Page 1 - Health Promotion and Maintenance Study Guide for the NCLEX-RN Exam
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, you will need to use this knowledge to educate and care for patients of different ages through your career.
Each age range has a unique list of expected development milestones, warning signs of deviation from the normal, and special needs to consider throughout a patient’s nursing care. These categories will be highlighted later in this study guide. The age range of each stage is listed below.
Infancy— 0 to 12 months
Preadolescent (in 2 stages)
- Preschool— 1 to 4 years
- School-age— 5 to 12 years
Adolescent— 13 to 18 years (beginning with puberty)
Adulthood (in three stages)
- 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 infant.
Also known as prenatal care, antepartum care consists of gathering information about and assessing the condition of the mother and her pregnancy prior to the birth of the child. Information regarding the mother’s previous health history, current state of health, critical health information, and counseling is collected by the nurse and healthcare team during this time. This information, or lack thereof, can impact the outcome of the mother’s pregnancy as well as indicate the need for several important examinations of both the mother and child.
Delivery Date Calculation
Upon learning she is pregnant, a mother will often want to know when her baby will be due. An estimated delivery date can be 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: subtract three months from the first day of the LMP and then add seven days. For example, if a woman’s LMP is January 23rd, her estimated delivery date would be October 30th. 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 an infant is considered overdue when the pregnancy extends past 42 weeks.
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 history, 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 and/or cause miscarriage. Medications in this category include: birth control pills, isotretinoin (Accutane), some hyperlipidemia drugs, warfarin (Coumadin), and misoprostol (Cytotec). The vaccinations for measles, mumps, and rubella (MMR) and smallpox can also be harmful to a developing fetus.
It is 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 testing is another important piece of proper prenatal care. If the mother is Rh-positive (has the factor) or both parents are Rh-negative (lacks 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.
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 provide information regarding gestational age, monitor fetal growth, and help identify fetal anatomy. Ultrasound can also 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 may be 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 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 promote the healthy development of their 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.
Nurses may educate mothers on normal pregnancy events. These events provide quality information regarding the status and health of both the mother and fetus. The first fetal movement or quickening should be felt around 17–19 weeks. In some pregnancies, this movement may be felt as early as 15 weeks or as late as 25 weeks. 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 mother on ways to take care of herself and her child during pregnancy, 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
It is important to get to know the religious and cultural backgrounds and practices of 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 possible.
Intrapartum care is defined as the nursing care provided from the onset of labor until birth of the newborn.
Three main factors trigger the onset of labor: the effect of hormones, the distension of the uterus, and the effect of oxytocin. Two recognizable signs that labor will begin in the near future include the loss of the cervical mucus plug and rupture of the amniotic membranes. For a mother’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. With each subsequent pregnancy, this time frame tends to shorten unless there is an extended period of time between pregnancies—usually more than several years.
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 efface (soften/stretch/thin). The main nursing interventions during this time 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 grows to include noting changes in the perineum that signal birth is imminent (bulging, increase in bloody show, crowning or visibility of other body parts of the baby), recording vital signs of both mother and baby, and identifying the position of the baby’s head in the birth canal.
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 assist the mother with breastfeeding, if appropriate.
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:
Explain that it 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 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.
The APGAR score is a number determined from the individual scores of five assessments done at 1 minute and again at 5 minutes 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. A baby with a score of 7 or above is considered to be a healthy newborn. Scores lower than 7 may indicate the newborn’s need for further medical support or intervention.
Complication Warning Signs
Infants must be carefully monitored for signs of distress or complications following birth. Some warning signs or reasons for concern include: sunken-in or bulging cranial soft spots, 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.
Nurses must provide important information and education regarding the care of a newborn. This may include answering questions on basic care, umbilical cord care, bathing, feeding, and parent-child bonding. Nurses may also address safety concerns such as car seats, preferred visitor policies, and sleep positioning.
Care of the Mother
It may be indicated for nurses to counsel postpartum women on their contraceptive options. A woman’s menstrual cycle may return within 6 to 8 weeks of delivery. While breastfeeding mothers may not see their menstrual cycle return until much later than non-breastfeeding mothers, breastfeeding compatible (progestin-only) contraceptive options should still be offered.
The postpartum period can be stressful for any new mother. Nurses should help mothers recognize signs of postpartum depression and encourage mothers to seek medical guidance if wide emotional swings are noted after the second or third postpartum week.