Pregnancy Nursing Diagnosis and Nursing Care Plans

Pregnancy Nursing Care Plans Diagnosis and Interventions

Pregnancy NCLEX Review and Nursing Care Plans

Pregnancy refers to the period during which a fetus develops inside a woman’s womb or uterus. It all begins with a sperm fertilizing an egg that has been released from the ovary during ovulation.

The fertilized egg, known as a zygote, makes its way down into the uterus, where it is successfully implanted, resulting in pregnancy. From the last menstrual cycle to delivery, a pregnancy generally lasts about 40 weeks or just over 9 months. On the other hand, premature babies are those born before the 37th week of pregnancy.

Pregnancy can be influenced by a variety of circumstances that a pregnant woman should be informed about. Those pregnant women who obtain an early pregnancy diagnosis and prenatal care are more likely to have a healthy pregnancy and baby.

Signs and Symptoms of Pregnancy

The experiences of each woman throughout pregnancy are unique. The symptoms from one pregnancy to the next of a woman might also be different.

A pregnant woman may also be unaware that she is pregnant because the early symptoms of pregnancy typically resemble those that a woman would experience just before and during menstruation.

In most cases, a woman may observe certain signs and symptoms of pregnancy before taking a pregnancy test. Others will show up weeks later when hormone levels fluctuate. The following are some of the signs and symptoms of pregnancy.

  • Missed Menstruation. A missed menstrual period is the most apparent early symptom of pregnancy and the one that triggers most women to take a pregnancy test. However, pregnancy isn’t the only reason for missed or delayed periods, especially if a woman’s menstrual cycle is irregular.
  • Headache. Many pregnant women complain of mild headaches frequently. Changes in hormone levels and an increase in blood volume are the most likely reasons. However, a pregnant woman should contact her healthcare provider if her headaches don’t go away or are terribly painful.
  • Frequent Urination. During the sixth or eighth week following conception, many women experience frequent urination. Although there are a variety of causes for this, it is most likely due to hormone levels if a woman is pregnant.
  • Light bleeding. Early in pregnancy, some women may have light bleeding or spotting, which is usually the result of implantation. A bacterial infection or irritation can also be the cause of early pregnancy bleeding. Irritation affects mainly the cervix’s surface, which is highly sensitive during pregnancy. Bleeding, on the other hand, can also indicate a major pregnancy concern like miscarriage, ectopic pregnancy, or placenta previa. A pregnant woman should always consult her doctor to see whether the condition should be treated or is simply a normal pregnancy symptom.
  • Cramps. The fertilized egg attaches itself to the uterine wall after conception, stretching and expanding the uterus. This produces spotting as well as cramping in some people. Some women mistake the cramps and spotting for the onset of their period since they resemble menstrual cramps. The cramps are mild, as does the spotting.
  • Morning Sickness. Morning sickness is a common pregnancy symptom that describes nausea and vomiting in the first four months of pregnancy, but it does not affect every pregnant woman. Although the specific etiology of morning sickness is unknown, pregnancy hormones are thought to play a role. Morning sickness can develop at any point during pregnancy, although it is most prevalent in the morning.
  • Constipation. Hormone changes, particularly higher levels of the hormone progesterone, cause the digestive tract to slow down during early pregnancy. Food passes through the intestines more slowly when progesterone is present, and a pregnant woman may develop constipation as a result. Drinking plenty of water, exercising often, and eating enough of high-fiber meals will help to alleviate the symptoms.
  • Breast changes. Breast changes are also one of the first indicators of pregnancy. The breasts may become painful, swollen, and generally heavy or full even before a positive pregnancy test. The areolae may darken and the nipples may grow larger and more sensitive. Other factors could cause breast changes, but if the changes are a sign of pregnancy, consider the fact that it will take many weeks for the body to adjust to the increased hormone levels. Breast pain should subside after this happens.
  • Hip pain. Hip discomfort is common in pregnancy, and it tends to get worse as the pregnancy progresses. It can be affected by a lot of factors, including ligament pressure, sciatica, changes in posture, and an enlarged uterus.
  • Acne. Many women develop acne during early pregnancy as a result of elevated androgen hormones, which cause the skin to become oilier and clog pores. Acne in pregnancy is often just brief and disappears after the baby is born.
  • Mood Swings. Pregnancy is usually a wonderful time, but it may often be stressful. Mood swings are typical, particularly during the first trimester, and are linked to hormonal changes.
  • Weight gain. In the first few months of pregnancy, a pregnant woman can anticipate gaining between 1 and 4 pounds. Beginning in the second trimester, weight gain becomes more apparent.

If any of these symptoms become persistent, they should seek medical advice to devise a health plan for dealing with them.

Phases of Pregnancy

Pregnancy is divided into three trimesters, which are medical terms used by healthcare professionals to represent the three stages of pregnancy. Specific fetal developments mark each trimester. The significant events of each trimester of pregnancy are outlined below.

  1. First trimester (weeks 1 to 12). The baby grows quickly during the first trimester of pregnancy. It is the stage where the brain, spinal cord, and other essential organs of the fetus begin to develop. The baby’s heart will start to beat as well. However, the risk of miscarriage is relatively high during the first trimester. If a pregnant woman is having miscarriage symptoms, she should seek medical attention right once.
  2. First trimester (weeks 13 to 28). An anatomy scan ultrasound will most likely be performed during the second trimester of pregnancy. This test looks for any developmental anomalies in the fetus’s body and can also indicate the sex of the child. A pregnant woman will most likely begin to feel the baby move around inside her uterus. A baby in utero is termed “viable” after 23 weeks, which implies it can survive outside the womb. However, babies delivered this early are more likely to have major medical conditions, such as respiratory and neurological defects. If a pregnant woman carries the pregnancy for a longer period, they have a far better chance of having a healthy baby.
  3. Third trimester (weeks 29 to 40). Weight gain will escalate in the third trimester, and a pregnant woman may feel more exhausted. The baby can now open and close its eyes as well as perceive light. Their bones are also formed. Pregnant women may experience pelvic discomfort and swollen feet as labor approaches. Braxton-Hicks contractions, contractions that do not lead to labor, may begin to occur in the weeks immediately before delivery.

Diagnosis of Pregnancy

Human chorionic gonadotropin (hCG), commonly regarded as the pregnancy hormone, is used to determine whether or not a woman is pregnant. hCG may not be discovered until a woman has missed a period. Following a missed menstrual period, hCG levels rise quickly and can now be identified via a urine or blood test.

  • Urine test. Urine tests can be performed at a doctor’s office and are identical to the tests that may be performed at home. After the first day of missing a period, home pregnancy tests are fairly accurate. If a woman’s home pregnancy test turns up positive, she should make an appointment with her doctor immediately.
  • Blood test. Blood tests can be carried out at a laboratory. Home pregnancy tests are about as accurate as hCG blood testing, but blood tests can be ordered as soon as six days following ovulation.
  • Ultrasound. To confirm the pregnancy and the gestational age, an ultrasound will be used.

Stages of Labor and Delivery

A pregnant woman may begin to feel Braxton-Hicks contractions, often known as false labor, after the fourth month of pregnancy. They’re quite natural and contribute to getting the uterus ready for the job ahead of the actual labor. 

False labor does not occur at regular intervals or become more intense over time. So, if a pregnant woman starts having regular contractions before week 37, it may be premature labor, and she should seek medical advice.

Labor is an individual experience that differs from pregnancy to pregnancy. In some situations, it can be over in a matter of hours, while in others, it can put a mother’s physical and emotional stamina to the test. Nobody knows how labor and delivery will go until it happens. A pregnant woman, on the other hand, can prepare by learning the normal series of events, as described below.

Stage 1: Early Labor and Active Labor. When a pregnant woman experiences persistent contractions, she enters the first stage of labor and delivery. Over time, these contractions became stronger, more regular, and more frequent. To allow the baby to move into the birth canal, they cause the cervix to dilate and soften, as well as shorten and thin (efface).

The first stage, which is separated into two periods — early labor and active labor — is the longest of the three.

  • Early labor. The cervix dilates and effaces during early labor, and the pregnant woman may have mild, irregular contractions. A clear pink or slightly bloody discharge from the vaginal area may be visible as the cervix opens. For first-time mothers, the usual duration of early labor varies from hours to days. For subsequent deliveries, it is frequently shorter. If the pregnancy is uncomplicated, the expectant mother may spend most of her early labor at home until the contractions become more frequent and intense.
  • Active labor. The cervix dilates from 6 to 10 cm during active labor. The contractions will grow more intense, regular, and more frequent. Leg cramps and nausea are possible to experience too. If the water hasn’t already broken, increased pressure in the back will most likely be felt. It is time for the expectant mother to go to the labor and delivery center if she hasn’t already. The discomfort increases as active labor continue and might last anywhere from 4 to 8 hours or more. The cervix will dilate at a rate of about 1 cm per hour on average.

Transition, the final part of active labor, can be very severe and painful, lasting anywhere from 15 to 60 minutes. Contractions will be close together and can last anywhere within 90 seconds or less. The pressure in the lower back and rectum will be felt and may feel compelled to push.

The health care provider may suggest waiting if the urge to push is already present but the cervix is not fully dilated. Pushing too quickly may exhaust the pregnant woman and cause her cervix to expand, causing delivery to be delayed.

Stage 2: Delivery of the Baby. The baby is delivered during the second stage of labor. Pushing the baby out might take anywhere from a few minutes to several hours or more. For first-time mothers and women who have had an epidural, it may take longer. The expectant mother will be asked to bear down during each contraction or told when to push by the health care provider. She may also be asked to push when she feels compelled to. Pushing can be done in a variety of positions, including squatting, sitting, lying down, or kneeling. Following the delivery of the baby’s head, the rest of the baby’s body will be delivered shortly after.

Stage 3: Delivery of the Placenta. The mother will undoubtedly feel relieved after the baby is delivered. There is still a lot going on while the infant is in the mother’s arms or on her abdomen. The placenta will be delivered during labor’s third stage. The placenta usually takes 30 minutes to deliver, but it might take up to an hour. Mild, less painful contractions will continue to occur.  The placenta is moved into the delivery canal by these contractions. The healthcare provider may advise pushing gently one more time to deliver the placenta, as well as administering medication before or after the placenta is delivered to promote uterine contractions and reduce bleeding.

Nursing Diagnosis for Pregnancy

Pregnancy Nursing Care Plan 1

Risk for Fluid Volume Deficit

Nursing Diagnosis: Risk for Fluid Volume Deficit related to decreased intake and increased losses secondary to the latent phase of labor as evidenced by dry mouth, nausea, and vomiting.

Desired Outcome:

The patient will maintain fluid intake as tolerated and demonstrate adequate hydration as evidenced by moist mucus membranes, appropriate urine output, stable vital signs, and fetal heart rate (FHR).

Pregnancy Nursing InterventionsRationale
Monitor and document the patient’s intake and output, as well as the specific gravity of her urine. Encourage also the patient to empty his bladder every one and a half to two hours.Intake and output should be relatively comparable, depending on hydration level, while urine concentration rises as urine production falls, signaling dehydration. If the bladder is distended, fetal descent may be delayed.
Monitor the patient’s vital signs and fetal heart rate of the baby as needed.Dehydration can be detected by escalations in temperature, blood pressure, pulse, respirations, and fetal heart rate.
Check the patient’s hematocrit level.In the case of severe dehydration, the hematocrit level of the patient rises as the plasma component falls.
Offer clear fluids and ice chips, as tolerated by the patient.It aids hydration while also providing some calories for energy generation.
Administer parenteral fluids to the patient, as ordered.If oral intake is insufficient or limited, parenteral fluids may be essential. Fluid resuscitation is also required in the event of dehydration or hemorrhage; it also helps to mitigate the effects of anesthesia and analgesia.
Offer mouth care and hard candy to the patient, as necessary.Dry mouth can be relieved with mouth care and hard candy.

Pregnancy Nursing Care Plan 2

Risk for Injury

Nursing Diagnosis: Risk for Fetal Injury related to hypercapnia and infection secondary to a prolonged phase of labor.

Desired Outcome:

The fetal heart rate will be within normal parameters, and there will be no concerning periodic alterations in reaction to uterine contractions.

Pregnancy Nursing InterventionsRationale
Monitor the patient’s labor progress.Infection, maternal strain, severe stress, and bleeding induced by uterine atony or rupture can all be exacerbated by prolonged or dysfunctional labor with a long latent phase, placing the fetus at risk for hypoxia and injury.
Monitor and measure the fetal heart rate at rest on a regular schedule. Take note of the fetal heart rate fluctuation and variations in response to uterine contractions.The normal fetal heart rate range is 120–160 beats per minute (bpm), with average fluctuation, and it increases in response to maternal activity, fetal motion, and uterine contractions.
Monitor fetal heart rate during membrane rupture, reassess as needed, and collect a 30-minute EFM strip for documentation.Umbilical cord compression, which reduces oxygen delivery to the fetus, may be indicated by changes in amniotic fluid pressure with rupture and/or varied decelerations of fetal heart rate.
Check the fetal heart rate for bradycardia, tachycardia, or a sinusoidal pattern.Fetal decompensation, hypoxia, or acidosis arising from anaerobic metabolism are reflected by severe and untreatable irregular decelerations of fetal heart rate, recurring late decelerations, or persistent bradycardia. The presence of a sinusoidal pattern is frequently linked to fetal anemia or severe fetal hypoxia immediately before fetal death.
Check for chlamydial discharges, vaginal warts, or herpetic lesions on the maternal perineum.The fetus can contract sexually transmitted diseases during pregnancy, where a cesarean section may be necessary, particularly for clients who have active herpes simplex virus type II.
In case of evident cord prolapse at vaginal introitus, elevate the client’s hips or instruct the client to assume the knee-chest position, push presenting section off the cord, and hold off until the nurse gets help.The position relieves pressure on the cord, as this is an urgent problem that necessitates surgical intervention.
In case of cord prolapse, inspect the cord for pulsations and wrap it in sterile gauze soaked in saline solution.Keeps the cord moist and reduces the likelihood of infection in the fetus.
Administer supplemental oxygen through a face mask, as necessary.It increases the amount of oxygen available for fetal absorption in the mother.
If oxytocin is infusing, turn it off and increase the plain IV solution.Improves circulating blood volume accessible for oxygen transfer inside the maternal circulation of the placenta; promotes longer periods of uterine relaxation and increases uteroplacental blood flow.

Pregnancy Nursing Care Plan 3

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to lack or misinterpretation of information about pregnancy as evidenced by frequent queries, incorrect follow-through of instructions, and occurrence of preventable pregnancy complications.

Desired Outcome:

Nursing Stat Facts
Nursing Stat Facts

The patient will verbalize understanding of pregnancy and recognize/initiate lifestyle changes to have a healthy pregnancy.

Pregnancy Nursing InterventionsRationale
Evaluate the patient’s understanding of her own pregnancy, difficulties, and lifestyle modifications.Assists in the planning of long-term modifications required for a safe pregnancy. Clients may be aware of medical facts but are unaware of the impact of an unhealthy lifestyle on pregnancy.
Assess the degree of anxiety of the patient and significant others.Anxiety can make it difficult for the patient and her significant others to gather and comprehend information.
Encourage regular physical exams, especially vaginal cultures for the detection of Sexually Transmitted Diseases (STDs).Vaginal cultures can detect the presence of microorganisms such as group B streptococcus (GBS), chlamydia, syphilis, and gonorrhea, which can be harmful to the fetus or baby.
Review the ultrasound results of the patient.The results of an ultrasound are used to evaluate fetal growth and development to detect intrauterine growth limitations and possible requirements of the baby.
Share information on the harmful consequences of drugs, cigarettes, and alcohol on the mother and the fetus.Recognizing the harmful consequences of alcohol, cigarettes, and other substances on pregnancy may inspire the client to avoid or discontinue her bad habits.
As needed, provide diverse material, such as a list of articles, books, and videos relevant to the patient’s and family’s needs, and encourage the patient to read and discuss what she learns.This intervention helps patients make informed decisions regarding their pregnancies and the baby’s health and safety in the future.
Engage the client in the learning process through group participation and discussions.The patient’s active participation improves learning about healthy pregnancy.
Check the patient’s pregnancy status and expectations for the future.Provides a data source from which patients can choose their treatment alternatives.
Examine the patient’s learning pace and tailor programs to her specific needs.When individual learning pace is recognized, information is more easily processed, which makes learning easier.

Pregnancy Nursing Care Plan 4

Imbalance Nutrition: Less than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements secondary to prenatal substance abuse as evidenced by decreased muscle mass, lack of appetite, protein, and vitamin deficiencies.

Desired Outcome:

The patient will demonstrate behaviors and lifestyle modifications to maintain an appropriate pregnancy weight.

Pregnancy Nursing InterventionsRationale
Examine and document the patient’s oral cavity condition, age, height/weight, body type, strength, and activity/rest routine.Assists in the formulation of a nutrition plan. The type of food consumed may have an impact on the state of mucous membranes and teeth.
Encourage the patient to keep a food diary of her intake, frequency, and eating patterns.Nutritional strengths, requirements, and insufficiencies will be determined based on the client’s dietary pattern.
Monitor and document the patient’s weight every week.Provides information about the present state of a dietary plan’s efficacy.
The nurse should work with a dietician.It aids in the identification of individual dietary requirements and serves as a supplement to learning about the importance of nutrition in both non-pregnant and pregnant women.
Develop a dietary plan after reviewing and discussing prenatal nutritional needs with the patient.Participation in the plan is simplified, and nutritional inadequacies are addressed.

Pregnancy Nursing Care Plan 5

Risk for Maternal Infection

Nursing Diagnosis: Risk for Maternal Infection related to repetitive vaginal internal examinations, fecal contamination, and rupture of amniotic membranes.

Desired Outcome:

The patient will be free of signs of infections as evidenced by clear amniotic fluid, and absence of fever.

Pregnancy Nursing InterventionsRationale
Monitor the patient’s vital signs and white blood cells (WBCs) level, as necessary.Within 4 hours of rupture of membranes, the risk of infection rises, as demonstrated by an increase in WBC count and unstable vital signs.
Conduct a preliminary vaginal examination and repeat only if the patient’s reaction shows that labor has progressed significantly.Incidence of ascending tract infections has been associated with frequent vaginal examinations.
Strictly observe the aseptic technique during a vaginal examination.It helps to keep bacteria away and keeps irritants out of the vaginal area.
Perform proper hand-washing procedures all the time.It lowers the chances of the patient acquiring infectious pathogens.
Assess and evaluate the patient’s amniotic fluid.The amniotic fluid in a healthy pregnancy must be clear and odorless. During an infection, it thickens and turns yellow, and it has unpleasant odors.
Emphasize perineal care after bowel movements and as needed. When the underpad or linen is soiled, change this as well.It minimizes the patient’s likelihood of an ascending tract infection.
Collect blood cultures if signs of sepsis are evident.Blood culture determines and specifies the organism that is causing the infection.
Administer a cleansing enema, as ordered by the healthcare provider.Bowel evacuation, though uncommon, can help to speed up labor and lessen the risk of infection from contamination of the sterile area during delivery.
Administer antibiotics intravenously as prophylaxis, as ordered by the healthcare provider.Antibiotic administration during the labor phase is complicated due to the antibiotic concentration on the fetus, although it may assist prevent infection if the client is in danger.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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