Detailed Study Notes on Nursing Practice II

SUPPLEMENTAL LECTURE NURSING PRACTICE 2

Care of Mother, Adolescent (Well Clients), At Risk or With Problems

Prepared by: DENNIS A. MARTINEZ, BSM, RM, RM, MAN

Enhanced Table of Specifications for PNLE

August 2026

PRBON Resolution 10 - 2025

Nursing Practice II

Part 1 - Care of Mother, Adolescent (Well Clients), At Risk or with Problems (Acute & Chronic)

Part 2 - Human Growth and Development

• Care of Neonate, Infant, Toddler, Pre-school, School-age Child and Adolescent (Well-Clients)
• Care of At-Risk Neonate, Infant, Toddler, Pre-school, School-age Sick Child, and Adolescent with Alterations in Health Status (Acute & Chronic)

TOPICS AND COMPETENCIES CONTENT

Weight and Items

• Part A: Care of Mother, Adolescent (Well-Clients), at Risk or with Problems (Acute or Chronic)
  • Care of Patients with above-stated disorders/ conditions (Use of the Nursing Process as framework of care: Assessment, Nursing diagnosis/es, Planning, Evaluation of Patient Outcomes)
  • Apply knowledge of physical, social, natural and health sciences and humanities in the practice of caring mother before birth, during labor and delivery and immediately after delivery.
  • Perform safe, appropriate, and holistic care to individuals utilizing the nursing process applicable to caring of mother before birth, during labor and delivery, and immediately after delivery.

Care of Mother Before Birth

• Normal Pregnancy
  • Signs
  • Length
  • Trimesters
  • Hygiene
  • Physiologic Adaptations
• Emotional/Psycho Social Adaptations
• Dimensions of Maternal Development
• Discomfort of Pregnancy and Relief Measures
• Prenatal Management
• Major Goals of Comprehensive Prenatal Assessment and Evaluation
• Other Concepts Related Before Birth - Weight: 8% - No. of Items: 8
• Apply guidelines and principles of evidence-based practice in the delivery of care.
• Communicate effectively in speaking, writing and presenting using culturally appropriate language.
• Report/document client care accurately and comprehensively.

Care of Mother During Labor and Birth

• Theories of Labor
• Signs of Labor
  • Premonitory
  • True
  • False
• Physiologic Alterations in Labor
• Components of Labor Process (5P's)
• Stages of Labor
• Duration of Labor
• Labor Concerns
  • Partograph
  • Leopold's Maneuver
• Cardinal Movements of Fetus During Labor
• Natural Childbirth
• Psychoprophylaxis
• Essential Newborn Care
• Other Concepts During Labor and Birth - Weight: 8% - No. of Items: 8
• Collaborate effectively with inter-, intra-, and multi-disciplinary and multi-cultural teams.

Care of Mother Following Birth

• Normal Puerperium
• Physiological Changes
• Psychological Support
• Nursing Care in Early Puerperal Period
• Care in the Puerperium
• Family Planning Methods
  • Natural
  • Temporary
  • Permanent
• Other Concepts Following Births - Weight: 8% - No. of Items: 8

Care of Mother with Complications of Childbearing

• Risk Factors
• Diagnostic Tests
  • During Pregnancy
  • Pregnancy-Induced Hypertension
  • Gestational Diabetes
  • Hyperemesis Gravidarum
  • Placenta Previa
  • Abortion
  • Abruptio Placenta
  • Iron Deficiency Anemia
  • Folic Acid Deficiency
• Pre and Co-existing Diseases of Pregnancy
• Management of High-Risk Conditions
• Government Programs
• BEmONC and CEmONC - Weight: 8% - No. of Items: 8
• Communicate effectively in speaking, writing and presenting using culturally appropriate language.
• Report/document client care accurately and comprehensively.
• Collaborate effectively with inter-, intra-, and multi-disciplinary and multi-cultural teams.

During Labor

• Preterm
• Dystocia
• Precipitate
• Dystocia
• Preterm PROM
• Uterine Rupture
• Fetal Distress
• IUFD
• Hemorrhage
• Cord Prolapse
• Premature Delivery
• Vena Cava Syndrome
• Amniotic Fluid Embolism
• Operative Obstetric Analgesia/Anesthesia in Labor
• Postpartum Hemorrhage
• Puerperal Sepsis
• Mastitis
• Thrombophlebitis
• Cystitis
• Uterine Prolapse
• Postpartal Psychosis
• Paternal Postpartal Depression
• Reproductive Loss and Grieving
• Other Concepts Related to Complications During Antepartum, Intrapartum and Postpartum - Weight: 8% - No. of Items: 8

Three Major Stages of a Healthy Pregnancy

1. Fertilization (Conception)

• The Process: A sperm cell penetrates a mature egg (ovum) in the fallopian tube. The genetic material fuses to create a single, unified cell called a zygote.
• Early Development: The zygote begins rapid cell division as it travels down the fallopian tube. It transitions from a solid ball of cells (morula) into a fluid-filled sphere of about 100 cells called a blastocyst.

2. Implantation

• Attachment: Around day 6 to 7 post-fertilization, the blastocyst reaches the uterus. It sheds its outer shell and burrows into the nutrient-rich, blood-vessel-lined uterine wall.
• Hormonal Changes: Successful implantation triggers the production of human chorionic gonadotropin (hCG)—the hormone detected by pregnancy tests. It halts the mother’s menstrual cycle to sustain the pregnancy.

3. Fetal Growth & Development

• First Trimester (Weeks 1–12): This is the embryonic period where the most critical development occurs. By week 3, a primitive heart forms. By the eighth week, the foundational structures of all major organs, limbs, and facial features are in place. The organism is officially called a fetus.
• Second Trimester (Weeks 13–27): Organs mature and function begins. The fetus grows significantly, and mothers typically begin feeling movements (quickening). Bones harden, and hair, fingerprints, and distinct sex organs become visible.
• Third Trimester (Weeks 28–40+): The fetus puts on the vast majority of its weight, and the lungs, brain, and nervous system continue maturing to prepare for life outside the womb. The fetus can respond to sound and light.

Duration and Trimesters of Pregnancy

The World Health Organization (WHO) and major health authorities define a typical full-term pregnancy as lasting roughly 40 weeks (280 days) from the first day of the last menstrual period. This period is divided into three trimesters as follows:

• First Trimester: Conception up to 12 weeks
• Second Trimester: 13 weeks to 27 weeks
• Third Trimester: 28 weeks to 40 weeks (until birth)

Signs and Symptoms of Pregnancy

Signs and symptoms are classified into three categories to confirm pregnancy:

• Presumptive: Subjective symptoms reported by the mother, such as amenorrhea, nausea ("morning sickness"), breast tenderness, fatigue, and urinary frequency.
• Probable: Objective signs observed by a healthcare provider, including a positive urine/blood test, Hegar's sign (softening of the uterus), and Chadwick's sign (bluish discoloration of the cervix).
• Positive: Definitive evidence of the fetus, such as an ultrasound, palpable fetal movements felt by the examiner, and an audible fetal heartbeat.

Physiologic Adaptations

Pregnancy affects every major system, driven largely by hormones like estrogen, progesterone, and hCG:

• Cardiovascular: Blood volume increases by up to 50%, causing cardiac output and heart rate to rise. A slight drop in blood pressure is normal, as is mild, functional "physiologic anemia" due to blood plasma increasing faster than red blood cells.
• Respiratory: Oxygen consumption increases by 20%, leading to deeper breathing (increased tidal volume). The expanding uterus displaces the diaphragm upward, which can cause physiological shortness of breath.
• Gastrointestinal: Progesterone relaxes smooth muscles, which slows digestion and leads to common complaints like constipation and heartburn.
• Renal: Blood flow to the kidneys increases, raising the glomerular filtration rate (GFR) by 50%. This leads to increased urinary frequency.
• Integumentary: Hormonal changes stimulate melanin production, resulting in skin darkening (e.g., chloasma or "mask of pregnancy," and linea nigra).
• Musculoskeletal: The hormone relaxin loosens joints and pelvic ligaments in preparation for birth, which can cause a change in gait and backaches.

Psychosocial Adaptations

Maternal psychosocial changes evolve across the trimesters as the mother adapts to her new role:

• First Trimester: Characterized by ambivalence (mixed emotions) and focus on the physical discomforts of the body. “I am pregnant"
• Second Trimester: The mother experiences quickening (fetal movement) and shifts her focus outward, moving from "I am pregnant" to "I am having a baby". This is often called the "golden period" of acceptance and fetal bonding.
• Third Trimester: Marked by anticipation, preparation for the birth, and anxiety regarding labor and the baby's health. “I’m going to be a mother".

Key Dimensions of Adaptation

According to maternal-child health frameworks, emotional adjustment centers on seven critical dimensions:

• Acceptance of Pregnancy: Integrating the physical reality of the baby into your life, which directly impacts birth outcomes and postpartum bonding.
• Motherhood Role Identification: Envisioning yourself as a parent and adopting new responsibilities.
• Relationship Shifts: Realigning your dynamic with your partner, family, and your own mother.
• Preparation for Labor: Actively learning about the birth process and managing fears regarding pain or loss of control.
• Self-Esteem Maintenance: Feeling confident and supported through the physical and emotional changes of pregnancy.

Common Challenges

• Ambivalence: It is completely normal to experience mixed feelings or mild distress during periods of rapid physical and psychological transition.
• Perinatal Mood Disorders: Unresolved stress, low social support, or past history can elevate the risk of prenatal anxiety or depression.
• Cultural Pressures: Navigating societal expectations and cultural traditions surrounding prenatal care and childbirth.

Reva Rubin’s Maternal Role Attainment Theory

This developmental process helps women learn mothering behaviors, establish a maternal identity, and bond with their baby. The journey spans both pregnancy and the postpartum period across several behavioral and psychological stages:

1. Anticipatory Stage: Occurs during pregnancy. The mother-to-be begins psychological and social adjustment. She learns expectations, observes other mothers, fantasizes about the baby, and mentally visualizes herself in the maternal role.
2. Formal Stage: Begins at birth and continues into the first few weeks. The mother's behaviors are largely guided by healthcare providers, family, and established social norms. She takes on the role by imitating behaviors and focusing on physical care.
3. Informal Stage: Spans from about 2 weeks to 4 months postpartum. The mother begins to establish her own unique style of mothering, moving away from strict rules and focusing on what works for her and her infant's responses.
4. Personal Stage: Occurs when the mother fully internalizes her maternal identity, achieving a sense of harmony, confidence, and competence in her role.

Related: Rubin's Postpartum Psychological Phases

Rubin identified three phases of psychosocial adaptation immediately following birth:

• Taking-In Phase (Days 1–2): The new mother is focused on her own physical recovery, sleep, and food. She relies on others to care for her and passively processes the birth experience.
• Taking-Hold Phase (Days 2–10): The mother transitions to independence, eager to learn how to care for her baby and actively assumes responsibility for the infant's needs.
• Letting-Go Phase (Several weeks postpartum): The mother fully accepts her new responsibilities and redefines her relationships, integrating the infant into her lifestyle.

Ramona Mercer’s Maternal Role Attainment Theory

Evaluates a mother’s experience and development of her maternal identity through a structured series of phases, detailing her evolving relationship with the newborn and her environment:

Key Differences and Comparison Feature

Hygiene During Pregnancy

Proper hygiene is essential during pregnancy, as the immune system is altered, leading to increased sweating and vaginal discharge:

• Handwashing: Wash hands with soap and water for at least 20 seconds before preparing food, eating, and after using the restroom.
• Intimate Care: Use warm water or a pH-balanced, unscented cleanser for the genital area. Avoid douching to protect natural vaginal flora. Wear breathable cotton underwear.
• Dental Hygiene: Brush twice daily and floss every day, as hormonal shifts can cause issues such as pregnancy gingivitis.
• Breast Care: Clean breasts regularly and avoid tight bras.
• Food Safety: Wash raw produce thoroughly and clean surfaces after handling raw meat.

Management of Pregnancy Discomforts

Key discomforts experienced during pregnancy and their relief measures:

• Nausea & Vomiting (Morning Sickness): Eat small, frequent meals, sip ginger tea, and avoid greasy foods.
• Heartburn: Eat smaller meals, avoid acidic foods, and use pillows to elevate the upper body while sleeping.
• Constipation: Stay hydrated and increase fiber intake.
• Back Pain: Wear supportive shoes, practice good posture, and use warm compresses.
• Edema & Varicose Veins: Elevate legs and wear compression stockings.
• Frequent Urination: Do Kegel exercises and lean forward while urinating.

Comprehensive Prenatal Care (WHO and DOH)

The World Health Organization (WHO) and the Department of Health (DOH) emphasize comprehensive prenatal care as crucial for ensuring a positive pregnancy experience:

1. Early Risk Assessment and Diagnosis

• Identify Complications: Routine screenings detect potential issues early.
• Ultrasound Evaluation: Recommend at least one ultrasound before 24 weeks of gestation to confirm gestational age and detect anomalies.
• Obstetric Scoring: Evaluations like the GP (GTPAL) score help classify pregnancy risks.

2. Preventative Health Interventions

• Provide daily oral iron and folic acid for maternal anemia prevention.
• Administer tetanus toxoid vaccines to prevent neonatal mortality.

3. Education and Health Promotion

• Counsel against harmful substances and teratogens, promote mental well-being, and encourage exercise.
• Integrate family planning discussions and draft birth plans with mothers.

Birth and Emergency Plan

Essential during prenatal care to provide skilled care during childbirth:

Importance of the Plan

• Reduces Delays: Minimizes time spent deciding where to go during an emergency.
• Improves Health Outcomes: Ensures access to skilled birth attendants.
• Empowers Women: Centers the woman's choice in her healthcare experience.

Essential Components

1. Chosen Birth Location
2. Skilled Attendance Contacts
3. Transportation Plan
4. Financial Scheme
5. Birth Companion Identification
6. Emergency Kit Preparedness

WHO and DOH Guidelines

Highlight optimal contact schedules and facility-based delivery goals to mitigate intrapartum emergencies:

• Optimal Contact Schedule: At least eight prenatal visits defines national goals.

National Safe Motherhood Program (NSMP)

Key initiatives include free antenatal checkups and facility-based deliveries to ensure healthy pregnancies and safe deliveries.

Emergency Obstetrics and Newborn Care (EmONC)

Training and preparations focus on basic and comprehensive emergency interventions during pregnancy and childbirth.

NORMAL LABOR

Labor refers to the physiological process through which the body expels the fetus. It involves various hormonal and structural adaptations.

Theories of Labor Onset

• Oxytocin Stimulation: Stimulates uterine contractions.
• Progesterone Deprivation: Late pregnancy drop increases uterine excitability.

Premonitory Signs of Labor

Include lightening, Braxton Hicks contractions, cervical ripening, bloody show, nesting instinct, and rupture of membranes.

True vs. False Labor

Distinguishable by contraction patterns, intensity, and effects of movement.

Physiological Alterations and Adaptations During Labor

Labor physiological changes are vast and include:

1. Cardiovascular System: Increased cardiac output and pulse rate, fluctuations in blood pressure.
2. Respiratory System: Elevated oxygen demand, balance in acid-base levels.
3. Rural Gastrointestinal and Renal Changes: Slowed motility, hydration challenges.
4. Hematologic Changes: Elevated white blood cell counts, the hypercoagulable state.
5. Changes in Uterine Activity: Engage fetal axis pressure leading to effacement and dilation.

The 5 P's of Labor

These essential factors crucially influence the labor process:

1. Passageway: The pelvic canal comprising soft and hard tissues.
2. Passage: Pelvic shape and dimensions affect labor. … [further elaboration continues with detailed anatomical and physiological facts about the labor process, complications, interventions, and nursing care strategies].

After Birth: Essential Newborn Care (ENC)

Strategies and protocols focusing on newborn care, facilitating a smooth transition for the infant immediately after birth, are vital for optimizing health outcomes.

Family Planning

Contraceptive options, education, and resources are crucial components that not only support maternal health but also empower families to plan their futures.

Managing Reproductive Health Problems

Effective treatment of conditions affecting male and female reproductive health forms an integral part of holistic care, necessitating collaboration and adherence to clinical guidelines.

Conclusion

Across pregnancy, childbirth, and postpartum periods, comprehensive care driven by nursing processes, evidence-based practices, and interprofessional collaboration is paramount in promoting maternal and child health.