MATERNAL ASSESSMENT

FIRST TRIMESTER (WEEKS 1 -12)

 Physical Assessment

The physical exam will include:

 Baseline vital signs, weight and height

 Head-to-toe, general well-being assessment
 Breast and abdominal examination
 Pelvic exam, possibly Pap test
 Lab tests:
o Urinalysis for glucose, protein, blood and bacteria
o Urine or blood hCG levels
o Complete blood count
o Blood type and Rh factor
o Rubella titer
o Possible screening for sexually transmitted infections, such as syphilis and HIV antibody (with
client's permission) and cervical culture for chlamydia and gonorrhea
o Hepatitis B surface antigen (HBSAG) and hepatitis B surface antibody (HBsAB)
o Possible tuberculin skin test

Psychological Assessment

Assess client's psychosocial response to pregnancy, including support systems, perception of

pregnancy and coping mechanisms.

The nurse should discuss how the client and her partner feels about the pregnancy. The
emotional response can range from tremendous excitement to ambivalence.

Discuss family relationships and available support systems.

 Nursing Care
First Trimester

MATERNAL CHANGES

The nurse discusses maternal changes and offers anticipatory guidance:

 Fatigue – suggest going to bed earlier, eating a balanced diet and taking iron supplements to
prevent anemia.
 Tender, swollen breasts – suggest wearing firm, supportive bras.
 Heartburn, nausea and/or vomiting (morning sickness) – suggest eating smaller and more
frequent meals, eating dry crackers and/or dry toast with tea, avoiding greasy and fried foods.
Acupuncture, acupressure, ginger root and vitamin B6 may also help.
 Constipation – explain that adequate fluid intake is important and to use only natural methods
to avoid constipation, such as eating prunes or drinking prune juice. Docusate (Colace) and
psyllium (Metamucil) can also be used.
 Headache or backache – chiropractic manipulation for backache works well. The nurse may
suggest applying a cold compress to the forehead. Acetaminophen is one of the safer
analgesics, but be sure to reinforce that no drug is completely safe. The nurse should also
explain that nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in the third
trimester of pregnancy (they are associated with early closure of the fetal ductus arteriosus and
decreasing fetal renal function).
 Provide instruction about Kegel exercises.

*OB Interventions - the Seven Rs

The 7Rs of OB Intervention:

1. Review and reinforce anticipatory guidance,

2. Relationship,
3. Risk data collection,
4. Return scheduling,
5. Referral resources,
6. Respond to questions and concerns,
7. Recommend diet, vitamins, exercise
NURSING PLAN INTERVENTION

During the first visit, the nurse should recommend that in addition to a healthy diet, the mother
will need to take prenatal vitamins, folic acid and iron supplements.

The nurse also needs to perform a risk assessment and reinforce that she should avoid all
medications, tobacco and other substances, avoid hot tubs and exposure to illness.

Be prepared to provide referrals for childbirth classes and discuss the schedule for antepartal
visits.

Figure 3-A.3: Calculate the due date using Naegele's Rule

Review fetal development with the mother and her partner and educate them to quickly report
warning signs including, including vaginal bleeding, abdominal cramping or pain, severe or
prolonged vomiting and/or a persistently elevated temperature greater than 101° F (38.3° C).
 ntepartum, Intrapartum & Postpartum Nursing
Points to Remember
Before birth:

 Early and regular antepartal (before birth) care is critical since first trimester health directly
influences the development of embryonic organs

 To identify risks, nurses need both subjective (client's opinions and statements) and objective
(measurable) assessment data

 Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for
the fetus and woman

 Pregnancy diet must include increased calcium, protein, iron and folic acid

 If the client's situation warrants, suggest ways to adapt activity, employment and travel

 It is helpful if the woman can have the same support person throughout pregnancy and birthing
classes

 A doula gives prenatal, labor, birth and postpartum support for mothers and families

Labor:

 Normal active labor progresses 1.2 cm per hour for primiparas and 1.5 cm per hour for
multiparas

 Maintain safety and medical asepsis through the labor and birth process to reduce risks to
mother and fetus/newborn

 Ideally, the same caregivers should stay through all stages of labor

 Reinforce the childbirth preparation techniques practiced by the couple during pregnancy but be
flexible since woman will have shorter attention span and increased discomfort and will
experience a fluctuation of emotions during labor

 Respect the cultural and religious beliefs of the woman and partner

 Involve the family in the birth process as noted in their birth plan or special requests

 Document ongoing assessments, changes in condition and care

 Pain and anxiety can impede progress of labor

 Safest time for the fetus is to administer analgesics is when the woman is dilated between 4-7
cm

 Be prepared to assist newborn transition to extrauterine environment

Postpartum:

 Teach (by demonstration and praise) self assessment and care, starting soon after birth

 Share your assessments and plans with the parents and welcome their input

 Respect the cultural and religious beliefs of the family

 Praise the parent's skills

 Postpartum physical assessment can be remembered using the acronym: B.U.B.B.L.E. (for
breasts, uterus, bowels, bladder, lochia and episiotomy or C-section incision)

 Perform Coombs' tests to detect antibodies after the birth of each Rh positive newborn:

o Direct Coombs' test on newborn using neonatal cord blood

o Indirect Coombs' test and antibody screen on the mother

 A normal (negative) indirect Coombs' test indicates that no antibodies are detected (there is no
clumping of the cells) and the woman is considered to be a candidate for RhoGAM®.
 Growth & Development
Points to Remember
General concepts:

 Both growth and development normally proceed in a regular fashion from simple to complex
and in a cephalocaudal and proximodistal pattern

 Growth and development are impacted by genetics, environment, health status, nutrition,
culture and family structures and practices

 Growth should be measured and evaluated at regular intervals throughout childhood and
deviations from normal growth and development should be thoroughly investigated and treated
as quickly as possible

 Development occurs through conflict and adaptation

Children:

 In the care of children, key concepts are anticipatory guidance and disease prevention

 Major developmental tasks of infancy include increase in mobility, separation and establishment
of trusting relationships

 In both toddlerhood and adolescence, the hallmarks of development are independence and
further separation

 Children and adolescents have rapid growth patterns, so nurses must stress optimum nutrition
and give anticipatory guidance related to nutrition

 Leading causes of death:

o Ages 0-1 year: developmental and genetic conditions that were present at birth, sudden infant
death syndrome (SIDS), all conditions associated with prematurity and low birth weight

o Ages 1-4 years: accidents, developmental and genetic conditions present at birth, cancer

o Ages 5-14 years: accidents, cancer, homicide

o Ages 15-24 years: accidents, homicide, suicide

Older adults:
 Older adults must adjust to lessening physical and cognitive abilities; a majority of older adults
have at least one chronic disease

 When older adults experience cognitive changes, check for possible substance abuse or
polypharmacy

 Cognitive impairment may be either acute and reversible or chronic and irreversible; investigate
all changes in cognition

 Many older adults have some impairment in performance of activities of daily living

 Some physiologic changes are a normal part of the aging process and do not signal disease

 Older adults need more time to complete tasks

 Age is a weak predictor of survival in traumatic injury and critical illness

Health risks in older adults:

 Major health problems typically include cardiovascular, cerebrovascular and respiratory

diseases, diabetes and cancer

 The older adult will change social roles and these changes may affect their psychological health,
e.g., depression

 Older adults need the same nutritional needs as other adults, but they need more bulk and
fiber, and a more nutrient dense diet containing fewer calories

 Older adults clear drugs from kidney and liver more slowly, so medications have longer half-
lives, and they can bring on side effects and toxicity at lower doses - remember "start low
(dose), go slow (gradually increase the dose)"

 Older adults with low protein levels may have increased risks of drug toxicity for drugs that are
protein-binding
 Health Assessment
Points to Remember
Health Assessment:

 Measure vital signs when the client is at rest

 Compare both sides of the body for symmetry

 Assess the systems related to the client's major complaint first

 Offer rest periods if client becomes tired

 Culture and religious beliefs may play a role in observed differences

 Warm hands and equipment such as stethoscope before touching the client

 Tell the client what you are going to do before touching the client

 Normal variations exist among clients and there is a range of normalcy for all physical findings

 Maintain the client's privacy throughout the examination

 Control for environmental factors which may distort findings

 Check equipment prior to exam for functioning

 Consider growth and developmental needs when assessing specific age groups

 Integrate client teaching throughout the exam

Vasculature:

 Compare blood pressure in both arms

 Compare blood pressure with client lying, sitting and standing

Lungs - Airway:

 Anemic patients may never become cyanotic (and are more commonly a dusky-ashen color
when hypoxic)

 Polycythemic patients may be cyanotic, even when oxygenation is normal

 Cough results from stimulation of irritant receptors, with implications of either acute or chronic
etiology

 Cyanosis indicates decreased available oxygen; etiology can be either peripheral or central in
origin

 Wheezes indicates narrowing/inflammatory process of lower airways

 Stridor is a harsh sound produced near the larynx by vibration of structures in upper airway,
producing the classic "barky cough"

 Crackles or rales are adventitious sounds, usually heard on inspiration, and can be described as
"moist", "dry," "fine" and "coarse"

Breasts:

 Breast tissue shrinks with menopause

 Teach client breast self examination

Abdomen

 Auscultation should be performed before palpation to prevent distortion of bowel sounds

 Tightening of abdominal muscles hinders accuracy of palpation and auscultation

 Warm hands before touching client's abdomen

 Men breathe abdominally; women breathe costally

 Auscultate all four quadrants for bowel sounds; start in the lower right quadrant

 Auscultate abdomen between meals

Musculoskeletal:

 Older adults walk with smaller steps and need a wider base of support

 Adolescents should be screened for scoliosis

Neurological:
 Glasgow Coma Score: assesses eye opening (possible scores range from 1 to 4), verbal
response (possible scores range from 1 to 5), and motor response (possible scores range from
1 to 6)

o Not valid in clients who have used alcohol or other mind-altering drugs

o Possibly not valid in patients who are hypoglycemic, in shock or hypothermic (below 93 F [34
C])

o Should be compared to total of 10 when client is intubated

 Reflexes are normally less brisk or even absent in older clients

 Reflex response diminishes in the lower extremities before the upper extremities are affected

 Absent reflexes may indicate neuropathy or lower motor neuron disorder, resulting in flaccidity

 Hyperactive reflexes suggest an upper motor neuron disorder, resulting in spasticity

Teaching client and family:

 Teaching-learning process mirrors the nursing process

 Select teaching strategies that are compatible with the client's learning style, age, culture and
level of education

 Client teaching should be multi-sensory – tell (auditory), show (visual), have them demonstrate
(tactile)

 Always confirm the client's understanding of the information presented

 Teaching must be geared to the level of the learner – most written materials are written at the
sixth to eighth grade level

 Repeat key information and summarize main points at intervals

 Explain medical terminology in lay terms

 Determine the client's learning style and gear teaching methods to using that style

 Sequence information the way the client will use it

 Be concrete and use the simplest words and the shortest sentences when teaching low literacy
clients or any client under stress