NUR 2421C Maternity Nursing Care
Concept Map & Comprehensive NCP
Client Initials: L. M.
Room: 5512 Client
Chief Complaint: Postpartum recovery Vignette
following vaginal delivery.
Admitting Dx: Normal spontaneous vaginal delivery (NSVD).
Age: 29
Medical Hx: No known medical history.
Plan
Sex: of care: Continue/revise/d
Female Physical Assessment Data: Alert, oriented ×4, calm, and cooperative. No acute distress. Ambulating independently with
______________________________________________________________________________
Weight: 175 lbs / 79.5 kg steady gait. Normocephalic, no lesions or tenderness. Hair clean and evenly distributed. PERRLA, sclera white, conjunctiva
Height: 5’4” / 164.59 cm pink and moist. No visual disturbances reported. Hearing intact bilaterally. No ear drainage or tenderness noted. Nose
patent bilaterally. Oral cavity mucous membranes moist, lips pink, no lesions. From a cardiovascular standpoint, regular
Admitting Diagnosis: Normal spontaneous rate and rhythm. No murmurs, gallops, or rubs. Capillary refill <2 seconds. No edema noted. Lungs clear to auscultation
vaginal delivery (NSVD). bilaterally. No wheezes, rales, or rhonchi. Abdomen soft, non-distended, non-tender. Bowel sounds present in all four
Chronic Diseases: None. quadrants. Passing flatus. Appetite intact. Fundus firm and midline at U-2, lochia rubra moderate, perineal laceration stage
II repaired, ambulating independently, voiding without difficulty, breastfeeding initiated.
Signs & Symptoms: Reports moderate uterine cramping, pain managed with medication. Mild swelling and tenderness at
laceration stage II; edges are approximated with no signs of infection. Breasts are slightly firm. Colostrum is present.
Nipples tender from breastfeeding but not cracked or bleeding. All vital signs are within expected limits. No bowel
movements reported yet but reports passing gas. Feelings of fatigue, ambulating independently, eating 100% of meals, and
- Diagnosis: Postpartum recovery following NSVD. initiating skin-to-skin contact. Expresses interest in the newborn, makes eye contact, and uses soft voice with the newborn.
- Pathophysiology of Medical (Client-specific):
Postpartum recovery following vaginal delivery involves a series of
physiological processes. During the postpartum period, the uterus
undergoes involution, returning to its non-pregnant state through
uterine contractions and hormonal regulation, mainly driven by
oxytocin (Terri, 2025, p. 465). These contractions also help compress
uterine blood vessels to prevent hemorrhage (Terri, 2025, p. 465). Prioritize #1 Prioritize #2 Prioritize #3
Lochia, or postpartum vaginal discharge, progresses from lochia rubra
(bloody) to lochia serosa (pink/brown) and finally to lochia alba
(yellow/white) over several weeks (Terri, 2025, p. 491). The cervix
gradually closes, while the vaginal tissues and perineum recover from Key Problem/ND: Acute pain. Key Problem/ND: Risk for Key Problem/ND: Knowledge
stretching or lacerations sustained during birth. Breast changes include infection. Deficit of Postpartum Self-Care
colostrum secretion transitioning to mature milk, which may cause
breast engorgement (Terri, 2025, p. 493). Urinary output increases due
Subjective / Objective Data:
to fluid mobilization, and gastrointestinal motility slowly returns to Subjective / Objective Data: Subjective / Objective Data:
normal (Terri, 2025, p. 493). Emotional and psychological adjustments
also occur as the mother adapts to her new role and bonding with the
3Subjective: “My stomach hurts
infant begins (Terri, 2025, p. 493). like cramps.” Pain rating 6 out of Subjective: “I’m worried about my Subjective: “I’m not sure how often
- Possible Complications: Postpartum hemorrhage is one of the most 10 when asked. Describes feeling stitches down there.” I should breastfeed or when to call
serious risks, often caused by uterine atony, retained placental
fragments, or lacerations (Terri, 2025, p. 488). Infection is another uncomfortable. the doctor. This is my first
concern, particularly endometritis, urinary tract infections, or perineal Objective: Perineal repair present pregnancy.” Expresses doubts on
wound infections (Terri, 2025, p. 487). Women may also experience
urinary retention or incontinence, constipation, or thromboembolic
Objective: Guarding behavior, from laceration stage II, lochia how to and when to exercise,
events due to reduced mobility (Terri, 2025, p. 501). Mastitis from grimacing, uterus firm and rubra moderate with no foul odor, bathe, and using contraception.
breastfeeding and mood disorders might occur as well, especially in contracting, midline and U-2. no large clots observed, vital signs
first-time mothers or those with limited support (Terri, 2025, p. 508).
- Expected Treatments: Postpartum hemorrhage is managed by uterine stable. Objective: First-time mother,
massage, administration of uterotonic medications such as oxytocin or asking questions about perineal
misoprostol, fluid resuscitation, and in severe cases, surgical
intervention or blood transfusion (Terri, 2025, p. 488). Infections such care due to laceration and
as endometritis or perineal wound infections are typically treated with newborn feeding cues.
appropriate antibiotics and wound care (Terri, 2025, p. 487). Urinary
retention may require temporary catheterization, while incontinence is
often managed with pelvic floor exercises (Terri, 2025, p. 501). Maslow's: Physiological Needs Maslow's: Safety and Security
Constipation is addressed with stool softeners, increased hydration, Needs Maslow's: Self-Actualization Needs
and a high-fiber diet (Terri, 2025, p. 501). To prevent thromboembolic
events, early ambulation and compression devices are encouraged,
and anticoagulants may be prescribed (Terri, 2025, p. 501). For
emotional complications, treatment may include counseling, support
1
groups, and medication (Terri, 2025, p. 512).
, Nursing Diagnosis (1): Acute pain related to uterine contractions and perineal trauma as evidenced by patient verbalization of
“My stomach hurts like cramps,” reported pain rating of 6/10, and guarding behavior.
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 reduced (At least 3 each goal)
to ≤3 on a 0–10 scale within 6 Assess pain level using a standardized Reports pain level after each Met
hours of nursing interventions. scale every 2 hours (NIC: Pain assessment. AEB: Patient reported pain
Management). decreased to 3/10 after
Rationale: Frequent pain assessment interventions.
ensures accurate monitoring and timely POC: Continue current plan.
response (Ricci et al., 2025).
Encourage use of relaxation techniques Patient used deep breathing when Partially Met
such as deep breathing every 4 hours prompted. AEB: Patient used deep
(NIC: Nonpharmacologic Pain breathing twice but asked for
Management). medication when pain
Rationale: Relaxation promotes increased.
endorphin release and reduces POC: Continue, reinforce
perception of pain (Ricci et al., 2025). education.
Administer prescribed ibuprofen 600 Pain relief noted within 30–45 Met
mg orally every 6 hours PRN (NIC: minutes of administration. AEB: Pain decreased from 6/10
Medication Administration). to 2/10 after ibuprofen.
2
Concept Map & Comprehensive NCP
Client Initials: L. M.
Room: 5512 Client
Chief Complaint: Postpartum recovery Vignette
following vaginal delivery.
Admitting Dx: Normal spontaneous vaginal delivery (NSVD).
Age: 29
Medical Hx: No known medical history.
Plan
Sex: of care: Continue/revise/d
Female Physical Assessment Data: Alert, oriented ×4, calm, and cooperative. No acute distress. Ambulating independently with
______________________________________________________________________________
Weight: 175 lbs / 79.5 kg steady gait. Normocephalic, no lesions or tenderness. Hair clean and evenly distributed. PERRLA, sclera white, conjunctiva
Height: 5’4” / 164.59 cm pink and moist. No visual disturbances reported. Hearing intact bilaterally. No ear drainage or tenderness noted. Nose
patent bilaterally. Oral cavity mucous membranes moist, lips pink, no lesions. From a cardiovascular standpoint, regular
Admitting Diagnosis: Normal spontaneous rate and rhythm. No murmurs, gallops, or rubs. Capillary refill <2 seconds. No edema noted. Lungs clear to auscultation
vaginal delivery (NSVD). bilaterally. No wheezes, rales, or rhonchi. Abdomen soft, non-distended, non-tender. Bowel sounds present in all four
Chronic Diseases: None. quadrants. Passing flatus. Appetite intact. Fundus firm and midline at U-2, lochia rubra moderate, perineal laceration stage
II repaired, ambulating independently, voiding without difficulty, breastfeeding initiated.
Signs & Symptoms: Reports moderate uterine cramping, pain managed with medication. Mild swelling and tenderness at
laceration stage II; edges are approximated with no signs of infection. Breasts are slightly firm. Colostrum is present.
Nipples tender from breastfeeding but not cracked or bleeding. All vital signs are within expected limits. No bowel
movements reported yet but reports passing gas. Feelings of fatigue, ambulating independently, eating 100% of meals, and
- Diagnosis: Postpartum recovery following NSVD. initiating skin-to-skin contact. Expresses interest in the newborn, makes eye contact, and uses soft voice with the newborn.
- Pathophysiology of Medical (Client-specific):
Postpartum recovery following vaginal delivery involves a series of
physiological processes. During the postpartum period, the uterus
undergoes involution, returning to its non-pregnant state through
uterine contractions and hormonal regulation, mainly driven by
oxytocin (Terri, 2025, p. 465). These contractions also help compress
uterine blood vessels to prevent hemorrhage (Terri, 2025, p. 465). Prioritize #1 Prioritize #2 Prioritize #3
Lochia, or postpartum vaginal discharge, progresses from lochia rubra
(bloody) to lochia serosa (pink/brown) and finally to lochia alba
(yellow/white) over several weeks (Terri, 2025, p. 491). The cervix
gradually closes, while the vaginal tissues and perineum recover from Key Problem/ND: Acute pain. Key Problem/ND: Risk for Key Problem/ND: Knowledge
stretching or lacerations sustained during birth. Breast changes include infection. Deficit of Postpartum Self-Care
colostrum secretion transitioning to mature milk, which may cause
breast engorgement (Terri, 2025, p. 493). Urinary output increases due
Subjective / Objective Data:
to fluid mobilization, and gastrointestinal motility slowly returns to Subjective / Objective Data: Subjective / Objective Data:
normal (Terri, 2025, p. 493). Emotional and psychological adjustments
also occur as the mother adapts to her new role and bonding with the
3Subjective: “My stomach hurts
infant begins (Terri, 2025, p. 493). like cramps.” Pain rating 6 out of Subjective: “I’m worried about my Subjective: “I’m not sure how often
- Possible Complications: Postpartum hemorrhage is one of the most 10 when asked. Describes feeling stitches down there.” I should breastfeed or when to call
serious risks, often caused by uterine atony, retained placental
fragments, or lacerations (Terri, 2025, p. 488). Infection is another uncomfortable. the doctor. This is my first
concern, particularly endometritis, urinary tract infections, or perineal Objective: Perineal repair present pregnancy.” Expresses doubts on
wound infections (Terri, 2025, p. 487). Women may also experience
urinary retention or incontinence, constipation, or thromboembolic
Objective: Guarding behavior, from laceration stage II, lochia how to and when to exercise,
events due to reduced mobility (Terri, 2025, p. 501). Mastitis from grimacing, uterus firm and rubra moderate with no foul odor, bathe, and using contraception.
breastfeeding and mood disorders might occur as well, especially in contracting, midline and U-2. no large clots observed, vital signs
first-time mothers or those with limited support (Terri, 2025, p. 508).
- Expected Treatments: Postpartum hemorrhage is managed by uterine stable. Objective: First-time mother,
massage, administration of uterotonic medications such as oxytocin or asking questions about perineal
misoprostol, fluid resuscitation, and in severe cases, surgical
intervention or blood transfusion (Terri, 2025, p. 488). Infections such care due to laceration and
as endometritis or perineal wound infections are typically treated with newborn feeding cues.
appropriate antibiotics and wound care (Terri, 2025, p. 487). Urinary
retention may require temporary catheterization, while incontinence is
often managed with pelvic floor exercises (Terri, 2025, p. 501). Maslow's: Physiological Needs Maslow's: Safety and Security
Constipation is addressed with stool softeners, increased hydration, Needs Maslow's: Self-Actualization Needs
and a high-fiber diet (Terri, 2025, p. 501). To prevent thromboembolic
events, early ambulation and compression devices are encouraged,
and anticoagulants may be prescribed (Terri, 2025, p. 501). For
emotional complications, treatment may include counseling, support
1
groups, and medication (Terri, 2025, p. 512).
, Nursing Diagnosis (1): Acute pain related to uterine contractions and perineal trauma as evidenced by patient verbalization of
“My stomach hurts like cramps,” reported pain rating of 6/10, and guarding behavior.
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 reduced (At least 3 each goal)
to ≤3 on a 0–10 scale within 6 Assess pain level using a standardized Reports pain level after each Met
hours of nursing interventions. scale every 2 hours (NIC: Pain assessment. AEB: Patient reported pain
Management). decreased to 3/10 after
Rationale: Frequent pain assessment interventions.
ensures accurate monitoring and timely POC: Continue current plan.
response (Ricci et al., 2025).
Encourage use of relaxation techniques Patient used deep breathing when Partially Met
such as deep breathing every 4 hours prompted. AEB: Patient used deep
(NIC: Nonpharmacologic Pain breathing twice but asked for
Management). medication when pain
Rationale: Relaxation promotes increased.
endorphin release and reduces POC: Continue, reinforce
perception of pain (Ricci et al., 2025). education.
Administer prescribed ibuprofen 600 Pain relief noted within 30–45 Met
mg orally every 6 hours PRN (NIC: minutes of administration. AEB: Pain decreased from 6/10
Medication Administration). to 2/10 after ibuprofen.
2
