antepartum Flashcards
1
Q
presumptive signs of pregnancy
A
- least reliable; subj & obj data from pt
- subjective
- amenorrhea
- fatigue
- N&V
- urinary frequency
- breast tenderness
- quickening
- breast changes
- darkened areolae
- enlarged Montgomery’s glands
- uterine enlargement
- skin changes
2
Q
probable signs of pregnancy
A
- obj to examiner; some can have other causes
- uterine enlargement
- Hegar’s sign
- Chadwick’s sign
- Goodell’s sign
- ballottement
- Braxton-Hicks ctx
- positive hCG: usually positive by first missed period; 97% accurate
- fetal outline (felt by examiner)
- cervical changes
3
Q
positive signs of pregnancy
A
- fetal heart sounds: Doppler @ 10-12 wks GA
- visualization of fetus by US
- abd US @ 5-6 wks GA
- vag US @ 16 days
- fetal movement (palpated by examiner)
4
Q
quickening
A
slight fluttering movements of fetus felt by mother, usually at 16-20 wks
5
Q
Hegar’s sign
A
- @ 6-8 wks
- softening and compressibility of lower uterus
6
Q
Chadwick’s sign
A
- @ 8-12 wks
- deepened violet-bluish color of cervix and vaginal mucosa
- r/t vascularity
7
Q
Goodell’s sign
A
- @ 6 wks
- softening of cervical tip
- r/t congestion of blood
8
Q
ballottement
A
- rebound of unengaged fetus
- fetus or a fetal part rebounds when displaced by a light tap of the examining finger through the vagina
9
Q
Braxton Hicks contractions
A
- false labor
- mostly painless, irregular, usually relieved by walking
- do not cause dilation and effacement of the cervix
10
Q
hCG
A
- human chorionic gonadotropin
- pregnancy hormone used for testing
- found in urine or blood
- can be detected 7-8 days before expected menses
11
Q
hCG production
A
- begins at impantation
- peaks 60-70 days
- ↓ at 100-130 days
12
Q
hCG levels
A
- ↑ could mean
- multifetal
- ectopic
- hydatidiform mole
- genetic abnormality (Down)
- ↓ could mean
- miscarriage
- ectopic
13
Q
meds that can cause false negative or positive pregnancy test result
A
- anticonvulsants
- diuretics
- tranquilizers
14
Q
pt teaching: home pregnancy test
A
- first-voided morning urine sample (hormone levels higher, easier to detect)
- follow directions on package for accuracy
15
Q
Nägele’s rule
A
1st day of last menstrual cycle – 3 months + 7 days + 1 year = EDD
16
Q
fundal height
A
- measured in cm
- symphysis pubis to top of uterine fundus (18-30 wks)
- approximates gestational age ± 2 wks
17
Q
gravidity
A
- number of pregnancies
- nulligravida: never
- primigravida: in first
- multigravida: second or more
18
Q
parity
A
- number of pregnancies in which fetus(es) reached 20 wks gestation
- not affected by stillbirth or live birth
- nullipara: none
- primipara: one
- multipara: two or more
19
Q
viability
A
- point in time when infant has capacity to survive outside uterus
- not a specific week number
- 22-25 wks considered threshold
20
Q
GP/GTPAL
A
- GP is incomplete: gravidity and para, regardless of outcome or number of fetuses
- gravidity: pregnancies
- para: pregnancies reaching 20 wks GA
- term births: 38+ wks
- preterm births: viability to end of 37 wks
- post-term/postdate: > 42 wks GA
- abortions/miscarriages before viability
- living children
21
Q
reproductive changes during pregancy
A
- uterus ↑ in size, changes shape and position
- ovulation and menses cease
22
Q
CV changes during pregnancy
A
- cardiac output ↑ 30-50%
- blood volume ↑ 30-45% by term
- HR ↑ 10-15 bpm at 32 wks
23
Q
repiratory changes during pregnancy
A
- ↑ O2 needs
- 2nd and 3rd trimesters: chest might enlarge for lung expansion as uterus expands upward
- RR ↑
- lung capacity ↓
24
Q
musculoskeletal
A
- r/t relaxin and progesterone
- begins in 2nd trimester
- body alterations + ↑ wt = posture adjustment
- pelvic joints relax = ↓ stability
- shift in center of gravity
- sciatic nerve pressure
- third trimester
- progressive lordosis
- diastasis recti (separation of abs)
25
GI changes during pregnancy
* N&V: hormone changes and/or ↑ intra-abd pressure
* constipation: ↑ transit time
26
renal changes during pregnancy
* ↑ filtration rate 2/2 hormones, ↑ blood volume and metabolism
* ↑ frequency common
* amt of urine produced remains same
27
endocrine changes during pregnancy
* placenta becomes endocrine organ, produces large amts of
* estrogen
* hCG
* progesterone
* human placental lactogen
* prostaglandins
* hormones maintain pregnancy and prep body for delivery
28
body image changes
* 1st trimester
* not obvious
* pt looks forward to more obvious changes
* 2nd trimester
* rapid physical changes in abd, breasts that can affect mobility
* stretch marks, hyperpigmentation
* ↓ balance, back and leg discomfort
* statements of anxiety or desire for pregnancy to be over
29
expected VS
* **BP**
* 1st trimester: prepregnancy range
* systolic: slight or no ↑
* diastolic: slight ↓ at 24-32 wks, back to prepregnancy level at term
* position strongly affects readings (esp. supine)
* **pulse**
* ↑ 10-15 bpm about 32 wks-term
* **respirations**
* unchanged or slight ↑ (elevation of diaphragm)
* SOB might be noted
30
expected fetal heart tones
* FHR = 110-160 bpm
* FHR accelerations indicate intact CNS
31
expected maternal CV changes
* cardiac hypertrophy, shape change
* volume ↑ 40-50 % (about 1500 mL)
* ↑ RBCs by 20-30%
* accommodates ↑ volume, cardiac output
* return to normal shortly after delivery
* pseudo/physiological anemia (RBCs diluted in expanded plasma volume)
* heart sounds
* more distinguishable splitting of S1 and S2
* S1 louder after 20 wks
* murmurs possible
* ↑ clotting factors and ↓ fibrinolytic activity
* ↓ risk of hemorrhage
* ↑ risk of thrombosis
* WBC ↑ up to 15,000
32
expected uterine changes
* weight: 50–1,000 g (0.1–2.2 lb)
* top of fundus reaches xiphoid process by 36 wks
* may cause SOB
33
expected cervical changes
* purplish-blue color extends into vagina and labia
* cervix becomes very soft
34
expected breast changes
* increase in size
* darkening and enlarging of areolae
* tenderness
* Montgomery Tubercles
* colostrum
* ↑ blood supply
* striae gravidarum
35
expected skin changes
* appearance: ↑ melanotropin from anterior pituitary, starting @ 2nd month
* chloasma: ↑ pigmentation on face
* linea nigra: dark line from umbilicus to pubic area
* striae gravidarm: stretch marks, mostly abd and thighs
* ↑ circulation → ↑ activity of sebaceous, sweat glands
* vascular spiders (telangiectasia)
* ↑ estrogen: palmar/plantar erythema
* pruritus
* gum hypertrophy
* acne vulgaris
36
nursing interventions
* acknowledge concerns
* encourage sharing feelings
* judgment-free atmosphere
* provide education
* help set postpartum goals
* refer to counseling if body image has negative effect on pregnancy
37
pt education
* expected changes
* timeline for return to prepregnancy state
* psychosocial changes
* common discomforts and solutions
* keep all follow-ups
* call immediately if bleeding, leakage, contractions during pregnancy
38
A nurse is caring for a pt who is pregnant and states her last menstrual period was April 1st. When is the expected delivery date?
April 1 – 3 mo + 1 yr + 7 days = **January 8**
39
A nurse in a prenatal clinic is caring for a pt in the first trimester of pregnancy. The pt's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information?
* G3 = multigravida; pt has had two prior pregnancies and is now pregnant
* T1 = pt has delivered one newborn at term
* P0 = pt has completed no preterm births
* A1 = pt has had one abortion/miscarriage before viability
* L1 = pt has one living child
40
A nurse is reviewing the health record of a pregnant pt. The provider indicated the pt exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (SATA)
1. Montgomery's glands
2. Goodell's sign
3. ballottement
4. Chadwick's sign
5. quickening
1. Montgomery's glands (presumptive sign)
2. **Goodell's sign**
3. **ballottement**
4. **Chadwick's sign**
5. quickening (presumptive sign)
41
A nurse in a prenatal clinical is caring for a pt who is pregnant and experiencing episodes of maternal hypotension. She asks the nurse what causes these episodes. What's an appropriate response?
* "increase in blood volume"
* "pressure on the diaphragm"
* "weight of uterus on vena cava"
* "increased cardiac output"
"weight of uterus on vena cava"
42
A nurse in a clinical gets a phone call from a pt who would like to be tested to confirm pregnancy. What information should the nurse provide?
* "wait until 4 wks after conception"
* "be off meds for 24 hr before test"
* "NPO for at least 8 hrs before test"
* "collect urine from first morning void"
"collect urine from first morning void"
43
elements of thorough prenatal Hx
* reproductive and OB Hx
* medical Hx
* nutritional Hx
* family Hx
* recent or current illness/infection
* current medications
* psychosocial Hx
* hazardous exposures and work conditions
* current exercise and lifestyle
* abuse Hx or risk
44
parts of prenatal assessment
* pt Hx
* birth plan
* physical assessments
* pt knowledge
45
reproductive and OB Hx
* contraception use
* gynecological dz
* Hx of STIs
* previous pregnancies
* obstetrical difficulties
46
medical Hx
* physical pre-existing conditions
* surgical procedures
* handicapping conditions
* immune status (rubella, hep B)
47
when asking about current meds
* be nonjudgmental
* ask about substance abuse, ETOH use
* observe for clinical findings such as lack of grooming
48
psychosocial Hx
* pt's emotional response to pregnancy
* adolescent pregnancy
* spouse
* support system
* Hx of depression
* domestic violence
49
abuse Hx or risk
* physical
* sexual
* psychological
* **assess all clients**
* **↑ risk during pregnancy**
50
prenatal assessments
* initial: within first 12 wks
* monthly: wks 16-28
* weekly: wks 29-36
51
initial prenatal visit
* estimate DOB based on last period
* get Hx: social supports and ROS
* determine risk factors
* physical assessment: wt, VS, pelvic
* initial labs
52
initial prenatal labs
* Hgb
* Hct
* WBC
* blood type and Rh
* rubella titer
* UA
* renal fxn
* Pap
* cervical culture
* HIV antibody
* hep B surface antigen
* toxoplasmosis
* RPR or VDRL titer (syphilis)
53
ongoing prenatal visits
* wt
* BP
* urine: glucose, protein, leukocytes
* check for edema
* monitor fetal development
* FHR (US early, doppler later)
* fundal height (2nd trimester)
* fetal movement (16-20 wks)
* education on self-care (N&V, fatigue, backache, heartburn, etc.)
54
nursing responsibilities
* perform or assist with Leopold maneuvers
* assist with GYN exam
* have pt empty bladder before
* have pt take deep breaths during
* give Rho(D) immune globulin IM to Rh-negative pt about 28 wks
55
CBC with diff
to check Hgb, Hct, and for infection
56
purpose of testing blood type, Rh factor, irregular antibodies
to assess for risk of maternal-fetal blood incompatibility (erythroblastosis fetalis)
57
erythroblastosis fetalis
maternal-fetal blood incompatibility
58
indirect Coombs' test
identifies pts who are Rh-positive sensitized
59
Hgb electrophoresis
finds hemoglobinopathies such as sickle cell, thalassemia
60
Rubella titer
determines immunity
61
hep B screen
determines if pt is a carrier of hep B
62
Group B Streptococcus (GBS) test
vaginal/anal culture at 35-37 wks to assess for GBS infection
63
UA
* identifies pregnancy, DM, HTN, renal dz, and infection
* pH
* specific gravity
* color
* sediment
* protein
* glucose
* albumin
* RBCs
* WBCs
* casts
* acetone
* hCG
64
glucose tolerance test
* 1 hr
* fasting not necessary
* check for hyperglycemia
* initial visit for at-risk pts
* 24-28 wks for all pts
* \> 140 mg/dL requires follow-up
* 3 hr
* fasting overnight
* oral or IV solution given
* sample taken at 1 hr, 2 hr, 3 hr
* screen for DM
* used in pts with elevated 1 hr test
65
gestational diabetes Dx
two elevated BG readings from glucose tolerance tests
66
Pap test
screen for cancer, herpes simplex 2, HPV
67
vaginal/cervical culture looks for
* streptococcus beta-hemolytic
* bacterial vaginosis
* STIs (gonorrhea, chlamydia)
68
PPD
* TB skin test
* chest X-ray after 20 wks
* identifies exposure to TB
69
VDRL
* syphilis screening
* mandated by law
70
HIV test
* recommended for all pts
* tests for HIV infection
71
MSAFP
* maternal serum alpha-fetoprotein
* screening at 15-22 wks
* rules out Down syndrome and neural tube defect
* more reliable indicator available (Quad)
72
Quad screen
* tests for Down syndrome and neural tube defects
* at 16-18 wks
* AFP, inhibin-A, combination analysis of hCG and estriol
73
Why should pregnant women avoid ETOH?
can cause birth defects
74
Why should pregnant women avoid tobacco?
can cause low birth weight
75
things to avoid during pregnancy
* ETOH
* tobacco
* OTC meds, supplements, Rx meds (unless OB/GYN knows about it)
* substance use
* hot tubs or saunas
76
How much should pts exercise during pregnancy?
30 min of moderate exercise daily unless contraindicated
77
How much water should pregnant pts consume?
* 2.3 L
* 8-10 glasses
78
first trimester teaching
* physical, psychosocial changes
* common discomforts and relief measures
* lifestyle
* exercise
* stress
* nutrition
* sexual health
* dental care
* OTC and Rx meds
* tobacco
* ETOH
* substance use
* STIs
* complications, indications to report
* fetal growth and development
* prenatal exercise
* expected lab tests
79
second trimester teaching
* benefits of breastfeeding
* common discomforts and relief measures
* lifestyle
* sex and pregnancy
* rest and relaxation
* posture
* body mechanics
* clothing
* seatbelt safety and travel
* fetal movement
* complications
* preterm labor
* gestational HTN
* gestational DM
* premature rupture of membranes
* prep for childbirth, classes
* birthing methods
* birth plan (written or verbal)
80
third trimester teaching
* childbirth prep
* fetal movement/kick counts
* Dx testing for fetal well-being
81
childbirth prep
* plan, classes
* coping methods
* breathing, relaxation techniques
* effleurage, counter pressure
* heat/cold therapy, touch and massage, water therapy
* TENS
* acupressure, acupuncture
* music, aromatherapy
* pain mangement discussion
* use of doula during labor
* indications of preterm labor
* labor process
* infant care
* postpartum care
82
fetal movement/kick count
* concerning counts
* \< 3/hr
* none for 12 hr
* downward trend over time
* movement peaks 9 p.m. to 1 a.m., when maternal glucose lowest
* babies have sleep cycles
83
Dx testing for fetal well-being
* nonstress test
* biophysical profile
* US
* contraction stress test
84
common discomforts of pregnancy
* N&V
* breast tenderness
* urinary frequency
* UTIs
* fatigue
* heartburn
* constipation
* hemorrhoids
* backaches
* SOB
* leg cramps
* varicose veins and lower-extremity edema
* gingivitis, nasal stuffiness, epistaxis
* Braxton Hicks contractions
* supine hypotension
85
N&V relief
* eat crackers or dry toast before rising in the morning
* avoid empty stomach
* avoid spicy, greasy, and gas-forming foods
* drink fluids between meals
86
breast tenderness relief
wear bra that provides adequate support
87
urinary frequency coping
* (first and third trimesters)
* ↓ fluid before bed
* empty bladder frequently
* use perineal pads
* Kegels to ↓ stress incontinence
88
UTI relief
* ↓ risk
* no bubble baths
* no tight pants
* wipe front to back
* drink plenty of water
* void before and after sex
* void as soon as urge occurs
* notify provider if urine smells foul, is cloudy, or has blood
89
fatigue relief
rest often
90
heartburn relief
* (2nd and 3rd trimesters)
* small, frequent meals
* don't let stomach get to empty or too full
* check with provider before taking OTC meds
* don't lie down immediately after eating
91
constipation relief/prevention
* (2nd and 3rd trimesters)
* drink lots of fluids
* eat plenty of fiber
* exercise regularly
92
hemorrhoid relief
* (2nd and 3rd trimesters)
* warm sitz bath
* witch hazel pads
* topical ointments
93
backache relief
* (2nd and 3rd trimesters)
* exercise regularly
* pelvic tilt exercises
* proper body mechanics
* side-lying position
94
SOB relief
* good posture
* sleep with extra pillows
* notify provider if it worsens
95
leg cramp relief
* (3rd trimester)
* extend affected leg, keeping knee straight, and dorsiflex foot
* apply heat over cramped muscle
* foot massage with leg extended
* notify provider if frequent
96
varicose vein and lower-extremity edema relief
* (2nd and 3rd trimesters)
* rest with legs and hips elevated
* avoid constricting clothing
* wear support hose
* avoid sitting or standing in one position for extended period
* don't sit with legs crossed at knees
* sleep in left-lateral
* exercise moderately with frequent walking
97
gingivitis, nasal stuffiness, epistaxis relief
* brush teeth gently/good dental hygiene
* use humidifier
* normal saline nose drops or spray
98
Braxton Hicks contractions relief
* change of position
* walking
* notify provider if ↑ intensity, frequency
99
supine hypotension relief
* aka vena cava syndrome
* weight of uterus occludes vena cava while in supine position
* effects
* ↓ blood return from legs
* ↓ cardiac OP
* ↓ BP
* bradycardia
* sx: faintness, lightheadedness, dizziness, agitation, nausea
* → fetal hypoxia
* Tx: don't lay on your back, elevate hips with wedge
100
1st trimester danger signs
* infection
* burning on urination
* diarrhea
* fever or chills
* miscarriage, ectopic pregnancy: abd cramping, vaginal bleeding
* hyperemesis gravidarum: severe vomiting
101
2nd and 3rd trimester danger signs
* gush of fluid from vagina before 37 wks
* vaginal bleeding
* abd pain
* changes in fetal activity
* persistent vomiting
* severe headaches
* elevated temp
* dysuria
* blurred vision
* edema of face and hands
* epigastric pain
* concurrent flushed dry skin, fruity breath, rapid breathing, ↑ thirst and urination, headache
* concurrent clammy pale skin, weakness, tremors, irritability, lightheadedness
102
gestational HTN signs
* severe headaches
* blurred vision
* edema of face and hands
* epigastric pain
103
abd pain in pregnancy could mean
* premature labor
* abruptio placentae
* ectopic pregnancy
104
A nurse is teaching pregnant pts about measures to relieve backache. Which of the following measures apply? (SATA)
1. avoid lifting
2. perform Kegels 2x/day
3. perform pelvic rock daily
4. use proper body mechanics
5. avoid constrictive clothing
1. avoid lifting
2. perform Kegels 2x/day
3. **perform pelvic rock daily**
4. **use proper body mechanics**
5. avoid constrictive clothing
105
A nurse is reviewing manifestations of complications the pt should promptly report to the provider. Which of the following should be included?
1. vaginal bleeding
2. swelling of ankles
3. heartburn after eating
4. lightheadedness while supine
vaginal bleeding
106
A pt at 7 wks gestation has morning N&V. What should the nurse teach her?
1. eat crackers or plain toast before rising
2. awaken at night to snack
3. skip breakfast and eat lunch after nausea
4. eat a large evening meal
eat crackers or plain toast before rising
107
A nurse is teaching a pt at 6 wks gestation about common discomforts. What should the nurse include? (SATA)
1. breast tenderness
2. urinary frequency
3. epistaxis
4. dysuria
5. epigastric pain
1. **breast tenderness**
2. **urinary frequency**
3. **epistaxis**
4. dysuria
5. epigastric pain
108
Pt at 8 wks gestation tells nurse, "I'm not sure I'm happy about being pregnant." How should the nurse respond?
1. "I will inform the provider."
2. "It's normal during the first few months."
3. "You should be happy."
4. "I'm going to make an appointment with the counselor."
"It's normal during the first few months."
109
subjective and objective dietary info
* food journal (habits, pattern, cravings)
* nutrition-related questionnaires
* health Hx: contraceptive, previous pregnancies, chronic dz
* wt at every visit
* labs: Hgb, iron
* caloric intake
110
average length of pregnancy
* 280 days
* 40 wks
* 10 lunar months
* 9 calendar months
111
LMP
last menstrual period
112
CD
conception date
113
* EDD
* EDC
* EDB
* estimated date of delivery
* estimated date of confinement
* estimated date of birth
114
trimester divisions
* first: 1-13 wks
* second: 14-26 wks
* third: 27-40 wks
115
AB
abortion
116
SAB
spontaneous abortion (miscarriage)
117
TAB
therapeutic abortion
118
EAB
elective abortion
119
US
* ultrasound
* done @ 18-22 wks to assess anatomical structures
* can determine sex
* usually sent to high-risk clinic for eval if abnormalities detected
120
PG
pregnancy
121
causes of false –
* too soon
* urine dilute
* ectopic PG
* improper technique
122
causes of false +
* protein or blood in urine (UTI)
* recent pregnancy (3-4 wks)
* drugs (ASA)
* tumor
123
pregnancy risk category A
* controlled studies show no risk
* possibility of fetal harm appears remote
124
pregnancy risk category B
* no evidence of human risk in controlled studies
* no studies in pregnant women or studies in pregnant women that did not confirm risks from animal studies
125
pregnancy risk category C
* risk cannot be ruled out
* only give if benefit outweighs risk
126
pregnancy risk category D
* positive evidence of risk
* use if needed in life-threatening situation or in serious dz when safer drugs aren't effective or can't be used
127
pregnancy risk category X
* contraindicated in pregnancy or possible pregnancy
* studies demonstrate fetal abnormalities and/or human experience shows evidence of fetal risk
* risk clearly outweighs benefit
128
pancreas changes in PG
* first trimester
* ↓ in glucose r/t to fetal need
* ↓ insulin production
* second and third trimesters
* ↑ in maternal peripheral resistance to insulin
* ↑ in glucose levels
* more available for fetus
* stimulates insulin production
129
progesterone in PG
* sources: ovaries, placenta, corpus luteum
* effects
* maintains uterine lining
* relaxes smooth muscle/prevents SAB
* prepares breasts for lactation
* maternal fat stores with help of estrogen
130
estrogen in PG
* sources: ovaries, placenta
* effects
* stim uterine, genital, breast growth
* stim ducts in breasts for lactation
* skin changes
131
hCG in pregnancy
* source: trophoblast (placenta), embryo/fetus
* effects
* causes positive PG test
* prevents involution of corpus luteum
132
hormones of miscarriage
* source of hCG stops (embryo, fetus, trophoblast)
* corpus luteum dies for lack of hCG
* progesterone production drops
* miscarriage occurs
133
relaxin
* sources: ovaries and placenta
* effects
* softens muscles and joints of pelvis
* inhibits uterine activity
134
oxytocin
* source: posterior pituitary
* effects
* stim uterin ctx
* milk ejection reflex ("let-down")
135
prolactin
* source: anterior pituitary
* effect: primary hormone of milk production
136
thyroxin (T4) during pregnancy
* ↑ levels with ↑ levels of estrogen
* source: thyroid, which ↑ in size
* effects
* stim BMR initially
* ↑ @ 6-9 wks
* plateaus @ 18 wks
* usually normal after first trimester
137
growth of uterus
* predictable pattern
* 12 wks: rises out of pelvis
* 16 wks: midway b/t symphysis pubis and umbilicus
* 20 wks: @ umbilicus
138
FH
fundal height
139
fundal height
* 20 cm @ 20 wks
* ↑ 1 cm per week after
* ↓ during lightening @ 38-40 wks
140
operculum
* mucus plug
* acts as barrier, protects baby from bacteria
* progesterone causes sloughing of vaginal cells to further protect baby
141
leukorrhea
* r/t to ↑ glycogen
* change in vaginal acidity to protect against infection
* ↑ lactic acid production = risk for yeast infection
* vaginal discharge: clear to white, thin or thick, odorless or faintly musty
* may be profuse
* ↑ sensitivity → ↑ sexual arousal in 2nd trimester
142
vaginal health in PG
* teach pt s/sx of infection: change of discharge color or odor, itching
* cotton-crotch panties
* mini-pads (change often)
* clean perineal area frequently
* no douching
143
breast changes in PG
tenderness
144
maternal VS changes
* HR ↑ by 10-15 bpm
* BP
* first trimester: no significant change
* second: diastolic and systolic down 5-10 mm Hg
* third: gradual return to first trimester value
* RR ↑ by 1-2/min
145
causes of varicose veins in PG
* 2/2 relaxation of valves in deep veins and surrounding muscle
* usually a genetic component
* impaired venous return
* constrictive clothing
* standing for long periods
146
Tx for varicose veins and physicological edema
* supper panty hose before edema occurs
* avoid tight knee-highs, socks, and shoes
* avoid prolonged standing
* elevate legs several times daily
* don't cross legs when sitting
* side-lying position → ↑ renal perfusion and UOP
147
repiratory system changes in PG
* hormones
* progesterone: relaxes smooth muscle
* estrogen: ↑ vascularity and congestion of upper airways
* ↑ O2 consumption
* 15-20% increase
* ↑ depth of resp
* enlarging uterus
* diaphragm lifted 4 cm → ↓ lung expansion
* sinus congestion
* OTC Tylenol Sinus
* avoid decongestant nasal spray
* epistaxis
* saline mist
* humidifier
148
In what trimesters is urinary frequency most likely to occur?
first and third
149
What happens to ureters during PG, and why is this important?
* ureter smooth muscle relaxed by progesterone, causing dilation
* → stasis, UTI risk
150
kidney changes in PG
* filtration rate ↑ 50%
* glycosuria common: ↑ UTI risk
151
bladder changes during PG
* capacity doubles
* frequency in first and third trimesters
152
proteinuria
* **not normal; check at each appt** (evidence changing this standard)
* trace to 1+ (\< 300 mg/24 hr): monitor
* HTN + proteinuria = risk for pre-eclampsia
153
ketones in urine
* normal = \< 20 in urine
* indicates lack of carbs, breakdown of fat and muscle
* could cause fetal harm
154
MSK interventions
* **r/o UTI and PTL**
* non-pharm
* heating pad
* avoid high heels
* proper body mechanics
* pelvic tilts
* good alignment
* maternity girdle
* pharm
* acetaminophen (class B)
* **no ASA**: ↑ hemorrhage risk
* **no NSAIDs**: premature closing of ductus arteriosis
155
leg cramps in PG
* causes
* impaired circulation
* low K+ and high P
* low Ca+
* low Mg
* Tx and prevention
* dorsiflex foot
* walking or other mild exercise
* elevate feet during the day
* diet with adequate K+
156
round ligament pain
* sharp pain in abd extending to pelvis or vagina
* non-pharm
* bend toward pain
* pelvic tilt/tailor stretch
* warm bath
* heating pad
* maternity abd supporter
* good alignment
157
fatigue
* one of the earliest signs of PG
* usually resolves or improves by month 4
* possible causes
* hypoglycemia
* initial fall in BMR
* progesterone
* Tx
* ↓ activity
* ↑ sleep, rest, naps
158
insomnia
* causes
* anxiety
* frequent voiding
* fetal movement
* Tx
* warm bath before bed
* warm milk
* non-stim activity before bed
* rest on side with pillow under abd
159
common neurologic issues in PG
* sciatic nerve pain
* sensory changes in legs (vascular stasis)
* tension headaches
* carpal tunnel syndrome
* acrothesias (numbness in hands)
* hypocalcemia: cramps or tetany
160
pica
* abnormal change in sense of taste → non-food cravings
* examples: ice, clay, laundry starch, baking soda
161
ptyalism
* excess saliva with bitter taste
* may have difficulty talking/swallowing r/t swollen glands
* starts: 2-3 wks GA, ends @ delivery
* cause: ↑ stim of salivary glands, pica
162
ptyalism/pica Tx
* eat small, frequent meals to ↓ nausea
* use gum or lozenges to help swallow
* frequent oral care
* **no safe pham Tx**
163
What causes morning sickness?
* ↑ hCG @ 4-6 wks; estrogen and progesterone ↑
* low blood glucose
* altered carb metabolism
* **r/o appendicitis**
164
hyperemesis
severe morning sickness that requires monitoring of wt and electrolytes, possible hospitalization
165
non-pharm Tx for N&V in PG
* small, frequent meals, bland diet
* dry crackers before getting OOB
* small protein-carb snack in evening or upon waking
* BRAT: bananas, rice, applesauce, toast
* avoid strong food odors
* acupressure bracelet: endorphin release via pressure on Neiguan point, 3 fingers above wrist
166
pharm Tx for N&V in PG
* Category A
* pyridoxine (vitamin B6): Rx or OTC
* Emetrol (dextrose/levulose/phosphoric acid): OTC, 15-30 mL q3hr
* Category B
* Dramamine (dimenhydrinate): OTC dosage
* Category C
* Benadryl (diphenhydramine): OTC dosage
* Phenergan (promethazine): 12.5-25 mg q3-4hr
* Zofran (ondansetron): 4-8 mg q3-4hr
167
pyrosis in PG
* reflux of gastric contents into esophagus causing burning sensation near heart
* cause: progesterone = ↓ peristalsis
168
non-pharm Tx for pyrosis in PG
* eat small, frequent meals
* avoid high-fat, spicy, and very cold foods
* avoid large meals just before bedtime/nap
169
pharm Tx for pyrosis in PG
* antacids (Tums, Class B)
* Gax-X (simethicone)
* Pepcid (famotidine)
170
Where is the appendix displaced to during pregnancy?
up and to the right
171
hiatal hernia in PG
* enlarging uterus pushes upper portion of stomach through diaphragm
* risk factors
* obesity
* multiparity
* advance age
172
Why would pregnancy ↓ PUD complaints?
* ↑ estrogen
* ↓ HCl in stomach
173
flatulence in PG
* when: 1st and 3rd trimesters
* cause: ↓ GI motility; displacement of bowel by enlarging uterus
* non-pharm
* have regular, daily BMs
* avoid gas-causing foods
* knee-chest position will help pass
* pharm: simethicone (Class B)
174
constipation in PG
* common in 3rd trimester
* causes
* progesterone → ↓ peristalsis and ↑ water absorption
* displacement and compression of bowel
* iron supplements
* dehydration
* ↓ activity
175
constipation Tx in PG
* 8-10 8-oz glasses of fluids/day
* high-fiber, high-bulk foods
* drink warm liquids to stim peristalsis
* regular exercise
* **avoid enemas or stim laxatives (can cause ctx)**
* pharm: Colace (docusate sodium, Class C)
176
hemorrhoids
* varicosity of rectal veins
* cause
* ↑ pressure on rectal veins r/t ↓ venous return
* constipation and straining
177
Tx for hemorrhoids in PG
* prevent straining r/t constipation
* sitz bath (kit or tub)
* ice compresses
* epsom salt compress
* analgesic ointment
* Tucks (witch hazel)
* **avoid products with hydrocortisone**
178
Why do dietary iron requirements ↑ during pregnancy?
* maternal demands
* more RBCs needed as plasma volume ↑ to carry adequate O2
* morning sickness: inability to retain/absorb from food
* fetal demands
* development of circulatory system, RBC production
* needs iron to store in liver (3rd trimester)
179
iron-rich foods
* meats (heme iron, more readily absorbed)
* red meat
* dark meat poultry
* other meats
* shellfish
* non-animal (non-heme iron)
* beans
* lentils
* tofu
* raisins
* dates
* prunes
* figs
* apricots
* potatoes with skin
* broccoli
* beets
* leafy green veggies (raw)
* whole grain breads
* nuts and seeds
* blackstrap molasses
* oatmeal
* iron-fortified cereals
180
What nutrients help and hinder iron absorption?
* helps: vitamin C
* hinders: milk, Ca, coffee, tea
181
vitamin C sources
* citrus fruits
* strawberries
* melons
* broccoli
* tomatoes
* peppers
* **raw** dark green leafy veggies
182
Ca in PG
important to fetal teeth and bone formation, maintenance of maternal bone and tooth health
183
recommended Ca intake for women
* 1000 mg/day for all \> 19 yo
* 1300 mg/day for those \< 19 yo
184
Ca sources
* milk, cheese, yogurt
* sardines or other fish with bones in
* fortified orange juice
* nuts
* legumes
* dark green leafy veggies
185
iron supplements
* ferrous gluconate: less likely to cause nausea, constipation
* ferrous sulfate
* take on empty stomach with vitamin C
* avoid milk, tea, coffee
186
What is recommended wt gain based on?
prepregnancy BMI
187
Why is adequate calorie and intake necessary?
to avoid SGA, IUGR
188
What conditions are associated with greater than necessary wt gain in PG?
* GDM
* PIH
* macrosomia
* fetopelvic disproportion
* C/S
* PP hemorrhage
* birth trauma
* genital trauma
189
GDM
gestational diabetes mellitus
190
PIH
pregnancy-induced HTN
191
macrosomia
birth wt \> 90th percentile
192
C/S
caesarean section
193
PP hemorrhage
postpartum hemorrhage
194
recommended wt gain values
195
caloric intake
* first trimester: no change
* second and third: ↑ by 300 kcal/day
* lactation
* 1st 6 months: + 30 kcal/day
* 2nd 6 months: + 70 kcal/day
* adolescents
* nutritional demands compete with fetus'
* highest priority for prenatal care
196
hyperemesis gravidarum
* perisistent, severe N&V early pregnancy
* → dehydration, wt loss, electrolyte imbalances
* Tx: NPO, IV, control N&V; progress slowly to small meals
197
adequate 1st trimester prenatal care
13 visits
198
late care
* beginning prenatal care after 20 wks
* risk factor
199
inadequate care
prenatal care beginning in 2nd or 3rd trimester
200
initial prenatal visit checklist
* comprehensive health Hx
* OB Hx
* GYN Hx
* contraceptive use
* infertility Hx
* family Hx
* psychosocial profile
* physical assessment
201
OB Hx components
* GTPAL
* length of previous PG and baby wts
* labor experience: type, place, attendant
* anesthesia? problems?
* complications with mom or baby
202
GYN Hx
* age of menarche
* menstrual Hx
* contraceptive Hx
* intertility or GYN conditions
* Hx of STDs
* sexual Hx
* date and result of last Pap
* date of LMP, CD, etc.
203
contraceptive Hx
* contraception in use at time of conception?
* Depo: may not have LMP
* pills: may still have withdrawal bleed during PG
* IUD: will need to be removed
204
first physical assessment
* verify PG and establish due date
* establish baseline: VS, wt, etc.
* CBC
* type and Rh
* rubella titer
* HBSaG (Hep B)
* RPR or VDRL (syphilis)
* gonorrhea/chlamydia culture
* UA and culture
205
CBC for PG
* baseline @ first visit
* Fe supplements if needed
* physiologic anemia: ↑ blood volume → false H/H drop
* Tx as anemia if Hgb \> 11
* monitor platelets for bleeding risk
* slight ↑ WBC normal
206
type and Rh in PG
* at initial visit
* screen for ABO and Rh incompatibilities to prevent fetal harm
* rechecked at 28 wks, rhogam given if Rh- mom
* redrawn on admission to L&D
207
ABO incompatibility
* types A and B don't mix well with O, regardless of Rh
* about 20% of babies affected, with only 5% showing sx
* frequently seen in firstborn
* milder than Rh incompatibility
* can → neonatal jaundice or anemia
208
nursing actions: ABO incompatibility
* observe neonate for jaundice and anemia
* notify provider of new or worsening jaundice
* good parent teaching about jaundice and Tx
209
Rh incompatibility
* Rh– mom who give birth to Rh+ babies can produce Rh antibodies
* antibodies made when Rh– blood exposed to Rh+ blood
* antibodies attack Rh+ fetus → serious illness and death
210
erythroblastosis fetalis
* hemolytic dz of the newborn marked by anemia, jaundice, enlargement of the liver and spleen, and generalized edema
* caused by exposure of Rh+ infant to blood of Rh– mother with Rh antibodies
211
rhogam
* drug that ↓ number of Rh antibodies produced 2/2 mix of Rh+ fetal blood and Rh– maternal blood; chance of production near 0%
* given
* at 28 wks for Rh– mothers
* any time there is a potential for blood mixing
* within 72 hr PP after type/Rh and antibody screen
* without Tx, 15% chance of antibody production
212
Rh antibody screen
* aka Indirect Coombs
* all pts screen intially
* test repeated @ 28 wks if pt Rh– AND negative antibody initially
213
rubella titer
* with initial prenatal labs, but preferably during pre-conception counseling
* if negative or equivocal, will be vaccinated PP
* must not get pregnant for several wks
* if negative titer and exposed to rubella, fetus can develop congenital rubella syndrome
214
congenital rubella syndrome
* infection of fetus early in PG via transplacental transmission of rubella
* → SAB, stillbirth, or major defects of the heart, eyes, or CNS, including deafness
* risk of CRS in fetus with rubella+ mother
* 85% in first trimester
* absent after 20 wks
215
HBSaG
* Hep B surface antigen
* indicates active infection
* surface antibodies indicate past/chronic infection or vaccination
* cannot treat mother during pregnancy
* infants born to + mothers get HBIg and Hep B vaccine within 12 hr of birth to ↓ risk of infection
216
HBIg
Hepatitis B immune globulin
217
RPR/VDRL
* syphilis tests
* required by law
* can have fals +
* usually redrawn on admit to L&D
* syphilis Tx with PCN during PG
218
PCN
penicillin
219
HIV screen
* drawn at initial prenatal visit and @ L&D
* no consent needed during PG; pt must opt out
* can get false +
* can treat during PG
* if viral count low enough, pt can have vaginal delivery
* **breastfeeding contraindicated** for HIV+ mothers
220
gonorrhea/chlamydia screen
* vaginal cultures
* done in all PG
* Tx with abx and TOC within 1 mo
* pt should abstain from sex during Tx
* partner should be treated
* **infections ↑ risk of preterm delivery**
221
UA and culture
* asymptomatic bacteruria common in PG
* infections treated, even asymptomatic, if colony count \> 100,000
222
reportable dz
* STDs are reportable to health dept.
* must report
* HIV
* syphillis
* gonorrhea
* chlamydia
* health dept. contacts pt for info about what partners to notify
223
HPV
* human papillomavirus
* h/o HPV very common
* can cause genital warts or cervical ca
* does not affect PG outcome unless invasive cervical ca or warts are large enough to cause obstruction (both rare)
* not transmitted to fetus
224
HSV
* herpes simplex virus
* HSV I: mouth
* HSV II: genitals
* can transfer sites
* NO vaginal delivery with active HSV lesions
* preventative Tx OK during PG
* do not do blood tests for these
225
Hgb electrophoresis
* detects hemoglobinopathies such as
* sickle cell anemia
* beta thalassemia
* not routine except in high-risk populations
226
special labs
* genetic screen (1st trimester)
* nucal translucency
* invasive procedures
* cystic fibrosis
* TORCH titer: only in potential exposure
* PPD screen (TB test): only in high-risk pop
* baseline labs for chronic medical conditions
* renal/liver fxn
* HgbA1c
* 24-hr urine
227
CMV
cytomegalovirus
228
PPD
purified protein derivative (skin test)
229
TORCH titer
* screen for viruses that do the most damage during 1st trimester
* can cross placenta
* effects include malformation, SAB, or stillbirth
* viruses
* Toxoplasmosis
* Other: syphillis, hepatitis, HIV
* Rubella
* Cytomegalovirus
* Herpes simplex virus
230
1st trimester US
* to confirm dates
* TV or TA
* assess viability
* single or multiple
* CRL if \< 13 wks
* \> 13 wks: measure head, abd, femur
* if dates don't match LMP within 3 days, EDD changed to match US
* gold standard for dating PG
231
1st trimester pt ed
* physical and psychosocial changes
* lifestyle education
* fetal growth and development
* expected lab testing
* danger signs to report
232
How does smoking in PG affect fetus?
* vasoconstriction in placenta →
* ↓ blood flow
* calcification of placenta
* thin umbilical cord
* fetal growth abnormalities
* ↑ risk of SIDS, other dz
233
1st trimester physical and psychosocial changes
* emotional lability normal
* abivalence toward PG normal
* fatigue normal and will get better
234
1st trimester lifestyle education
* smoking cessation
* exercise
* diet
* meds/teratogens
* sexual health
* dental health
* flu shot
235
Leopold's maneuvers
palpation to determine position of baby
236
typical visit 2nd trimester
* BP
* urine dip for protein, blood, ketones, glucose, and bacteria
* measure fundal ht (after 20 wks)
* Leopold's
* FHTs by Doppler
* assess for edema, DTR, DVT
* ask about HA, visual problems, N&V, etc.
* usually quick if no problems
237
genetic screening
* quad screen done @ 15-22 wks
* not diagnostic
* optional
* blood draw
238
2nd trimester pt ed
* childbirth prep
* common discomforts/relief measures
* danger signs
* fetal movements/kick counts
239
2nd trimester - childbirth prep
* review of birthing methods
* pain relief plans
* birth plans
* benefits of breastfeeding
240
2nd trimester - discomforts
* back pain
* round ligament pain
* GERD
* edema
241
3rd trimester visit
* VS, wt, urine dip
* Leopold's, fundal ht, FHTs
* lower extremity edema, DTR, DVT
* assess for nausea, abd pain, ctx, HA, fetal movement
* 37 wks: start routine cervical exam for dilation
242
2nd trimester labs
* GDM screen
* Rh antibody screen (repeat, if negative initially): give Rhogam if still negative-negative
* CBC
243
GDM screening
* (24-28 wks)
* 1 hr, 50 g GTT
* non-fasting
* check BG after 1 hr
* \> 140 mg/dL = move to 3 hr GTT
* \> 200 mg/dL = GDM
* 3 hr, 100 g GTT
* fasting
* check BG @ 1, 2, and 3 hr
* 2 abnormals = GDM
244
group beta strep (GBS) test
* vaginal-rectal swab
* done @ 35-37 wks on every pt
* exception: pt already tested +
* + pts get abx during delivery
245
AFI
amniotic fluid index
246
3rd trimester labs/diagnostics
* US (optional)
* GBS swab
* BPP
247
3rd trimester pt ed
* prep for childbirth
* pain relief techniques
* discuss/finalize birth plan if needed
* labor precautions
* kick counts
* infant care/PP care
248
