LaGuardia Community College
Practical Nursing Program
SCL 115 Maternity Child Health Nursing
Antepartal Observations
On a Patient with
Threatened Prelabor
Direction: Complete this observation chart by writing the appropriate value, observation
and nursing intervention for each of the nursing assessment areas
By
Anaise E. Ikama
Area of Nursing
Assessment
Normal P. P. State
Describe your observations
Nursing Interventions
Para: 0010 with intact
membrane, abdominal soft,
nontender uterus and active
fetus.
Continuously assess the membrane,
palpate the abdominal and assess fetal
movement
Para/Gravida status
Depends on each patient
VS/FH
BP 120-140/80, P 60-80, T
(should not exceed 100.4),
FHR 110-160
BP 118/73, P 90, RR 20, T
98.2 and lower back pain
(5/10), FHR 150
Massage and put some pressure at the
lower back. Suggest that the patient,
support her arms, feet, and back with
pillow when sitting
Calculation of EDC/
Gestational age
Depends from the date of
conception
11/20/07 and 36 weeks
Teach client how to come up with the
estimated date of delivery
Mother’s weight Gain
Signs and symptoms
Should gain 15 to 25 lbs (7
to 11.5kg)
Increase weight, ascends of
the uterus into the
abdomen. No frequent
abdominal pain
Active fetus
Gained…….
Total weight: 244 lbs
Frequent abdominal pain,
painless contraction
Fetal movement
Put the client on regular healthy diet
Massage and put some pressure at the
lower back. Administer meds as ordered:
magnesium tocolysis and dexomethone as
ordered to aid in fetal lung maturity
Continuously assess the fetus
Appropriate for
client’s Trimester
Normal Discomforts
Danger signals
Fatigue, lost interest of
activities, unwelcome body
changes.
Obesity, threatened
prelabor and immaturity of
the fetal lungs
Fatigue, lost interest of
activities, unwelcome body
changes
Lower abdominal cramp, mild
contraction every 4 minute,
Increase in glucose level and
Urinary Tract Infection
Assure the woman that these changes are
temporary. Help her explore expressions
such as loving and caring.
Put patient on partial bed rest; administer
meds as ordered: magnesium tocolysis
and dexomethone as ordered to aid in fetal
lung maturity; Ampiciline for urinary tract
infection. Assess vital signs, I/O
Complications
Ultrasound
Gestational diabetes,
hyperemesis graviderum,
preeclampsia, placenta
previa and abruptia,
premature rupture of the
membrane
A shortened cervix
Threatened premature labor
Did not observe
Observation/ Result
OCT results
NST Result
Pertinent Lab Data
Shows no deceleration of
fetal heart rate during
uterine contraction, which
is interpreted as being
negative
15 fetal beats per minute
lasting for 15 to 20 seconds
over a 20-minute period.
Normal Magnesium level
1.5-2.5
Did not observe
Did not observe
Client’s actual magnesium
level was 4.6; almost twice the
normal range
Administer terbutaline as ordered,
continue maternal and fetal vital sign
assessment; assess the woman pain using
a pain scale, characteristic and intensity.
Encourage the woman to verbalize her
fears and concerns.
Usually for a woman who is preterm
labor, the nurse should position her on her
side for better placenta blood flow
For positive test result that cannot be
corrected, the nurse should prepare the
client for cesarean section delivery.
If the result is abnormal, the nurse will
prepare the patient for further evaluation
of the baby by inducing contractions with
an oxytocin Challenge Test, for example.
Assess patient for any sign of weakness
and drowsiness.