Chapter 20: Assessment of the pregnant patient

Question 1

initial health history of a pregnant patient does not differ greatly from the health history of any other adult patient.

Answer 1

• The gynecologic and obstetric history include information about the last menstrual period, expected date of delivery, and the course of past pregnancies and deliveries.

Question 2

Prenatal visits are recommended

Answer 2

every 4 weeks up to 28 weeks; every 2 weeks from 28 to
36 weeks; and weekly after 36 weeks. The initial prenatal visit
includes a comprehensive history and examination; follow-up
visits are more limited in scope, monitoring the progress of
the pregnancy and assessing for complications.

Question 3

Laboratory tests used to determine pregnancy

Answer 3

detect an antigen-antibody
reaction between human chorionic gonadotropin (hCG)
hormone and an antiserum within the urine or blood

Question 4

Many
physiologic changes are recognized as signs and symptoms of
pregnancy. Some of these findings are categorized as:

Answer 4

(1) presumptive symptoms (i.e., symptoms experienced by the
woman); (2) probable signs (i.e., changes observed by the
nurse); and (3) positive signs (i.e., findings that prove
the presence of a fetus).

Question 5

Integumentary System

Answer 5

• Increased estrogen increases vascularity to the skin, causing
itching and hands and feet to take on reddened appearance.
• Increased secretion of melanotropin causes pigmentation
changes to the skin, including chloasma (mask of pregnancy);
linea nigra (dark-pigmented line on abdomen); and
increased pigmentation to nipples, areolae, axillae, and vulva.
• Increasing size of breasts and abdomen contribute to striae
gravidarum (stretch marks) over abdomen and breasts.
• Increased hair or nail growth is reported by some individuals.

Question 6

Respiratory System

Answer 6

• Uterine enlargement pushes up on diaphragm, causing periodic
shortness of breath.
• Respiratory rate may increase slightly; tidal volume increases;
breathing becomes more thoracic than abdominal; thoracic
cage widens.

Question 7

Cardiovascular System

Answer 7

• Blood volume increases by 1500 mL to meet the need of an
enlarged uterus and fetal tissue, causing increased cardiac
workload (increased heart rate).
• Uterine enlargement pushes up on the heart, causing it to
shift upward and forward.
• Enlarged uterus increases pelvic pressure, causing decreased
venous return, which results in varicosities and edema in
lower extremities.

Question 8

Gastrointestinal System

Answer 8

• Rise in human chorionic gonadotropin early in pregnancy
causes nausea and vomiting (morning sickness).
• Uterine enlargement results in displacement of intestines
and decreased peristalsis, causing heartburn and constipation,
respectively • Increased pelvic pressure and vascularity cause
hemorrhoids.
• Increased estrogen increases vascularity and tissue proliferation
of gums, resulting in swollen and bleeding gums.

Question 9

Urinary System

Answer 9

• Increased pressure of growing uterus on bladder in early
pregnancy and fetal head exerting pressure on bladder in late
pregnancy result in nocturia and urinary frequency

Question 10

Musculoskeletal System

Answer 10

• Increased size of uterus and growing fetus results in the
center of gravity moving forward, causing lordosis (increased
spinal curvature) and back discomfort; waddling gait and
balance problems may occur.
• Abdominal wall muscles stretch and lose tone, which may
lead to separation of abdominal muscles (diastasis recti) in
the third trimester.

Question 11

Reproductive System

Answer 11

• Uterus enlarges, and fundus becomes palpable because of
growing fetus.
• Vagina, vulva, and cervix take on bluish color caused by
increased vascularity.

Question 12

Breasts

Answer 12

• Breasts become full and tender early in pregnancy.
• Breasts enlarge as pregnancy progresses.
• Nipples and areolae are more prominent and deeply
pigmented.
• Increased mammary vascularization causes veins to become
engorged; visible under skin surface.

Question 13

Presumptive signs

Answer 13

Breast fullness/tenderness 3-4
Amenorrhea 4
Nausea, vomiting 4-12
Urinary frequency 6-12
Quickening (fetal movement) 16-20

Question 14

Probable signs

Answer 14

Chadwick’s sign (violet-blue color to cervix) 6-8
Goodell’s sign (softening of cervix) 5
Hegar’s sign (softening of lower uterine segment) 6-12
Positive pregnancy test (hCG):
Serum 4-12
Urine 6-12
Ballottement 16-28

Question 15

Positive signs

Answer 15

Visualization of fetus by ultrasound 5-6
Auscultation of fetal heart tones:
Doppler 8-17
Fetoscope 17-19
Palpation of fetal movements 19-22
Observable fetal movements Late pregnancy

Question 16

An obstetric history includes gravidity

The acronym GTPAL may be of help
in remembering this system of documentation

Answer 16

(G) (number of
pregnancies, including current pregnancy); the number of
full-term births (T); the number of preterm births (P); the
number of abortions (A) (both spontaneous “miscarriages”
and “therapeutic” pregnancy interruptions); and the number
of living children (L).

Question 17

The obstetric history also includes specific data regarding

each pregnancy. Document the following information:

Answer 17

• The course of each pregnancy (including the duration
of gestation, date of delivery, and significant problems
or complications)
• The process of labor (including manner in which labor
was started [i.e., spontaneous or induced], length of
labor, and complications associated with labor)
• The delivery (presentation of the infant, method of
delivery [i.e., vaginal or cesarean section], and pain
management strategies used for delivery, if any)
• Condition of the infant at birth (including weight)
• Postpartum course (including any maternal or infant
problems)

Question 18

ESTIMATED DATE OF BIRTH

Nägele’s Rule

Answer 18

Determine the first day of the last menstrual period (LMP),
subtract 3 months, and then add 7 days.
Example:
First day of LMP =November 1
− 3 months = August 1
\+ 7 days = August 8 EDB*

Question 19

pregnant woman’s family history should specifically address

the childbearing history of her mother and sister(s),

Answer 19

including
multiple births, chromosome abnormalities, genetic disorders,
congenital disorders, and chronic illnesses such as
diabetes mellitus or renal disease and cancer.

Question 20

Compared with other known painful
events or experiences, the potential for achieving satisfactory
pain relief is high because of the uniqueness of this pain
experience. Unique points include the following:

Answer 20

• The woman knows that the pain will happen.
• The woman knows approximately when (within a week or
so) the pain will happen.
• The woman knows that there will be a predictable pattern
to the pain.
• The woman knows that there is a time limit to the pain
experience (hours as opposed to days or weeks) and that
it will end.
• The woman knows that there is a tangible end product
associated with the birth (i.e., the birth of her child).

Question 21

Pica

Answer 21

ingestion of nonnutritive substances….

Clay, starch, baking soda, and dirt are some of the reported cravings
during pregnancy

Question 22

smoking increases the

need for

Answer 22

vitamin C, a nutrient that has increased intake

requirements during pregnancy

Question 23

Pulse: The heart rate

Answer 23

increases as much as 10 to 15 beats/min

Question 24

Preexisting hypertension in pregnancy

Answer 24

significantly increases risk

of preterm delivery and infant mortality.

Question 25

Pregnancy-induced hypertension
(PIH), also known as gestational
hypertension

Answer 25

It is characterized
by systolic blood pressure of at
least 140 mm Hg, a rise of 30 mm Hg
or more above the usual level in two
readings 6 hours apart, diastolic blood
pressure of 90 mm Hg or more, or a
rise of 15 mm Hg above baseline in
two readings done 6 hours apart.

Question 26

EXPECTED WEIGHT GAIN

DURING PREGNANCY

Answer 26

First trimester 3-5 lbs (1.6-2.3 kg)

Additional pounds
Second trimester 12-15 lbs (5.5-6.8 kg)
Third trimester 12-15 lbs (5.5-6.8 kg)

Question 27

palmar erythema and is considered an expected finding.

Answer 27

Pinkish-red blotches or diffuse mottling of the hands caused by an increase in estrogen
is termed palmar erythema

Question 28

chloasma, or the mask of pregnancy

Answer 28

Blotchy, brownish pigmentation of the face (i.e., chloasma, or the mask of pregnancy)
is an expected finding

Question 29

these may be caused by

PIH

Answer 29

PIH may cause blurred vision.
Chromatopsia may be noted, characterized
by unusual color perception,
seeing spots, or blindness in the
lateral visual field. This requires
immediate follow-up. Retinal arteriole
constriction, disc edema, and retinal
detachment

Question 30

A normal

variation seen in many women toward the end of the third trimester is an epulis

Answer 30

An epulis is hypertrophied gum tissue that presents as a small painless raised nodule.

Question 31

The heart shifts laterally in response to the positions of the uterus and diaphragm

Answer 31

The point of maximum impulse also shifts upward and rotates slightly to
the left. Murmurs, splitting of S1 and S2, and the presence of S3 may be heard after the
twentieth week of gestation

Question 32

Following the first trimester, colostrum may be expressed from

Answer 32

the breast (a yellowish
discharge).

Question 33

breasts,,,, signs

consistent with malignancy.

Answer 33

Thickening of the nipple tissue, a mass, and loss of elasticity
Nipple discharge is considered an abnormal
finding (except for expression of colostrum as described).

Question 34

Any discrepancy greater than 2 cm
between fundal height and the estimate
of gestational age (based on last
menstrual period) should be evaluated
further.

Answer 34

A uterus that is larger
than expected may be caused by inaccurate
dating of the pregnancy, more than one fetus, gestational diabetes,
or polyhydramnios (excessive fluid in
the uterus). A uterus that is smaller than expected for gestational age may
be caused by inaccurate dating of the pregnancy or growth retardation
of the fetus.

Question 35

The expected fetal heart rate ranges

Answer 35

between 120 and 160 beats/min.

Question 36

Leopold’s maneuvers

Answer 36

The outline of the fetus can be determined after 26 to 28 weeks

The patient should be lying supine, with
head slightly elevated and knees flexed slightly. The fetal lie, presentation, position,
and attitude can be determined through these maneuvers