WELCOME

LEVEL 2
NURSING
STUDENTS!!!
NCM 107 – SKILLS LABORATORY
MOTHER
Standard Protocol for All
Nursing Interventions
 All nursing skills must include
certain basic steps for the safety
and well-being of the patient and
the nurse. To prevent repetition,
these steps are referred to at the
beginning of and the end of each
skill as standard protocols.
The complete Standard Protocol
includes the essential steps, which
must be done consistently with each
patient contact in order to deliver
responsible and safe nursing care.

Before the Skill

1. Verify the physician’s orders.
2. Gather the equipment and
supplies.
Supplies for all nursing interventions
include:

• Armband for patient identification

• Consent Form if required by agency
policy
• Clean disposable gloves if contact
with mucous membranes, non-intact
skin, or moist body substances is
anticipated.

College of Nursing (2018)

3. Perform hand hygiene for at least 10
to 15 seconds before each patient
contact.
4. Introduce yourself to the patient
including both your name and title
or role.
5. Identify the patient by checking the
identification bracelet and having
the patient state his or her name (if
able to do so).
6. Explain what you plan to do.
Understanding what is done
enhances the patient’s level of
comfort and ability to cooperate.
7. Identify the teaching needed and
describe what the patient can expect
in simple terms.
8. Assess the patient to determine that
the intervention is still appropriate.
Each skill indicates specific
assessments as indicated. Check for
allergies as appropriate.
9. Adjust the bed to the appropriate
height and lower the side rail on the
side nearest you. Check the locks on
the bed wheels. Minimizes caregiver’s
muscle strain and prevents injury.
Prevents bed from moving.
[Link] adequate lighting for the
procedure.
[Link] privacy for the patient.
Position and drape the patient as
needed.
During the Skill
[Link] patient independence
and involvement, if possible.
Participation enhances patient
motivation and cooperation.

[Link] patient tolerance, being

alert for signs of discomfort and
fatigue.
End of skill (Completion Protocol )
14. Assist the patient to a position of
comfort, and organize needed toiletry or
personal items within reach.
15. Be certain the patient has a way to
call for help and knows how to use it.
16. Raise the appropriate number of
side rails and lower the bed to the
lowest position.
End of skill (Completion Protocol )
17. Dispose of used supplies properly, and
return reusable equipment to its proper
storage location.
18. Remove and dispose of gloves, if used.
Perform hand hygiene for at least 10 to 15
seconds. Wearing gloves does not
eliminate the need for hand hygiene.
19. Document and report the patient’s
response and expected or unexpected
outcomes.
 Objectives of Training
At the end of the clinical experience, the student should be able
to:

1. Perform a complete assessment of the childbearing

female and neonate.
2. Demonstrate skill in monitoring different health
needs during the childbearing periods.
3. Recognize the role of the nurse and in providing
care for mothers and infants.
4. Apply nursing process in providing care during normal
and complicated childbearing condition
5. Demonstrate competence in management of normal and
complicated cases in different childbearing periods
6. Implement health education and teaching plan for
childbearing patients and families related to different
maternal aspects during the different childbearing periods.
TERMS RELATED TO
PREGNANCY
 Pregnancy: Period between conception and
delivery (40 weeks, 280 days, 9 month).
 Antepartal Period/Prenatal Period/ Prepartal
Period: Time of fetal development and
maternal adaptation with pregnancy. It
started from the beginning of conception and
ends with the onset of labor.
 Trimester: Division of pregnancy into time
segments of about 13 weeks.
 Gravida: Pregnancy.
 Primi gravida: A woman who is pregnant
for the first time.
 Multigravida: A woman who has been
pregnant two or more time.
 Nulligravida: A woman who is never been
pregnant
 Para: Birth after 20 weeks' gestation
regardless of alive or dead.
 Multipara: A woman who has had two
or more births at more than 20 weeks'
gestation.
 Primipara: A woman who is delivered
at more than 20 weeks' gestation for
the first time
 Nullipara: A woman who is never
delivered at more than 20 weeks'
gestation.
 Preterm labor: Labor that occurs after
20 weeks but before the completion of
37 weeks' gestation.
 Stillbirth: A fetus born dead after 20
weeks' gestation
 Term:A fetus born after 37 weeks'
gestation but before the end of the
42nd week of gestation.
 Post-term Delivery: Birth occurs
after the 42nd week of gestation.
 Abortion:Termination of
pregnancy before viability of the
fetus ( Wt ˂ 500 gm or gestational
weeks less than 20 weeks).
Physical Examination
 Is a general examination done to the
patient from head to toe using different
ways of physical examination:
Inspection, Palpation, Auscultation and
Percussion.
 Preparation for physical examination
 Privacy
 Hand washing
 Explain the procedure
 Ask client to empty bladder
 Do urine test (for glucose & albumin)
 Measure client height & weight, and vital sign
Essential Procedures in
Normal Pregnancy
 Estimating Ovulation Time
 Ovulationusually occurs approximately
14 days before the first day of the
succeeding menstrual bleeding.
 Signs and symptoms of ovulation:
 Abrupt
slight rise in basal body
temperature
 Presence of mittelschmerz
 Identification of fertile cervical muucus
 Positive Spinnbarkeit test
Determining Gravidity and
Parity
 Principles of identifying parity
The number of pregnancies is
counted and not the number
of fetuses
Abortion is not included in
parity count
Live birth or stillbirth is
counted in parity count
Obstetrical Scoring
 G-T – P – A – L
G – Gravida
T – Term births
P – preterm births
A – abortions
L – living children
What do the following
obstetrical scores mean?

1. 4 – 2 – 1 – 1 – 3
2. 6 – 3 – 0 – 3 – 3
3. 5 – 5 – 0 – 0 – 5
4. 3 – 0 – 2 – 1 – 2
5. 7 – 4 – 1 – 1 – 4
Estimating Expected Date of Delivery (EDD)
Naegele’s Rule

1. Determine the last menstrual period (LMP).

2. Consider the first day of LMP.
3. Consider the month in numeric terms. For the
first three months of the year, add 9 to the
numeric value of months and 7 days.
4. Using the Naegele’s formula, subtract three
months and add 7 days to the first day of the
last menstraul period.
Determine the EDD of the
following LMPs.
1. January 5 – 8, 2025
2. March 16 – 19, 2025
3. June 22 – 24, 2025
4. November 3 – 6, 2024
5. December 29, 2024 – January 2, 2025
6. May 31, 2025
7. February 25, 2025
8. March 25, 2025
Estimating Fundic Height:
McDonald’s Rule
 Fundic height (FH) in centimeters correlates well
with weeks of gestation between 20 to 31 weeks.
 Equipment: tape measure
 Procedures:
1. Explain the procedure to the client.
2. Ask the client to empty her bladder.
3. Position the client in dorsal recumbent.
4. Drape.
5. Measure the distance abdominally from the top
of the symphysis pubis over the curve of the
abdomen to the top of the uterine fundus.
Estimating Gestational
Age: McDonald’s Rule

Computing in lunar months,

multiply the fundic height
by two, then divide by
seven.
Computing in weeks,
multiply the fundic height
by eight, then divide by
seven.
Using McDonal’s Rule, Determine the
AOG in weeks and lunar months of the
following measurements.

1. 33 centimeters
2. 25 centimeters
3. 38 centimeters
4. 30 centimeters
5. 20 centimeters