1. What other assessment data would you obtain?

ASSESSMENT
PHYSICAL ASSESSMENT/
NORMAL FINDINGS

ALTERATIONS
POSSIBLE CAUSES

NURSING RESPONSES
TO DATA

VITAL SIGNS

Blood pressure (BP): 130

systolic and 85 diastolic in
adult 18 years of age or older
or no more than 1520 mm Hg
rise in systolic pressure over
baseline BP during early
pregnancy
Pulse: 6090 beats per minute
(bpm)
Respirations: 1422/minute (or
pulse rate divided by 4)
Pulse oximeter (if used) 95%
or greater
Temperature:36.237.6C (98
99.6F)

High BP (essential hypertension Evaluate history of

preeclampsia, renal disease, preexisting disorders and
check for presence of other
apprehension or anxiety)
signs of preeclampsia.
Low BP (supine hypotension)
Increased pulse rate (excitement Do not assess during
or anxiety, cardiac disorders, contractions; implement
measures to decrease
early shock)
anxiety and reassess.
Marked tachypnea (respiratory
disease), hyperventilation in
transition phase
Hyperventilation (anxiety)
90%; hypoxia, hypotension,
hemorrhage

Turn woman on her side and

recheck BP.
Provide quiet environment.
Have O2 available.

Elevated temperature (infection, Evaluate cause, reassess to

dehydration, prolonged rupture see if rate continues; report
of membranes epidural regional to physician.
block)
Assess between
contractions; if marked
tachypnea continues, assess
for signs of respiratory
disease.
Encourage slow breaths if
woman is hyperventilating.
Apply O2 ; notify physician
Assess for other signs of
infection or dehydration.

WEIGHT
2535 lb greater than prepregnant
weight

Weight gain 35 lb (fluid

retention, obesity, large infant,
diabetes mellitus,
preeclampsia), weight gain 15lb

Assess for signs of edema.

Evaluate pattern from
prenatal record.

(SGA, substance abuse,

psychosocial problems).

LUNGS
Normal breath sounds, clear and equal

Rales, rhonchi, friction rub

(infection), pulmonary edema,
asthma

Reassess; refer to physician

Uterine size not compatible

with estimated date of birth
(SGA, large for gestational age
[LGA], hydramnios, multiple
pregnancy, placental/fetal
anomalies, malpresentation)

Reevaluate history
regarding pregnancy dating.
Refer to physician for
additional assessment.

Pitting edema of face, hands,

legs, abdomen, sacral area
(preeclampsia)

Check deep tendon reflexes

for hyperactivity; check
for clonus; refer to
physician.

Poor skin turgor (dehydration)

Assess skin turgor; refer to

physician for deviations

Varicose veins of vulva, herpes

lesions, genital warts

Exercise care while doing a

perineal prep; note on client
record need for follow-up in
postpartal period; reassess
after birth; refer to
physician/CNM.

Uterine contractions: regular pattern

Failure to establish a regular

pattern, prolonged latent phase
Hypertonicity
Hypotonicity
Dehydration

Cervical dilatation: progressive

cervical dilatation from size of
fingertip to 10 cm

Rigidity of cervix (frequent

cervical infections, scar
tissue, failure of presenting part
to descend)

Evaluate whether woman is

in true labor; ambulate if in
early labor. Evaluate client
status and contractile
pattern. Obtain a 20-minute
EFM strip. Notify physician
or CNM. Provide hydration.

Cervical effacement: progressive

Failure to efface (rigidity of

FUNDUS
At 40 weeks gestation located just
below xiphoid process

EDEMA
Slight amount of dependent edema

HYDRATION
Normal skin turgor, elastic

PERINEUM
Tissues smooth, pink color

LABOR STATUS

Evaluate contractions, fetal

engagement, position, and
cervical dilatation. Inform
client of progress.
Evaluate contractions, fetal

thinning of cervix

cervix, failure of presenting part

to engage); cervical edema
(pushing effort by woman
before cervix is fully dilated
and effaced, trapped cervix)

engagement, and position.

Notify physician or CNM if
cervix is becoming
edematous; work with
woman to prevent pushing
until cervix is completely
Fetal descent: progressive descent of Failure of descent (abnormal dilated. Keep vaginal exams
fetal presenting part from station 25 to fetal position or presentation, to a minimum.
macrosomic fetus, inadequate Evaluate fetal position,
14.
pelvic measurement)
presentation, and size.
Evaluate maternal pelvic
measurements.
Membranes: may rupture before or
during labor.

Rupture of membranes more

than 1224 hours before
initiation of labor

Findings on Nitrazine test tape:

Membranes probably intact
Yellow pH 5.0
Olive pH 5.5
Olive green pH 6.0
Membranes probably ruptured
Blue-green pH 6.5
Blue-gray pH 7.0
Deep blue pH 7.5

False-positive results may be

obtained if large amount of
bloody show is present previous
vaginal examination has been
done using lubricant, or tape is
touched by nurses fingers.

Assess for ruptured

membranes using Nitrazine
test tape before doing
vaginal exam. Follow
universal precautions.
Instruct woman with
ruptured membranes to
remain on bed rest if
presenting part is not
engaged and firmly down
against the cervix. Keep
vaginal exams to a
minimum to prevent
infection. When membranes
rupture in the birth setting,
immediately assess FHR to
detect changes associated
with prolapsed of umbilical
cord (FHR slows). Assess
fluid for consistency,
amount, and odor, assess
FHR frequently.

Assess fluid at regular

intervals for presence of
meconium staining. Follow
universal precautions while
assessing amniotic fluid.
Teach woman that amniotic

fluid is continually
produced (to allay fear of
dry birth). Teach woman
that she may feel amniotic
fluid trickle or gush with
contractions. Change chux
pads often.

LABOR STATUS
Amniotic fluid clear, with earthy or
human odor, no foul-smelling odor

Greenish amniotic fluid (fetal

stress) Bloody fluid (abruptio
placenta) Strong or foul odor
(amnionitis)

Assess FHR; do vaginal

exam to evaluate for
prolapsed cord; apply fetal
monitor for continuous
data; report to physician
CNM. Take womans
temperature and report to
Physician/ CNM.

FETAL STATUS
FHR: 110160 bpm

Presentation: Cephalic, 97%

Breech, 3%
Position: left occiput anterior (LOA)
most common

Activity: fetal movement

<110 or> 160 bpm

(nonreassuring fetal status);
abnormal patterns on fetal
monitor: decreased variability,
late decelerations, variable
decelerations, absence of
accelerations with fetal
movement
Face, brow, breech, or shoulder
presentation
Persistent occipital posterior
(OP) position; transverse arrest

Initiate interventions based

on particular FHR pattern.

Report to physician/CNM;
after presentation is
confirmed as face, brow,
breech, or shoulder, woman
may be prepared for
cesarean birth.

Carefully monitor maternal

Hyperactivity (may precede
and fetal status. Reposition
fetal hypoxia) Complete lack of
mother to sidelying or hands
movement (fetal distress or fetal
and knees to promote
demise)
rotation of fetal head.
Carefully evaluate FHR;
apply fetal monitor.

LABORATORY EVALUATION
Hematologic tests
Evaluate woman for

Hemoglobin: 1216 g/dL

<11 g/dL (anemia, hemorrhage)

Complete blood count (CBC)

Hematocrit: 38%47%
Red blood cell count (RBC):
4.25.4 million/mm3
White blood cell count (WBC):
4,50011,000/mm3 although
leukocytosis to 20,000/mm3 is not
unusual
Platelets: 150,000400,000/mm3

Presence of infection or blood

dyscrasias, loss of blood
(hemorrhage, disseminated
intravascular coagulation
[DIC])

problems due to decreased

oxygen-carrying capacity
caused by lowered
hemoglobin.
Evaluate for other signs of
infection or for petechiae,
bruising or unusual
bleeding.

Serologic testing
For reactive test, notify
newborn nursery and
pediatrician. Assess prenatal
record for titer levels during
pregnancy.

Serologic test for syphilis (STS) or

Venereal Disease Research Laboratory
(VDRL) test: nonreactive

Positive reaction

Rh factor

Rh-positive fetus in Rh negative Obtain cord blood for direct

woman
Coombs at birth.

Urinalysis
Glucose: negative
Ketones: negative
Proteins: negative

Red blood cells: negative

White blood cells: negative

Casts: none

Glycosuria (low renal threshold Assess blood glucose level;

for glucose, diabetes mellitus)
test urine for ketones;
Ketonuria (starvation ketosis)
ketonuria and glycosuria
require further assessment
Proteinuria (urine specimen
of blood sugar levels.
contaminated with vaginal
Instruct woman in
secretions, fever, kidney
collection technique;
disease); proteinuria of 2 or
incidence of
greater found in
contamination from vaginal
uncontaminated urine may be a discharge is common.
sign of ensuing preeclampsia
Report any increase in
proteinuria to Physician/
Blood in urine (calculi, cystitis, CNM.
glomerulonephritis, neoplasm)
Assess collection technique
Presence of white blood cells
(may be bloody show).
(infection in genitourinary tract)
Presence of casts (nephrotic
syndrome)
Assess for signs of urinary
tract infection.