THE COLLEGE OF STATEN ISLAND

School of Health Sciences

Department of Nursing
Nursing 220 Family Centered Maternity Nursing

Antepartal Nursing Assessment

Student________________________________ Hospital/Unit__________________________________

Instructor______________________________ Date_________________________________________

Admitting Diagnosis (if on antepartal unit)_______________________________Gestational Age_________

Prenatal History(Interview)

1. Marital Status____________ Religion_________________ Languages Spoken________________

Age______ Occupation____________________________ Educational Level________________

2. Husband (significant other) occupation_____________________________________ Age_______

Educational level_________________

3. Children/ages_________________________________________________________________________

4. Other dependents______________________________________________________________________

5. Was this pregnancy planned?________ Method of contraception used___________________________

6. Feelings regarding this pregnancy_________________________________________________________

7. Expectant fathers reaction to the pregnancy_________________________________________________

8. Cultural or religious concerns about the pregnancy____________________________________________

9. Does the couple plan to attend childbirth classes?_____ If no, why not?____________________________

10. Does the expectant father plan to be with the woman during Labor and Delivery?____________________

11. How will this pregnancy and infant alter the couples plans for:

Education_____________________________________________________________________________

Career and employment__________________________________________________________________

Lifestyle______________________________________________________________________________

12. Housing arrangements___________________________________________________________________

13. Financial Concerns______________________________________________________________________

14. Habits: Smoking: Amount per day_________________ Duration_________________________________

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15. Caffeine intake_________________ Alcohol intake_____________ Drug intake_________________

16. Nutritional status: Food Allergies_______________________________ Pica________________________

Typical diet at home

Breakfast______________________________________________________________________________

Lunch_________________________________________________________________________________

Dinner_________________________________________________________________________________

Snacks_________________________________________________________________________________

Describe any teaching done regarding nutrition:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Secondary Sources (Chart, Kardex)

1. Vital Signs Pulse__________ Respiration__________ B/P___________ F.H.R.___________________

2. Prepregnant weight____________ Present weight_______________

3. Description of previous pregnancies

Year Length Length Type of Hospital of Delivery Fetal Outcome
of of Delivery (alive, stillbirth, problem?)
gestation Labor

4. Using TPAL system describe the number of pregnancies T P A L

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5. Antepartal, Intrapartal, or Postpartal complications with previous pregnancies:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

6. Description of present pregnancy

LMP__________ EDD__________ Gravida__________ Para____________

7. Risk Factors 8. Discomforts of Pregnancy

Diabetes Mellitus Psychosocial

PIH Skin

Multiple Gestation GI

Hyperemesis Gravidarum GU

Cardiac Respiratory

Bleeding Disorders Musculoskeletal

Other(describe Cardiovascular

Other (describe)

9. Laboratory Studies (identify lab values and indicate if abnormal by *)

Urine: Urinalysis____________ Culture and Sensitivity____________

Protein______________ Ketones______________ Glucose________________

Blood: Blood type_________ Rh factor_____________ Hct__________ Hgb__________

WBC___________ VDRL__________ Rubella Titer____________ Hbsag____________

PPD______________ Chest XRay?____________ Treatment if positive____________________

Cultures: Pap smear___________G.C. culture__________ HIV_________GBS_________HSV_______

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Physicians orders

Date Order

Medications

Diet

Activity

Treatments

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