What would the nurse expect the patient to report as presumptive signs of pregnancy?

Pregnancy occurs when a fertilized egg (ovum) develops into a fetus inside a woman’s uterus. When counting from the first day of the last regular menstrual cycle, pregnancy lasts roughly 40 weeks. The body goes through amazing changes to prepare for birth by that time. 

Pregnancy is divided into three trimesters:

• The first trimester: week 1 to the end of week 12
• The second trimester: week 13 to the end of week 26
• The third trimester: week 27 to the end of pregnancy

Fetal growth and development can also be separated into three time periods:

• Pre-embryonic stage (first 2 weeks, beginning with fertilization)
• Embryonic (weeks 3 through 8)
• Fetal (from week 8 through birth)

With the development of the embryo, the placenta and membranes will act as the fetus’s organs while in the uterus and provide its protection, oxygen, and nutrients.

A woman’s life changes significantly during pregnancy, psychologically and physically. As the woman’s body adapts to the development of a growing fetus, blood volume increases along with cardiac output and heart rate. As oxygen consumption increases, the woman’s respiratory rate may increase and there may be episodes of shortness of breath. Estrogen and progesterone increase. The uterus enlarges, displacing internal abdominal organs. Breasts grow tender and larger. Pelvic ligaments loosen to prepare for labor and birth.

Symptoms of pregnancy vary from woman to woman and from pregnancy to pregnancy. 

Signs and symptoms are divided into three classifications: 

• Presumptive (subjective symptoms)
• Probable (objective signs)
• Positive (documented signs)

Presumptive and probable signs and symptoms are reliable but still need to be verified. Positive signs confirm the pregnancy.

Positive signs of pregnancy include:

• Evidence of a fetal heartbeat that is distinct from the mother’s
• Presence of fetal movements
• Ultrasound imaging of the developing fetus

The Nursing Process

Ensuring the care of both the mother and fetus is important for a safe delivery. Physiologic and psychological changes should be monitored for potential risks. The nurse evaluates these changes through detailed maternal history taking and regular prenatal checks. 

An essential component of prenatal care is prenatal education. Pregnancy is a major life change and requires diet, activity, and lifestyle changes. The more informed the mother is, the more likely it is that they will follow the plan of care. 

The nurse is a source of support for the mother, baby, and other support persons involved. From the first prenatal visit through labor and delivery and beyond, the nurse monitors for complications, provides resources, offers empathy, and advocates for the health and safety of the patient.

Nursing Care Plans Related to Pregnancy

Risk for Imbalanced Nutrition: Less Than Body Requirements Care Plan

Risk for imbalanced nutrition: less than body requirements associated with pregnancy can be caused by a poor diet and deficiency in essential nutrients during pregnancy. If not prevented, it can result in anemia, preeclampsia, hemorrhage, and mortality in mothers as well as low birth weight in infants and developmental problems in the fetus.

Nursing Diagnosis: Risk for Imbalanced Nutrition

Related to:

• Change in sense of taste (dysgeusia)
• Dental problems
• Lack of appetite
• Inadequate intake
• Nausea
• Vomiting
• Difficulty meeting increased metabolic demands
• Elevated thyroid activity associated with the fetal growth
• Medications
• Insufficient financial resources
• Lack of nutritional knowledge

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.

Expected outcomes:

• Patient will be able to manifest weight gain within the expected ranges during pregnancy
• Patient will be able to verbalize understanding of proper nutrition during pregnancy
• Patient will demonstrate a proper meal plan based on the recommended nutrition guidelines for pregnancy

Risk for imbalanced Nutrition: Less than Body Requirements Assessment

1. Determine the patient’s risk factors for imbalanced nutrition.
A nutritional risk assessment identifies which pregnant women are more likely to encounter poor health outcomes. Risk factors include low socioeconomic status, low health literacy, or comorbidities. This enables healthcare professionals to deliver risk-appropriate prenatal care. 

2. Assess the patient’s daily nutritional intake.
Poor dietary patterns have been linked to negative pregnancy outcomes. Healthy eating habits during pregnancy promote fetal growth and development while lowering the chances of pregnancy complications.

3. Monitor weight.
Women who gain appropriate weight while pregnant have healthier pregnancies. Recommended nutrients during pregnancy promote fetal growth and development. A woman should gain approximately 25-35 pounds during pregnancy.

4. Assess for signs and symptoms of malnutrition. 
Dietary intake affects fetal growth. An increased risk of stillbirths, low birth weight, and small size for gestational age babies are linked to malnutrition.

Signs and symptoms of malnutrition in pregnancy include the following:

• Fatigue
• Anemia
• Low pregnancy weight
• Dizziness
• High blood pressure
• Hair loss
• Dry skin
• Dental problems
• Low immunity

5. Assess the patient’s activity level.
Activity levels affect the nutritional needs of the patient. Consider the caloric intake compared to the patient’s activity level when creating diet plans.

Risk for imbalanced Nutrition: Less than Body Requirements Interventions

1. Establish nutritional goals.
Establish nutritional goals together with the patient. It is more likely that the patient will adhere to the care plan if they participate in creating a nutritional plan that works for their lifestyle.

2. Collaborate with a dietitian.
A registered dietician can coordinate the nutritional requirements appropriate for the pregnant patient. They can create an individualized dietary plan to meet the needs of the pregnant patient while also taking into account other dietary considerations.

3. Administer dietary supplements as prescribed.
Prenatal supplementation is the easiest way to prevent fetal defects. The following supplements may be required during pregnancy:

• Folic acid
• Iron
• Calcium
• Vitamin D
• Choline
• Omega-3 fatty acids
• B vitamins
• Vitamin C 

4. Instruct on ways to overcome morning sickness.
Nausea and vomiting during pregnancy are common but can prevent required intake and lead to dehydration. Overcome morning sickness by consuming ginger, avoiding triggers such as smells, eating smaller meals, and drinking plenty of fluids.

Risk for Disturbed Maternal-Fetal Dyad Care Plan

Risk for disturbed maternal-fetal dyad associated with pregnancy can be caused by intrinsic and extrinsic factors causing pregnancy-related conditions. These can be thought of as “high-risk” pregnancies. Complications may disrupt the biological relationship between mother and baby or may result in maternal or fetal demise.

Nursing Diagnosis: Risk for Disturbed Maternal-Fetal Dyad

Related to:

• Insufficient prenatal care
• Incidence of abuse (physical, psychological, or sexual)
• Substance abuse
• Impaired glucose metabolism
• Inadequate nutrition
• Medications
• Increased maternal age
• Maternal comorbidities
• Depression or mental health conditions
• Compromised fetal oxygen support
• Placental abnormality (such as abruptio placenta, placenta previa)

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.

Expected outcomes:

• Patient will be able to verbalize understanding of conditions that disturb the maternal-fetal dyad
• Patient will be able to identify her risk factors for the disturbed maternal-fetal dyad
• Patient will be able to practice preventive measures against disturbed maternal-fetal dyad

Risk for Disturbed Maternal-Fetal Dyad Assessment

1. Review the patient’s obstetric history.
Reviewing the patient’s current and previous pregnancies is part of their obstetric history. A thorough obstetric history reflects the patient’s health risks and the potential for maternal and fetal complications.

2. Assess the patient’s history of prenatal visits and compliance.
A healthy pregnancy can be achieved when the patient receives early and consistent prenatal care. Lack of prenatal care might endanger the mother and the fetus. Hence, adherence to prenatal visits is crucial.

3. Review the patient’s health history and risk factors.
Uteroplacental blood flow and gas exchange are directly affected by other comorbidities. Conditions and factors that can increase vascular changes, decrease placental blood flow, or affect the ability to transport oxygen include:

• Diabetes
• Gestational hypertension
• Cardiac conditions
• Smoking
• Substance/medication use and abuse 
• Respiratory conditions such as asthma or COPD
• Vascular conditions such as anemia, Rh incompatibility, and hemorrhage
• Placental abnormalities such as abruptio placenta and placenta previa

4. Assess the patient’s respiratory status.
The patient’s respiratory status can affect the oxygen-carrying blood flow from the mother to the fetus. Congenital cardiovascular abnormalities may be due to a lack of oxygen during pregnancy.

5. Assess for signs and symptoms of abuse.
The nurse can assess for signs of domestic abuse. Low maternal and fetal weight and preterm birth are associated with abuse during pregnancy.

6. Assess the patient’s knowledge of conditions that may disturb the maternal-fetal dyad.
Pregnant patients can actively prevent or manage conditions that may disturb the maternal-fetal dyad if they are well-informed.

7. Monitor fetal activity and heart rate.
The nurse must routinely assess the status of the fetus including the fetal heart rate (FHR), growth, and activity as well as measuring amniotic fluid and placenta health through routine ultrasounds.

Risk for Disturbed Maternal-Fetal Dyad Interventions

1. Weigh the patient routinely.
Weight is often a good indicator of pregnancy-related problems. Weigh and compare the result to the pre-pregnancy weight. Underweight and obese patients have a higher risk of developing gestational conditions such as hypertension and diabetes. 

2. Offer resources for substance abuse.
The cessation of smoking, alcohol, and drugs is vital to maternal and fetal health. Offer support groups and resources for help in controlling addiction and substance use.

4. Include support persons.
Managing a healthy pregnancy through optimal nutrition, stress relief, symptom control, and more requires support. Include family members, friends, and intimate partners and educate them on how they can support the pregnant patient.

5. Intervene when psychological needs arise.
Depression and other mental health conditions can worsen during pregnancy. Routinely assess for increased stress and changes in mood and alert the healthcare provider.

Deficient Knowledge Care Plan

Deficient Knowledge associated with pregnancy can be caused by inadequate knowledge of normal body changes and self-care needs. First-time mothers especially often misinterpret or lack information during pregnancy.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Inadequate knowledge about body changes
• Insufficient knowledge of self-care needs
• Lack of information about prenatal care
• Misinterpretation of changes during pregnancy
• Unpreparedness for changes during and after pregnancy

As evidenced by:

• Verbalization of concerns
• Inquiries about what to expect with pregnancy
• Misconceptions about pregnancy
• Inaccurate or insufficient instructions in self-care
• Development of preventable complications
• Nonadherence with treatment

Expected outcomes:

• Patient will be able to verbalize understanding of expected body changes during pregnancy
• Patient will be able to identify behavior and lifestyle modifications suitable for her pregnancy

Deficient knowledge Assessment

1. Determine the patient’s knowledge level.
To individualize health teaching, the nurse must first assess the patient’s knowledge level about pregnancy expectations. The nurse can then tailor appropriate teaching.

2. Establish the patient’s capacity, readiness, and learning obstacles.
The nurse must assess the patient’s capacity, readiness, and barriers to receiving health teaching. Ensure the patient is mentally and emotionally ready and interested in receiving information.

3. Assess for misconceptions and cultural beliefs about pregnancy.
Cultural beliefs may affect the patient’s understanding of pregnancy. The nurse must identify cultural norms and beliefs to filter the information and identify facts versus myths. The nurse must remain nonjudgemental while also prioritizing accurate information.

Deficient knowledge Interventions

1. Develop a birth plan. 
Each pregnancy is different and each mother has their own goals for delivery. While a birthing plan requires flexibility, helping the mother determine her expectations will ease anxiety and support preparedness.

2. Provide information at their educational level.
Each person learns differently. Teenage mothers may require information at a lower learning level or through videos. Support verbal instructions with written pamphlets or brochures.

3. Encourage questions.
Patients should feel confident in asking questions. Offer a warm, patient demeanor where questions feel welcome.

4. Provide positive reinforcement.
Adhering to follow-up appointments and prenatal care can be time-consuming. Provide positive feedback for meeting health goals or preventing complications.

References and Sources

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
2. Pillitteri, A., & Silbert-Flagg, J. (2015). Nursing Care Related to Psychological and Physiologic Changes of Pregnancy. In Maternal & child health nursing: Care of the childbearing & Childrearing family (8th ed., pp. 469-472). LWW.
3. Silvestri, L. A., & CNE, A. E. (2019). Prenatal Period. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 637-664). Saunders.

Which of the following would the nurse expect to find as presumptive signs of pregnancy?

Which of the following signs of pregnancy would be considered presumptive?

Which findings would be considered positive signs of pregnancy?

What is the most common presenting complication of a patient in the early stage of pregnancy?