Care of Mother, Child, and Family (RLE) – Reviewer #1

Chapter I: Nursing Assessment for Mother

First Prenatal Visit

 To establish baseline data relevant to health assessment and health promotion strategies.
 To obtain health history for the screening or teratogens and to know any concerns of the mother.
 Explain why specific assessment data is related to the pregnancy of the mother.

Initial Interview

 Good Interview Technique; to obtain thorough and meaningful health histories.

 Lengthy; inform the patient that the interview will be long.
 Ask what the patient wants you to call them by.

Components of Health History

1. Establish rapport.
2. Gaining information about a woman’s physical and psychosocial health.
3. Obtaining a basis for anticipatory guidance for the pregnancy,

 Establish a baseline health picture once a symptom is mentioned at the initial pregnancy allows you
to be able to verify that it is truly a new symptom and a woman is not just becoming more aware of
it.

Demographic Data

a. Name d. Telephone Number

b. Age e. Religion
c. Address f. Health Insurance Information
Chief Complaints

 The reason why a woman has come to the healthcare setting, the fact that she is or thinks she is
pregnant.

1. Date of her last menstrual period and whether she has had a pregnancy test or a home test kit.
2. Elicit information about the early signs of pregnancy.
a. Nausea
b. Vomiting
c. Breast Changes
d. Fatigue
3. Ask if she has any discomfort.
a. Constipation
b. Backache
c. Frequent Urination
 4. Danger signs of pregnancy.
a. Bleeding
b. Frequent Headache
c. Visual Disturbances
d. Swelling of the Hands and Face
5. Document whether or not the pregnancy was planned.

Family Profile

1. Woman’s Age and Her Sexual Partner’s

2. Educational Level
3. Occupation (does it involve heavy lifting? Long hours of standing? Is she exposed to toxic substance?)
4. Marital Status and Support People
5. Housing Status (ask for the size of the house, discuss about a bedroom or space for the baby)

Past and Present Medical History

A. History of Past Illnesses

1. Representative Diseases
 Pose potential difficulty during pregnancy.

a. Kidney Disease h. Gallbladder Disease

b. Heart Disease i. Urinary Tract Infections
c. Hypertension j. Varicosities
d. Sexually Transmitted Disease k. Phenylketonuria
e. Diabetes l. Tuberculosis
f. Thyroid Disease m. Asthma
g. Recurrent Seizures

2. Childhood Diseases
 Also ask if a woman has had immunizations against these.

a. Chickenpox (varicella)
b. Mumps (epidemic parotitis)
c. Measles (rubella)
d. German Measles
e. Poliomyelitis

3. Allergies
 Any drug sensitivities.

4. Past Surgical Procedures

 Past abdominal surgery, such as appendicitis, could interfere with urine growth.
 B. History of Family Illnesses
 Documents illnesses that occur frequently in the family and can help identify potential problems in a
woman during pregnancy or in her infant at birth.

Specifically Ask About:

a. Cardiovascular and Renal Disease

b. Cognitive Impairment
c. Blood Disorders
d. Any Known Genetically Inherited Disease or Congenital Anomalies

Day History or Social Profile

1. Ask for a woman to describe a typical day of her life (nutrition, elimination, sleep, recreation,
and interpersonal interactions).
2. 24 hour recall on the woman’s nutrition.
3. Type, amount, and frequency of exercise.
4. Ask about hobbies that may teratogenic.
5. Smoking Habits (woman and her family).
6. Record the amount of alcohol that the woman consumes.
7. Ask enough questions to be certain if a woman is in an abusive relationship.
8. Ask if a woman is taking any medications, prescribed or over the counter.
a. Herbal Supplements
b. Recreational Drugs (e.g. marijuana, cocaine)
c. IV Drugs that may lead to HIV or Hepatitis B

Gynecologic – Obstetric History

A. Gynecologic History

1. Reproductive tract or women’s health problems (e.g. breast disease)

2. Obtain information about a woman’s menarche age and how well she was prepared for it.
3. Ask about her usual cycle (interval, duration, amount of menstrual flow, and discomfort).
4. Ask if she does a monthly perineal self – examination to inspect for lesions or ulcers.
5. Ask for past surgeries on the reproductive tract.
6. Ask if she had uterine surgery because her uterus may not be able to expand and contract during
normal delivery, leading to a caesarian section instead.
7. Ask if she has undergone frequent dilation and curettage of the uterus, her cervix may weaken or
not open for 9 months.
8. Ask about what reproductive planning methods were used.
9. Include a sexual history (number of sexual partners, safer sex practice) to establish if she has any
risks for STIs during pregnancy.
10. Assess for the possibility of stress incontinence (incontinence of urine on laughing, coughing,
deep inspiration, jogging or running).
 B. Obstetric History

1. Ask questions such as:

a. Did she have any complications, such as vaginal spotting?
b. Did she take any medication? If so, what and why?
c. Did she receive prenatal care? If so, when did she start?
d. What was the duration of the pregnancy?
e. Was labor what she expected? Worse? Better?
f. What was the type of birth? Vaginal or cesarean? Vertex or breech? In a hospital or at
home?
2. Ask about any previous miscarriages or therapeutic abortions and whether she has had
complications during these.
 If her blood type is Rh-negative, ask if she received Rh immunoglobulin after any
miscarriage or abortions.
3. Ask if she has had any blood transfusions to establish possible risk of hepatitis B or HIV or Rh
sensitization from a blood transfusion.

Determination of Estimated Date of Birth or Estimated Date of Delivery

Nagele’s Rule

 Standard method to predict the length of a pregnancy.

Months of January to March

1. LMP Date
2. Add 9 Months
3. Add 7 Days

Months of April to December

1. LMP Date
2. Subtract 3 Months
3. Add 7 Days
4. Add 1 Year

McDonald’s Rule

 A symphysis – fundal height measurement.

 Easy method of determining during midpregnancy that a fetus is growing in utero.
 Measurement is from the notch of the symphysis pubis to over the top of the uterine fundus
(supine).
 The distance is equal to the week of gestation between the 20th and 31st weeks of pregnancy.

 Over the Symphysis = 12 Weeks

 At the Umbilicus = 20 Weeks
 Xiphoid Process = 36 Weeks