EMILIO AGUINALDO COLLEGE

Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEM

SCHOOL OF MIDWIFERY
NCM -QUIZ/ASSIGNMENT 1022R (RLE)
2ND
Semester 2020

VISION
Emilio Aguinaldo College envisions itself as an internationally recognized private non-sectarian, academic
institution rooted in the Filipino nationalist tradition that consistently pursues the advancement and welfare of
humanity.
MISSION
Emilio Aguinaldo College provides an outcomes-based education with relevant curricula geared towards
excellent research, active industry cooperation and sustainable community extension.
NAME: _Oteda, Jan Kyle S._______________________________________ __ DATE: 31/03/2020

INSTRUCTION: Provide possible examples for Nursing Care of Clients with Pregnancy
Induced-Hypertension, Clients Experiencing Abortion and clients with Postpartal Bleeding in
terms of Assessment, Analysis/Nursing Diagnoses, Planning/Implemantation and
Evaluation/Outcomes.

Nursing Care of Clients with Pregnancy- Induced Hypertension

Assessment
1. Assess vital signs, especially blood pressure. An elevated blood pressure of 140/90
mmHg and above would indicate hypertension.
2. Presence of protein could be determined through urine tests.
3. Assess patient for the presence of edema on the face, fingers, and upper extremities.
4. Weigh patient regularly because a sudden increase indicates fluid retention and may
signify progression of disease and impaired renal function.
5. Assess for vision disturbances and cognitive function
6. Monitor labs and diagnostic test results
Analysis/Nursing Diagnoses
1. Ineffective tissue perfusion related to vasoconstriction of blood vessels.
2. Decrease Cardiac Output related to decrease venous return
3. Risk for maternal injury related to abnormal blood profile and/or clotting factors
4. Imbalanced Nutrition: Less Than Body Requirements related to Intake insufficient to
meet metabolic demands and replace losses
Planning/Implementation
1. Present information to patient/couple concerning home assessment or noting daily fetal
movements and when to seek immediate medical attention.
2. Report signs of abruptio placentae (i.e., vaginal the bleeding, uterine tenderness,
abdominal pain, and decreased fetal activity).
3. Check FHR manually or electronically, as indicated.
4. Evaluate fetal growth; measure progressive fundal accompany growth at each office
visit or periodically during stress home visits, as appropriate.
5. Assist with assessment of fetal maturity and well-being using L/S ratio, presence of PG,
estriol levels, FBM, and sequential sonography beginning at 20–26 weeks’ gestation.
6. Record and graph vital signs especially BP and pulse.
7. Institute bedrest with patient in lateral position.
8. Check for CNS involvement (i.e., headache, irritability, visual disturbances or changes
on funduscopic examination).
9. Emphasize importance of patient promptly reporting signs/symptoms of CNS
involvement.
10. Assess for signs of impending eclampsia: hyperactivity of deep tendon reflexes (3+ to
4+), ankle clonus, decreased pulse and respirations, epigastric pain, and oliguria (less
than 50 ml/hr).
11. Establish measures to lessen likelihood of seizures; i.e., keep room quiet and dimly lit,
limit visitors, plan and coordinate care, and promote rest.
14. Enforce seizure precautions per protocol.

QF-ACD-032 (10.24.2019) Rev.1

 15. Monitor BP before, during, and after MgSO4 administration. Note serum magnesium
levels in conjunction with respiratory rate, patellar/deep tendon reflex (DTRs), and urine output.
16. Determine patient’s nutritional status, condition of hair and nails, and height and
pregravid weight.
17. Collaborate with dietitian, as indicated.
18 Provide information about normal weight gain in pregnancy, modifying it to meet
client’s needs.
19. Prepare for cesarean birth if PIH is severe, placental functioning is compromised, and
cervix is not ripe or is not responsive to induction.
Evaluation/Outcomes
1. Patient has no decrease in FHR on contraction stress test/oxytocin challenge test
(CST/OCT).
2. Patient must exhibit a normal blood pressure of 120/70 mmHg.
3. Edema should be confined to the lower extremities only.
4. No presence of protein should be detected on her urine.

Nursing Care of Clients Experiencing Abortion

Assessment
1. Assess for vaginal Spotting
2. Ask of the pregnant woman’s actions before the spotting or bleeding occurred and
identifies the measures she did when she first noticed the bleeding.
3. Inquire of the duration and intensity of the bleeding or pain felt. Lastly, identify the
client’s blood type for cases of Rh incompatibility.
4. As nurses, we are always the first to receive the initial information so we should be
aware of the guidelines in assessing bleeding during pregnancy.
Analysis/nursing diagnoses
1. Fear related to implications for future pregnancies
2. Disabled family coping related to unresolved feelings about loss
3. Disturbed body image related to perceived inability to carry pregnancy
4. Risk for deficient fluid volume related to bleeding during pregnancy
Planning/Implementation
1. If bleeding is profuse, place the woman flat in bed on her side and monitor uterine
contractions and fetal heart rate through an external monitor.
2. Also measure intake and output to establish renal function and assess the woman’s
vital signs to establish maternal response to blood loss.
3. Measure the maternal blood loss by saving and weighing the used pads
4. Save any tissue found in the pads because this might be a part of the products of
conception.
5. Acknowledge denial, anger, or depression as normal feelings and allow patients to
share emotions when they are ready, rather than rushing them
6. Encourage significant others to offer support
7. Discuss the situation with the client and help distinguish between real and imagine
threats to well-being
8. Maintain bed rest. Schedule activities to provide undisturbed rest periods
9. Administer fluids as indicated.
10. Monitor Hb, Hct, RBC count.
11. Note patient’s individual physiological response to bleeding such as changes in
mentation, weakness, restlessness, and pallor.
Evaluation/outcomes
1. The client’s urine output should be more than 30 mL/hr, and only minimal bleeding
should be apparent for not more than 24 hours.
2. aim for evaluation is inclined towards restoring the maternal blood volume and
stopping the source of the bleeding.

Nursing Care of Clients with Postpartal Bleeding

ASSESSMENT
1. Assess the amount of bleeding.
2. Assess maternal vital signs to establish baseline data.
3. Assess for signs of shock.
4. Assess the condition of the uterus.
5. Assess if there is a decrease in urine output
6. Obtain an accurate previous obstetrical, prenatal and antepartum history of the mother

QF-ACD-032 (10.24.2019) Rev.1

Analysis/Nursing Diagnoses
1. Deficient fluid volume related to excessive bleeding after birth.
2. Ineffective Tissue Perfusion related to hypovolemia
3. Risk for infection related to excessive blood loss
4. Body weakness related to altered body chemistry (Insufficient electrolytes)
5.Anxiety related to knowledge deficit regarding procedures, management, and disease
condition.
Planning /implementation
1. Save all perineal pads used during bleeding and weigh them to determine the amount
of blood loss.
2. Place the woman in a side lying position to make sure that no blood is pooling
underneath her.
3. Assess lochia frequently to determine if the amount discharged is still within the
normal limits.
4. Provide information about the treatment regimen and effectiveness of the
interventions.
5. Perform uterine massage to stimulate contractions following delivery
6. Monitor and manage pain
7. Prepare patient for surgery if indicated; remain on NPO status
8. Administer IV fluids, medications and blood products as necessary
Evaluation/Outcomes
1. Patient will maintain optimal fluid balance and vital signs within normal limits
2. Flow of lochia is less than a saturated pad per hour.
3. Patient will identify health ways to deal with and express anxiety.
4. Patient will demonstrate normal hormonal functioning by adequate milk supply for
lactation (as appropriate) and resumption of normal menstruation.

Goodluck and God Bless!

Prepared by: Josephine A. Flores

(Faculty SMW/SON)

QF-ACD-032 (10.24.2019) Rev.1