Maternal-Newborn | NCLEXprep

Prenatal labs, stages of labor, Bishop score, Apgar scoring, and postpartum assessment using BUBBLE-HE.

Essential Prenatal Labs

Test	Timing	Purpose
Blood type, Rh, antibody screen	First visit	Identify Rh incompatibility; give RhoGAM at 28 weeks and within 72 hours postpartum if Rh-negative mother with Rh-positive infant
CBC	First visit, 28 weeks	Assess for anemia (Hgb < 11 g/dL in pregnancy)
Rubella titer	First visit	Non-immune: vaccinate postpartum (live vaccine — not during pregnancy); avoid pregnancy for 1 month after
Hepatitis B surface antigen	First visit	If positive: newborn gets HepB vaccine + HBIG within 12 hours of birth
HIV screening	First visit	If positive: antiretroviral therapy to reduce vertical transmission
GBS culture	35–37 weeks	If positive: IV penicillin during labor (give ≥ 4 hours before delivery)
1-hour glucose challenge	24–28 weeks	Screening for gestational diabetes (≥ 140 mg/dL → 3-hour GTT)
Quad screen	15–20 weeks	AFP, hCG, estriol, inhibin-A. Screens for trisomy 21, 18, neural tube defects

Stage	Phase	Cervical Dilation	Contractions	Nursing Care
Stage 1 (Onset of true labor to complete dilation)	Latent (Early)	0 – 6 cm	Mild, q5–30 min, 30–45 sec	Encourage ambulation, rest, hydration; talkative/excited patient
	Active	6 – 8 cm	Moderate, q3–5 min, 40–60 sec	Breathing techniques, position changes, pain management; focused patient
	Transition	8 – 10 cm	Strong, q2–3 min, 60–90 sec	Most intense phase; nausea/vomiting common; provide support, coaching; patient may feel loss of control
Stage 2 (Complete dilation to delivery of baby)		10 cm (complete)	Urge to push	Push with contractions; monitor FHR; prepare for delivery. Primipara: up to 2–3 hrs; Multipara: up to 1–2 hrs
Stage 3 (Delivery of baby to delivery of placenta)		—	Mild cramping	Signs of placental separation: gush of blood, cord lengthening, globular uterus. Usually 5–30 min. Inspect placenta for completeness (3 vessels: 2 arteries, 1 vein)
Stage 4 (First 1–2 hours postpartum)		—	—	Monitor VS q15 min, fundal checks, lochia, bladder, bonding. Highest risk for hemorrhage

Used to assess cervical readiness for induction. Score ≥ 8 = favorable for induction.

Factor	0	1	2	3
Dilation (cm)	Closed	1–2	3–4	5–6
Effacement (%)	0–30	40–50	60–70	≥ 80
Station	-3	-2	-1, 0	+1, +2
Consistency	Firm	Medium	Soft	—
Position	Posterior	Mid	Anterior	—

Assessed at 1 minute (transition) and 5 minutes (adaptation) after birth. Score 0–2 for each category.

Sign	0	1	2
Appearance (Color)	Blue/pale all over	Pink body, blue extremities (acrocyanosis)	Completely pink
Pulse (Heart Rate)	Absent	< 100 bpm	≥ 100 bpm
Grimace (Reflex Irritability)	No response	Grimace/weak cry	Vigorous cry, cough, sneeze
Activity (Muscle Tone)	Limp/flaccid	Some flexion	Active motion
Respirations	Absent	Slow, irregular, weak cry	Good cry, regular respirations

Letter	Assessment	Key Points
B	Breasts	Soft, filling, engorged? Nipple condition. Colostrum present (days 1–3), transitional milk (days 3–5)
U	Uterus (Fundus)	Firm, midline, at or below umbilicus. Should descend ~1 fingerbreadth/day. Boggy = massage; displaced = full bladder
B	Bladder	Should void within 6–8 hrs postpartum. Full bladder displaces uterus → hemorrhage risk
B	Bowel	Assess bowel sounds, flatus, BM. Stool softeners PRN; may take 2–3 days
L	Lochia	Rubra (red, days 1–3) → Serosa (pinkish, days 4–10) → Alba (white/yellow, 10 days – 6 weeks). Foul smell = infection. Clots > golf ball = report
E	Episiotomy/Perineum	Assess using REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation. Ice first 24 hrs, then sitz baths
H	Homan's sign / Hemorrhoids / Hemoglobin	Assess for DVT risk (calf pain, swelling); hemorrhoids common; check H/H for blood loss
E	Emotional Status	Baby blues (days 2–3, resolves in 2 weeks) vs postpartum depression (persists > 2 weeks, impaired function). Screen with Edinburgh scale