MODULE 4 ASSESSMENT FOR A FIRST PREGNANCY VISIT

INTRODUCTION

Before we begin, it is assumed that you have watched some videos and read some
books about ASSESSMENT FOR A FIRST PREGNANCY VISIT. This will be the springboard to your
meaningful understanding of this module.

Take a quick look at the parts of this module:

1. Initial Interview
2. Demographic Data
3. Chief Concern
4. History of Past Illnesses
5. History of Family Illnesses
6. Social Profile
7. Gynecologic History
8. Obstetric History
9. Systemic Assessment
10. Laboratory Assessment
11. Papanicolaou Smear (Pap smear)
12. Blood Studies
13. Glucose Tolerance Test
14. Urinalysis
15. Ultrasonography

OBJECTIVES

LEARNING OUTCOMES

At the end of this module students will be able to:

1. Demonstrate the proper nursing care procedure in assessing pregnant women by

following the right protocol in performing assessment by:
a. Showing the right manner and steps in conducting an initial interview with
pregnant women during their first pregnancy visit;
b. Conducting ethical manner of data gathering, screening, recording, and analyzing
important demographic data of pregnant patients useful for the purpose of
performing the assessment in accordance with the provisions of the Data Privacy
Law.
 After working on this module, the students will be able to perform an assessment for a
first pregnancy visit.

Guide Question

As you go through this module, keep in mind: What are the steps in performing
the assessment?

INTRODUCTION TO ASSESSMENT FOR A FIRST PREGNANCY VISIT

The pregnant woman’s first prenatal visit should be the

building block of a healthy, happy pregnancy. Everything is
established during the first visit, such as the assessment,
whether the pregnancy is confirmed, and a little bit of
planning for the future. It’s time to focus on the woman
herself and the details that could make or break her
pregnancy glow.

Conduct an Initial Interview

 The first prenatal interview could take a long time, so the person who is scheduling
appointments for the visits should make the woman aware to avoid cancelling
appointments or rushing the interview because the woman has an errand to attend to.
 It is important that the healthcare provider should establish rapport even on the first
visit because information such as what the woman feels about her pregnancy and if she
has any fears can only be taken once the woman trusts her healthcare provider.
 Personal interviews can also make the woman feel important and that she is not just
one of the patients that would immediately be forgotten after the visit.
 The interview must take place in a private, quiet environment because it would be
difficult for the woman to answer all the questions when you are in a sitting room full of
waiting patients or on the hallway.
  The woman must also understand your role in the assessment, because if she views you
only as the interviewer you would only get superficial information from her.

Demographic Data
 The demographic data are the superficial data that can be obtained from the woman.
 These include the name, age, address, telephone number, and health insurances.

Chief Concern
 The chief concern of the woman when she visits the
clinic is she thinks she might be pregnant.
 Assess the first day of the last menstrual period of
the woman.
 Assess any early signs of pregnancy such as nausea
and vomiting, fatigue, and breast tenderness.
 Inquire if she has tried any home pregnancy test kit or had a pregnancy test from a clinic
to establish her pregnancy.

History of Past Illnesses

 It is important to assess any past illness because it
might become active during or after the
pregnancy.
 Assess if there are any infections from the past,
especially sexually transmitted diseases so you
could educate the woman and suggest any
vaccines available.
 There are vaccines that are not friendly for a pregnant woman; however, vaccines such
as influenza and poliomyelitis can be administered.
 Assess any allergies present even before pregnancy to avoid triggers that could also
affect the fetus.

History of Family Illnesses

• Assess the presence of family illnesses such as
hypertension, diabetes, or asthma on both the
father and mother.
 • There are illnesses that could become a potential problem during pregnancy or one
that could be transferred to the fetus.

Social Profile
• Assess the woman’s current nutrition profile, or ask her to have a 24-hour recall to
obtain nutrition information.
• Assess the frequency, type, and amount of exercise she does to determine if her
pattern of activities is still recommended during pregnancy.
• Assess if the woman smokes or drinks, its frequency, and amount because these
vices could cause fetal alcohol syndrome or preterm birth.
• Assess history of medication intake and what medication the woman is taking
during pregnancy to determine its possible effects on the fetus.

Gynecologic History
• Obtain the age of the woman’s menarche,
her usual cycle, the duration, and the
amount of menstrual flow.
• Assess any past reproductive tract
surgery as it can affect the present
pregnancy, such as tubal surgery from
ectopic pregnancy.
• Assess the reproductive planning
method that the woman used or will be using
after pregnancy, and also her sexual history to educate her about safe sex practices.

Obstetric History
• Assess the woman’s pregnancy history using GTPAL.
Systemic Assessment
• Assess the woman’s respiratory system, if she is currently experiencing cough,
asthma, pain upon breathing, or any serious
respiratory illnesses such as tuberculosis.
• Assess the cardiovascular system and any
history of heart murmurs, heart diseases,
hypertension, and if she knows her blood pressure
level and any experience of blood transfusion.
• Assess her gastrointestinal system; ask about
her pre-pregnancy weight, any discomforts such as
vomiting, diarrhea or constipation, hemorrhoids, and
changes in bowel habits.
• Assess her genitourinary system and ask about any urinary tract infections, STIs,
PIDs, any difficulties in conceiving, and hematuria.
• Assess any breast lumps, secretions, pain upon
palpation of the breast, or tenderness.
• Assess the woman’s last dental exam, the use of
any dentures, the condition of the teeth, and if
she is experiencing any difficulty in swallowing.

Laboratory Assessment
Papanicolaou Smear (Pap smear)
• Pap smear is performed to detect and diagnose the presence of precancerous and
cancerous conditions of the cervix, vulva, or vagina.
• The test also reveals infectious diseases and inflammation.
• The classification of Pap smear can be seen in the Bethesda classification of Pap
smears.
• Women who have multiple sexual partners, smoke cigarettes, have a history of HPV,
and sexually active before 21 years old should have Pap smear done more
frequently.

Blood Studies
• Complete blood count should be taken to assess the hemoglobin, hematocrit, and
red cell index and determine the presence of anemia.
 • White blood cell count and platelet count must also be obtained to assess for
infection clotting ability.
• Blood typing with Rh factor is also important because blood needs to be available if
ever the woman experiences bleeding during pregnancy.
• Maternal serum alpha fetoprotein detects birth defects such as neural tube defects
if elevated and chromosomal anomalies if decreased.
Antibody titers for rubella and hepatitis B or HBsAG determine whether the woman is protected
against rubella and if the newborn would have a chance of developing hepatitis B.

Glucose Tolerance Test

• A woman with a history of diabetes, large for gestational age babies, obese, or has
glycosuria should undergo glucose tolerance test.
• A 50-g oral toward the end of the first trimester should be performed to rule out
gestational diabetes.
• The plasma glucose level should not exceed 140mg/dl at 1 hour.

Urinalysis
• Urinalysis is performed to assess proteinuria, glycosuria, and pyuria.
• These can be done through test strips or microscopic examination of the urine.
Ultrasonography
• To confirm pregnancy, an ultrasound must be scheduled especially if the woman is
unsure of the date of her last menstrual period.
• Ultrasonography would also determine the growth of the fetus, but only the
gestational sac would be seen at this stage.

Task:
Write a conversation between a nurse and a
pregnant patient on her first pregnancy visit using the correct technique in
communicating/interacting with your patient. Below is an example of a written conversation
between a nurse and a patient. You can also use the checklist below to serve as your guide.
Write it on a short bond paper, write your name and the date today. The deadline is on
September 16, 2022, on or before 5:00 PM.
Please watch these videos as your guide:
https://vimeo.com/258397578
https://www.youtube.com/watch?v=AwwH20GrV_I
https://www.youtube.com/watch?v=dAha5SSHbc4

MANUEL V. GALLEGO FOUNDATION COLLEGES, INC.

CABANATUAN CITY

INSTITUTE OF NURSING AND ALLIED HEALTH SCIENCES

SKILLS –ASSESSMENT FOR A FIRST PREGNANCY VISIT

Space is available below each checklist to record a final pass/fail evaluation, date, and the signature of
the student and evaluating faculty member. The Comments section allows you to highlight suggestions
that will improve skills.

PREPARATION/PROCEDURE 4 3 2 1 COMMENTS
1. Have the woman sit and rest.
2. Introduce yourself to make the patients comfortable. Ask a
general question such as name, address, age, telephone
number, and health insurance.
 Chief concern
3. When was your last menstrual period? Was pregnancy
planned? Any exposure to infectious diseases or ingestion of
drugs since a woman thinks she has been pregnant?
Family and social profile
4. What is family composition? Does the woman have a
support person? What is her occupation? Source of income?
Level of exercise? Hobbies? Recreational drug use? Living
conditions? Nutrition? Sleep pattern?
Past medical history
5. Any abdominal surgery, kidney, heart, hypertension,
sexually transmitted infections, diabetes, allergies? What
immunizations has she had?
Gynecologic history
6. When was menarche? What is the length and duration of
the menstrual cycle?
Obstetric history - TPAL
7. Any previous pregnancies? When? Type and outcome
of birth? Any history of previous miscarriages?
Physical Examination
Baseline data
8. Height, weight, vital signs, fundal height measurements
(after 12 weeks), and fetal heart sounds.
Laboratory Assessment
Blood
9. Complete blood count, serologic test for syphilis, blood
type and Rh, alpha-fetoprotein, antibody titer against Rh,
hepatitis B, rubella, and possibly varicella and HIV
Urinalysis
10. Clean catch for glucose, protein, ketones, and culture
Tuberculosis PPD test.
Ultrasound
11. To date pregnancy or confirm fetal health (if the date of
last menstrual period is unknown).
Total Score

RS/total score x 100 = 100%

Rating Scale
4 3 2 1
Excellent Satisfactory Unacceptable Consider Remediation
76-100 51-75 26-50 1-25

RATING: _______ CLINICAL INSTRUCTOR: ___________________________________ DATE: __________

NAME AND SIGNATURE OF THE STUDENT _______________________________DATE __________

FOUNDATIONS OF MATERNAL-NEWBORN AND WOMEN’S HEALTH NURSING, SIXTH EDITION Copyright © 2014, by
Saunders. P 107