NEW ERA UNIVERSITY

COLLEGE OF NURSING
#9 Central Avenue, Saint Joseph Street, New Era
Quezon City, 1107 Metro Manila
College of Nursing
NCM 109-18 Care of Mother and Child, at Risk or with
Problems (Acute and Chronic
2nd Semester AY 2022-2023
Module 3 Assignment

Abarientos, Merry Rozette B.

CON-2A

Sarah is a 16-year-old gravida 1, para 0 at 34 weeks of gestation, who is visiting her

physician for a routine prenatal visit. When weighing Patricia, the nurse finds that
she has gained 6 lb in the past 2 weeks. The nurse obtains a clean-catch urine
specimen from Sarah and takes her vital signs (temperature, 37° C [98.6° F]; pulse,
82 bpm; respirations, 20 breaths/min; blood pressure, 146/90 mm Hg); the FHR is
144 to 150 bpm. Deep tendon reflexes are normal (2+), and no clonus is present.

1. What is the possible medical diagnosis? Justify your answer (2pts)

- The possible medical diagnosis to Sarah is Preeclampsia without severe features. The
patient is at risk factors, because her gravida is younger than 20 years. Also, her Blood
pressure is high 146/90 mmHg. It is already categorized in Preeclampsia without severe
features. Lastly, Sarah gained 6 lb for the past 2 weeks for 3rd trimester which is not
normal.

2. Describe how generalized vasospasm of her condition affects each organ

and how these effects are manifested. (5pts)

a. Kidneys- Blood urea nitrogen (BUN), creatinine, and uric acid levels rise when blood
flow is lowered because it lowers the glomerular filtration rate. Protein can leak across
the glomerular membrane due to glomerular injury brought on by decreased perfusion,
which causes interstitial fluid to build up, hypovolemia, and increased blood viscosity and
hematocrit (hemoconcentration) values. In response to hypovolemia, the body releases
angiotensin II and aldosterone, which raises blood pressure even further.

b. Liver-Liver function declines with reduced perfusion. Subcapsular hemorrhaging and

hepatic edema can happen. Possible increased liver enzyme levels in the serum.

c. Brain- Vasoconstriction causes the small capillaries to break under pressure, which
causes minor brain hemorrhages. There may be side effects, including headaches and
vision problems.

d. Lungs-Pulmonary edema could develop as a result of decreased colloid oncotic

pressure.

e. Placenta-Infarctions or abruptio placentae may result from reduced perfusion. A higher

risk exists for HELLP syndrome. A growth restriction and ongoing hypoxemia are possible
in the fetus.

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 3. Identify at least 2 nursing diagnosis and give appropriate interventions with
rationale (6 pts)

1. Decreased cardiac outputs.

• Assess blood pressure and pulse every one hour or as indicated.
- For the early detection of hypertensive illnesses, accurate blood pressure
measurement is essential.
• Assess and record the client's urine output. Maintain strict intake and
output.
- The kidneys respond to a decreased cardiac output in preeclampsia by retaining
water and salt. Due to a decrease in glomerular filtration rate, intrarenal
vasospasms in severe preeclampsia lead to oliguria. Vasospasm-induced
intravascular space contraction affects renal salt and water retention (ACOG,
2020).
• Monitor antiplatelet therapy. A low-dose aspirin is given.
- Low platelet counts are associated with a higher risk of abnormal coagulation
and reduced cardiac output in preeclamptic women. Also patients with high-risk
pregnancies, low-dose aspirin effectively reduces preeclampsia, severe
preeclampsia, preterm birth, and intrauterine growth restriction.
• Monitor fetal well-being and status.
- Fetal death is significantly influenced by preeclampsia. The fetus is more likely
to experience hypoxia and growth retardation if fluid balance is not maintained.

2. Knowledge deficit related to normal changes of pregnancy versus illness

complications.

• Instruct any danger signs to report.

- Instructions should be given both verbally and in writing regarding which

symptoms, such as blurred vision, headaches, epigastric pain, or difficulty
breathing, should be reported to the doctor.

• Encourage using positive reinforcement.

- To promote behavior modification and impart new abilities, positive

reinforcement can be utilized. It encourages persistence in learning efforts.

• Instruct on appointments and tests.

- Completing follow-up appointments, glucose monitoring, and blood pressure

assessments will ensure a healthy pregnancy and delivery.

4.What conditions are necessary for a woman to receive Rho(D) immune

globulin? What does each mean?4pts

a. Rh factor of the woman- These blood groups are incompatible with one another
when a mother is Rh-negative and is having a baby with Rh-positive blood; mixing them
can be fatal. In order to prevent the creation of antibodies that kill the fetus' cells,
women will therefore get RhIG.

b. Rh factor of the fetus or newborn-Rh-positive blood is required for the fetus since
Rh-negative blood cannot cause the woman to produce anti-Rh antibodies.

c. Indirect Coombs’ test (woman)- When a woman's indirect Coombs test comes out
negative, it means that she has not developed anti-Rh antibodies or been sensitized to
Rh-positive blood during her pregnancy.
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 d. Direct Coombs’ test (newborn)- The direct Coombs test should provide a negative
result since it looks for maternal antibodies in the blood of the newborn.

References:

Flagg, J. (2018). Maternal and child health nursing: Care of the childbearing and
childbearing family (8thed.). Philadelphia, PA: WoltersKluwer.

Famorca, Z.U., M.A.Nies and M. McEwen. Nursing Care of the Community: A

comprehensive text on community and public health nursing in the Philippines (6th ed.).
Singapore, Elsevier

Preeclampsia Nursing Diagnosis & Care Plan. (2022, September 24). NurseTogether.
https://www.nursetogether.com/preeclampsia-nursing-diagnosis-care-plan/

Wayne, G. (2016, September 26). 6 Preeclampsia & Gestational Hypertensive

Disorders Nursing Care Plans. Nurseslabs. https://nurseslabs.com/preeclampsia-

gestional-hypertensive-disorders-nursing-care-plans/

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