KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
STUDENT DATE: CURRENT COHORT:
NAME: 49
CLIENT INITIALS: DATE OF ADMISSION: AGE: ALLERGIES:
CH 32 No Known Allergies
HT: PRE- CURRENT TOTAL WT GAIN: BMI
165 CM PREGNANT WT: 20 kg
WT:
61 kg 81 Kg
LIVING SITUATION/MARITAL STATUS
Married with 1 child in the home at this time
RACE/ETHNIC CULTURAL CONSIDERATIONS PERTINENT TO LABOR, DELIVERY,
ITY: & POSTPARTUM/NEWBORN CARE:
Hispanic None noted at this time
RELIGION/SPIRITUAL CONSIDERATIONS PERTINENT TO LABOR, DELIVERY,
& POSTPARTUM/NEWBORN CARE:
None noted at this time
PAST MEDICAL HISTORY/IMMUNIZATIONS: (UP TO DATE)
Patient is current on immunizations and pre-pregnacy stated she is healthy and active no
sinificant past medical history
PAST OBSTETRICAL HISTORY: Include dates of previous deliveries, Cesarean or vaginal
births, USE OF forceps or vacuum extractions, length of labor, analgesia/anesthesia
used, any difficulties with infants at birth.
Birth of child Aug 2016 normal vaginal birth without complications. Birth of child Jun
2018 vaginal without complications
GRAVIDA _2 TERM 1 PRETERM 0 ABORTIONS 0 LIVING 1
DUE DATE: (LMP)_21 Sep 2020 due date LMP Dec 11, 2019(ULTRASOUND)_15 July 2010_
GESTATIONAL AGE 39 Weeks 5/7
PRENATAL CARE BEGAN Jan 5, 2020
PREGNANCY PLANNED? Yes No
ALCOHOL USE: Before pregnancy? Yes No During pregnancy? Yes No
If yes: type, frequency, amount Patient stated she was a social drinker but abstained from
alcohol use during pregnancy
TOBACCO USE: Before pregnancy? Yes No During pregnancy? Yes No
1
, KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
If yes: Type, frequency, amount (packs per day)
ILLEGAL DRUG USE: Before pregnancy? No During pregnancy? No
If yes: type, frequency, amount
Have siblings been prepared for new baby? Yes How? _help set up baby room did
a sibling class at the hospital N/A
FAMILY DYNAMICS:
LABOR &
MEMBRANES RUPTURED: Date/Time_ 1500 Amniotomy ruptured membrains SROM
AROM
AMNIOTIC FLUID: Clear Light meconium-stained Thick meconium-stained Poly-
hydramnios Oligo-hydramnios
Foul-smelling
MONITORING USED: External Fetal Monitoring Internal Fetal Monitoring (IUPC
Intermittent auscultation
FHR: Reassuring Non-reassuring
Fetal Heart Rate Baseline 110
Fetal Heart Variability Minimum
variability
FHR Periodic Rate
Changes
FHR Accelerations None
FHR Early Decelerations none
FHR Late Decelerations Positive for late
decelerations
FHR Variable none
Decelerations
Nursing Interventions Repositioned mom
done for
FHR Periodic Rate
Changes
Uterine Contraction
Pattern
Frequency/Duration/Inten 4 min apart lasting 50
sity sec in duration
1st Stage
STAGE II AND III DELI VERYof: Labor
DELIVERY DATE AND TIME: 18 Aug 2020 @ 0125
DELIVERY METHOD:
Spontaneous Forceps Vacuum Assisted Vaginal Birth after Cesarean Cesarean
Section
2
, KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
3
, KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
PLACENTA DELIVERY:
Spontaneous Manual Time:
BILATERAL TUBAL LIGATION Yes No
EPISIOTOMY None ML RML LML Extensions Not Applicable
LACERATIONS: 1st degree 2nd degree 3rd degree 4th degree Not Applicable
ESTIMATED BLOOD LOSS (EBL) _1000 mL FETAL POSITION/PRESENTATION N/A c-
section
COMPLICATIONS OF LABOR/DELIVERY: Prolapsed cord
MATERNAL PHYSIOLOGIC ASSESSMENT:
CARDIOVASCULAR/ RESPIRATORY/LOWER EXTREMITIES
VITAL SIGNS: T _99F P 87 R 22 BP 134/80 O2 Sat. _97%
HEART SOUNDS: (State rhythm, murmurs, gallops, rubs) lungs clear bilaterlly no murmurs
or arrythmyas found
LUNGS: Clear bilaterlly
COLOR OF SKIN/ MUCOUS MEMBRANES: _Pink and moist
EDEMA: Yes No If yes, location & amount
PEDAL PULSES _found 88
CAPILLARY REFILL 2_ seconds
BREASTS
PREFERRED METHOD OF INFANT FEEDING: Breast Bottle Both Undecided
PRIOR EXPERIENCE WITH PREFERRED METHOD? Yes No
PRESENCE OF: Colostrum Mature milk Engorgement
If breastfeeding, shape of nipple? erect flat inverted Nipples intact? Yes
No
UTERUS/ LOCHIA
LOCATION & FIRMNESS OF FUNDUS _12 hours after delivery_is firm and at the level of the
umbilicus
UTERINE CRAMPING? Yes No If yes, pain rating (0-10 scale): 2 while
breastfeeding 6
4
MATERNITY NURSING CARE PLAN
STUDENT DATE: CURRENT COHORT:
NAME: 49
CLIENT INITIALS: DATE OF ADMISSION: AGE: ALLERGIES:
CH 32 No Known Allergies
HT: PRE- CURRENT TOTAL WT GAIN: BMI
165 CM PREGNANT WT: 20 kg
WT:
61 kg 81 Kg
LIVING SITUATION/MARITAL STATUS
Married with 1 child in the home at this time
RACE/ETHNIC CULTURAL CONSIDERATIONS PERTINENT TO LABOR, DELIVERY,
ITY: & POSTPARTUM/NEWBORN CARE:
Hispanic None noted at this time
RELIGION/SPIRITUAL CONSIDERATIONS PERTINENT TO LABOR, DELIVERY,
& POSTPARTUM/NEWBORN CARE:
None noted at this time
PAST MEDICAL HISTORY/IMMUNIZATIONS: (UP TO DATE)
Patient is current on immunizations and pre-pregnacy stated she is healthy and active no
sinificant past medical history
PAST OBSTETRICAL HISTORY: Include dates of previous deliveries, Cesarean or vaginal
births, USE OF forceps or vacuum extractions, length of labor, analgesia/anesthesia
used, any difficulties with infants at birth.
Birth of child Aug 2016 normal vaginal birth without complications. Birth of child Jun
2018 vaginal without complications
GRAVIDA _2 TERM 1 PRETERM 0 ABORTIONS 0 LIVING 1
DUE DATE: (LMP)_21 Sep 2020 due date LMP Dec 11, 2019(ULTRASOUND)_15 July 2010_
GESTATIONAL AGE 39 Weeks 5/7
PRENATAL CARE BEGAN Jan 5, 2020
PREGNANCY PLANNED? Yes No
ALCOHOL USE: Before pregnancy? Yes No During pregnancy? Yes No
If yes: type, frequency, amount Patient stated she was a social drinker but abstained from
alcohol use during pregnancy
TOBACCO USE: Before pregnancy? Yes No During pregnancy? Yes No
1
, KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
If yes: Type, frequency, amount (packs per day)
ILLEGAL DRUG USE: Before pregnancy? No During pregnancy? No
If yes: type, frequency, amount
Have siblings been prepared for new baby? Yes How? _help set up baby room did
a sibling class at the hospital N/A
FAMILY DYNAMICS:
LABOR &
MEMBRANES RUPTURED: Date/Time_ 1500 Amniotomy ruptured membrains SROM
AROM
AMNIOTIC FLUID: Clear Light meconium-stained Thick meconium-stained Poly-
hydramnios Oligo-hydramnios
Foul-smelling
MONITORING USED: External Fetal Monitoring Internal Fetal Monitoring (IUPC
Intermittent auscultation
FHR: Reassuring Non-reassuring
Fetal Heart Rate Baseline 110
Fetal Heart Variability Minimum
variability
FHR Periodic Rate
Changes
FHR Accelerations None
FHR Early Decelerations none
FHR Late Decelerations Positive for late
decelerations
FHR Variable none
Decelerations
Nursing Interventions Repositioned mom
done for
FHR Periodic Rate
Changes
Uterine Contraction
Pattern
Frequency/Duration/Inten 4 min apart lasting 50
sity sec in duration
1st Stage
STAGE II AND III DELI VERYof: Labor
DELIVERY DATE AND TIME: 18 Aug 2020 @ 0125
DELIVERY METHOD:
Spontaneous Forceps Vacuum Assisted Vaginal Birth after Cesarean Cesarean
Section
2
, KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
3
, KEISER UNIVERSITY
MATERNITY NURSING CARE PLAN
PLACENTA DELIVERY:
Spontaneous Manual Time:
BILATERAL TUBAL LIGATION Yes No
EPISIOTOMY None ML RML LML Extensions Not Applicable
LACERATIONS: 1st degree 2nd degree 3rd degree 4th degree Not Applicable
ESTIMATED BLOOD LOSS (EBL) _1000 mL FETAL POSITION/PRESENTATION N/A c-
section
COMPLICATIONS OF LABOR/DELIVERY: Prolapsed cord
MATERNAL PHYSIOLOGIC ASSESSMENT:
CARDIOVASCULAR/ RESPIRATORY/LOWER EXTREMITIES
VITAL SIGNS: T _99F P 87 R 22 BP 134/80 O2 Sat. _97%
HEART SOUNDS: (State rhythm, murmurs, gallops, rubs) lungs clear bilaterlly no murmurs
or arrythmyas found
LUNGS: Clear bilaterlly
COLOR OF SKIN/ MUCOUS MEMBRANES: _Pink and moist
EDEMA: Yes No If yes, location & amount
PEDAL PULSES _found 88
CAPILLARY REFILL 2_ seconds
BREASTS
PREFERRED METHOD OF INFANT FEEDING: Breast Bottle Both Undecided
PRIOR EXPERIENCE WITH PREFERRED METHOD? Yes No
PRESENCE OF: Colostrum Mature milk Engorgement
If breastfeeding, shape of nipple? erect flat inverted Nipples intact? Yes
No
UTERUS/ LOCHIA
LOCATION & FIRMNESS OF FUNDUS _12 hours after delivery_is firm and at the level of the
umbilicus
UTERINE CRAMPING? Yes No If yes, pain rating (0-10 scale): 2 while
breastfeeding 6
4
