A 33 year old multipara has been in labor for 13 hours.

Her partner states, "Why is it taking so

long?” The client asks, "Is the baby okay?" The primary health care provider orders an oxytocin
infusion to assist with contractions.

Nursing Diagnosis: Risk for injury (maternal and fetal) related to prolonged labor with ineffective
contractions and use of oxytocin.

Interventions:
1. Assess vital signs, fetal heart rate and pattern, and contractions.
Rationale: Assessment provides a baseline for future comparisons.
2. Administer intravenous fluids as ordered. Use an infusion pump.
Rationale: Intravenous fluid replacement helps to prevent possible dehydration secondary to
prolonged labor. An infusion pump ensures an accurate flow rate.
3. Maintain client's NPO status.
Rationale: Withholding food and fluids minimizes the risk for aspiration should anesthesia be
necessary.
4. Encourage the client toile on her side as much as possible.
Rationale: A side-lying position enhances placental perfusion.
5. Begin intravenous oxytocin administration as ordered using an infusion control device.
Rationale: Oxytocin stimulates uterine contractions.

A 32 year old pregnant woman admitted in early labor states, “My contractions aren’t too bad but
my back hurts. I want to try and do this as naturally as possible. I was asleep when my last baby
was born 6 years ago.”

Nursing Diagnosis: Pain related to effects of uterine contractions and pressure on pelvic
structures.

Interventions:
1. Assess level of client’s pain from uterine contractions and pelvic pressure.
Rationale: assessment helps to identify areas of chief concern, providing a baseline for future
interventions.
2. Provide a comfortable environment; change sheets frequently, adjust room temperature,
offer cool washcloths to forehead, and close door.
Rationale: A comfortable environment aids n relaxation and minimizes distractions, promoting
effective coping to manage discomfort.
3. Encourage the client to assume different positions and change them regularly. Allow the
client to walk or sit in the chair, if not contraindicated.
Rationale: Position changes promote comfort, reduce muscle tension, relieve pressure and
promote fetal descent.
4. Encourage husband to massage back area, using pressure as tolerated by client.
Rationale: Back massage aids in muscle relaxation. Pressure helps counteract some of the
pain.
5. Respect the need for focusing during contractions. Refrain from intervening with client
during a contraction.
Rationale: Interrupting the client’s focusing is distracting, making the technique ineffective as
a pain relief measure.

A pregnant woman is now entering the active phase of the first stage of labor. Her husband
states, “She’s having stronger contractions now, more regular, and they’re coming every 4
minutes. She was doing so well before with her breathing. Now I think she’s losing it.”

Nursing Diagnosis: Powerlessness related to change in labor pattern and increase in

contraction intensity and frequency.
Interventions:
1. Assess couple for contributing factors related to feelings loss of control.
Rationale: Assessment of factors provides a baseline for developing future strategies.
2. Assist couple with using controlled breathing exercises and position changes. Reinforce
information learned in childbirth education classes.
Rationale: Use of controlled breathing and position changes helps to reduce pain of
contractions and enhances feelings of control. Reinforcement of previous learning provides
additional resources for the couple to use.
3. Slowly and clearly explain the events and changes occurring with the active stage of
labor. Inform the couple of things that can and cannot be controlled.
Rationale: Explanation provides the couple with an understanding of what is happening and
why. Information about things that can be controlled provides a means for focused
participation.
4. Reassure, as appropriate that labor is proceeding without problems.
Rationale: Reassurance helps to minimize anxiety and increase motivation and hope.
5. Allow opportunities for the couple to manipulate the environment. Offer couple options
from which they can choose.
Rationale: Opportunities and options allow for active participation in care and decision
making.

An adolescent female, 15 years old, comes to the clinic. She has noticed weight gain and has
been feeling nauseated in the early morning for the past 3 months.

Nursing Diagnosis: Imbalanced nutrition related to increased nutritional demands of

pregnancy superimposed on adolescent nutritional needs.

Interventions:
1. Explain the need for consumption of adequate nutrients.
Rationale: Adequate nutrient intake is essential for both the client’s and fetus’ optimal growth
and development.
2. Question the client bout food likes and dislikes.
Rationale: Ascertaining food preferences helps to determine suggestions that the client would
be more apt to comply with.
3. Assess client’s nutritional habits; discuss with client ideas and beliefs about “eating for
two”
Rationale: Assessment provides a baseline from which to develop future suggestions and
teaching strategies.
4. Offer choices for food selections based on the adolescent’s school and activity lifestyle.
Rationale: Offering choices individualizes care and allows the adolescent some control with
decision making, thus increasing the possibility for compliance.
5. Instruct client to keep a daily dietary journal, recording all food and fluid intake until next
visit.
Rationale: Journal recordings provide the adolescent with a concrete activity for participating
in care and also aid in evaluating the client’s understanding of and in compliance with
nutritional plan.

A 22 year old single woman at 28 weeks’ gestation with tins is admitted in preterm labor.
Tears in her eyes she states, “I’m so scared. I don’t want to lose my babies”

Nursing Diagnosis: Risk for injury (maternal and fetal) related to effects of preterm labor and
tocolytic therapy.

Interventions:
1. Assess status of client and fetus. Obtain laboratory studies, including complete blood
 count, hemoglobin and hematocrit, serum electrolytes; anticipate need for ECG. Obtain
urine, vaginal and cervical cultures as ordered.
Rationale: Assessment provides baseline for future comparisons. Urine, vaginal and cervical
cultures help to rule out infection as a causative factor for preterm labor.
2. Institute bed rest with client in side-lying position. Apply external uterine and fetal
monitoring.
Rationale: Bed rest relieves pressure of the fetus on the cervix. Side-lying position enhances
uterine perfusion. Uterine and fetal monitoring provides evidence of maternal and fetal well-
being.
3. Begin intravenous fluid therapy as ordered. Assist with or insert an intravenous line.
Rationale: Intravenous fluid improves hydration, which may help to minimize contractions.
4. Administer terbutaline intravenously as an intravenous piggyback solution with a main
intravenous infusion.
Rationale: Piggyback administration allows for stoppage of tocolytic should adverse effects
occur.
5. Anticipate administration of betamethasone as ordered.
Rationale: Betamethasone may be administered to hasten fetal lung maturity; helping to
decrease the risk of respiratory distress syndrome should birth of the fetuses become
necessary.

A woman in postpartum breastfeed her infant and complains for breast engorgement.

Nursing Diagnosis: Pain related to primary breast engorgement.

Interventions:
1. Encourage the mother to suck her newborn at the breast.
Rationale: For relief of the tenderness and soreness of primary breast engorgement.
2. Breast care during the postpartal period.
Rationale: Directed toward cleanliness and support. Promote breast hygiene.

Nursing Diagnosis: Imbalanced nutrition, less than body requirements, related to lack of
knowledge about postpartal needs.

Interventions:
1. Explain the need for consumption of adequate nutrients.
Rationale: Adequate nutrient intake is essential for the client’s nutrition.
2. Plan for postpartal menu should include a diet of between 2200 and 2300 calories daily.
Rationale: To help restore the peristaltic action of the bowel.

Nursing Diagnosis: A client is 6 hours postpartum following birth of her fourth child. She
states, “I haven’t urinated since before I had baby.”

Nursing Diagnosis: Impaired urinary elimination related to perineal edema and decreased
bladder tone from fetal head pressure during labor and birth.

Interventions:
1. Assess client’s overall intake, both intravenously and orally, since last voiding.
Rationale: Assessment of overall intake provides information about the degree of bladder that
may be occurring.
2. Assessment client with ambulating to the bathroom and sitting on the commode to void.
Rationale: Assisting with ambulation maintains safety should the client experience orthostatic
hypotension from blood and fluid loss during labor and birth.
3. Run water in the sink, allow client to place her hand in warm water and encourage her
relax.
 Rationale: The sound or feel of running water coupled with relaxation can help stimulate
voiding.
4. Allow client time and privacy while staying nearby.
Rationale: providing time and privacy allows the client some control over the situation.
5. Assess amount of urine voided and reassess fundal height and position.
Rationale: Measuring amount of urine voided and assessing fundal height and position
provides evidence about the degree of bladder.

Nursing Diagnosis: Pain related to uterine cramping o perineal sutures.

Interventions:
1. Provide pain relief for afterpains.
2. Relieve Muscular aches.
3. Give episiotomy care
4. Promote perineal exercises.
5. Administer hot and cold therapy.

A 30 year old client pregnant Asian-American woman comes to the antepartal health care facility
for a visit. She states, “I don’t want to gain too much weight.

Nursing Diagnosis: Imbalanced nutrition, less than body requirements, related to inadequate
intake of calories and desire to control weight.

Interventions:

1. Explain the need for adequate consumption of nutrients and calories while listening to
client’s concern about weight gain.
Rationale: Adequate nutrition is essential for optimal fetal growth and development. Listening,
to client’s concerns aids in validating the client’s feelings and establishing trust.
2. Question client about food likes and dislikes. Investigate any cultural influences on food
choices.
Rationale: Ascertaining food preferences and cultural influences on food provides baseline for
future food selections and suggestions.
3. Consult with the dietitian and maternal health care provider about recommended caloric
and mineral intake.
Rationale: Caloric recommendation may need to be increased in light of client’s BMI and
prepregnancy and current weight.
4. Assist client with food suggestions. Enlist the aid of a dietitian to assist with meal planning
and culturally acceptable food choices. Provide written information as needed.
Rationale: Assistance from a dietitian ensures a nutritionally sound diet with culturally
acceptable food choices. Printed information enhances learning.
5. Instruct client to keep a diet journal recording all food and fluid intake for 1 week, and
review with client on next visit.
Rationale: Keeping a journal provides concrete evidence of client’s compliance with
nutritional plan.

A 20 year old pregnant woman comes to the prenatal clinic reporting mild nausea and
occasional vomiting in the morning. “Some times I just can’t eat. My friend said that I should try
smoking marijuana to help”.

Nursing Diagnosis: Risk for fetal injury related to knowledge deficit concerning possible fetal
exposure to teratogens.
Interventions:

1. Review history of sinus headache for onset, type, duration, and relief obtained.
Rationale: History review provides a baseline to determine future interventions and provides
information of the severity of the client’s condition.
2. Consult with client’s primary and maternal health care providers about safety of over the
counter (OTC) medications.
Rationale: OTC medication must use must be addressed to determine the degree of
possible teratogenicity to the fetus.
3. Discuss with client possible nonpharmacologic measures to assist with sinus headache
relief, including saline nasal sprays, humidification, and warm compresses to nasal area.
Rationale: nonpharmacologic comfort measures may provide symptomatic relief without
danger to the fetus.
4. Discuss possible dangers of drug and alcohol use during pregnancy and instruct client
about possible dangers.
Rationale: Alcohol and drug use, including OTC, medications, can be teratogenic to the
fetus. Education provides valuable information to foster client’s motivation for changing
behaviors.
5. Encourage the client to decrease smoking and quit if possible. Offer suggestions to
accomplish this, including use of sugar free gums or candies, distraction, and
activity.Refer to a smoking cessation group if appropriate.
Rationale: Cigarette use during pregnancy can lead to fetal growth retardation .Support and
suggestions provide concrete measures to assist client with cutting down and cessation.

A 31 years old African-American woman comes to the obstetrician’s office for evaluation. She
states, “I think I’ pregnant. I did one of those home pregnancy tests and it was positive. Plus
I’m late with my period and I feel like I did when I was pregnant with my first child, Oh I hope
it’s not as bad as my last pregnancy.”

Nursing Diagnosis: Health-seeking behaviors related to guidelines for second pregnancy.

Interventions:

1. Assist with and perform initial assessment, including vital signs, height and weight
measurement, and history and physical examination.
Rationale: Initial assessment provides a baseline for future comparison and identification
of factors that may place the client at risk for problems.
2. Assess the client’s knowledge about guidelines for healthy pregnancy and antepartal care.
Rationale: Although the guidelines for each pregnancy are usually similar, each
pregnancy experiences is different. Assessment of client’s knowledge provides a baseline
to identify teaching needs.
3. Review the plans for antepartal care visits, examinations, and laboratory testing. Include
information about physiologic and psychological of pregnancy. Assist client with setting up
appointments for visits and tests to evaluate fetal well-being as necessary.
Rationale: Reviewing information provides reinforcement of what is to come and helps to
alleviate fears, and anxieties related to pregnancy. Assisting with appointment setting
helps to ensure compliance.
4. Instruct the client about the effects of smoking on the fetus. Assist client with methods to
reduce and stop, if possible.
Rationale: nicotine in cigarette has been shown to be teratogenic to the fetus.
 5. Discuss with the client the increased nutritional needs during pregnancy. Provide
information about a well-balanced diet, including food selections, such as fresh fruits and
vegetables, calcium sources, and high-protein foods, fluid intake, and prenatal vitamin
supplementation.
Rationale: a well-balanced diet with adequate fluid intake and use of prenatal vitamins
helps to ensure an optimal environment for fetal growth and development.

A 30 years old client with a history of heart disease comes to the clinic for evaluation. She
states” I think I’m pregnant. I just want to make sure everything goes okay with pregnancy.”

Nursing Diagnosis: Health-seeking behavior related to effect of heart disease of pregnancy.

Interventions:

1. Assist with and perform initial assessment, including vital signs and height and weight,
comparing to prepregnancy levels.
Rationale: Initial assessment provides a baseline for future comparison and identifies
factors placing the client at risk.
2. Assess client’s knowledge of heart disease and changes of pregnancy. Evaluate lifestyle
and activity level.
Rationale: Assessment of client’s knowledge provides baseline from which to build future
teaching strategies. Lifestyle and activity levels can be affected, depending on the degree
of cardiac compromise.

3. Review plans for laboratory testing and scheduling of antepartal care visits.
Rationale: Reviewing information reinforces what is to come and helps to alleviate fears
and anxiety. More frequent antepartal visits may be necessary to ensure optimal fetal and
maternal well-being.