HOLY ANGEL UNIVERSITY

Holy Angel University

School of Nursing and Allied Medical Sciences
Angeles City

NCM107RLE
CARE OF MOTHER, CHILD, ADOLESCENT (WELL)
(OB-Gyne)

Case Study 1: Prenatal Assessment and Care

Submitted by:
Alyssa Marie R. Mercado

Submitted to:
Prof. Arlene M. Gaddi, RN, MAN

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CLIENT PROFILE

Mrs. A is a 30-year-old Gravida 2/Para 1 with no living children. Her first child died
at 4 months due to “diarrhea.” Mrs. A presents today for her first prenatal visit.

1. Before beginning your assessment, what should you do for and ask Mrs. A?

- As a responsible student nurse, before I begin the assessment proper, I will first
perform the proper hand washing.

- Then I will introduce myself first and explain the things that I need to do and as
well as their significance.

- Upon introducing myself, I will first ask my patient if she is comfortable enough
and how will she describe her feelings about being in the hospital, in a professional
but at the same time well-mannered way of asking

- With that, I will ask for the patient’s personal information such as her complete
name, age, birthdate, contact number, address, occupation, source of income and
availability of transportation.

- All of this information should be included in the pre-assessment of the patient to

establish rapport so that I will be able to gather the other necessary information.

ASSESSMENT (information gathering through history, physical examination, and

testing)

2. What history will you include in your assessment of Mrs. A and why?

- The questions that should be asked in the history assessment of Mrs. A are:

• If how many previous pregnancy and childbirth she had?

- Ask this question to guide individualization of health messages as well
as counselling and other aspects of basic care provision.

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• If this is not her first pregnancy, consider asking how did she deliver the first
baby, if it is normal delivery or cesarean section?
• If this is not her first pregnancy, consider asking if she experienced
convulsion during her pregnancy or childbirth, still-births, preterm or a baby
who died before 1 month of age?
- Ask these questions to serve as a guide in individualization of health
messages as well as counselling and other aspects of basic care provision.
• Her last menstrual period
- Ask this question to be able to know her age of gestation.
• If she is having difficulty or any problems with her present pregnancy
- Ask this question to be aware if certain complications will occur that may
be address and prevent immediately
• If she breastfed her first baby? and if not, consider asking the reason why
- Ask this question to guide individualization of health messages as well
as counselling and other aspects of basic care provision.
• If she has any allergies?
- Ask this question to guide individualization of health messages as well
as counselling and other aspects of basic care provision.
• If she is taking any medication or vitamins?
- Ask this question to guide individualization of health messages as well
as counselling and other aspects of basic care provision.
• If she had a complete series of the five-tetanus toxoid (TT) immunization,
which is very important for pregnant women
- Ask this question to assess whether the client obtained the recommended
TT immunization
• Family health history such as chronic diseases or medical conditions caused
by genetic abnormality
- This information will help the medical provider to be alert and aware of the
problems that the patient might encounter in her pregnancy

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3. What physical examination will you include in your assessment of Mrs. A and
why?

- The physical examination that should be included in the assessment of Mrs. A are:

• Checking of vital signs

- to have a baseline data that may used to compare for the patient’s later
prenatal visits
o Blood pressure
o Heart rate
o Pulse rate
o Temperature
• Height and weight
• Gait and movements
• Checking of the conjunctiva
• Breast exam
- to check for any lumps, inverted nipple, swelling, dimpling, puckering
and changes in the skin texture to have a baseline data of the changes that
may happen to your breasts during pregnancy and for breastfeeding.
• Abdominal examination
- to check for any masses or lumps as well as for the initial measurement
of the height of fundus
• Pelvic examination
- to help the medical provider to look for any changes in the woman’s
cervix and the size of the uterus
• Bimanual internal exam
- to check if there are any abnormalities in the uterus, ovaries or fallopian
tubes

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4. What laboratory tests will you include in your assessment of Mrs. A and why?

- The laboratory tests that should be included in Mrs. A’s assessment are:

• Pap smear test

- to test for cervical cancer and for any sexually transmitted infections
(STIs)
• Blood tests
o Complete blood count
- to assess the hemoglobin, hematocrit and red cell index and to
determine the presence of anemia
o WBC and platelet count
- to assess for infection clotting ability
o Blood typing with Rh factor
o Rapid plasma reagin (RPR) test
- to screen for syphilis
o HIV test
• Urinalysis
- to give information about the levels of glucose and protein or
possible infections

DIAGNOSIS (interpreting information to identify problems/needs)

You have completed your assessment of Mrs. A and your main findings include the
following:

History:

• She reports that she did not breastfeed her first baby, nor did she try, because
she was told that something was wrong with her nipples. She believes she
will not be able to breastfeed this baby either. Mrs. A also says that after her
first baby was born, she did not have the funds to buy the recommended

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amount of breastmilk substitute, and she did not always have access to clean
water to prepare it.
• According to Mrs. A’s menstrual history, she is 16 weeks pregnant.
• All other aspects of Mrs. A’s history are normal or without significance.
o She denies any problems during the previous pregnancy, labor, and birth.
She reports that her baby was “very healthy” at birth.
o She denies any problems during this pregnancy.

Physical Examination:

• Mrs. A’s breast exam is normal except that her nipples appear to be inverted.
However, when the areola is gently squeezed on either side of the nipple, the
nipple protrudes and the inversion is corrected.
• All other aspects of her physical examination are within normal range.
o Mrs. A appears well-nourished and healthy.
o Her blood pressure is 110/80.
o The conjunctiva is pink.
o The fundal height is approximately halfway between the symphysis
pubis and umbilicus, consistent with the EDC.
o The genital exam is normal.

Diagnostic Tests:

• Test results were:

o HIV – negative
o RPR – non-reactive
o Hemoglobin – 11.5 Gm/dl
o Blood type O, Rh positive

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5. Based on these findings, what is your most appropriate nursing

diagnosis/diagnoses (if multiple problems are identified) for Mrs. A and why?

- Risk for impaired parenting related to lack of knowledge about child health
maintenance

IMPLEMENTATION (plan of care and interventions)

6. Based on your nursing diagnosis, what is your plan of care for Mrs. A and
why?

- As for the plan of care for Mrs. A:

1. Educate the parents about the importance of the child’s health maintenance
especially breastfeeding
2. Improve the parents’ knowledge about the significance of having access to
clean environment such as water
3. Improve the parents’ knowledge about the importance of having mother-
infant relationship

EVALUATION/FOLLOW-UP

• Mrs. A returns for her scheduled prenatal care visits. She reports that she
has decided to breastfeed, and even tells you that she knows she must
breastfeed so that this baby will live and be healthy.
• Mrs. A is also adhering to the care plan and following other
recommendations discussed on previous visits.

7. Based on these findings, what is your continuing plan of care for Mrs. A?

- As for the continuing plan of care for Mrs. A:

1. Encourage the parents to apply for different health programs
2. Encourage the parents to attend seminars and counselling (if available) about
effective parenting

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