NUR 2421C Maternity Nursing Care
Concept Map & Comprehensive NCP
Client Initials: C. N.
Room: 5514 Client
Chief Complaint: Postpartum care following Vignette
scheduled C-section, 2 days post C-section.
Age: 22 Admitting Dx: Scheduled cesarean section delivery.
Plan
Sex: of care: Continue/revise/d
Female Medical Hx: No known medical history.
Weight: 65 kg Physical Assessment Data: Patient is alert and oriented ×4, calm, and cooperative. Vital signs are stable: BP
______________________________________________________________________________
95/70 mmHg, HR 85 bpm, RR 18 breaths/min, Temp 97°F, SpO₂ 99% on room air. Fundus is firm, midline, 2
Height: 156.8 cm
cm below the umbilicus (U-2). Lochia rubra is scant with no foul odor. Perineum is intact with no edema,
Admitting Diagnosis: Scheduled cesarean bruising, or lacerations noted. Low transverse abdominal incision is clean, dry, well-approximated with Steri-
section delivery. Strips, and without erythema, swelling, or drainage. Bowel sounds present in all four quadrants; patient is
Chronic Diseases: None. tolerating a regular diet and passing flatus. No nausea or vomiting reported. Voiding spontaneously without
dysuria. Extremities warm, no swelling, redness, or tenderness; negative Homan’s sign bilaterally. Pain is
reported as 3/10 at rest and 5/10 with movement, controlled with scheduled oral analgesics. Ambulating
independently with a steady gait. Skin is warm, dry, and intact. Emotional status is calm, patient engages
appropriately during assessment. Infant feeding with formula only; bonding observed through holding,
talking to, and making eye contact with the newborn.
- Diagnosis: Cesarian section delivery.
- Definition: Cesarean section is a surgical delivery through
an incision in the abdomen and uterus (Ricci et al., 2025).
The most common incision is a low transverse uterine
incision, which involves a horizontal cut made through the
Prioritize #1 Prioritize #2 Prioritize #3
lower segment of the uterus, minimizing blood loss,
preserving uterine integrity, and reducing the risk of
rupture in subsequent pregnancies (Ricci et al., 2025). Key Problem/ND: Acute pain. Key Problem/ND: Risk for Key Problem/ND: Risk for infection.
Postpartum healing involves uterine involution, incision postpartum hemorrhage.
healing, and prevention of complications such as
hemorrhage, infection, and impaired mobility.
Subjective / Objective Data Subjective / Objective Data
- Pathophysiology of Medical (Client-specific): Subjective / Objective Data
A C-section bypasses the natural vaginal birth canal, Subjective: Reports pain score Subjective: Patient verbalizes
altering the physiological process of delivery (Ricci et al., 3/10 at rest, 5/10 with Subjective: Patient denies understanding of keeping incision
2025). It is typically performed when vaginal delivery ambulation. dizziness or lightheadedness. clean and dry.
poses risks to the mother, fetus, or both. This procedure
can be scheduled (elective) or emergent (urgent)
depending on the indication, this patient had a scheduled Objective: Guarding behavior Objective: Fundus firm, midline, Objective: Incision intact with no
c-section (Ricci et al., 2025). when changing position; incision U-2; lochia rubra scant; vitals erythema or drainage; afebrile;
Regional anesthesia (spinal or epidural) is most common; well-approximated, clean, and stable; hemoglobin within normal WBC within normal limits.
general anesthesia may be used in emergencies (Ricci et dry. range.
al., 2025). The abdominal area is cleaned, and a sterile
field is maintained. This patient had spinal anesthesia.
- Possible Complications: Postpartum hemorrhage, surgical
site infection, thromboembolism, constipation, or
impaired mobility (Ricci et al., 2025). For the newborn, Maslow's: Safety and Security
complications could be respiratory distress, surgical injury Maslow's: Safety and Security Needs.
(rare), delayed bonding or breastfeeding initiation. Maslow's: Physiological Needs. Needs.
- Expected Treatments: Pain management, incision care,
fundal and lochia monitoring, early ambulation, stool
softeners, breastfeeding support, patient education on
warning signs of complications (Ricci et al., 2025).. 1
, Nursing Diagnosis (1): Acute pain related to surgical incision and uterine involution as evidenced by patient’s verbal reports of
pain 3/10 at rest and 5/10 with movement, guarding behavior during position changes, and facial grimacing.
EXPECTED OUTCOMES (must be INTERVENTIONS (rationale must be CLINICAL RESPONSE to nursing EVALUATION (state if met,
measurable; follow SMART) included – cited & referenced) interventions and care provided. partially met, or not me; must
Nursing Outcome Classification Nursing Intervention Classification be supported with evidences;
(NOC): (NIC): include plan of care – e.g.
revise, continue, discontinue
POC)
Short-term Goal 1: Nursing interventions for ST Goal 1: Response: Evaluation for ST Goal 1:
Patient will report pain ≤ 3/10 (At least 3 each goal)
within 60 minutes after Assess pain intensity, location, and Patient reported pain 5/10 before Met — Pain decreased to ≤
analgesic administration during quality using a 0–10 scale every 4 hours morning analgesic 3/10 consistently after
the next 6 hours of shift and before/after analgesic medication; plan: continue
interventions. administration to evaluate pain control scheduled pain assessments to
effectiveness. maintain comfort.
Rationale: Regular pain assessments
allow objective measurement of
effectiveness of interventions and early
identification of inadequate pain
control. Pain is a subjective experience
and must be consistently monitored to
adjust treatment accordingly (Ricci et
al., 2025).
Administer prescribed analgesics (e.g., Decreased pain rating to 3/10 Met — Goal achieved within
acetaminophen, NSAIDs, opioids) as within 45 minutes post- target timeframe; plan:
ordered, and reassess pain 30–60 medication continue prescribed regimen
2
Concept Map & Comprehensive NCP
Client Initials: C. N.
Room: 5514 Client
Chief Complaint: Postpartum care following Vignette
scheduled C-section, 2 days post C-section.
Age: 22 Admitting Dx: Scheduled cesarean section delivery.
Plan
Sex: of care: Continue/revise/d
Female Medical Hx: No known medical history.
Weight: 65 kg Physical Assessment Data: Patient is alert and oriented ×4, calm, and cooperative. Vital signs are stable: BP
______________________________________________________________________________
95/70 mmHg, HR 85 bpm, RR 18 breaths/min, Temp 97°F, SpO₂ 99% on room air. Fundus is firm, midline, 2
Height: 156.8 cm
cm below the umbilicus (U-2). Lochia rubra is scant with no foul odor. Perineum is intact with no edema,
Admitting Diagnosis: Scheduled cesarean bruising, or lacerations noted. Low transverse abdominal incision is clean, dry, well-approximated with Steri-
section delivery. Strips, and without erythema, swelling, or drainage. Bowel sounds present in all four quadrants; patient is
Chronic Diseases: None. tolerating a regular diet and passing flatus. No nausea or vomiting reported. Voiding spontaneously without
dysuria. Extremities warm, no swelling, redness, or tenderness; negative Homan’s sign bilaterally. Pain is
reported as 3/10 at rest and 5/10 with movement, controlled with scheduled oral analgesics. Ambulating
independently with a steady gait. Skin is warm, dry, and intact. Emotional status is calm, patient engages
appropriately during assessment. Infant feeding with formula only; bonding observed through holding,
talking to, and making eye contact with the newborn.
- Diagnosis: Cesarian section delivery.
- Definition: Cesarean section is a surgical delivery through
an incision in the abdomen and uterus (Ricci et al., 2025).
The most common incision is a low transverse uterine
incision, which involves a horizontal cut made through the
Prioritize #1 Prioritize #2 Prioritize #3
lower segment of the uterus, minimizing blood loss,
preserving uterine integrity, and reducing the risk of
rupture in subsequent pregnancies (Ricci et al., 2025). Key Problem/ND: Acute pain. Key Problem/ND: Risk for Key Problem/ND: Risk for infection.
Postpartum healing involves uterine involution, incision postpartum hemorrhage.
healing, and prevention of complications such as
hemorrhage, infection, and impaired mobility.
Subjective / Objective Data Subjective / Objective Data
- Pathophysiology of Medical (Client-specific): Subjective / Objective Data
A C-section bypasses the natural vaginal birth canal, Subjective: Reports pain score Subjective: Patient verbalizes
altering the physiological process of delivery (Ricci et al., 3/10 at rest, 5/10 with Subjective: Patient denies understanding of keeping incision
2025). It is typically performed when vaginal delivery ambulation. dizziness or lightheadedness. clean and dry.
poses risks to the mother, fetus, or both. This procedure
can be scheduled (elective) or emergent (urgent)
depending on the indication, this patient had a scheduled Objective: Guarding behavior Objective: Fundus firm, midline, Objective: Incision intact with no
c-section (Ricci et al., 2025). when changing position; incision U-2; lochia rubra scant; vitals erythema or drainage; afebrile;
Regional anesthesia (spinal or epidural) is most common; well-approximated, clean, and stable; hemoglobin within normal WBC within normal limits.
general anesthesia may be used in emergencies (Ricci et dry. range.
al., 2025). The abdominal area is cleaned, and a sterile
field is maintained. This patient had spinal anesthesia.
- Possible Complications: Postpartum hemorrhage, surgical
site infection, thromboembolism, constipation, or
impaired mobility (Ricci et al., 2025). For the newborn, Maslow's: Safety and Security
complications could be respiratory distress, surgical injury Maslow's: Safety and Security Needs.
(rare), delayed bonding or breastfeeding initiation. Maslow's: Physiological Needs. Needs.
- Expected Treatments: Pain management, incision care,
fundal and lochia monitoring, early ambulation, stool
softeners, breastfeeding support, patient education on
warning signs of complications (Ricci et al., 2025).. 1
, Nursing Diagnosis (1): Acute pain related to surgical incision and uterine involution as evidenced by patient’s verbal reports of
pain 3/10 at rest and 5/10 with movement, guarding behavior during position changes, and facial grimacing.
EXPECTED OUTCOMES (must be INTERVENTIONS (rationale must be CLINICAL RESPONSE to nursing EVALUATION (state if met,
measurable; follow SMART) included – cited & referenced) interventions and care provided. partially met, or not me; must
Nursing Outcome Classification Nursing Intervention Classification be supported with evidences;
(NOC): (NIC): include plan of care – e.g.
revise, continue, discontinue
POC)
Short-term Goal 1: Nursing interventions for ST Goal 1: Response: Evaluation for ST Goal 1:
Patient will report pain ≤ 3/10 (At least 3 each goal)
within 60 minutes after Assess pain intensity, location, and Patient reported pain 5/10 before Met — Pain decreased to ≤
analgesic administration during quality using a 0–10 scale every 4 hours morning analgesic 3/10 consistently after
the next 6 hours of shift and before/after analgesic medication; plan: continue
interventions. administration to evaluate pain control scheduled pain assessments to
effectiveness. maintain comfort.
Rationale: Regular pain assessments
allow objective measurement of
effectiveness of interventions and early
identification of inadequate pain
control. Pain is a subjective experience
and must be consistently monitored to
adjust treatment accordingly (Ricci et
al., 2025).
Administer prescribed analgesics (e.g., Decreased pain rating to 3/10 Met — Goal achieved within
acetaminophen, NSAIDs, opioids) as within 45 minutes post- target timeframe; plan:
ordered, and reassess pain 30–60 medication continue prescribed regimen
2
