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First Trimester

NURSING PRIORITIES
1. Encourage client to adopt health-promoting behaviors.
2. Detect actual or potential risk factors.
3. Prevent/treat complications.
4. Foster client’s/couple’s positive adaptation to pregnancy.

NURSING DIAGNOSIS: Nutrition: altered, risk for less than body requirements
Risk Factors May Include: Changes in appetite, presence of nausea/vomiting, insufficient
finances, unfamiliarity with increasing metabolic/nutritional needs
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Explain the components of a well-balanced
CRITERIA—CLIENT WILL: prenatal diet, giving food sources of vitamins, minerals, protein, and
iron.
Follow recommended diet.
Take iron/vitamin supplement as prescribed.
Demonstrate individually appropriate weight gain (usually a
minimum of 3 lb by the end of the first trimester).

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine adequacy of past/present nutritional Fetal/maternal well-being depends on maternal
habits using 24-hr recall. Note condition of hair, nutrition during pregnancy as well as during the 2
nails, and skin. yr preceding pregnancy.
Obtain health history; note age (especially less Adolescents may be prone to malnutrition, eating
than 17 yr, more than 35 yr). disorders, anemia; and older clients may be prone to
obesity/gestational diabetes. (Refer to CPs: The
Pregnant Adolescent; Diabetes Mellitus:
Prepregnancy/Gestational.)

Elicit beliefs regarding culturally proscribed diet May affect motivation to follow recommendations and taboos during pregnancy. Microwaving food contaminants. owing to increased thyroid activity associated with the growth of fetal and maternal tissues. Inadequate cooking of meats/eggs increases risk of bacterial/parasitic infection. cultural degree of motivation for eating them. well-balanced diet. Determines specific learning needs. gravidarum). especially at critical periods in fetal development.) .g. about prenatal diet. Evaluate motivation/attitude by listening to client’s If client is not motivated to improve diet. Weigh client. Note: Ingestion of laundry starch may potentiate iron deficiency anemia.4 mg of folate to prevent maternal deficiencies.Ascertain knowledge level of dietary needs. and a balanced diet meeting increased caloric needs is usually adequate. believing that it hardens maternal bones and makes delivery difficult. further comments and asking for feedback about evaluation or other interventions may be information given. ascertain usual pregravid weight. the basal metabolic rate (BMR) increases by 20%–25% (especially in late pregnancy). During the first trimester. the demand for iron is minimal. refuse iron. Inadequate prenatal weight gain and/or below Provide information about optimal prenatal gain. creating a potential risk for the client with poor nutrition. and/or a bodily response to the need for nutrients (e. destroys more folic acid than conventional cooking. An additional 800 mg of iron is necessary during pregnancy for developing maternal/fetal tissue and fetal storage.g. chewing on ice may indicate anemia). response to hunger. Review food preparation techniques to preserve Cooking vegetables in large volume of water may nutrients and reduce risk of exposure to cause vitamins to be lost. For example. (Note: Iron preparations are not commonly prescribed in the first trimester because they may potentiate nausea. indicated. and ingestion of clay may lead to fecal impaction. First-trimester nausea/vomiting can have a Rule out pernicious vomiting (hyperemesis negative impact on prenatal nutritional status. Review frequency and severity of nausea/vomiting.. and daily increasing the likelihood that the client will select a vitamin/iron supplements. Provide appropriate oral/written information Reference material can be reviewed at home. Provide alternative of healthcare provider. (Refer to CP: The High-Risk Pregnancy. Research studies have found a positive correlation between pregravid maternal obesity and increased perinatal morbidity rates (e. Note presence of pica (craving for nonfood The ingestion of nonfood substances in pregnancy substances).) Folic acid is crucial to fetal development requiring daily supplement of 0. risk for less than body requirements. phenomenon. In the prenatal period.. some cultures choices to meet dietary needs. hypertension and gestational diabetes) associated with preterm births and macrosomia. normal prepregnancy weight increases the risk of intrauterine growth retardation (IUGR)/restriction in the fetus and delivery of low-birth-weight (LBW) infant. Assess choices of substances and may be based on a psychological need. ND: Nutrition: altered. food choices.

Test urine for acetone. Report absence/successful management of discomfort. NURSING DIAGNOSIS: [Discomfort] May Be Related To: Physical changes and hormonal influences Possibly Evidenced By: Verbalizations. and pregnancy-induced hypertension (PIH). Clients with Hb levels less than 12 g/dL or Hct levels less than or equal to 37% are considered anemic in the first trimester. diabetic ketoacidosis. Collaborative Obtain baseline Hb/Hct levels. and glucose. May need additional assistance with nutritional dietitian. Children (WIC) food Supplemental federally funded food program helps program as appropriate. may have budget/financial constraints. alteration in muscle tone DESIRED OUTCOMES/EVALUATION Identify measures that provide relief. Identifies presence of anemia and potential for reduced maternal oxygen-carrying capacity. CRITERIA—CLIENT WILL: Assume responsibility for alleviation of discomfort. Refer to Women. is clue to client’s response to discomfort and pain. social services). restlessness. which results in developmental lags in infancy and possibly beyond. promote optimal maternal/fetal nutrition. choices.g. Infants.. . Make necessary referrals as indicated (e. is performed routinely to detect potential high-risk situations such as inadequate carbohydrate ingestion. Establishes baseline. ACTIONS/INTERVENTIONS RATIONALE Independent Note presence/degree of minor discomfort. albumin. Provides information for selection of interventions. Maternal malnutrition may negatively affect fetal growth and contribute to reduced complement of brain cells in the fetus. Measure uterine growth.

labia minora. spices. through the release of oxytocin. displacement of bowel and pressure on vasculature by enlarging uterus can predispose client to the development of hemorrhoids. Woolrich Use of specially designed breast shields helps to breast shields) in bra for flat/inverted nipples. creating an imbalance that may result in muscle cramping. bleeding. and a dusting of cornstarch to vaginal secretions. Instruct in use of ice packs. or topical Reduces discomfort and swelling. break adhesions and cause flat/inverted nipple to evert and to become more erect. Reduced gastrointestinal (GI) motility and swelling. it is important to anticipate the discomfort experienced by these clients because they may not ask questions or express discomfort/pain.g. eating dry toast). Stress importance of avoiding excessive nipple Stimulation may contribute to preterm labor manipulation. expose to air for 20 min daily. phosphorus than calcium. sprays/decongestants absorbed systemically can be harmful to the fetus. and avoiding strong odors if on the empty stomach or by increased nausea/vomiting is a recurrent problem. eating small and may be caused by the effects of hydrochloric acid frequent meals. Although humidification of air may be congestion. Suggest humidification of air and avoidance of Increased estrogen levels contribute to nasal nasal sprays and decongestants to treat nasal congestion. or adolescents. women with a history of childhood or adult sexual abuse may experience a variety of physical and emotional discomforts with vaginal examination.) foods. suggest periodically elevating buttocks on pillow. use Promotes hygiene by removing/absorbing excess of cotton underwear. risk for deficit. with lubricated finger. (Refer to sensitivity/aversion to odors. noncaffeinated fluids. Recommend wearing of hard plastic cup (e. Use extreme gentleness and pictures or occur. Adolescents may be self-conscious during an examination.g. the raw areas are drawn over the vagina to heal closed). and milk dairy products results in greater levels of ingested if leg cramps develop. a female circumcision or infibulation (whereby. Excess intake of and to reduce amount of cheese. (Refer to ND: Constipation. . medial aspect of the labia majora.. and history of sexual abuse. avoid soaps).g. toughens areolar tissue. development of cervical cancers. fruits/vegetables. Recommend wearing of supportive bra. female circumcision. Assess for hemorrhoids: note reports of itching. encourage diet high in fiber. In addition. especially for the client with infibulation. Application of talcum powder absorb discharge (leukorrhea). promotes GI anesthetics.. tissues. Tell client to avoid in the genital area is believed to contribute to the use of talcum powder. heat. especially in the foreign client who has had models.) Instruct client to dorsiflex foot with leg extended Increases blood supply to the leg. especially when the husband is present at the procedure. Although many foreign women are intimidated by the American healthcare system and male physicians.Evaluate degree of discomfort during internal Discomfort during internal examination may examination. teach how to reinsert hemorrhoid motility. which may further increase discomfort. yogurt. those with after removal of the clitoris. Encourage frequent bathing and perineal care.. or certain ND: Fluid Volume. of limited benefit. Review Provides proper support for enlarging breast nipple care (e. Recommend increasing carbohydrate intake on Reduces likelihood of gastric disturbances that arising (e.

be a cause of irritation. Recommend that client maintain diary of intake/ Helpful in determining presence of pernicious output. and reducing muscle cramping. cholecystitis).g. and urine specific gravity. . mucous Indicators assisting in evaluation of hydration membranes. increased fluid needs Possibly Evidenced By: [Not applicable. ACTIONS/INTERVENTIONS RATIONALE Independent Auscultate FHT. intake/output. and altered. Assess skin temperature and turgor. necessitating further intervention. Recommend avoidance of caffeinated pressure of the enlarging uterus on the bladder can beverages. gastritis.) Collaborative Substitute daily calcium supplements if intake of Assists in restoring calcium/phosphorus balance dairy products is reduced.. Review history for other possible medical Assists in ruling out other causes and in problems (e. level/needs. Increased levels of HCG. temperature. Identify signs and symptoms of dehydration necessitating treatment. and weight loss. Coping: potential for growth. dehydration. urinary frequency caused by frequency. NURSING DIAGNOSIS: Fluid Volume risk for deficit Risk Factors May Include: Impaired intake and/or excessive losses (vomiting). identifying interventions to address specific problems. Obtain client weight and compare with pregravid weight. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Identify and practice measures to reduce CRITERIA—CLIENT WILL: frequency and severity of episodes of nausea/vomiting. CP: The High-Risk Pregnancy. Determine frequency/severity of nausea/vomiting. Caffeine has diuretic properties that can further aggravate the problem of frequency. (Refer to vomiting (hyperemisis gravidarum). risk for less than body requirements. Initially. peptic ulcer. ND: Nutrition: vomiting may result in alkalosis. Provides data regarding extent of condition. blood pressure (BP). urine testing. and reduced gastric motility contribute to first-trimester nausea and vomiting. changes in carbohydrate metabolism. (Refer to NDs: Fatigue and Family for rest. Ingest individually appropriate amounts of fluid daily. Assess fatigue level and nature of family/work Encourages client to set priorities and include time commitments.) electrolyte imbalance. Presence of a fetal heart tones confirms presence of a fetus and rules out gestational trophoblastic disease (hydatidiform mole). Untreated or severe vomiting may lead to acidosis.Review physiological changes resulting in urinary Although normal.

dry toast before arising). of pregnancy. Identify who provides support/instruction within Helps ensure quality/continuity of care because the client’s culture (e.. other healer). Fears usually arise out of misinformation and may interfere with further learning. cuerandero/Doula. maintaining relationship. Clarify misconceptions. with support person(s) when possible. ACTIONS/INTERVENTIONS RATIONALE Independent Establish an ongoing and supportive nurse. Client may have difficulty learning unless the need for it is clear. Display self-care behaviors that promote wellness. plain popcorn. as well as beliefs about activities. and foods high in carbohydrates (e. Modesty or cultural demands may prohibit care by males and/or may require that husband remain in room when care is being given. and so forth. self care needs May Be Related To: Lack of understanding of normal physiological/psychological changes and their impact on the client/family Possibly Evidenced By: Request for information. anticipatory guidance and promote individual responsibility for wellness. using interpreter as needed. Maintain open attitude toward beliefs of Acceptance is important to developing and client/couple. statement of misconceptions DESIRED OUTCOMES/EVALUATION Explain normal physiological/psychological CRITERIA—CLIENT WILL: changes associated with the first trimester. six small meals per day. self-care. Evaluate current knowledge and cultural beliefs Provides information to assist in identifying needs regarding normal physical/psychological changes and creating a plan of care. Work healthcare provider in communicating information. Determine degree of motivation for learning. reducing gastric acidity. healthy state of childbirth. grandmother/other family support person(s) may be more successful than the member.g.Encourage increased intake of noncaffeinated Helpful in minimizing nausea/vomiting by carbonated beverages. Identify danger signs of pregnancy.. . Determine attitude of client toward care given by Some cultures view the medical doctor as someone male provider versus Certified Nurse-Midwife (CNM) seen for illness and use midwives/cueranderos for or female practitioner.g. NURSING DIAGNOSIS: Knowledge deficit [Learning Need] regarding natural progression of pregnancy. The role of teacher/counselor can provide client relationship. supporting independence.

Elicit/answer questions about infant care and feeding. Helps maintain normal Hb levels.. backache. acute abdominal pain. appropriate healthcare. including discussion Information encourages acceptance of of nutrition. alcohol. BP monitoring. Using pictures. and fetal malformation. iron may be contraindicated in the presence of sickle cell anemia. and assistance may not be sought.g. or postnatal). and so forth). presence of genetic disorders Possibly Evidenced By: [Not applicable. Review need for prenatal vitamins. Reinforce importance of keeping regular cultures put emphasis on different phases of appointments. which is the period of organogenesis. Visualization enhances reality of child and strengthens learning process. such as Helps client to distinguish normal from abnormal bleeding. and positive outcome for mother/baby. Different weight). use of drugs (nicotine. thus assisting her in seeking timely. comfort measures. when fetal demand is great. Provides information that can be useful for making choices. health habits/lifestyle. however. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Initiate behaviors that promote health for self and CRITERIA—CLIENT WILL: fetus. rest. Folic acid and folic acid. urine testing. cocaine. possible abruptio placentae.g. Provide a list of suggested readings. Abstain from smoking and use of alcohol or illicit drugs. Note: Because of the possibility of overload. breast care. NURSING DIAGNOSIS: Injury. headaches. Refer client/couple to childbirth preparation Knowledge gained helps reduce fear of unknown class. Identify danger signals of pregnancy. client may require increased folic acid during and after sickle cell crisis. findings. sexual activity. Provide anticipatory guidance. and self-care. symptoms may be viewed as “normal” occurrences in pregnancy. exercise. Assess client’s The fetus is most vulnerable in the first 3–8 wk. risk for fetal Risk Factors May Include: Maternal malnutrition.) Identify agents harmful to the fetus. discuss fetal development. exposure to teratogens/infectious agents. . Refrain from self-medication without first contacting the obstetric health practitioner. abortion. prenatal. visual disturbance. Stress the need to avoid all medications until the healthcare provider is consulted. marijuana. and the client’s cultural group may not consider prenatal visits as important.Explain office visit routine and rationale for Reinforces relationship between health assessment interventions (e. (Adverse signs and and pelvic pressure. and increases confidence that couple can manage their preparation for the birth of their child.. pregnancy (e. Research indicates that iron supplements may not be necessary until the second and third trimester. deficiency contributes to megablastic anemia. responsibility and promotes willingness to assume employment. edema. ferrous sulfate. cramping. delivery.

including HIV and other viruses).g. Review dietary habits and cultural practices. or exposure to STDs. bradycardia. Fetal well-being is directly related to maternal well- being. Discuss normal activity level and exercise Blood flow to the uterus can decrease by 70% with practices. herpes simplex). and decrease need for oxytocin augmentation. including CVS in first trimester or amniocentesis in second trimester.. Tay-Sachs disease).ACTIONS/INTERVENTIONS RATIONALE Independent Discuss importance of maternal well-being. emotional stressors. (Refer to CP: Genetic Counseling. offspring. potential teratogens such as alcohol or nicotine or environmental toxins. Protein intake is essential to development of fetal (Refer to ND: Nutrition: altered. live attenuated behaviors/environment that can promote healthy viruses. strenuous exercises. and need for additional evaluation and/or altitude. Yet nonendurance antepartal exercise regimens tend to shorten labor. advanced maternal desire testing to determine whether fetus is age for Down syndrome. Discuss options. use of intervention. Hb is essential for oxygen transport. nicotine. when developing organ systems are most vulnerable to injury from environmental/hereditary factors.. (Refer to CP: Prenatal increase risk of transmission of STDs. Helps client make decisions/choices about such as x-rays. body requirements. IUGR..) HIV. Pregravid maternal obesity has been linked to preterm births. especially during the first trimester. medications. for each trimester. culture. alcohol. swimming. and HIV. especially Infection.g. rubella. STORCH group of viruses (syphilis. producing transient non–weight-bearing exercise (e. abusive relationship. Jewish background for affected. . increase likelihood of a spontaneous vaginal delivery. risk for less than brain tissue. Encourage client to engage in moderate. Discuss normal weight gain curve IUGR in fetus and low-birth-weight infants. Encourage client to engage in safer sex practices. possible fetal hyperthermia.) Review obstetric/medical history for high-risk Identifies physical and psychological risk factors factors (e. lifestyle.g.) Provide information about potential teratogens. toxoplasmosis. Malnutrition in the mother is associated with Weigh client. other. Note protein intake. Assess for possible high-risk situation associated Clients at risk for certain genetic disorders may with genetic disorders (e. and bicycling). Monitor Hb and Hct. if client does not know sexual history or contacts of partner. cytomegalovirus. Failure to use condoms during intercourse may proper use of condoms.

screens growth. serum should be culture report. . and placenta previa. STDs. Smoking negatively affects placental circulation. damage in utero. Do serological testing. In the United States. Treat client appropriately when herpes culture is In cases of herpes simplex virus type II. i. Vaginal culture should be obtained from client with fever of nonspecific origin or with history of Listeria infection. to detect problems. obtained for HIV testing. Encourage cessation of tobacco usage. Exposure may have negative following delivery. lesions. CVS is an (Refer to CP: Genetic Counseling. between 9 and 12 weeks’ gestation. and assess uterine Provides information about gestation of fetus. which is spread is not immune.Discuss mode of transmission of certain infections. (Refer to CP: 20 weeks’ gestation. such as open spine or ventral wall defects. Obtain vaginal/rectal culture to rule out beta Appropriate treatment may be instituted based on streptococcus. Refer to CVS/other testing as indicated if client is CVS can detect abnormalities or genetic defects over age 35 or is at risk for a specific genetic disorder. Down syndrome. if inactive. which cannot be performed until 14–16 weeks’ gestation. and trisomy 18. Determine history of may be considered if disease is diagnosed before Listeria monocytogenes infection. abruptio placentae. Low Apgar scores at birth (below 7 at 5 min) are associated with smoking.. Note Screening for susceptibility allows client to take need for postpartum immunization. Evaluate rubella titer for immunity (0. a cesarean birth is indicated. for IUGR. identifies multiple pregnancies. Collaborative Perform internal examination.1:10). Even smoking fewer than 10 cigarettes per day carries an increased risk of fetal death. along with lower-birth- weight and premature delivery. Toxoplasma gondii is most Stress need to wash hands after animal contact. Listeria monocytogenes is Prenatal Infection. Refer to appropriate resources if substance More help may be needed to deal with resolution abuse exists. the client positive. Immunization after delivery results in immunity during subsequent pregnancies. other cultures Advise against changing cat’s litter box or eating may acquire it through ingestion of raw or improperly cooked meat. unconjugated estriol. In the presence of visible for self-care is provided. especially in first trimester. can be done at about 16–22 wk to measure AFP. for active infection.) effects on fetal development. appropriate precautions. frequently transmitted in cat feces. Therapeutic abortion gloves while gardening.) thought to be transmitted via animal contact. Triple screen (MSAFP3).e. and about the need to be immunized by droplet infection. Positive diagnosis of conditions such as toxoplasmosis can be made. (Refer to CP: Prenatal Infection. and Listeria. and HCG.) earlier alternative to amniocentesis. Recommend wearing improperly cooked meat. Provide information about avoiding contact with Approximately 5%–15% of women of childbearing persons known to have rubella infection if client age are still susceptible to rubella. thereby reducing likelihood of prenatal exposure. (Refer to CP: Prenatal Substance of problem and ensure well-being of pregnancy Dependence/Abuse. a maternal blood test. medication such should be free of lesions at the time of labor or as acyclovir may be ordered.) and fetus. information rupture of membranes.

NURSING DIAGNOSIS: Fatigue. Fluctuating hormone levels (cortisol. prioritizing and curtailing some outside commitments. Client may need to make adjustments. with growth of maternal/fetal tissues. ACTIONS/INTERVENTIONS RATIONALE Independent Determine normal sleep-wake cycle and Helps in setting realistic priorities and examining commitments to work. community. Therapeutic abortion may be considered if disease is diagnosed before 20 weeks’ gestation. to be restricted in the presence of sickle cell anemia. as indicated. risk for Risk Factors May Include: Increased carbohydrate metabolism. avoidance of foods/fluids containing caffeine. Note: Iron may need between meals. Prepare for/discuss transvaginal sonography. seems to have a sedative effect. Encourage regular exercise in moderation. drinking warm milk/eating a light snack at bedtime. L -Tryptophan in milk keeping crackers at bedside. 8 hr of sleep Provides rest to meet metabolic needs associated each night in a dark/cool room. estrogen) may limit restful sleep.Refer to genetic counseling if appropriate. and so forth. Modify lifestyle to meet changing needs/energy level. increased energy requirements to perform activities of daily living Possibly Evidenced By: [Not applicable. Suggest client limit fluid intake 1 or 2 hr before bedtime. such as abortion. Provides support for tender breasts during sleep. Low Hb levels result in greater fatigue due to de- encourage daily iron supplement to be taken creased oxygen-carrying capacity. Additional information may be necessary. and self. Report improved sense of energy. progesterone. and crackers may help reduce feelings of nausea on awakening. Enhances ability to fall asleep and obtain adequate rest. Encourage a 1. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Identify basis of fatigue and individual areas of CRITERIA—CLIENT WILL: control. Can be carried out as early as 41/2 weeks’ gestation as a diagnostic tool for suspected fetal abnormalities or for prompt detection of tubal gestation. such as changing work shift to accommodate early-morning nausea (changing to a later morning shift) or provide more rest (changing from night shift to day shift). Discuss possible treatment options. family. time commitments. altered body chemistry. May decrease frequency of nighttime voiding. Explain role of iron in the body. A bedtime snack may prevent awakening because of hunger. .to 2-hr nap each day. shifting of household chores/responsibilities. Recommend use of comfortable bra/jogging top. Monitor Hb level.

increased efforts at bearing down. Adequate bulk and consistency in diet choices help vegetables. ACTIONS/INTERVENTIONS RATIONALE Independent Determine pregravid elimination habits. resulting in fetal bradycardia. ingestion of iron supplements Possibly Evidenced By: [Not applicable. Iron supplements also contribute to problems of constipation.) Varicosities of the rectum frequently develop as a result of prolonged constipation. (Refer to ND: [Discomfort]. Collaborative Discuss cautious use of stool softener or bulk. noting Usual elimination patterns need to be maintained. In some cultures. possibly beliefs about exercise. The presence of hemorrhoids can cause pain with defecation. when possible. nonstrenuous exercise Promotes peristalsis and assists in prevention of program. increased absorption of water from GI tract. Strenuous exercise is thought to strenuous. alteration with pregnancy. Tell client to avoid constipation. Provide dietary information about fresh fruits. fiber. May be necessary to assist in combatting persistent producing agent if diet/exercise is not effective. presence of signs/symptoms establishes in actual diagnosis] DESIRED OUTCOMES/EVALUATION Maintain normal pattern of bowel function. or increased circulating volume and hormonal relaxation of blood vessels. NURSING DIAGNOSIS: Constipation. Encourage regular. Report adoption of individually appropriate behaviors to promote elimination. or growth restriction/retardation. Note cultural reduce uteroplacental circulation. presence of hemorrhoids. roughage. grains. CRITERIA—CLIENT WILL: Identify individual contributing factors/risk behaviors. and adequate promote effective bowel pattern. constipation and establishing a regular routine. risk for Risk Factors May Include: Smooth muscle relaxation. fluid intake (preferably decaffeinated). Increasing progesterone level relaxes smooth muscle within the GI tract. inactivity may be viewed as a protection for mother/child. . such as walking. hyperthermia. resulting in reluctance of the client to evacuate her bowels. resulting in reduced peristalsis and increased reabsorption of water and electrolytes. Assess for hemorrhoids. prolonged exercise.

preterm labor. May help to prevent urinating and voiding after intercourse. transmission of STDs. and chorioamnionitis. before meals and food handling. prenatal client to UTI. until after such notification. which increases risk of premature rupture of membranes. they are associated with healthcare provider and to avoid self-medication preterm labor/birth. pH. NURSING DIAGNOSIS: Infection. As many as 2%–10% of culture and sensitivity. and after toileting. Recommend that client drink 6–8 glasses of Helps prevent stasis in the urinary tract. Encourage practice of Kegel exercise (tightening Improves support to the pelvic organs.000/ml). insufficient knowledge to avoid exposure to pathogens Possibly Evidenced By: [Not applicable. Contributory factors. strengthening and increasing elasticity of the pubococcygeus muscle. Stress need for frequent/thorough hand washing Many viruses. poor hygienic practices. provides more control over urination. and Proteus vulgaris infection. can add to potential for exposure to infection. Provide information about other hygiene measures. may noncaffeinated liquid daily. can be excreted in the urine for up to 4 yr after exposure and can possibly be transmitted through poor hygienic practices. . presence of white blood cells.000/ml. especially CMV and nongonococcal urethritis. (colony count greater than 100. ACTIONS/INTERVENTIONS RATIONALE Independent Provide information about signs/symptoms of Maternal UTIs respond well to treatment and may UTI. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Identify behaviors to reduce urinary stasis/risk of CRITERIA—CLIENT WILL: infection. in diet and addition of cranberry/orange juice. Discuss role of acid residue acidify urine and help prevent UTI. especially if history includes urinary/kidney problems. such as wearing manmade fabrics and sitting in bath water. however. as indicated. Helps prevent rectal Escherichia coli contaminants including wiping vulva from front to back after from reaching the vagina. Stress need to report signs of infection to not be serious. List signs and symptoms requiring evaluation/interventions. risk for urinary tract infection (UTI) Risk Factors May Include: Urinary stasis. such as cytomegalovirus (CMV). Suggest use of cotton underwear and showers Urinary stasis and glycosuria can predispose the instead of tub baths if client has a history of UTI. Report pregnant women have asymptomatic bacteriuria colony counts of greater than 100. Be free of signs and symptoms of infection. of the perineum) throughout the day. Collaborative Obtain routine urine sample for microscopic Alkaline urine predisposes client to a possible examination.

Edema of facies and/or upper extremities may indicate PIH. owing to edema. Assess for location/degree of edema. Cardiac ventricles undergo slight hypertrophy to Review contributory history of cardiac problems compensate for increase in circulating volume and or rheumatic fever. Prompt recognition and intervention reduce risk of adverse outcome. ACTIONS/INTERVENTIONS RATIONALE Independent Review physiological process and normal or Prenatally. which relax blood vessel walls. Although this is a normal process. Systolic murmur may be created by decreased blood viscosity. Treats infection as indicated. CRITERIA—CLIENT WILL: Remain normotensive. NURSING DIAGNOSIS: Cardiac Output [maximally compensated] May Be Related To: Increased fluid volume (preload). changes in peripheral resistance (afterload) Possibly Evidenced By: Variations in blood pressure and pulse.. (Refer to CP: Pregnancy-Induced venous stasis caused by uterine pressure and Hypertension. ventricular hypertrophy.Administer antibiotics (e. (Refer to CP: Pregnancy-Induced Hypertension. Obtain baseline BP and pulse measurement. owing to potentially negative effects on the fetus. prescribing antibiotics prenatally. diastolic increase greater than 15 mm Hg. Hormonal effects of progesterone and relaxin reduce resistance to cardiac output by relaxing smooth muscle within the blood vessel walls. ampicillin. displacement of the heart. Care must be taken in erythromycin) as appropriate. syncopal episodes. The body compensates for the increase in fluid volume by increasing cardiac output through ventricular hypertrophy. Be free of pathological edema. presence of pathological edema DESIRED OUTCOMES/EVALUATION Differentiate normal and abnormal changes. An increase in BP may indicate PIH. to maximize output. . as appropriate. note any murmurs. Pulse increase Report systolic increase of greater than 30 mm Hg or above 10–15 bpm may indicate cardiac stress. plasma and red blood cells increases 30%–50% to meet maternal/fetal nutritional and oxygen needs and to act as a safeguard against blood loss during delivery. Distinguish Dependent edema of the lower extremities between physiological and potentially harmful (physiological edema) often occurs. Display no more than 1+ albumin in urinalysis. the client is maximally compensated and could be at risk for hypertension and/or circulatory failure as the pregnancy progresses. hormonal effects of progesterone and relaxin. or torsion of great vessels. ND: Fluid Volume risk for deficit).g. circulating blood volume in the form of abnormal changes and signs/symptoms.) Auscultate heart sounds.

which can increase heart rate and cardiac workload. elevated Hct may indicate dehydration with PIH fluid shifts. grandmother. ACTIONS/INTERVENTIONS RATIONALE Independent Determine attitude toward pregnancy. Identify basic sense of client’s self-esteem in relation Because of a changing body shape. create a crisis situation that negatively affects both the pregnancy and parenting abilities in clients with poor self-esteem and a weak ego identity. positively with her changing body shape and maintain positive self-esteem. attitudes. alterations in to the changes of pregnancy and responsibilities body image occur normally in pregnancy and may related to this new role.Assess for varicosities of legs. Increased fluid load and hormonal relaxation of blood vessel walls potentiates risk for vascular engorgement and venous stasis. Review physiological changes of pregnancy. and how these her ability to develop positive feelings about her issues are viewed by significant other(s). changing body contours. Adequate support can help client to cope cultural healer. NURSING DIAGNOSIS: Body Image. rectum. Demonstrate a positive self-image by maintaining an overall satisfactory appearance. past experiences. and spiritual beliefs Possibly Evidenced By: [Not applicable. as well as her ability to adapt positively to her parenting roles. Low Hb may indicate anemia. Provide Verbalizing helps sort out feelings. and environment in which couple can discuss feelings. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Verbalize understanding/acceptance of body CRITERIA—CLIENT WILL: changes. client that mixed feelings are normal. assure Helps decrease stress associated with pregnancy. Assess support systems such as aunt. risk for disturbance Risk Factors May Include: Perception of biophysical changes. cultural. Proteinuria with elevation of albumin above 1+ suggests glomerular edema or spasm (developing PIH). and job situation. Test urine for albumin as indicated. Discuss the need to avoid rapid position changes Client may be prone to postural hypotension caused from sitting or lying to standing. Collaborative Monitor Hb and Hct levels. . especially in client whose lifestyle requires prolonged sitting/standing. vulva. Verbalize acceptance of self in situation. changing The client’s feelings toward the pregnancy affect body image. psychosocial. and so on. by reduced venous return. requiring prompt intervention.

ACTIONS/INTERVENTIONS RATIONALE Independent Evaluate the client’s/couple’s response to Identifies needs to assist in planning interventions. this “crisis” depends on support systems. developmental level (immaturity on the part of the client and/or significant other). resources can create added stress. Initially.. tend to be used in subsequent crises. CRITERIA—CLIENT WILL: Verbalize realistic perception and acceptance of self in changing role. Client may require more intensive intervention to counseling/therapy). . Develop realistic plans for adapting to new role/ role changes. ability to deal positively with stress. Talk with family/significant other about situation and changes that have occurred or may occur. pregnancy.” Explain emotional lability as characteristic of Helps client/couple understand mood swings. risk for altered Risk Factors May Include: Maturational crisis. cultural beliefs. history of maladaptive coping. Members of some cultures may view healthcare as unaffordable and. individual and family stressors. absence of support systems Possibly Evidenced By: [Not applicable. and effective coping mechanisms developed in dealing with past stressors. and possible role changes that a child will necessitate. and The client’s/couple’s ability to adapt positively to cultural implications of pregnancy/childbirth. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Identify perceived stressors. Discuss normalcy of ambivalence.g. Partner realizes the need to offer support/affection at these times. either positive or negative. pregnancy. may seek abortion or may not seek prenatal care. Learned coping methods. result in child’s death or that planning ahead has the potential of “defying God’s will. Ascertain from client/couple how stressors have Provides information regarding client’s/couple’s been dealt with in the past. the expectant mother may feel ambivalent toward the pregnancy because of personal/professional goals. as a result. resources. Elicit information about preparations or lack of May have fears that visible preparations may preparations being made for this infant. facilitate acceptance of self/pregnancy. financial concerns. Assess economic situation and financial needs.Collaborative Refer to other resources as indicated (e. Impact of pregnancy on family without adequate Make necessary referrals. NURSING DIAGNOSIS: Role Performance. even if the pregnancy is planned.

emotional lability. goals. adaptive tasks are effectively addressed to enable goals of self-actualization to surface Possibly Evidenced By: Family member/individual makes realistic appraisal of growth impact of pregnancy on own values. fatigue. Further assistance in developing problem-solving skills may be helpful. chooses experiences that optimize wellness DESIRED OUTCOMES/EVALUATION Explore anticipated role changes.g. priorities.Provide information about. that necessitates adaptation to new roles and responsibilities. Assess relationship of client/couple to own parents. interactions among members). By the end of the first trimester. Assess for maladaptive behaviors (e. Determine roles/responsibilities within family unit Family members will need to be flexible in and use of supportive resources. the client/couple should have successfully achieved the task of accepting the pregnancy. May be invaluable in providing support to client/couple although adjustment to role changes may require mutual support. and peer support. Collaborative Refer for psychological counseling. feelings. as necessary. inappropriate self-care). CRITERIA—CLIENT/COUPLE WILL: Undertake appropriate tasks in preparation for the birth. Note strengths/stressors (e.g. withdrawal. sharing of problems. lack of or with stress and the need for intervention. Determine availability/involvement of grandparents. and family members. or relationships. . assist client to meet her needs related to the demands of pregnancy both expected and unplanned. Identify anticipated adjusting own roles/responsibilities in order to adaptations necessitated by pregnancy. such as prolonged nausea. Report feelings of self-confidence and satisfaction with progress being made. moving in direction of health-promoting and enriching lifestyle. Provides information about client’s ability to deal inappropriate anger/reactions. NURSING DIAGNOSIS: Family Coping: potential for growth May Be Related To: Client and family needs are sufficiently met. New parents tend to use their own parents as role models and may thus adopt positive or negative parenting behaviors. resulting in a disequilibrium communication styles.. childbirth classes.. ACTIONS/INTERVENTIONS RATIONALE Independent Identify relationship of family members to one Pregnancy is a crisis situation for client/couple another. May provide insight for assisting couple in assuming parenting role. and encourage Provides an opportunity for formal/informal attendance at.

siblings regarding adjusting changes in family structure.Evaluate sibling responses to pregnancy and In the first trimester. changes in comfort level Possibly Evidenced By: Reported difficulties. or changes in sexual response/activities DESIRED OUTCOMES/EVALUATION Share feelings related to changes in sexual desire. to newborn. as client desires. altered May Be Related To: Knowledge/skill deficit about altered body function/structure. Encourage father/siblings to attend prenatal Promotes a sense of involvement. . couple. and behaviors. participation in delivery. young siblings may not be upcoming change in family structure. Provide information about father/sibling or Helps family members to realize they are an grandparent attendance at childbirth classes and integral part of the pregnancy and delivery. Performance.) NURSING DIAGNOSIS: Sexuality Patterns. aware of the reality and long-term consequences of pregnancy. Provide list of appropriate reading materials for Information helps individual realistically analyze client. Family members may be concerned about anticipated changes and may express a desire to prepare themselves and siblings for role/life change(s). (Refer to ND: Role pregnancy. risk for altered. Older children may not manifest negative feelings outwardly. CRITERIA—CLIENT/PARTNER WILL: Take desired steps to remedy situation. Report satisfaction with/acceptance of changes or modifications required by pregnancy. helps make baby office visits and listen to FHT. a reality for family members. roles. limitations. Collaborative Provide information/referral about community Reducing stressors in the home allows the resources if client/couple is having concerns expectant couple to devote emotional energy to the about parenting abilities. yet internally they may begin to fear a change in the security of their relationship with their parent(s).

Reduced libidinal urges in the first trimester are common for the prenatal client. correct misconceptions. and a changing body image. Assess for Intercourse is not usually contraindicated in the vaginal bleeding/spotting. Client/couple may be helped couple’s response to the changes. Review information about the normalcy of these Helps the couple understand the changes from a changes. Determine and sexual patterns during pregnancy may affect the impact of pregnancy on the pattern and the the relationship. when they know that desire may be diminished because the woman is not feeling well owing to breast tenderness. fatigue. couples to cope positively with sexuality issues in pregnancy. However. (Refer to ND: Body Image. Assess couple’s relationship to one another and The nature of the relationship before pregnancy ability to cope with decrease in frequency of affects how well the couple copes during sexual intercourse. This decreased desire may be difficult for the couple. nausea. Note client’s/couple’s response to changing body Acceptance of sexuality issues is directly related to shape. they should know it is all right to continue sexual activity/alternatives as the couple desires. Create a teaching plan to discuss sexual a positive self-concept and individual’s sense of changes for prenatal client in the second and identity. . third trimester.ACTIONS/INTERVENTIONS RATIONALE Independent Determine the couple’s usual pattern of sexual How the couple copes with changes in sexuality activity using a sexual assessment tool. pregnancy. vomiting. and especially for the male partner.) Review obstetric history with couple. first trimester unless the client has experienced complications such as bleeding during this pregnancy or in past pregnancies. risk for disturbance. physiological viewpoint. to understand. Collaborative Refer the couple for counseling if sexual concerns Professional counseling may be necessary to help are not resolved.