Nurse home visiting may address challenges and resource disparities that threaten maternal and infant well-being in rural areas, but little is known about United States' program implementation. This qualitative study explored how family and community characteristics affected rural nurse home visiting.The sample for content analysis included families beginning services in 2010-2011 living in the rural counties with the highest caseloads (433 families).Electronic nurse home visiting case files from three rural counties were analyzed using a content analysis approach. The partner agency provided input on key constructs of interest but independent coding was also done to capture additional themes. Quantitative county level data and comments from member checking informed interpretation. Member checking included individual nurses serving the selected counties (n = 3) and input from an agency level supervisory meeting for validation.Concerns of families served (e.g., mental health) may not be unique to rural areas, but challenges to accessing resources and constellation of needs were. Nurses adapted engagement and service strategies to meet these needs.Agencies serving rural areas should allocate resources and adapt training to support nurses based on unique community profiles. More research on rural nurse home visiting practice and outcomes is needed.