Pregnancy: Prenatal Visits, Fetal Movement Counts, and Warning Signs

Who needs this teaching

Every pregnant client from the first prenatal visit, and the partner or support person. Early recognition of warning signs prevents complications such as preterm birth, preeclampsia, placental abruption, and stillbirth.

The priority teaching points

1. Prenatal visits. The usual schedule is every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, and weekly from 36 weeks until birth. Each visit includes blood pressure, weight, urine testing for protein and glucose, the fetal heart rate (normal 110 to 160/min), and fundal height from about 20 weeks. Scheduled tests include glucose screening at 24 to 28 weeks and group B streptococcus screening at 36 to 37 weeks. Unsensitized Rh-negative clients receive Rh immune globulin at 28 weeks.
2. Folic acid. Take a daily prenatal vitamin with at least 400 mcg (0.4 mg) of folic acid. Folic acid reduces the risk of neural tube defects. A client with a prior pregnancy affected by a neural tube defect takes the higher prescribed dose, usually 4 mg daily.
3. Fetal movement counting. From about 28 weeks, count fetal movements once daily, at a time the fetus is usually active. Lie on the left side and count kicks, rolls, and flutters. Expect 10 movements within 2 hours, or follow the method taught. Fewer than 10 movements in 2 hours, or a clear decrease from the usual pattern, requires prompt evaluation in labor and delivery.
4. Exposures to avoid. Avoid all alcohol; no amount is known to be safe. Stop smoking and vaping, and avoid secondhand smoke. Avoid raw or undercooked fish, meat, and eggs, unpasteurized milk and soft cheese, and deli meats unless heated until steaming. These foods transmit listeriosis. Ask another person to change cat litter, because cat feces transmit toxoplasmosis. Limit caffeine to less than 200 mg daily.
5. Preterm labor. Before 37 weeks, report regular contractions (every 10 minutes or more often for 1 hour), menstrual-like cramps, a low dull backache, pelvic pressure, or a change in vaginal discharge. Go to labor and delivery for regular contractions or leaking fluid.
6. Hypertensive warning signs. After 20 weeks, a severe headache, vision changes, epigastric or right upper quadrant pain, and sudden edema of the face or hands indicate possible preeclampsia. Go to labor and delivery now for headache or vision changes.
7. Infection. Dysuria, urinary frequency, or a temperature of 100.4 F (38 C) or higher requires a same-day call. Untreated urinary tract infection increases the risk of pyelonephritis and preterm labor.

Red flags the client reports

Teach-back questions

• "How often will you come for prenatal visits?"
• "How much folic acid is in your prenatal vitamin?"
• "Show me how you will count your baby's movements."
• "Which foods will you avoid, and why?"
• "Which signs mean you go straight to labor and delivery?"

Teaching tips

• Write the due date and the labor and delivery phone number on the handout.
• Give a fetal movement chart at 28 weeks.
• Review the warning signs again at each visit.

Read more on NCLEXPace

• Cord Prolapse, Abruption, Previa and Postpartum Hemorrhage: First Actions
• Preeclampsia vs HELLP on the NCLEX: Findings and First Actions
• Fetal Heart Tracings: VEAL CHOP Explained Like a Nurse Thinks

Sources

• American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 8th ed. AAP/ACOG; 2017.
• US Preventive Services Task Force. Folic Acid Supplementation to Prevent Neural Tube Defects: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2023;330(5):454-459.
• American College of Obstetricians and Gynecologists. Antepartum Fetal Surveillance: ACOG Practice Bulletin No. 229. Obstet Gynecol. 2021;137(6):e116-e127.
• American College of Obstetricians and Gynecologists. Moderate Caffeine Consumption During Pregnancy: ACOG Committee Opinion No. 462. Obstet Gynecol. 2010;116(2 Pt 1):467-468.