Body Parts/System & Normal Findings Actual Findings Interpretation

Method of
Assessment Used
Skin, Hair and Nails
 Inspect the  Linea nigra, striae,  Striae Gravidarum and  All findings
skin. Note gravidarum, linea negra is present are normal
hyperpigmente chloasma, and  Palmar erythema is
d areas spider nevi may be present
associated with present.  Full hair distribution on
pregnancy.  Angiomas and scalp
 Observe skin palmar erythema  No detection of any
for vascular are common. abnormalities in color or
markings  Hair and nails tend shape of nails
associated with to increase in
pregnancy. growth; softening
 Inspect the hair and thinning are
and nails. common.
Head and Neck
 Inspect and  Head is rounded  All findings
palpate the head (normocephalic) are normal
for size, shape  Client performed the test
and with ease meaning CN VII
configuration. is intact
 Observe face  Client performed the test
for symmetry, with ease meaning CN V
facial features, is intact
expressions,  No cervical nodes
and skin palpable
condition.  Client performed the
 Check function ROM extremities test with
of CN VII. ease
Have the client
smile, frown,
show teeth,
blow out
cheeks, raise
eyebrows, and
tightly close
eyes.
 Evaluate
function CN V.
Using the sharp
and dull sides
of a paper clip,
test sensations
of forehead,  Smooth,
cheeks, and nontender, small
chin. cervical nodes may
 Inspect and be palpable. Slight
palpate the enlargement of the
neck. Assess thyroid may be
 the anterior and noted during
posterior pregnancy.
cervical chain
lymph nodes.
Also palpate
the thyroid
gland.
 Test range of
motion (ROM)
Eyes
 Inspect eyes.  Pupils are equal  Pupils are equal and  All findings
Examine and round, reactive round, reactive to light, are normal
cornea, lens, to light, and and accommodate
iris, and pupil. accommodate.
Inspect the
position and
alignment of
the eyeball in
eye socket.
Inspect the
bulbar
conjunctiva and
sclera. Inspect
the palpebral
conjunctiva and
lacrimal
apparatus.
Ears
 Inspect the  Symmetrical  All findings
auricle, tragus,  Cerumen is waxy in are normal
and lobule for consistency
shape, position,  Able to hear properly
lesions,
discolorations,
and discharge.
 Palpate the
auricle and
mastoid process
for tenderness
 Test hearing by
performing the
whisper test.
Mouth Throat and
Nose
 Inspect the  Hypertrophy of  No signs of gingival tissue  All findings
mouth. Pay gingival tissue is hypertrophy and no are normal
particular common. Bleeding bleeding during brushing
attention to the may occur due to of teeth or dental
teeth and brushing teeth or examinations
gingival tissues, dental  Throat is pink
which may examinations.  No experience of
 normally  Throat pink, no Epistaxis (nosebleed) and
appear swollen redness or exudate. there are no presence of
and slightly  Nasal mucosal redness and swelling of
reddened swelling and nasal mucosal.
 Assess CN VII redness may result
and CN IX. from increased
Have the estrogen
patient close production.
eyes. Check Epistaxis is a
taste by placing common variation
salt, sugar, and because of the
lemon on increased vascular
tongue supply to the nares
 Inspect the during pregnancy.
throat.
 Inspect the
nose. Check
patency of
airflow through
nostrils.
 Test CN 1. Ask
the client to
close eyes and
smell for soap,
coffee, or
vanilla (occlude
each nostril).
Arms, Hands, and
Fingers
 Inspect the  The skin color is uniform,  All findings
upper and it is not too dry and are normal
extremities for not too oily. It is smooth,
overall skin clean, and no presence of
coloration, edema, lesions and other
texture, skin disorders.
moisture,  The shoulders shrug and
masses, and the head movement intact
lesions. and equal bilaterally.
 Test function of  No presence of nodules
CN XI spinal and edema in arms and
by shoulder shoulder. Skin turgor is
shrug and also normal because it
turning head snaps rapidly back to its
against normal position. The
resistance. temperature is in normal
 Palpate state.
shoulder and  All ROM of elbows,
arms for wrists, and fingers
tenderness, including flexion,
swelling and extension, and supination
temperature. and pronation is normal.
  Test ROM of  The brachial, ulnar and
the elbows, radial pulses are obvious
wrist, and and proportional to each
fingers. of it.
 Palpate the
brachial, ulnar
and radial
pulses.
Thorax and Lungs  There are no visible
 Inspect,  Normal findings deformities including  All findings
palpate, include increased barrel chest, kyphosis, or are normal
percuss, and antero-posterior scoliosis. There are no
auscultate the diameter, thoracic presence of lymph nodes
chest. breathing, slight and any skin disorder.
hyperventilation;
shortness of breath
in late pregnancy.
Lung sounds are
clear to
auscultation
bilaterally.
Breasts
 Inspect and  Venous congestion  Client refused to perform
palpate the is noted with the procedure
breasts and prominence of  Client stated that
nipples for veins. Colostrum is excreted in 6
symmetry and Montgomery’s and a half months
color. tubercles are
prominent. Breast
size is increased
and nodular.
Breasts are more
sensitive to touch.
Colostrum is
excreted,
especially in the
third trimester.
Hyperpigmentation
of nipples and
areolae is evident.
Heart
 Auscultate the  Normal sinus  Soft systolic murmurs are  All findings
Heart rhythm. Soft audible are normal
systolic murmurs
are audible during
pregnancy
secondary to the
increased blood
volume.
Peripheral Vascular
 Inspect face and  During the third  All findings
 extremities. trimester,  Edema is present are normal
Note color and dependent edema  Reflexes are normal 1+
edema is normal.  Clonus is absent
 Percuss deep Varicose veins
tendon reflexes. may also appear.
 Normal reflexes 1-
2+. Clonus is
absent.
Abdomen
 Inspect the  Striae and linea  Striae gravidarum and  All findings
abdomen. For nigra are normal. linea Negra is prominent are normal
this part of the The size of the  Uterus is palpable
examination, abdomen may  As stated by the client,
ask the client to indicate gestational fetal movement was first
recline with a age. The shape of felt at around 13 weeks (3
pillow under the uterus may months)
her head and suggest fetal  No contractions
her knees presentation and
flexed. Note position in later
striae, scars, pregnancy.
and the shape  The uterus is
and size of the palpable beginning
abdomen. at 10-12 weeks’
 Palpate the gestation.
abdomen. Note  Fetal movement
organs and any should be felt by
masses. the mother by
 Palpate for fetal approximately 18-
movement after 20 weeks.
24 weeks.  The uterus
 Palpate for contracts and feels
uterine firm to the
contractions. examiner.
Note intensity, Note: Regular
duration, and contractions prior
frequency of to 37 weeks’ AOG
contractions. suggests premature
 Palpate the labor which is an
abdomen. abnormal finding
Notice the  Intensity of
difference contractions may
between the be mild, moderate,
uterus at rest or firm to
and during the palpation.
contraction.  Contractions may
 Time the length last 40-60 seconds
of the and occur every 5-
contraction 6 minutes.
from the
beginning to
the end. Also
 note the
frequency of
the
contractions,
timing from the
beginning of
one contraction
until the
beginning of
the next.
Fundal Height
 Measure fundal  Uterine size should  The fundic height is 26.5  All findings
height. Do this approximately cm are normal
by placing one equal the number
hand on each of weeks of
side of the gestation (e.g.,
abdomen and the uterus at 28
walk hands up weeks’ gestation
the sides of the should measure
uterus until you approximately 28
feel the uterus cm) (Fig. 29-12).
curve; hands Measurements
should meet. may vary by about
Take a tape 2 cm and
measure and examiners’
place the zero techniques may
point on the vary, but
symphysis measurements
pubis and should be about
measure to the the same.
top of the
fundus.
Fetal Position
 Using  A longitudinal lie,  The fetal presentation is  All findings
Leopold’s in which the fetal cephalic are normal
maneuvers, spine axis is  The fetal position is left
palpate the parallel to the occiput posterior (LOP)
fundus, lateral maternal spine 
aspects of the axis, is the
abdomen, and expected finding.
the lower pelvic The presentation
area. Leopold’s may be cephalic,
maneuvers breech, or
assist in shoulder. The size
determining the of the fetus may be
fetal lie (where estimated by
the fetus is measuring fundal
lying in relation height and by
to the mother’s palpation. Fetal
back), positions include
presentation right occiput
 (the presenting anterior (ROA),
part of the fetus left occiput
into the posterior (LOP),
maternal left sacrum
pelvis), size, anterior (LSA),
and position and so on.
(the fetal  The soft mass is
presentation in the fetal buttocks.
relation to the The fetal head
maternal feels round and
pelvis). hard.
 For the first  On one side of the
maneuver, face abdomen, you will
the client’s palpate round
head. Place nodules; these are
your hands on the fists and feet of
the fundal area, the fetus. Kicking
expecting to and movement are
palpate a soft, expected to be felt.
irregular mass The other side of
in the upper the abdomen feels
quadrant of the smooth; this is the
maternal fetus’s back.
abdomen  The unengaged
 For the second head is round,
maneuver, firm, and
move your ballottable,
hands to the whereas the
lateral sides of buttocks are soft
the abdomen and irregular.
 For the third  If the hands move
maneuver, together easily, the
move your fetal head has not
hands down to descended into the
the lower pelvic maternal pelvic
area and palpate inlet. If the hands
the area just do not move
above the together and stop
symphysis to resistance met,
pubis to the fetal head is
determine the engaged into the
presenting part. pelvic inlet.
Grasp the
presenting part
with the thumb
and third finger.
 For the fourth
maneuver, face
the client’s feet,
place your
hands on the
 abdomen, and
point your
fingers toward
the mother’s
feet. Then try to
move your
hands toward
each other
while applying
downward
pressure.
Fetal Heart
 Determine the  Fetal heart rate  Fetal heart rate is located  All findings
location, rate, ranges from 120 to at left lower quadrant with are normal
and rhythm of 160 beats/min. 128 bpm
the fetal heart. During the third
Auscultate the trimester, the fetal
fetal heart rate heart rate should
in the woman’s accelerate with
left lower fetal movement.
abdominal
quadrant when
the fetal back is
positioned on
maternal left,
vertex position.
In breech
presentations,
fetal heart rate
is heard in the
upper quadrant
of the maternal
abdomen.
Legs, Feet and Toes
 Inspect the  Generally uniformed skin  All findings
lower color are normal
extremities for  No presence of masses,
overall skin lesions and varicosities
coloration,  Presence of edema on
texture, both feet
moisture,  The skin temperature is
masses, lesions, normal
and  Hair distribution is normal
varicosities.  Popliteal pulse is 78 bpm
Observe  Dorsalis pedis is
muscles of the
legs and feet.
Note hair
distribution.
 Palpate for
edema, skin
 temperature,
popliteal pulse
and dorsalis
pedis.
Genitalia
 Inspect the  Normal findings  Client refused to perform
external include enlarged the procedure
genitalia. Note labia and clitoris,
hair parous relaxation
distribution, of the introitus,
color of skin, and scars from an
varicosities, episiotomy or
and scars. perineal
 Palpate lacerations (in
Bartholin’s and multiparous
Skene’s glands. women).
 Inspect vaginal  There should be no
opening for discomfort or
cystocele or discharge with
rectocele. examination.
 No cystocele or
rectocele.