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Blueprint for Mock NCLEX
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Pregnancy-induced hypertension (PIH)
Hypertension Disorders in Pregnancy (Preeclampsia) → Can develop anytime during pregnancy
Preeclampsia is caused because of abnormal developmental of the placenta.
Screening for PIH→ sudden weight gain, proteinuria, HTN 140/90, pitting edema, headache, blurry vision, RUQ pain
Preeclampsia Risk Factors:
Primigravida/New Partner
Teen/Geriatric Pregnancy
Multifetal (Twins/Triplets)
Obesity
Pre-existing (Diabetes/HTN/CKD)
African American
IVF, Egg Donor, or Donor Insemination
Clinical Manifestations→ increased BP, decreased placental perfusion, IUGR (Intrauterine growth restriction), HELLP
syndrome (Check ALT & AST), Extreme Fatigue, Flu-like Symptoms, Epigastric Pain, N/V, Headache
Pre-Eclampsia Nursing Management
● Premature Infant: Betamethasone Shots (Promote Lung Development)
● Pharmacologic Treatment: Antihypertensives (Labetalol) 1st Line
● Magnesium Sulfate (IV) (Hospital Only) (Severe Signs of H/A & Blurry Vision)
○ Antidote→ Calcium Gluconate
● Seizure Precaution: Suction, Oxygen, Seizure Pads
Eclampsia→ S/S of HELLP (Hemolysis, Elevated Liver enzyme, Low Platelet) or Pre-Eclampsia with:
★ Altered mental statue
★ Convulsions appearing w/out warning
★ Vision problems
Management
★ Ensuring patent airway & client safety
★ Magnesium Sulfate
★ Maternal stabilization
★ Emergent Delivery
Placental Abruption
Premature separation of the placenta from the uterine wall after the 20th week of gestation and
before the fetus is delivered.
Assessment
1. Dark red vaginal bleeding. If the bleeding is high in the uterus or is minimal, there can be
an absence of visible blood.
2. Uterine pain or tenderness or both
3. Uterine rigidity
4. Severe abdominal pain
5. Signs of fetal distress
6. Signs of shock if bleeding is excessive
Interventions
1. Monitor the client’s vital signs and fetal heart rate.
2. Assess for excessive vaginal bleeding, abdominal pain, and an increase in fundal height.
3. Maintain bed rest; administer oxygen, IV fluids, and blood products as prescribed.
4. Place the client in Trendelenburg’s position if indicated to decrease the pressure of the fetus
on the placenta, or place in the lateral position with the head of the bed if hypovolemic
shock occurs.
5. Monitor and report any uterine activity.
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6. Prepare for delivery of the fetus as quickly as possible, with vaginal delivery preferable if the fetus is
healthy and stable and the presenting part is in the pelvis; emergency cesarean delivery is performed if the
fetus is alive but shows signs of distress.
7. Monitor for signs of disseminated intravascular coagulation in the postpartum period.
In placenta previa, there is painless, bright red vaginal bleeding, and the uterus is soft, relaxed, and nontender.
In abruptio placentae, there is dark red vaginal bleeding, uterine pain or tenderness or both, and uterine rigidity.
DIC (disseminated intravascular coagulation) → uncontrolled bleeding, oozing from IV site, petechiae
Late deceleration is a sign of fetal distress for placental deficiency and immediate delivery is needed.
Diagnosis confirmed by ultrasound
Nursing Interventions:
● Monitor vital signs, FHR, and fetal activity
● Avoid vaginal examinations
● Maintain bedrest in side-lying position
● Monitor and treat signs of shock
● Administer IV fluids, blood replacement products, or tocolytics, as well as RhoGAM if indicated
Magnesium Sulfate
● Magnesium sulfate is a central nervous system depressant and antiseizure medication.
● The medication causes smooth muscle relaxation.
● The antidote is calcium gluconate.
Use to prevent preterm birth and preventing and controlling seizures in preeclamptic and eclamptic clients.
Magnesium sulfate can cause respiratory depression, depressed reflexes, flushing, hypotension, extreme muscle
weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.
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Non-stress tests
● The test is performed to assess placental function and oxygenation.
● The test determines fetal well-being.
● The test evaluates the fetal heart rate (FHR) response to fetal movement.
Interventions
1. An external ultrasound transducer and tocodynamometer are applied to the client, and a tracing of at least
20 minutes duration is obtained so that the FHR and uterine activity can be observed.
2. Baseline blood pressure is obtained, and blood pressure is monitored frequently.
3. The client is placed in the lateral (side-lying) position to avoid vena cava compression.
4. The client may be asked to press a button every time the client feels fetal movement; the monitor records a
mark at each point of fetal movement, which is used as a reference point to assess the FHR response.
Results
Reactive Nonstress Test (Normal, Negative) “Reactive” indicates a healthy fetus. The result requires 2 or
more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of
the acceleration to the end, in association with fetal movement, during a 20-minute period.
Nonreactive Nonstress Test (Abnormal) No accelerations or accelerations of less than 15 beats per minute
or lasting less than 15 seconds in duration occur during a 40-minute observation.
Unsatisfactory The result cannot be interpreted because of the poor quality of the FHR tracing.
Thermoregulation of newborn
Newborns do not shiver to produce heat. Newborns have brown fat deposits, which produce heat.
Heat loss can occur via evaporation, radiation, convection, and conduction.
● Prevent heat loss resulting from evaporation by keeping the newborn dry and well-wrapped with a blanket.
● Prevent heat loss resulting from radiation by keeping the newborn away from cold objects & outside walls.
● Prevent heat loss resulting from convection by shielding the newborn from drafts.
● Prevent heat loss resulting from conduction by performing all treatments on a warm, padded surface.
Take the newborn’s axillary temperature every 30 minutes for the first 2 hours of life until the newborn is stable,
every 4 hours for the remainder of the first 24 hours, and then every shift (as per agency protocol).
Postpartum Hemorrhage
● > 500mL of Blood Loss in Vaginal Delivery
● > 1000mL of Blood Loss in C-Section
S&S: Uncontracted uterus; Large gush or slow steady trickle of blood; Saturation of more than 1 pad/hour; Severe,
unrelieved perineal or rectal pain; Tachycardia; Boggy Fundus; Excessive lochia w/ Large Clots; Displaced Fundus;
Hypotension is a LATE SIGN; Hypovolemic Shock
Causes of PPH: 4 T’s→ Tone, Trauma, Tissue, Thrombin
Hemabate (Avoid in patients w/ Asthma) & Methergine (can cause HTN)
● Stimulates contraction of the uterus.
Nursing Interventions
Massage Fundus
Monitor V/S
Weigh pads/assess how many are saturated
Empty bladder if fundus displaced to the right
Pharmacologic Measures (Pain, Bleeding)
Call a physician and prepare to administer blood products
Hypovolemic Shock → Results from complications of postpartum hemorrhage
S&S: Tachycardia (Early Sign)
● Hypotension
● Tachypnea; Increased Anxiety
● As hemorrhage worsens: Increased Pallor; Cold & Clammy Skin
● As shock progresses: CNS Changes (Anxiety, Confusion, Lethargy); Urine output 5mL/hr
● If signs are present, notify the provider, ↑ fluid volume, locate the source of bleeding, & prepare for surgery.
Treatment: Restoring circulating blood volume & eliminating the cause of the hemorrhage
● Fluid or blood replacement therapy
● Restore oxygen delivery to the tissues and maintain cardiac output
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Goals → Control bleeding & prevent hypovolemic shock from becoming irreversible.
Nursing intervention
2nd Large Bore IV Line for Blood
Increase the fluid volume until urine output is 30 mL/hr
Evaluate & Record VS (BP & P Q3-5 minutes)
Height, Consistency of Fundus, & Amount of Lochia
Skin Temp., Color, Capillary Refill, O2 SATs
Labs: H & H, Clotting Studies, Type & Cross Match
Insert catheter to monitor hourly urine outputs
Hyperemesis Gravidarum
Intractable nausea and vomiting during the first trimester that causes disturbances in nutrition and fluid and
electrolyte balance
Assessment
1. Nausea most pronounced on arising; may occur at other times during the day
2. Persistent vomiting
3. Weight loss
4. Signs of dehydration
5. Fluid and electrolyte imbalances
Interventions
● Initiate measures to alleviate nausea, including medication therapy; if unsuccessful and if weight loss and
fluid and electrolyte imbalances occur, intravenously administered fluid and electrolyte replacement or
parenteral nutrition may be necessary.
● Monitor urine for ketones.
● Monitor fetal heart rate, activity, and growth.
● Encourage intake of small portions of food (low-fat, easily digestible carbohydrates, such as cereals, rice,
and pasta).
● Eat a few dry crackers (crabs) before you get up in the morning
● Encourage the intake of liquids between meals to avoid distending the stomach and triggering vomiting.
● Encourage the client to sit upright after meals.
Fetal Heart
Fetal monitoring: VEAL CHOP
Priority Nursing Interventions: Non-Reassuring
FHR Patterns (LIONS)
● L: Left Side Lie
● I: IV Fluids
● O: Oxygen (8-10 L/min)
● N: Notify Provider
● S: Stop Oxytocin
