Pregnancy is a transformative journey for women, marked by profound physiological and psychological changes to nurture fetal development. Prenatal care plays a crucial role in ensuring a healthy pregnancy and safe delivery for both mother and child. Nurses are integral to this process, employing the nursing process to monitor these changes, identify potential risks, and provide essential education and support. A key aspect of this care is the application of nursing diagnoses to guide interventions and optimize patient outcomes.
This article delves into the essential nursing diagnoses relevant to prenatal care, providing a comprehensive guide for healthcare professionals to deliver effective and patient-centered care throughout pregnancy.
Stages of Pregnancy: A Foundation for Nursing Care
Understanding the stages of pregnancy is fundamental to providing targeted nursing care. Pregnancy is conventionally divided into three trimesters, each characterized by distinct developmental milestones and maternal physiological adaptations:
- First Trimester (Week 1 to Week 12): This period encompasses early embryonic and fetal development. Maternal changes include hormonal shifts, initial symptoms like nausea and fatigue, and psychological adjustments to pregnancy.
- Second Trimester (Week 13 to Week 26): Characterized by rapid fetal growth and maternal adaptation to the growing fetus. “Quickening,” or fetal movement, is typically felt during this trimester.
- Third Trimester (Week 27 to Birth): Focuses on fetal maturation and preparation for labor and delivery. Maternal discomfort may increase as the fetus grows larger.
Fetal development is also categorized into stages:
- Pre-embryonic Stage (First 2 Weeks): Begins with fertilization and concludes with implantation.
- Embryonic Stage (Weeks 3 to 8): Organogenesis, the formation of major organs, occurs during this critical stage.
- Fetal Stage (Week 9 to Birth): Characterized by growth and maturation of fetal organs and systems.
Throughout these stages, the placenta and fetal membranes function as the fetus’s life support system, providing oxygen, nutrients, and protection within the uterus. Maternal physiology undergoes significant adaptations, including increased blood volume, cardiac output, and respiratory rate, all to support the developing fetus.
The Nursing Process in Prenatal Care
The nursing process serves as the framework for providing systematic and individualized prenatal care. It involves:
- Assessment: Comprehensive data collection including maternal history, physical examination, and psychosocial assessment. This includes identifying presumptive, probable, and positive signs of pregnancy.
- Diagnosis: Formulating nursing diagnoses based on assessment data, identifying actual or potential health problems related to pregnancy.
- Planning: Developing individualized care plans with specific goals and interventions to address identified nursing diagnoses.
- Implementation: Executing the planned interventions, including education, counseling, monitoring, and direct care.
- Evaluation: Assessing the effectiveness of interventions and progress towards achieving desired outcomes.
Nursing care plans are essential tools in prenatal care, providing a structured approach to address identified nursing diagnoses. These plans prioritize assessments and interventions to achieve both short-term and long-term goals for maternal and fetal well-being.
Common Nursing Diagnoses in Prenatal Care
Several nursing diagnoses are frequently encountered in prenatal care. Understanding these diagnoses and their associated care plans is crucial for nurses providing prenatal care.
Anxiety
Anxiety is a common emotional response during pregnancy, particularly in the first trimester, driven by hormonal fluctuations and the significant life changes pregnancy entails.
Nursing Diagnosis: Anxiety
Related Factors:
- Interpersonal conflicts
- Stressors related to pregnancy and impending parenthood
- Pain or discomfort
- Unmet needs or concerns
- Value conflicts related to pregnancy decisions
- Unfamiliarity with the pregnancy process and childbirth
- Lack of social or emotional support
- Financial worries related to pregnancy and childcare
As Evidenced By:
- Verbalization of anxious feelings and worries about pregnancy, childbirth, and the future
- Crying spells or increased tearfulness
- Expressing distress or feeling overwhelmed
- Feelings of insecurity or uncertainty about pregnancy and parenting
- Nervousness, restlessness, or irritability
- Feelings of helplessness or lack of control
- Poor impulse control or difficulty making decisions
- Decreased attention span and concentration
- Physical manifestations of anxiety such as tachycardia, tachypnea, and muscle tension.
Desired Outcomes:
- Patient will verbalize a reduced level of anxiety and an increased sense of control over her pregnancy experience.
- Patient will identify and demonstrate effective coping mechanisms to manage anxiety throughout pregnancy.
- Patient will report feeling supported and understood in her anxieties and concerns.
Nursing Assessments:
1. Assess the patient’s anxiety level and manifestations.
- Rationale: Understanding the severity and presentation of anxiety is crucial for tailoring appropriate interventions. Anxiety can manifest emotionally, cognitively, behaviorally, and physically. Identifying specific anxieties related to pregnancy (e.g., health of the baby, labor pain, changes in lifestyle) is essential.
2. Evaluate the patient’s knowledge and preparation for childbirth.
- Rationale: Fear of the unknown, particularly regarding childbirth, is a significant contributor to anxiety. Lack of knowledge and preparation can exacerbate these fears. Assessing the patient’s understanding of labor and delivery allows for targeted education and reassurance.
3. Assess the patient’s support system.
- Rationale: Social and emotional support are vital buffers against anxiety. A strong support system can significantly alleviate stress and fear associated with pregnancy and childbirth. Identifying the patient’s support network (partner, family, friends) and its perceived adequacy is important.
Nursing Interventions:
1. Encourage the patient to openly express fears and feelings about pregnancy and childbirth.
- Rationale: Verbalizing feelings is a therapeutic outlet that can reduce anxiety. Creating a safe and supportive environment where the patient feels comfortable sharing her concerns is paramount. Active listening and empathetic responses are essential nursing skills in this intervention.
2. Provide accurate and comprehensive information about pregnancy and the childbirth process.
- Rationale: Education empowers patients and reduces anxiety stemming from misinformation or lack of knowledge. Addressing specific concerns and misconceptions with evidence-based information can significantly alleviate anxiety. This can include childbirth classes, written materials, and reputable online resources.
3. Explain all procedures and tests thoroughly and obtain informed consent.
- Rationale: Many prenatal tests and procedures can be anxiety-provoking, especially if they are invasive or unfamiliar. Providing clear explanations and ensuring informed consent promotes patient autonomy and reduces anxiety related to the unknown and lack of control.
4. Teach and encourage the use of relaxation techniques and deep breathing exercises.
- Rationale: These techniques are effective non-pharmacological methods for managing anxiety. Deep breathing and relaxation exercises can reduce physiological arousal associated with anxiety and promote a sense of calm and control. Practice and reinforcement are key to the patient effectively utilizing these techniques.
5. Refer to support groups, counseling services, or mental health professionals as needed.
- Rationale: For patients with significant anxiety or those lacking adequate support, professional help may be necessary. Support groups provide peer support and shared experiences, while counseling or therapy can address underlying emotional issues contributing to anxiety. Referral to mental health professionals is crucial for managing more severe anxiety disorders.
Deficient Knowledge
Deficient Knowledge is a common nursing diagnosis in prenatal care, particularly for first-time mothers or those with limited access to information. It arises from inadequate understanding of the physiological changes of pregnancy and essential self-care practices.
Nursing Diagnosis: Deficient Knowledge
Related Factors:
- Inadequate exposure to information about pregnancy and prenatal care
- Misunderstanding or misinterpretation of pregnancy-related information
- Lack of recall of previously learned information
- Cognitive limitations or learning difficulties
- Information overload
- Cultural or language barriers to accessing information
- Insufficient health literacy
- Unfamiliarity with resources and support systems
As Evidenced By:
- Verbalization of questions and concerns about pregnancy, labor, delivery, and newborn care
- Frequent inquiries about expected changes during pregnancy
- Expressing misconceptions or inaccurate beliefs about pregnancy and related topics
- Demonstrating inaccurate or insufficient self-care practices
- Development of preventable complications due to lack of knowledge
- Nonadherence to recommended prenatal care regimens
- Seeking information from unreliable sources
Desired Outcomes:
- Patient will accurately verbalize understanding of expected body changes during pregnancy.
- Patient will identify and implement appropriate self-care measures throughout pregnancy.
- Patient will demonstrate adherence to the recommended prenatal care plan.
- Patient will access and utilize reliable sources of information related to pregnancy and newborn care.
Nursing Assessments:
1. Determine the patient’s current knowledge level regarding pregnancy, childbirth, and newborn care.
- Rationale: Individualized teaching requires assessing the patient’s baseline knowledge. This avoids redundant information and focuses teaching on areas where knowledge gaps exist. Open-ended questions and assessing previous experiences with pregnancy can help gauge knowledge level.
2. Assess the patient’s learning style, readiness to learn, and potential barriers to learning.
- Rationale: Effective teaching must be tailored to the patient’s learning style (visual, auditory, kinesthetic) and consider their readiness to learn, which can be affected by anxiety, discomfort, or emotional state. Identifying barriers such as language, literacy, or cognitive limitations is crucial for adapting teaching methods.
3. Identify any misconceptions or cultural beliefs that may influence the patient’s understanding of pregnancy.
- Rationale: Cultural beliefs and myths can significantly impact a patient’s understanding and acceptance of prenatal care recommendations. Recognizing and addressing these beliefs with sensitivity and culturally appropriate information is essential. The goal is to provide accurate information while respecting cultural diversity.
Nursing Interventions:
1. Develop a personalized birth plan in collaboration with the patient.
- Rationale: Creating a birth plan is an educational process that empowers the patient and facilitates informed decision-making. It helps clarify expectations, preferences, and options related to labor and delivery. While flexibility is important, a birth plan promotes preparedness and reduces anxiety associated with the unknown.
2. Provide information at the patient’s appropriate educational level and in a preferred learning format.
- Rationale: Teaching materials and methods should be adapted to the patient’s educational background, literacy level, and preferred learning style. Using clear, simple language, visuals, videos, and hands-on demonstrations can enhance understanding and retention. For example, teenage mothers may benefit from simpler language and visual aids.
3. Encourage questions and create a welcoming environment for open communication.
- Rationale: Patients should feel comfortable asking questions without fear of judgment. A warm, patient, and approachable demeanor encourages active participation in learning and allows the nurse to address specific concerns and knowledge gaps.
4. Provide positive reinforcement and encouragement for adherence to prenatal care recommendations.
- Rationale: Prenatal care requires ongoing commitment and lifestyle adjustments. Positive feedback and encouragement reinforce healthy behaviors and motivate continued adherence to appointments, dietary recommendations, and other aspects of prenatal care. Acknowledging efforts and progress promotes patient engagement.
5. Utilize various teaching methods and resources, including written materials, videos, websites, and community resources.
- Rationale: Multi-modal teaching enhances learning and caters to different learning styles. Providing a variety of resources ensures that patients have access to information in formats that are accessible and convenient for them. This includes pamphlets, brochures, reputable websites, and information about local prenatal classes and support services.
Ineffective Sexuality Pattern
Pregnancy-related physiological and psychological changes can significantly impact a woman’s sexuality and sexual function.
Nursing Diagnosis: Ineffective Sexuality Pattern
Related Factors:
- Physical symptoms of pregnancy such as fatigue, nausea, and vomiting
- Breast tenderness and sensitivity
- Body image changes and feelings of unattractiveness
- Weight gain and physical discomfort
- Hormonal fluctuations affecting libido and sexual desire
- Psychological factors such as anxiety, fear, or concerns about fetal well-being during intercourse
- Role changes and shifts in relationship dynamics with partner
- Relationship conflicts or communication difficulties with partner
- Insufficient knowledge about safe sexual practices during pregnancy
As Evidenced By:
- Reported decrease in sexual desire or libido
- Altered sexual activity or avoidance of sexual intimacy
- Verbalization of concerns or dissatisfaction with sexual expression
- Reports of feeling physically unattractive or undesirable
- Difficulty with sexual arousal or achieving orgasm
- Changes in sexual behavior or patterns of intimacy
Desired Outcomes:
- Patient will verbalize understanding of the physiological and psychological factors influencing sexuality during pregnancy.
- Patient will express acceptance of changes in sexuality patterns and body image during pregnancy.
- Patient will identify and explore acceptable alternative sexual practices and expressions of intimacy during pregnancy.
- Patient and partner will communicate openly and respectfully about sexual needs and concerns during pregnancy.
Nursing Assessments:
1. Assess the extent and nature of alterations in the patient’s sexuality patterns.
- Rationale: Pregnancy affects sexuality in diverse ways. Assessing the specific changes in libido, sexual activity, comfort levels, and satisfaction helps tailor interventions. Open and non-judgmental questioning is crucial to elicit honest information about this sensitive topic.
2. Identify any pregnancy complications that may contraindicate or affect sexual activity.
- Rationale: Certain pregnancy complications, such as placenta previa, preterm labor risk, or unexplained vaginal bleeding, may necessitate abstinence from intercourse. Identifying these contraindications is essential for patient safety and providing appropriate guidance.
Nursing Interventions:
1. Provide sexual counseling and education to the patient and her partner.
- Rationale: Openly discussing sexuality during pregnancy normalizes the topic and addresses potential anxieties and misconceptions. Providing information about physiological changes, safe sexual practices, and alternative forms of intimacy can empower couples to maintain intimacy and sexual satisfaction throughout pregnancy.
2. Encourage open communication between the patient and her partner regarding sexual needs and concerns.
- Rationale: Effective communication is essential for addressing sexual changes and maintaining intimacy in a relationship. Encouraging couples to openly discuss their feelings, needs, and concerns fosters understanding, empathy, and collaborative problem-solving.
3. Discuss and suggest alternative forms of sexual expression and intimacy, especially when intercourse is contraindicated.
- Rationale: When intercourse is not advisable, exploring alternative forms of intimacy is crucial for maintaining sexual connection and satisfaction. This can include mutual masturbation, oral sex (if safe), massage, cuddling, and other forms of physical and emotional closeness.
4. Provide accurate information and reassurance that sexual activity is generally safe during pregnancy, as long as there are no contraindications.
- Rationale: Many pregnant women and their partners fear that intercourse may harm the baby. Providing accurate information that sex is safe throughout pregnancy (in the absence of contraindications) can alleviate anxiety and encourage continued sexual intimacy.
5. Refer the patient or couple to specialized resources such as sex therapists or counselors if needed.
- Rationale: For couples experiencing significant sexual difficulties or relationship issues related to sexuality during pregnancy, referral to a sex therapist or counselor may be beneficial. These professionals can provide specialized guidance and support to address complex sexual concerns.
Risk for Disturbed Maternal-Fetal Dyad
This nursing diagnosis highlights the potential for disruption in the physiological and psychological relationship between the mother and fetus, which can arise from various maternal or fetal risk factors.
Nursing Diagnosis: Risk for Disturbed Maternal-Fetal Dyad
Related Factors:
- Insufficient or delayed prenatal care
- History of abuse (physical, psychological, or sexual)
- Substance abuse or dependence
- Impaired glucose metabolism (gestational diabetes or pre-existing diabetes)
- Inadequate nutrition or malnutrition
- Use of certain medications or teratogens
- Advanced maternal age or adolescent pregnancy
- Pre-existing maternal comorbidities (e.g., hypertension, cardiac disease, autoimmune disorders)
- Maternal depression or other mental health conditions
- Conditions compromising fetal oxygen support (e.g., maternal respiratory or cardiac disease)
- Placental abnormalities (e.g., abruptio placenta, placenta previa, placental insufficiency)
- Multiple gestation
- Intrauterine growth restriction (IUGR)
- Fetal anomalies or genetic conditions
- Rh incompatibility or other isoimmunization
As Evidenced By:
- Risk diagnoses are not evidenced by signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.
Desired Outcomes:
- Patient will verbalize understanding of the conditions and risk factors that can disturb the maternal-fetal dyad.
- Patient will identify her specific risk factors for disturbed maternal-fetal dyad.
- Patient will actively participate in preventive measures and interventions to minimize risks to the maternal-fetal dyad.
- Patient will maintain optimal maternal and fetal well-being throughout pregnancy.
Nursing Assessments:
1. Thoroughly review the patient’s obstetric history, including previous pregnancies and outcomes.
- Rationale: Past pregnancy experiences, including complications, preterm births, or fetal losses, can indicate increased risk in the current pregnancy. A detailed obstetric history helps identify recurring risk patterns and guide targeted monitoring and interventions.
2. Assess the patient’s history of prenatal care attendance and compliance with recommendations.
- Rationale: Consistent prenatal care is crucial for early detection and management of potential complications. Poor prenatal care attendance is a significant risk factor for adverse maternal and fetal outcomes. Assessing adherence to appointments and recommended screenings helps identify patients at higher risk.
3. Comprehensive review of the patient’s medical history and identification of pre-existing health conditions and risk factors.
- Rationale: Maternal comorbidities and lifestyle factors directly impact uteroplacental blood flow, fetal oxygenation, and overall fetal well-being. Identifying conditions like diabetes, hypertension, cardiac disease, respiratory disorders, substance use, and mental health issues is critical for risk stratification and targeted management.
4. Assess the patient’s respiratory status and oxygenation levels.
- Rationale: Maternal respiratory compromise directly affects oxygen delivery to the fetus. Conditions like asthma, COPD, or sleep apnea can impair maternal oxygenation and subsequently fetal oxygen supply. Assessing respiratory function is important, especially in women with pre-existing respiratory conditions.
5. Screen for signs and symptoms of abuse and domestic violence.
- Rationale: Abuse during pregnancy is a serious risk factor for both maternal and fetal health. It is associated with preterm birth, low birth weight, and other adverse outcomes. Routine screening for domestic violence is an essential component of prenatal care.
6. Evaluate the patient’s understanding of conditions that can disturb the maternal-fetal dyad and preventive measures.
- Rationale: Patient education and awareness are key to risk reduction. Assessing the patient’s knowledge about risk factors and preventive strategies allows for targeted education and empowers them to actively participate in maintaining a healthy pregnancy.
7. Monitor fetal activity, heart rate, growth, and amniotic fluid volume throughout pregnancy.
- Rationale: Regular fetal surveillance is essential for detecting early signs of fetal distress or compromise. Monitoring fetal heart rate, activity patterns, growth parameters, and amniotic fluid volume provides valuable information about fetal well-being and guides timely interventions.
Nursing Interventions:
1. Monitor maternal weight gain and nutritional status routinely.
- Rationale: Maternal weight and nutrition are key indicators of pregnancy health. Inadequate or excessive weight gain and poor nutrition are associated with increased risks. Regular weight monitoring and nutritional counseling help ensure optimal maternal and fetal nutrition. Underweight and obese patients are at higher risk and require close monitoring.
2. Provide resources and support for cessation of substance abuse (smoking, alcohol, drugs).
- Rationale: Substance use during pregnancy is detrimental to both maternal and fetal health. Providing resources for substance abuse treatment, support groups, and counseling is crucial for promoting cessation and minimizing harm.
3. Educate the patient and family about the importance of consistent prenatal care and adherence to recommendations.
- Rationale: Emphasizing the benefits of prenatal care and addressing any barriers to access or adherence is essential. Education should highlight the importance of regular check-ups, screenings, and following healthcare provider recommendations for a healthy pregnancy.
4. Involve support persons (family, partner) in prenatal education and care planning.
- Rationale: Support from family and partners is vital for a healthy pregnancy. Including support persons in education and care planning enhances their understanding of pregnancy needs and enables them to provide effective support to the pregnant woman.
5. Provide ongoing assessment and intervention for psychological needs, including screening for depression and anxiety.
- Rationale: Maternal mental health is integral to overall pregnancy well-being. Depression and anxiety can negatively impact pregnancy outcomes. Routine screening and timely intervention for mental health conditions are essential components of prenatal care. Increased stress should be monitored and addressed.
Risk for Imbalanced Nutrition: Less Than Body Requirements
This diagnosis addresses the risk of inadequate nutritional intake during pregnancy, which can have serious consequences for both mother and fetus.
Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements
Related Factors:
- Changes in taste and smell (dysgeusia) affecting appetite
- Dental problems or oral discomfort impacting food intake
- Decreased appetite due to pregnancy symptoms or emotional factors
- Inadequate dietary intake of essential nutrients
- Nausea and vomiting of pregnancy (morning sickness)
- Difficulty meeting increased metabolic demands of pregnancy
- Elevated thyroid activity associated with fetal growth
- Certain medications that may affect appetite or nutrient absorption
- Insufficient financial resources to afford adequate food
- Lack of knowledge about nutritional needs during pregnancy
As Evidenced By:
- Risk diagnoses are not evidenced by signs and symptoms, as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Desired Outcomes:
- Patient will achieve and maintain weight gain within recommended ranges for pregnancy.
- Patient will verbalize understanding of proper nutrition and dietary recommendations during pregnancy.
- Patient will demonstrate a meal plan that aligns with recommended nutritional guidelines for pregnancy.
- Patient will report adequate energy levels and absence of signs and symptoms of nutritional deficiencies.
Nursing Assessments:
1. Identify the patient’s individual risk factors for imbalanced nutrition during pregnancy.
- Rationale: Nutritional risk assessment helps identify women at higher likelihood of poor nutritional outcomes. Risk factors like low socioeconomic status, limited health literacy, pre-existing health conditions, or history of eating disorders require focused attention and intervention.
2. Assess the patient’s typical daily nutritional intake, dietary habits, and food preferences.
- Rationale: Understanding current dietary patterns is crucial for identifying nutritional gaps and tailoring dietary recommendations. Assessing food preferences, cultural dietary practices, and any dietary restrictions or allergies is also important for developing a realistic and acceptable meal plan.
3. Monitor maternal weight and weight gain patterns throughout pregnancy.
- Rationale: Weight gain is a key indicator of nutritional status during pregnancy. Monitoring weight at each prenatal visit and comparing it to recommended weight gain guidelines helps identify potential nutritional imbalances. Inadequate weight gain can signal insufficient calorie or nutrient intake. The recommended weight gain during pregnancy is approximately 25-35 pounds for women with a normal pre-pregnancy BMI.
4. Assess for signs and symptoms of malnutrition or nutritional deficiencies.
- Rationale: Early detection of malnutrition or deficiencies allows for timely intervention. Signs and symptoms can be subtle initially but can progress if left unaddressed. Recognizing symptoms like fatigue, anemia, dizziness, high blood pressure, hair loss, dry skin, and dental problems is important.
5. Assess the patient’s activity level and energy expenditure.
- Rationale: Activity levels influence caloric and nutrient needs. Considering the patient’s activity level when developing a meal plan ensures adequate calorie intake to meet energy demands and support both maternal and fetal needs.
Nursing Interventions:
1. Collaboratively establish individualized nutritional goals with the patient.
- Rationale: Patient involvement in goal setting increases adherence and promotes ownership of the care plan. Working together to develop realistic and achievable nutritional goals, considering the patient’s lifestyle and preferences, is crucial for success.
2. Consult and collaborate with a registered dietitian for comprehensive nutritional counseling and meal planning.
- Rationale: Registered dietitians are experts in nutrition and can provide specialized guidance tailored to the individual needs of pregnant women. They can create personalized meal plans, address specific dietary concerns, and provide in-depth nutritional education.
3. Administer or recommend prenatal vitamin and mineral supplements as prescribed or indicated.
- Rationale: Prenatal supplements are often recommended to ensure adequate intake of essential nutrients, particularly folic acid, iron, calcium, and vitamin D, which are crucial for fetal development and maternal health. Supplementation is especially important when dietary intake may be insufficient.
4. Provide education and strategies to manage common pregnancy symptoms that interfere with nutrition, such as nausea and vomiting (morning sickness).
- Rationale: Morning sickness can significantly impact nutritional intake. Providing practical strategies to manage nausea and vomiting, such as consuming ginger, avoiding trigger foods and smells, eating smaller, more frequent meals, and staying hydrated, helps improve nutrient intake and prevent dehydration. Nausea and vomiting during pregnancy should be addressed proactively.
5. Provide information about community resources for food assistance if financial constraints are a barrier to adequate nutrition.
- Rationale: Financial limitations can significantly impact access to healthy food. Connecting patients with food banks, WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), and other food assistance programs can help ensure they have access to nutritious food throughout pregnancy.
Conclusion
Nursing diagnoses are indispensable tools in prenatal care, enabling nurses to provide individualized, evidence-based care that addresses the unique needs of each pregnant woman. By understanding common nursing diagnoses such as Anxiety, Deficient Knowledge, Ineffective Sexuality Pattern, Risk for Disturbed Maternal-Fetal Dyad, and Risk for Imbalanced Nutrition, nurses can effectively assess, plan, implement, and evaluate care to promote optimal maternal and fetal health throughout pregnancy. Continuous professional development and utilization of these diagnostic frameworks are essential for nurses to excel in providing comprehensive and compassionate prenatal care.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Pillitteri, A., & Silbert-Flagg, J. (2015). Nursing Care Related to Psychological and Physiologic Changes of Pregnancy. In Maternal & child health nursing: Care of the childbearing & Childrearing family (8th ed., pp. 469-472). LWW.
- Silvestri, L. A., & CNE, A. E. (2019). Prenatal Period. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 637-664). Saunders.
