Maternity & obstetric nursing: practice questions with explanations

1Pregnancy: dates, growth and screening

Maternity nursing follows a woman and her baby through pregnancy (antepartum), labour and birth (intrapartum), the weeks after birth (postpartum) and the first days of the newborn.

Naegele’s rule estimates the due date from the first day of the last menstrual period (LMP):

It assumes a regular 28-day cycle. An early dating ultrasound is more accurate when the cycle is irregular.

Obstetric history is written as GTPAL: Gravida (all pregnancies, including the current one), Term births (37 weeks or more), Preterm births (20–36 weeks), Abortions or miscarriages (before 20 weeks) and Living children. Twins count as one birth but two living children.

Fundal height shows uterine growth. The fundus is just above the symphysis pubis at about 12 weeks and at the umbilicus at about 20 weeks. From 20 to 36 weeks, the height in centimetres is about the number of weeks, give or take 2 cm.

Typical screening times (exact programmes differ between countries):

• First-trimester screening with nuchal translucency: about 11–14 weeks.
• Detailed anatomy ultrasound: about 18–22 weeks.
• Gestational diabetes screening: about 24–28 weeks.
• Group B streptococcus swab, where universal screening is used: about 36–37 weeks.
• Anti-D for Rh-negative women: routinely around 28 weeks in many programmes, and within 72 hours after the birth of an Rh-positive baby.

2Labour and the fetal heart rate

Labour has four stages:

1. First stage: regular contractions until the cervix is fully dilated (10 cm). It has a slow latent phase and a faster active phase.
2. Second stage: full dilation to the birth of the baby.
3. Third stage: birth of the baby to delivery of the placenta.
4. Fourth stage: the first 1–2 hours of recovery, with close checks for bleeding.

Contraction frequency is measured from the start of one contraction to the start of the next; duration from the start to the end of one contraction. More than 5 contractions in 10 minutes (averaged over 30 minutes) is tachysystole.

The normal fetal heart rate baseline is 110–160 bpm with moderate variability (6–25 bpm). Accelerations are reassuring.

The memory aid VEAL CHOP links each pattern with its cause:

• Variable decelerations: Cord compression. Abrupt drops of varying shape. Change the woman’s position.
• Early decelerations: Head compression. They mirror the contraction and are benign.
• Accelerations: OK, a sign of a well-oxygenated fetus.
• Late decelerations: Placental insufficiency. They start after the contraction peaks and always need action.

For late decelerations or other worrying patterns, start intrauterine resuscitation: stop the oxytocin, turn the woman onto her side, give IV fluid as ordered, check her blood pressure and call the provider.

3After the birth: BUBBLE-HE

Postpartum assessment follows BUBBLE-HE:

• Breasts: soft, filling or engorged; nipples intact.
• Uterus: the fundus should be firm and in the midline. It is at about the umbilicus in the first 12 hours, then descends about 1 cm a day.
• Bladder: a full bladder pushes the uterus up and to the side and causes bleeding.
• Bowel: bowel sounds, passing wind, constipation.
• Lochia: rubra (red) for about 3–4 days, serosa (pinkish-brown) until about day 10, then alba (yellowish-white).
• Episiotomy or perineum: use REEDA (redness, oedema, ecchymosis, discharge, approximation).
• Homans’ sign is no longer recommended: check the legs for one-sided swelling, warmth, redness and pain instead.
• Emotions: baby blues settle within about 2 weeks; longer symptoms suggest postpartum depression.

A boggy fundus needs fundal massage first, while the other hand supports the lower uterus. Then check the bladder.

Bleeding with a firm uterus suggests a tear. Soaking a pad within 15 minutes, a rising heart rate or cool, clammy skin needs escalation at once. In healthy women, blood pressure often falls late.

4The newborn

Typical newborn values: heart rate about 110–160/min, respiratory rate 30–60/min (irregular), axillary temperature about 36.5–37.5 °C. Reference ranges vary slightly between sources.

The APGAR score is given at 1 and 5 minutes. Appearance, Pulse, Grimace, Activity and Respiration each score 0–2; a heart rate below 100/min scores 1.

• Prevent heat loss: dry the baby at once, use skin-to-skin contact and a hat. Cold stress uses up glucose.
• Vitamin K is given to prevent vitamin K deficiency bleeding.
• Acrocyanosis (blue hands and feet) is common at first; central cyanosis is not.
• Jaundice in the first 24 hours is pathological and needs prompt assessment.
• A loss of up to about 7–10% of birth weight in the first days is common.
• Grunting, nasal flaring and retractions are signs of respiratory distress.

If the baby is apnoeic, gasping or has a heart rate below 100/min after drying and stimulation, positive-pressure ventilation starts. Chest compressions start only if the heart rate stays below 60/min despite effective ventilation.

5Complications to recognise

• Pre-eclampsia: blood pressure of 140/90 mmHg or more after 20 weeks with proteinuria or organ involvement. Severe features include 160/110 or more, severe headache, visual disturbance, epigastric or right upper quadrant pain and low platelets. HELLP is haemolysis, elevated liver enzymes and low platelets.
• Magnesium sulfate prevents eclamptic seizures. Watch for toxicity: loss of deep tendon reflexes, respiratory depression and low urine output. Keep calcium gluconate ready.
• Postpartum haemorrhage: think of the four Ts: tone (the most common), trauma, tissue and thrombin. Treat with massage, uterotonics and early escalation; tranexamic acid is given early.
• Placenta praevia: painless bright red bleeding. No digital vaginal examination.
• Placental abruption: pain, a rigid uterus and dark bleeding, which may be concealed.
• Gestational diabetes: risk of macrosomia, shoulder dystocia and neonatal hypoglycaemia. Insulin needs fall right after birth.

Drug cautions: methylergonovine is avoided in hypertension, and carboprost is avoided in asthma.

6A worked example

Decide what you would do at each step before you open it.

7How exam questions look

• Easy (key terms and facts): Naegele’s rule, normal fetal heart rate, stages of labour, lochia, APGAR, VEAL CHOP.
• Medium (applying the concepts): GTPAL, fundal height, screening times, the first action for a deceleration, drug contraindications, cephalhaematoma or caput.
• Hard (cases and analysis): which action first, or which finding needs immediate follow-up: late decelerations on oxytocin, a prolapsed cord, haemorrhage, magnesium toxicity, newborn distress.

Remember that mother and fetus share the same circulation: improving the mother’s blood flow and oxygenation (side-lying, fluids, stopping oxytocin) is often the first step for the fetus too.