Antepartum Care
UNFOLDING Reasoning
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
1. Nutrition
2. Patient Education
3.
... [Show More] Stress
4. Coping
5. Clinical Judgment
6. Communication
NCLEX Client Need Categories Percentage of Items from Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
• Management of Care 17-23% ✓
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
• Basic Care and Comfort 6-12% ✓
• Pharmacological and Parenteral Therapies 12-18% ✓
• Reduction of Risk Potential 9-15% ✓
• Physiological Adaptation 11-17% ✓
Anne Jones, 17 years oldHistory of Present Problem:
Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods.
Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but
didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the
morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant.
Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis.
Personal/Social History:
Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas
daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for
headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to
Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of
pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including
cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants
to keep the baby but has not told her parents.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present
Problem:
Clinical Significance:
1. 17-year-old female reports two missed
periods.
2. Reported some spotting last week
3. C/O breast tenderness, swelling,
increased frequent in urination, and
a.m. nausea
4. (+) pregnancy test
5. Provider has ordered urinalysis and
pre-natal lab panel
-These are all presumptive signs of pregnancy.
RELEVANT Data from Social History: Clinical Significance:
1. Senior in H/S.
2. Works in a job that requires constant
standing
3. Denies use of alcohol/nicotine & is
not on any prescription medications
4. Reports a daily diet of poor nutritional
value
5. Does not currently have a support
system, as she has not informed
anyone of her present situation
-Patient is in stable health with no known major medical concerns
at this point. We know that she will need her nutrition and dietary
habits addressed to successfully accommodate a growing fetus.
She will also need a support system and education on what to
expect in the coming months. We’ll know more when her lab
panel comes back.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness
P: 76 (regular) Quality: Tender to touch and movement
R: 18 (regular) Region/Radiation: Both breasts
BP: 125/80 Severity: 4/10 but better if wears a bra
O2 sat: not assessed Timing: For the past couple of monthsWhat VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction
of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS
Data:
Clinical Significance:
1. Temp, HR, & RR
are all within
expected/acceptabl
e ranges
2. BP is on the upper
end of acceptable
-There really is no significance to her first three VS, but her BP being on the higher
end of acceptable is mildly concerning. Considering how young she is and that she
isn’t overweight and doesn’t have any other diagnosed medical conditions, we’d like
to see that number be a little lower; especially because as she progresses further into
the pregnancy we know that BP will continue to rise. So with her current baseline,
she’s at an increased risk of having a BP that’s excessively high later on down the
line.
Current Assessment:
GENERAL
APPEARANCE:
Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm),
weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite.
BMI 18
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial, brisk cap refill
NEURO: Alert and oriented to person, place, time, and situation (x4)
HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale
Chest: Breasts tender on palpation, areola darkened and occasional veins present
Abdomen: Soft; no masses, uterus palpable below the level of the symphysis pubis,
Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+
Pelvic Exam: Vagina and cervix deep purple in color, uterus slightly enlarged, and Hagar’s sign present
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction
of Risk Potential/Health Promotion and Maintenance)
RELEVANT Assessment Data: Clinical Significance:
1. She’s had a 5lb weight loss since
pregnancy
2. She reports some bleeding at the
gums
3. Her conjunctiva is pale
a. Breasts tender
b. Varicose veins—lower
extremity
c. Purple cervix/ + Hagar’s
sign
-Her weight lost is concerning, especially since she was so thin to
begin with. We already know she has a poor diet that lacks many of
the basic nutrients that she and her baby will need
-Bleeding of the gums is a common issue during pregnancy, however,
it’s one that needs to be addressed. She is more susceptible to plaque
buildup with leads in inflammation and bleeding. We’ll need to make
sure she focuses more on oral care as far as brushing and flossing her
teeth are concerned
-The paleness of her conjunctive makes me think we’re looking at
some anemia here, especially with the pregnancy and her nutritional
history
-The other assessment findings are expected and of no concern at this
pointLab Results:
Prenatal Panel
Hemoglobin RPR/VDRL HBsAG Blood
type
Rubella HCG ELISA
Current: 11.0 mg/dL Negative Negative B- Nonimmune 20,700
mlU/ml
Negative
What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT
Lab(s):
Clinical Significance: TREND:
Improve/ Worsening/
Stable:
1. All these labs are
relevant; however,
there are some that
will need to be
addressed.
a. Hemoglobi
n
b. – Rh status
c. – neg
immunity to
Rubella
-Her hemoglobin is slightly lower than the expected range
in 1st trimester pregnancies. However, since she is
pregnant we know that this is something that continue to
be depleted with the increased 02 needs of the fetus. It’s
important to make sure we can have those levels as high
as possible to prepare for this. This can be accomplished
by diet and by the use of vitamins as well.
-Although, there really isn’t anything we’re going to do
with her Rh- status, it needs to be noted
-We also can so anything with her lack of immunity to
Rubella except remind her to stay away from those that
have the disease and urge her to get the vaccine right after
she delivers while still in the hospital
-This is her initial set of
labs, so we have
established a baseline for
her going forward but
not a trend at this point
Urine Dipstick
Color: Clarity: Sp.
Gr.
Protein Glucose Ketones Leukocytes/Nitrite Blood Chlamydia
Gonorrhea
Current: Yellow Clear 1.010 neg neg neg none none positive
What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction
of Risk Potential/Physiologic Adaptation)
RELEVANT
Lab(s):
Clinical Significance:
1. Urine
specific
gravity
2. + C/G
result
-Her urine dipstick didn’t reveal to many concerning findings; although, her urine specific
gravity is quite high meaning she may not be hydrating herself enough
-And her chlamydia/gonorrhea screen came back positive, so we’re going to need to address
that and also make sure this isn’t something that she exposes herself to again in the futureLab Planning: Creating a Plan of Care with a PRIORITY Lab
(Reduction of Risk Potential/Physiologic Adaptation)
Lab: Normal
Value:
Clinical Significance: Nursing Assessments/Interventions Required:
HGB:
11.0
Critical
Value:
-This low hemoglobin value
puts the patient at risk for
anemia. Since Hg equals a
decreased amount of RBCs,
this means there is less 02 to
circulate for both mom and
baby
-explain to the patient to role of hemoglobin for her
and her baby and inform her of the results of her
blood test
-provide supplementation in the way of vitamins
- possibly consider IV iron if needed
-educate patient on dietary sources of iron so that she
can increase her daily intake of those particular items
Lab: Normal
Value:
Clinical Significance: Nursing Assessments/Interventions
Required:
Chlamydia
Gonorrhea
POSITIVE Critica
l Value:
-This is a significant finding. It’s
important that we address this. Left
intreated, this can lead to lower birth
weights and pre-term labor.
-We need to make sure we treat the infection
successfully and also obtain follow up
testing after treatment to ensure there is no
evidence of infection
-Education also needs to be provided on safe
sex practices so as to not become re-infected
prior to delivery
Clinical Reasoning Begins…
1. Interpreting relevant clinical data, what is the primary concern? What primary health related concepts does this
primary problem represent? (Management of Care/Physiologic Adaptation)
Problem: Physiology of Changes in OWN Words: Primary Concept:
-Our primary
concern at this
point is the
patient’s poor
diet and
nutrition status
-As the fetus grows, more and more energy and nutrients
are needed to provide and environment that is suitable
for this growth.
-Things like protein, glucose, iron, and oxygen are
necessary components to this successful growth, and
most of this comes from our diet.
-It’s important to consume foods that foster that growth
and supplement what we can’t get from our diet in the
form of vitamins
-Healthy mom = healthy baby
-You don’t have to eat for two, but
you need to increase your caloric
intake
-Make food choices that encourage
optimal growth and function
Collaborative Care: Nursing
2. What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY: Provide education to patient and their support persons about theimportance of proper diet and vitamin supplementation during
pregnancy
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
1. Schedule some sessions with the
patient and her support people and
provide education on nutrition and
diet
2. Provide the patient with prenatal
vitamins and explain their purpose
and give instructions on usage
If the patient and her support system
is aware of the benefits of proper diet
and nutrition during pregnancy and
the negative effects of poor nutrition
on mom and baby, it stands to reason
that this will increase compliance of
the plan of care
The outcome of these
interventions should moderate
the behavior of the patient to
initiate a healthier diet that is
more conducive to fetal health
and growth
3. What body system(s) will you assess most thoroughly based on the primary/priority need? (Reduction of Risk
Potential/Physiologic Adaptation)
PRIORITY Body System: PRIORITY Nursing Assessments:
The GI/Digestive system is the priority
body system to that will most heavily be
impacted and monitored to assess progress
and current status
-We will need to consistently monitor the patient’s weight as this
is a good indicator of how she is doing with her eating.
-We’re also going to want to keep an eye on her labs so that we
can assess not only that she is eating, but that she is eating foods
that are high in protein, iron, calcium, magnesium etc.
4. What is the worst possible/most likely complication(s) to anticipate based on the primary need for this patient?
(Reduction of Risk Potential/Physiologic Adaptation)
Worst Possible/Most Likely
Complication to Anticipate:
Continued lack of adherence to increased dietary needs
Nursing Interventions to
PREVENT this Complication:
Assessments to Identify Problem
EARLY:
Nursing Interventions to Rescue:
1. Close follow up and
monitoring of patient’s
nutritional state by
assessment of blood work
and weight monitoring
during the pregnancy
2. Positive reinforcement of
compliance
3. Setting reasonable goals that
allow the patient to have
some input
4. Compromise on things
things can be compromised
on
-Frequently monitor weight at prenatal office visits
-Have the patient keep a food journal
to be reviewed with the nurse so that
planned interventions are properly
targeted
-As the patient is 17 and still lives at
home, involve her parents (if possible)
in helping to make sure that she stays
on track with appropriate consumption
of nutrient dense foods and selfadministration of supplements
-As she is still an adolescent, there
may be some body image issues
going on here. In the event that
compliance is difficult to obtain, a
nutrition expert and a counselor
should be brought in to consult on
the matter as well5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES: Factor in patient’s age and stage in life when making treatment
decisions and interventions
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
CARE/COMFORT:
Caring/compassion as a nurse
-schedule follow up appointments in the
later part of the afternoon so that the
patient doesn’t need to leave school early
and feel more divided from her peers
Physical comfort measures
-provide resources that can help the
patient feel more comfortable as her
pregnancy progresses and make sure she
is adequately comfortable during school
hours; help with accommodating this if
needed
-Pregnancy is already a difficult
transition for any women; it’s that
much more difficult for someone
who hasn’t even fully transitioned
themselves into adulthood
-Using the same methods of care and
treatment will not have the same
effect because your patient has
different priorities and different
goals and needs
- With a treatment plan and goals
that take into account the lifestyle
modifications of an adolescent, you
increase the probability of their
compliance
-With goals that the patient
has had input in and that
factor their individuality
into the mix, the patient
will maintain adequate
levels of caloric intake and
nutrition
EMOTIONAL (How to develop a
therapeutic relationship):
Discuss the following principles needed
as conditions essential for a therapeutic
relationship:
• Rapport
• Trust
• Respect
• Genuineness
• Empathy
Lack of support system
-discuss the importance of having a
support system in place during pregnancy
and offer to set the patient up with a
counselor or social worker to meet with
her and her mom/dad
Unplanned pregnancy
-start to discuss what resources the patient
has in place for the baby since this was
not a planned pregnancy
-Emotional support is just as
important as physical and/or
financial support. Lack of this will
have just as much of a fall out if not
properly addressed, especially
during pregnancy when emotions
tend to run rampant.
-The patient will have a
less stressful pregnancy
and a solid support system
that will aid her in
preparing for the birth of
her baby.SPIRITUAL:
-Inquire if the patient has any spiritual
beliefs; and if so, if any of these beliefs
will need to be incorporated into the
pregnancy or the birth experience
-It’s important to be aware of
people’s spiritual beliefs, especially
because many times this is a factor
in their healthcare as far as decisions
and treatment compliance may be
concerned.
-The patient will express
any spiritual beliefs and
concerns at initial
appointment so that care
and treatment decisions can
take those beliefs into
consideration
TWELVE-WEEKS LATER…
Anne returns to the office for her fourth visit. She is now 20 weeks pregnant. She states
her morning sickness has gotten better and she felt the baby move a few weeks ago. She
has gained 10 lbs. (4.5 kg) since the first visit. She had her MFAP and triple marker
blood screening labs drawn at 16 weeks which was negative. She has told her parents,
and they are supportive. She also told her boyfriend, but he has no interest to be involved.
RELEVANT Data: Clinical Significance:
-20wks gestation
-Resolution of morning
sickness
-10lb weight gain
-16wk screening labs all –
(neg)
-Support system in place
-The patient is halfway through the pregnancy
-The resolution of her morning sickness has dissipated allowing patient to
gain weight
-Patient has an established support system
Current VS: First visit: Current PQRST:
T: 98.6 F/37.0 C (oral) 98.6 F/37.0 C (oral) Provoking/Palliative: Standing for long time
P: 80 (regular) 76 (regular) Quality: Dull
R: 18 (regular) 18 (regular) Region/Radiation: Lower back
BP: 120/70 125/80 Severity: Mild, 3/10
O2 sat: not assessed not assessed Timing: occasional
Current Assessment:
GENERAL
APPEARANCE:
Calm, body relaxed, no grimacing, appears to be resting comfortably
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with soft murmur heard at the left sternal
border, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill
NEURO: Alert and oriented to person, place, time, and situation (x4)
HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids appear pale
Chest: Breasts tender on palpation, areola darkened and occasional veins present
Abdomen: Soft; no masses, uterus palpable at midway between symphysis pubis and umbilicus, light linea
nigra present
Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+
Fetal Heart Rate: 150 bpm, Lower Left Quadrant (LLQ)Lab Results:
Prenatal Labs
Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG MFAP Triple
Marker
Current: 10.1 mg/dL Normal Negative
Most Recent:
First visit
11.0 mg/dL Positive Negative B- Nonimmun
e
20,700
mlU/ml
1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk
Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
-BP has decreased since last
visit
-Reports occasional mild
lower back pain when
standing for long periods of
time
-Her decrease in blood pressure is a good sign and therefore a trend in a
positive direction
-She complains of some back back, but that is not an unexpected finding at this
point. She does have a job at McDonald’s where constant standing would be
involved
RELEVANT Assessment
Data:
Clinical Significance:
-Bleeding at the gum line
-Pale conjunctiva
-Bleeding gums indicate that perhaps there has been no increase in dental
hygiene
-Pale conjunctiva indicates anemia
RELEVANT Lab Data: Clinical Significance:
-Hg has decreased even
further
-Indicates that either iron rich foods have not been getting consumes or
perhaps pre-natal vitamins are not being taken regularly
2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be
modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
-There has been improvement to the status,
just not 100 percent of the goal has been
reached
-Schedule consultation with a nutrition to see if any alterations
can be made to increase dietary intake to more nutrient dense
foods
3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management
of Care)
CURRENT Nursing
PRIORITY:
Focus more heavily on diet and nutrition intake to increase hemoglobin levels
PRIORITY Nursing
Interventions:
Rationale: Expected Outcome:
-Have the patient consult with a
nutritionist to provide more
education and possible meal plan
to include necessary items of
nutrition during pregnancy
-A specialist will more easily be
able to pinpoint the source of the
problem, whether it is dietary or
not and how to better address the
issue of correcting the problem
-With the help of the specialist, a meal
plan can be incorporated into the patient’s
daily routing that incorporate the foods
needed to obtain adequate nutrition for
mom and babyEducation Priorities/Discharge Planning
What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health
Promotion and Maintenance)
Education PRIORITY: Adequate day-day care of a newborn
PRIORITY Topics to Teach: Rationale:
-General care of the newborn: feeding,
bathing, sleeping/eating habits, and
when to call the provider
-As a 17-year-old soon to be parent, it’s probably this patient doesn’t
have much experience with babies. She will need education on how
to care for the infant to keep them safe and healthy
Caring and the “Art” of Nursing
What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with
this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity)
What Patient is Experiencing: How to Engage:
-The patient is probably feeling very nervous and
scared. There’s no doubt some feeling of excitement,
but fear of the unknown (labor, motherhood) is
probably the strongest emotion at this point.
-Ask the patient how she feels. Find out if she does
indeed have any fears, and if so, what they are. Try to
see if there are things you can do as the nurse, to address
some of those fears.
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention at
the moment as the events are unfolding to make a correct clinical judgment.
What did you learn that you can apply to future patients you care for? Reflect on your current strengths and
weaknesses this case study identified. What is your plan to make any weakness a future strength?
What Did You Learn? What did you do well in this case study?
I learned that you can lead the horse to water, but you can’t
make them drink. Patients are individuals, with their own
thoughts, perceptions, beliefs, fears and values. Just because
you tell them to do something doesn’t mean that they are
going to just automatically listen. You have to be in tune with
each patient on an individual level if you want them to change
a particular way of being. Without understanding their beliefs
and who they are fundamentally, it will be impossible to
provide any care that involves the patient making a change to
their life as they know. It sounds crazy because you’re just
trying to provide the best care to your patients, but without
their “buy in” so to speak, you are dead in the water.
I think it’s easy to look at a picture and
determine what doesn’t “fit”. I’ve always been
good at stepping out of the box and trying to
assess a situation with a different lens than just
the immediate one that’s right in front of one’s
face. Critically thinking and determining the
root cause of a problem is a strength of mine,
some might say to a fault. I say it’s what I do
best.
What could have been done better? What is your plan to make any weakness a
future strength?
Determining a contingency plan is something I could have
done better. In my personal life, I am the Queen Contingency!
I have a backup plan for the backup plan… in the backup plan
fails. There’s always a Plan A, Plan B, contingency to Plan B,
and a Plan C—in case Plan B’s contingency is a wash. I
practice that mindset in my day to day work in the clinical
setting with patients in the real world. When I tell a patient
The plan is to learn—learn from every mistake,
everyone else’s mistakes, and not make that
mistake again. We are all going to walk into
clinical experiences with weaknesses, that’s a
give in. Don’t let that weakness define you;
and if you do, let it be the motivation behind
making yourself stronger. When we’re dealingthat they can’t smoke anymore now that they have oxygen at
home, I’m already thinking of what other resources we can
get them set up with to facilitate that when they come back in
a month and they still reek of cigarettes. By the time they’ve
walked in through the door, I’ve already got brochures ready
on quitting, and support group information, and literature on
Chantix. I somehow assumed a pregnant woman would be
different; that they would immediately follow any and all
recommendations because…let’s face it—they’re single
handedly responsible for keeping another human safe and
protected inside of them. I guess I should know better.
with our own weaknesses, I’ve found that I can
“treat” it in a similar fashion to treating our
patients. ADPIE! [Show Less]