital signs as well as the position of the baby’s head in the birth canal. Once the baby is born, the assessment will shift to the newborn.

Delivery of baby to delivery of placenta— The placenta is usually delivered within 5 to 20 minutes after the baby’s birth. The nurse should assess the umbilical cord for two arteries and one vein.

Immediate recovery— A new mother’s uterus should be checked frequently for both position and tone for the first hour after birth. Approximately 2 hours after birth, the mother’s vital signs, fundal height, and vaginal bleeding/discharge should be assessed. Her bladder should be checked for signs of distention and the nurse may be needed to assist with breastfeeding if appropriate.

#### Postpartum Care

After the birth of the baby, the new mother will need to be continuously monitored for and instructed on the signs of serious complications. These include:

Hemorrhage

Explain that is is normal to have some bleeding mixed with vaginal discharge for 3 to 6 weeks following delivery. Assess for and educate the patient on abnormal bleeding, such as the passage of large clots or more intense spurts of bleeding.

Infection and Illness

New mothers need to be watched for an increased temperature (over 100.4ºF or 38ºC). Physical signs of infection can include: a sudden increase in perineal pain; copious or smelly vaginal discharge; warm, red or tender breasts; pain with urination; pain with or without swelling in the legs; and chest pain or cough.

#### Neonatal Care

Neonatal care is defined as the care that is given to a newborn infant. One minute following birth, a newborn will be assessed on his or her appearance, vital signs, and breathing. This helps guide appropriate interventions for the baby if indicated.

APGAR Score

The APGAR score is an overall number that is determined from the individual scores of five assessments done 1 minute after birth. The five assessment categories are: appearance (color), heart rate (pulse), grimace (reflex irritability), activity (muscle tone), and respiration (respiratory effort). In each category, a score of 0 to 2 is given where 0 is poor, 1 is okay, and 2 is good. The higher the score, the better. An optimal score is 10.

Complication Warning Signs

Infants must be monitored both in the nursery and by their new mothers carefully for signs of problems or complications following birth. Some warning signs may include: sunken-in or bulging of the cranial soft spots, a fever of greater than 100.4ºF or 38ºC, vomiting more than once in a 24-hour period, the inability to keep food and water down, and labored and/or difficulty breathing.

Newborn Care

Especially for the first-time mother, the nurse can and will provide important information about caring for a newborn. This may include answering questions on basic care, umbilical cord care, bathing, feeding, and parent-child bonding as well as other safety concerns such as carseats, visitors, and sleep positioning.

Other Considerations

The nurse may also need to counsel the new mother on the need for contraception as her menstrual cycle may return within 6 to 8 weeks of delivery. This period may be longer for breastfeeding mothers, and they will need specific forms of contraception while nursing. The postpartum period can be stressful for any new mother. Nurses can educate and inform on the need for intervention if wide emotional swings are noted after the second or third postpartum week.