Chapter 9: The Prenatal Assessment

Question 1

What is a normal response to pregnancy that a woman might experience?

Answer 1

Ambivalence

• begin to question their desire to be pregnant
• occurs irrespective of how determined and committed the couple is to the goal of beginning or expanding a family
• relates to the sudden realization that life as it has been known is going to change dramatically and will be a life-long endeavor
• woman can anticipate role changes in relation to her career and relationships and a need to prepare for the role of being a mother to an infant who will be dependent on her for survival

Question 2

What is essential in helping the woman positively embrace and celebrate her journey into motherhood?

Answer 2

-recognizing ambivalence and its normalcy in relation to pregnancy during the first trimester and providing support and reassurance are essential

Question 3

The World Health Report “Make Every Woman and Every Child Count” (World Health Organization)

Answer 3

focuses on making pregnancy safer and asserts that reaching this goal centers on providing excellent antenatal care and constructing societies that support pregnant woman
-antenatal care must be consistently accessible and responsive while incorporating patient-centered interventions, thereby removing barriers that prevent access to care

Question 4

The nurses role in the WHO goal

Answer 4

promoting optimal prenatal care for all woman

Question 5

Essential Components of Prenatal Care

Answer 5

• actively listening to the woman
• provide individualized education
• respecting woman’s choices
• the woman has the right to expect continuity of care, clear explanations, consistent information, and the opportunity to discuss any aspect of her care at any time

Question 6

Essential Nursing Goals when providing care for the prenatal patient

Answer 6

• to recognize deviations from normal
• to provide individualized, evidence-based care
• actively listening to the patient
• provide culturally appropriate prenatal education designed to meet the patient’s learning style and needs
• to empower woman to become actively involved in their pregnancy by being informed recipients and shared decision makers

Question 7

Possible Nursing Diagnoses for the Prenatal Patient

Answer 7

• knowledge deficit r/t normal physiological changes of pregnancy
• altered nutrition risk: less than body requirements
• risk for fatigue
• risk for disturbance in body image
• risk for altered role performance
• altered sexual patterns
• family coping
• change in comfort level r/t advancing pregnancy
• change in sleep patterns
• altered urinary elimination due to enlarging uterus or engagement of fetal part
• anxiety
• adolescent
• family processes, altered

Question 8

When does prenatal care usually begin?

Answer 8

in the first trimester of pregnancy, when the patient is seen every 4 weeks until she reaches 28 to 32 weeks gestation
-at that time, appointments change to visits every 2 weeks and then occur weekly from 36 weeks of gestation until birth

Question 9

Prenatal Visits

Answer 9

during the first trimester, the patient is seen every 4 weeks until she reaches 28 to 32 weeks gestation
-at that time, appointments change to visits every 2 weeks and then occur weekly from 36 weeks of gestation until birth
>the number of total prenatal visits varies

Question 10

Nurses role for CAREing for the Prenatal Patient

Answer 10

-Communicate
-Advocate
-Respect
-Empower Woman
>help women become informed recipient of care
>facilitate shared decision making

Question 11

CARE Principles

Answer 11

the nurses primary role is to CARE for the patient

• Communicate
• Advocate
• Respect
• Enable/empower

Question 12

CARE Principles: Communicate

Answer 12

the exchange of information between individuals, for example, by means of speaking, writing, or using a common system of signs of behavior

• a spoken or written message
• the communicating of information
• a sense of mutual understanding and sympathy

Question 13

CARE Principles: Advocate

Answer 13

• one who argues for a cause; a supporter or defender
• one who pleads in another’s behalf; an intercessor: advocates for abused children and spouses
• the nurses role encompasses being an advocate
• an advocate verbalizes the patients wishes if the patient is unable to do so and ensures that the patient’s questions are answered in an understandable and comprehensive way
• to help the patient to become an informed recipient of care
• supports and represents the rights and interests of another individual to ensure the individuals full legal rights and access to services

Question 14

Respecting the Patient Involves what?

Answer 14

valuing the patient as an individual, listening attentively, and addressing all of her concerns

Question 15

CARE Principles: Respect

Answer 15

• to feel or show admiration and deference toward somebody or something
• to pay due attention to and refrain from violating something
• to show consideration or thoughtfulness in relation to somebody or something

Question 16

CARE Principles: Enable/Empower

Answer 16

-to provide somebody with the resources, authority, or opportunity to do something
-to make something possible or feasible
>nurses need to empower women by caring, actively listening, and recognizing their inner wisdom, strength, and abilities; in doing so, nurses gain insights to help them meet their patients needs in relation to education; health promotion; and physical, psychological, emotional, and spiritual support

Question 17

An Informed recipient of care is what and is able to do what?

Answer 17

-is an individual who has been made aware of available health-care options and the possible consequences or outcomes of the choices made
-the informed pregnant woman is able to discuss the advantages and disadvantages of various screening tools, diagnostic tests, and treatment options, and she is empowered to make an informed choice that is right for her and her family
>nurses should remain non-judgmental, and able to listen and respond accurately and objectively

Question 18

What are the Reasons during pregnancy that can be associated with Maternal Stress?

Answer 18

-difficulty with accessing care
>transportation problems, appointment schedules that conflict with work commitments, and personal or family illness may prevent the woman from keeping her prenatal appointments
-communication difficulties
-perceptions of staff disinterest
-lack of understanding about the importance of frequent prenatal visits

Question 19

How can Nurses reduce Maternal Stress

Answer 19

-using an individualized approach with a focus on communication, personalized care, and education
-use the CARE principles
-provide stress management
social support; nurses and health-care providers may give support

Question 20

The First Prenatal Visit: The Initial Interview Time should be used to do what?

Answer 20

build a positive, nonthreatening relationship, and gain her confidence
-strategies useful: active listening, validating responses when needed, maintaining eye-to-eye contact, and the use of humor as appropriate to relax the patient; honesty is essential for effective communication

Question 21

Strategies to use during the Initial Interview at the first prenatal visit

Answer 21

active listening, validating responses when needed, eye-to-eye contact, and the use of humor as appropriate to relax the patient

• honesty is essential for effective communication
• when uncertain of the answer to a question, the nurse should make a note to find the answer and report back to the patient at the end of the interview

Question 22

What should the nurse do before initiating the Interview at the first prenatal visit?

Answer 22

helpful for the nurse to review the paperwork to become familiar with the information to be gathered and to ensure an understanding of the relevance and appropriateness of the questions to be asked

Question 23

Essential Components of Caring Communication Skills

Answer 23

-qualities of “comfort”, “acceptance”, “responsiveness”, and “empathy”
>comfort and acceptance refer to one’s ability to deal with difficult topics without displaying uneasiness and accepting attitudes the patient brings to the interview without showing annoyance or intolerance
>responsiveness and empathy refer to the quality of reacting to indirect messages expressed by the patient; empathetic listening helps the nurse to understand what the patient is actually saying

Question 24

First Prenatal Visit Reminders for the Nurse

Answer 24

• manage the environment to promote privacy and provide the patient with psychological and physical comfort
• avoid medical or technical jargon
• open-ended questions

Question 25

Comprehensive Health History Includes

Answer 25

• biographical data
• social history
• hx of intimate partner violence
• psychological assessment
• obstetric hx
• current pregnancy
• medical hx
• gynecological hx

Question 26

Comprehensive Health History Assessment: Biographical Data

Answer 26

• contact information for the patient such as address, phone number(s), occupation and educational level, marital/relationship status, insurance data, and contact person information
• some forms may contain spiritual or cultural considerations
• woman’s age and date of birth

Question 27

How to facilitate collection of data for the healthy history assessment?

Answer 27

to facilitate the collection of data, a number of prenatal forms such as the Prenatal Plus Program–Initial Assessment form is available
-this form allows for the collection of info relating to the patients pregnancy hx, medical hx, nutritional and exercise patters, financial income, vocation and educational goals, living arrangements, psychosocial hx, and lifestyle choices

Question 28

Comprehensive Health History Assessment: Social History

Answer 28

• educational level and occupation
• these data help to establish patients socioeconomic group
• may provide info regarding family income, standard of housing, and nutrition
• marital status

Question 29

Comprehensive Health History Assessment: Hx of Intimate Partner Violence

Answer 29

-a nonthreatening approach is to ask patients directly whether they feel safe going home and whether they have been hurt physically, emotionally, or sexually by a past or present partner
>if the partner accompanied to prenatal visit, these questions are postponed until the nurse is alone with the patient
-alternate method: use a standardized form that has valid and reliable questions concerning IPV
>IVP can occur for the first time during pregnancy

Question 30

Femicide

Answer 30

-the death of a woman resulting from an act of violence against that woman
>common death among pregnant woman

Question 31

“RADAR” to guide nurses as they interview patients about relationship violence

Answer 31

• Routinely screen every patient
• Ask directly, kindly, and in a nonjudgmental manner
• Document your findings
• Assess the patient’s safety
• Review options and provide referrals

Question 32

Comprehensive Health History Assessment: Drug Use

Answer 32

drug use; defense to emotionally deal with abuse

• use of nonprescription drugs such as cocaine, amphetamines, heroin, marijuana, or ectasy
• detrimental effects; spontaneous abortion, low birth weight, placental abruption, and preterm labor)

Question 33

Comprehensive Health History Assessment: Psychological Assessment

Answer 33

each patient harbors a host of unique medical and psychological factors
ex: a woman with a hx of a previous eating disorder may experience difficulty maintaining a healthy diet and achieving appropriate weight gain during pregnancy
ex: another woman may have struggled with anxiety and depression, alcohol or drug use, or issues r/t domestic violence before pregnancy
>these factors can have a significant impact on the prenatal course

Question 34

Comprehensive Health History Assessment: The Obstetric History

Answer 34

include the current pregnancy and all previous pregnancies and their outcomes because complications experienced in a prior pregnancy often reoccur in subsequent pregnancies
>educate the woman about the developing embryo/ fetus during first few weeks of pregnancy; be conscious of potential teratogens

Question 35

Presumptive Signs of Pregnancy

Answer 35

subjective
>these signs can be caused by other conditions
-Amenorrhea (absence of menses)
-Nausea and Vomiting (“morning sickness”)
-Frequent Urination (urinary frequency)
-Breast Tenderness
-Perception of fetal movement (quickening)
-Skin changes include stretch marks (striae gravidarum) and increased pigmentation
-fatigue

Question 36

Subjective Signs (of pregnancy)

Answer 36

the symptoms that the patient experiences and reports

>because these symptoms may be caused by other conditions, they are the least indicative of pregnancy

Question 37

Probable Signs of Pregnancy

Answer 37

• abdominal enlargement
• Piskacek’s Sign (uterine asymmetry with a soft prominence on the implantation side)
• Hegar’s Sign (softening of the lower uterine segment)
• Goodell’s Sign (softening of the tip of the cervix)
• Chadwick’s Sign (violet-bluish color of the vaginal mucosa and cervix)
• Braxton Hicks contractions (intermittent uterine contractions)
• positive pregnancy test
• Ballottement (passive movement of the unengaged fetus)

Question 38

Objective Signs (of Pregnancy)

Answer 38

observed by the examiner
-these signs result from physical changes in the reproductive system
>these can be caused by other conditions, so a positive diagnosis of pregnancy cannot be based on these findings alone

Question 39

Probable Signs of Pregnancy: Piskacek’s Sign

Answer 39

uterine asymmetry with a soft prominence on the implantation side

Question 40

Probable Signs of Pregnancy: Hegar’s Sign

Answer 40

softening of the lower uterine segment

Question 41

Probable Signs of Pregnancy: Goodell’s Sign

Answer 41

softening of the tip of the cervix

Question 42

Probable Signs of Pregnancy: Chadwick’s Sign

Answer 42

violet-bluish color of the vaginal mucosa and cervix

Question 43

Probable Signs of Pregnancy: Ballottement

Answer 43

passive movement of the unengaged fetus

Question 44

Each Trimester is how long?

Answer 44

14 weeks or 3 months in duration

Question 45

Naegele’s Rule

Answer 45

used to calculate the expected date of birth (EDD)
-based on first day of the woman’s last normal menstrual period (LMP); based on a 28-day cycle
-7 days are added
-3 months are subtracted
-a year added when necessary
>menstrual cycle irregularity and variations in cycle length most likely invalidate the use of this rule as the sole method for estimating gestational age. A gestation wheel is a useful tool for that

Question 46

Gravid, Gravida, Gravidity

Answer 46

Gravid= state of being pregnant
Gravida= a pregnant woman
Gravidity= number of times a woman has been pregnant, irrespective of the outcome

Question 47

Gravid

Answer 47

state of being pregnant

Question 48

Gravida

Answer 48

a pregnant woman

Question 49

Gravidity

Answer 49

number of times a woman has been pregnant, irrespective of the outcome

Question 50

Nulligravida

Answer 50

a woman who has never experienced a pregnancy

Question 51

Primigravida

Answer 51

woman pregnant for the first time

Question 52

Secundigravida

Answer 52

woman pregnant for the second time

Question 53

Multigravida

Answer 53

describes a woman who is pregnant for the third time (or more times)

Question 54

Parity

Answer 54

refers to the number of pregnancies carried to a point of viability (20 weeks), regardless of the outcome
ex: para 1 = one pregnancy reached the age of viability
para 2= two pregnancies reached the age of viability
>para denotes number of pregnancies not number of baby/fetus

Question 55

GTPAL

Answer 55

G= Gravida (# of pregnancies)
T= number of term pregnancies
P= number of Preterm deliveries
A= number of abortions (spontaneous and induced)
L= number of living children

Question 56

What makes a pregnancy test positive?

Answer 56

a detectable level of human chorionic gonadotropin (hCG) must be present in the urine or blood

• hCG levels peak between days 60 and 70 of pregnancy than gradually decrease approximately over the next 40 days to reach a plateau that is maintained throughout pregnancy
• can be detected in blood as early as 1 day after implantation and in the urine around day 26

Question 57

Human Chorionic Gonadotropin (hCG)

Answer 57

this must be present in the urine to have a positive pregnancy test
-these levels peak between days 60 and 70 of pregnancy then gradually decrease for the next 40 days to reach a level that is maintained throughout pregnancy
-can be detected in the blood as early as 1 day after implantation and in the urine around day 26
-hCG molecule contains both an alpha subunit and a beta subunit
>woman should be advised to use a home pregnancy test that is specific for the beta subunit of hCG because this marker prevents cross reactions with other hormones

Question 58

Which Pregnancy Test Is advised for woman?

Answer 58

use a home pregnancy test that is specific for the beta subunit of hCG because this marker prevents cross reactions with other hormones
-the alpha subunit is similar in molecular structure to luteinizing hormone (LH), so woman with high LH levels (ex; those experiencing menopause) who use a pregnancy test designed to detect the complete hCG molecule risk obtaining a false-positive
>follow manufacturers recommendation to avoid unreliable results
>if home pregnancy test is negative, but signs of pregnancy persist, the test should be repeated in a week or woman should see healthcare provider

Question 59

Chemical Pregnancy

Answer 59

term used to describe a situation that occurs when a home pregnancy test has confirmed the presence of hCG, but a late and often heavy menstrual period follows
>conception probably occurred but for some reason the pregnancy was unable to continue and develop into a viable embryo

Question 60

Assessment: Medical History

Answer 60

-obtain contact information for the primary care provider to facilitate continuity of care
>if lack of one, nurse can explore these issues through sensitive and respectful questioning, and when appropriate, refer to local agencies that provide services such as the WIC (woman, infants, and children) program for nutritional support
-dental health, eye health, immunizations, preexisting medical conditions, environmental hazards

Question 61

How does a nurse promote dental health

Answer 61

• encourage regular dental examinations
• promote twice daily brushing and flossing
• recommend use of a fluoride toothpaste
• encourage a healthy diet
• encourage chewing gum containing xylitol after meals

Question 62

Medical Hx: Dental Health and Pregnancy

Answer 62

hormones of pregnancy predispose women to an increased plaque and the development of gingivitis, or gum inflammation
-link between periodontal disease in pregnancy, gingivitis, and preterm labor

Question 63

Medical hx: Eye health

Answer 63

ophthalmic evaluation is recommended early in pregnancy or at any time visual changes occur

• important for women with medical conditions such as essential hypertension, Graves disease, or diabetes mellitus; and for women who wear contact lenses
• normal changes that occur: decreased intraocular pressure, corneal thickening, corneal sensitivity, and increased curvature of the cornea; all of which resolve spontaneously during post-partum

Question 64

Medical Hx: Immunizations

Answer 64

-Vaccination against influenza is considered safe throughout pregnancy and is an essential element of prenatal care
-nurses and their patients also need to be aware that some infections contracted during pregnancy can be detrimental to the fetus (ex: Rubella, Varicella (chicken pox) and Rubeola (red measles))
-a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has never received the vaccine for tetanus, diphtheria, and pertussis (Tdap) or if 10 years have elapsed since immunization
>Tdap should be administered during the third or late second trimester (after 20 weeks gestation) of pregnancy
>recommend rubella vaccination after childbirth if not immune; wait at least 4 weeks to get pregnant after vaccination

Question 65

Eye Exam Important Notes/ Patient Education

Answer 65

-during an exam, it is relatively common practice to dilate the pupils to facilitate ocular assessment
>occasional use of parasympatholytics (ex: atropine) and sympathomimetics (ex: epinephrine) is thought to be safe, repeated use is contraindicated because of possible teratogenic effects
-Mydriatics (medications that dilate the pupils) are contraindicated in breastfeeding mothers because they have a hypersensitive and anticholinergic effect on the infant
>all prenatal and breastfeeding patients should be advised that certain components of the eye examination may carry risks during pregnancy, and make certain eye care professional is aware if pregnant or breastfeeding
>CDC recommendations endorse Hepatitis B vaccinations during pregnancy for those at risk

Question 66

Rubella

Answer 66

most commonly recognized viral infection known to cause congenital problems
-if woman contracts rubella during the first 12 weeks of pregnancy, the fetus has a 90% chance of being adversely affected
-Symptoms: intrauterine growth restriction, cardiac defects, sensorineural defects, cataracts, and microcephaly (small head)
>a maternity patient who is not immune to rubella should be offered the rubella immunization after childbirth, ideally before discharge
>if possible, be tested greater than or equal to 3 months to check for immunity
>after vaccination, be advised not to become pregnant for at least 4 weeks

Question 67

Neonatal Pertussis

Answer 67

“whooping cough”
-contagious bacterial infection caused by gram-negative coccobacillis Bordetella pertussis, which causes disease through the elaboration of toxins that damage respiratory epithelium
-transmitted by respiratory droplets
-carries significant morbidity and mortality in newborns
>a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has never received the vaccine for tetanus, diphtheria, and pertussis (Tdap) or if 10 year have elapsed since immunization

Question 68

Neonatal Pertussis

Answer 68

“whooping cough”
-contagious bacterial infection caused by gram-negative coccobacillis Bordetella pertussis, which causes disease through the elaboration of toxins that damage respiratory epithelium
-transmitted by respiratory droplets
-carries significant morbidity and mortality in newborns
>a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has never received the vaccine for tetanus, diphtheria, and pertussis (Tdap) or if 10 year have elapsed since immunization
>Tdap should be administered during the third or late second trimester (after 20 weeks gestation) of pregnancy

Question 69

During the Prenatal period, why is it important to screen for Hepatitis B?

Answer 69

because a positive diagnosis will influence both the maternal and newborn medical management

Question 70

Patients at higher risk for Hepatitis B

Answer 70

-persons with conditions that require immunosuppressive or immune modifying therapy
-blood or tissue donors
-hemodialysis patients
-HIV-positive persons
>those at higher risk for acquiring the hepatitis B virus should also be tested for the antibody to hepatitis B surface antigen
>persons negative for both markers and who are at risk for infection should be vaccinated
>CDC endorses vaccination during pregnancy who are at risk

Question 71

Nurse Teachings: educational strategies for patients who are Hepatitis Carriers

Answer 71

• avoid drugs that are hepatotoxic such as acetaminophen (Tylenol)
• avoid alcohol
• if possible choose noninvasive prenatal diagnostic techniques, such as ultrasound and AFP screening rather than invasive procedures, such as chorionic villus sampling (CVS) and amniocentesis
• make sure pediatrician is aware of maternal hepatitis B status
• practice “daily living” precautions to prevent transmission to household members; covering cuts or skin lesions and not sharing toothbrushes or razors
• the neonate will receive hepatitis B immune globulin (GBIG) at birth; this action will provide antibodies to the hep B virus and give some protection to newborn; the IM injection must be administered within 12 hours of birth; the hepatitis B vaccine (Recombivax HB, Energix-B0, which includes protective antihepatitis B antibodies, may be administered at the same time as HBIG but at a different site; Hep B vaccine is given again at 1,2, and 12 months of age
• the method of birth does not appear to influence the incidence of mother-to-child transmission
• in HAV-infected women, breastfeeding is permissible with appropriate hygienic precautions
• Breastfeeding is not contraindicated in woman chronically infected with HBV if infant receives the HBIG passive prophylaxis and vaccine active prophylaxis

Question 72

Medical Hx: Environmental Hazards

Answer 72

-fetus is at risk from maternal exposure to environmental toxins such as pesticides and other compounds (ex: polychlorinated biphenyl, substance used as a coolant and lubricant on electrical equipment) that can accumulate in maternal adipose tissue and possibly be transmitted to the infant via breast milk
-air pollutants
>use the Environmental and Occupational Health History Profile tool
-Direct and Passive Smoking

Question 73

Asking the prenatal patient about the potential for pesticide exposure

Answer 73

-because of widespread use of pesticide, the nurse needs to assess every prenatal patient for the potential for pesticide exposure
-ask:
>do you use pesticides in your home, lawn, or workplace?
>do you use pesticides on your pets? (flea collars, dips, and once-a-month products)
>if you do use pesticides, what do you use?; Where and how often do you use them?

Question 74

Effects of tobacco use during pregnancy

Answer 74

-premature rupture of the membranes
-preterm labor
-placental abruption
-placenta previa
-infants who are small for gestation age (SGA)
>the detrimental effects continue into childhood and are associated with upper respiratory infections, childhood asthma, and wheezing
>smoking cessation programs are available through CSC, the ACOG, and other organizations

Question 75

Gynecological Hx

Answer 75

need to be performed to determine if any event in the patients past places the current pregnancy at risk or warrants further investigation
-women age 35 and older and foreign-born should be questioned about in utero exposure to diethylstilbestrol (DES); is a nonsteroidal, synthetic estrogen that is more powerful than natural estrogens

Question 76

What should happen before a patient is asked to consent to any investigation?

Answer 76

she should be counseled about the purpose of the test, its reliability, and the implications of a negative or positive result
-explain the difference between a screening test and a diagnostic test

Question 77

A screening test

Answer 77

• identifies patients at increased risk for developing a disorder or disease
• identifies patients who need diagnostic testing

Question 78

A diagnostic test

Answer 78

confirms the presence of a disorder or a disease

Question 79

Blood is drawn at the First Prenatal Visit for a number of Tests:

Answer 79

-patients blood group and rhesus (Rh) factor
-antibody screen (Kell, Duffy, rubella, varicella, toxoplasmosis, and anti-Rh)
-RPR/VDRL (rapid plasma reagent/ Venereal Disease Research Laboratory) screen for syphillis
-if not received Hepatitis B vaccine, she is tested for Hep B surface antigen (HbsAG) and Hep B surface antibody (HbsAB)
-a complete blood count (CBC) with hemoglobin, hematocrit, and differential count is obtained and assessed using laboratory values established for pregnancy
>Testing for antibody to HIV is recommended
>Sickle cell screen recommended for women of African, Asian, or Middle Eastern descent
>a Tine or purified protein derivative (PPD) tuberculin test may be assessed for exposure to tuberculosis

Question 80

An STI can predispose to a number of adverse pregnancy outcomes such as?

Answer 80

• ectopic pregnancy
• spontaneous abortion
• preterm labor
• increased neonatal morbidity

Question 81

What should the sexual history assessment include?

Answer 81

• signs or symptoms (eg. vaginal/rectal discharge, dyspareunia (painful intercourse), ulcers, rashes, or anogenital itching) that may be indicative of infection
• information concerning recent sexual partners so that when indicated, prior contacts can be notified and offered treatment
• high-risk behaviors should be noted such a intravenous drug use, acquisition of tattoos, exposure to blood or blood products, or sex with an individual from high-risk category (e.g. sex industry worker)

Question 82

Tips for Taking a Sexual History

Answer 82

> Self-awareness: know your own comfort level and your ease at discussing sexual issues with patients; acknowledge areas of discomfort
Effective Communication: if you are embarrassed this will be apparent through body language, eye-to-eye contact, tone of voice, and type of questioning chosen (e.g closed-ended questions as opposed to exploratory questions)
-use words and terms that the patient understands
-environment: ensure privacy and confidentiality
-never make assumptions or be judgmental in your response or attitude

Question 83

Sexually Transmitted Infections

Answer 83

• Human Immunodeficiency Virus (HIV)
• Syphillis
• Chlamydia Trachomatis, Neisseria Gonorrhoeae
• Herpes Simplex Virus

Question 84

Sexually Transmitted Infections: Human Immunodeficiency Virus (HIV)

Answer 84

infection with HIV leads to a progressive disease that results in AIDS
-perinatal transmission may occur transplacentally, at birth from exposure to maternal blood and vaginal secretions, and via breast milk
>maternal treatment with zidovudine (AZT, Retrovir) reduces the risk of perinatal transmission and the risk of infant death
>Elective C-section has been shown to reduce the risk of transmission from the mother to the infant
>recommended all pregnant women be tested for HIV as part of the routine battery of prenatal tests; patients can choose to opt out

Question 85

How is screening for HIV done?

Answer 85

via a enzyme-linked immunosorbent assay (ELISA) on a blood sample; if positive, finding is confirmed via a Western blot test

Question 86

When should repeat testing of HIV be done?

Answer 86

in the third trimester or rapid HIV testing should be used in labor for women with undocumented HIV status following opt-out screening

Question 87

What happens if a rapid HIV test in labor is positive?

Answer 87

immediate initiation of antiretroviral prophylaxis should be initiated without waiting for the results of the confirmatory test

Question 88

Syphilis

Answer 88

infection during pregnancy that can cause damage to the fetus after the 16th to 18th week of intrauterine life
-cause by spirochete Treponema pallidum
-readily treated with penicillin or erythromycin; if treated before 18th week, fetus is rarely affected
>left untreated, transplacental transmission is likely to occur (congenital syphilis) and may result in deafness, cognitive difficulties, osteochondritis, or fetal death)

Question 89

Chlamydia Trachomatis

Answer 89

screening tests for chlamydia are obtained during the pelvic exam
-secretions from the cervix, vagina, and anus may be used to obtain samples from culture media
-Chlamydia trachomatis is a bacterial infection that is prevalent in sexually active populations; most appear asymptomatic and do not seek treatment
-Complications of chlamydia include salpingitis (inflammation of fallopian tubes), pelvic inflammatory disease, infertility, ectopic pregnancy, premature rupture of the membranes, and preterm birth
-Transmission to neonate may occur during birth and result in ophthalmia neonatorum and chlamydial neonatal pneumonia
>Treatment for chlamydia is with oral anti-infectives or penicillin based agents; pregnant women be tested 3 weeks after treatment

Question 90

Neisseria Gonorrhoeae

Answer 90

screening tests for Gonorrhea is obtained during pelvic exam
-caused by gram-negative intracellular diplococcal bacteria Neisseria gonorrhoeae
>readily treated with antibiotics
>when left untreated, ascending maternal infection may occur after rupture of the membranes
-transmission to fetus can occur during vaginal delivery and may result in disseminated infection and ophthalmia neonatorum

Question 91

Herpes Simplex Virus

Answer 91

-Herpes simplex virus type 1 (HSV-1), transmitted nonsexually and most common with fevr blisters
-Herpes simplex virus type 2 (HSV-2) is usually transmitted sexually and associated with genital lesions
>The initial HSV genital infection produces flu-like symptoms including malaise, muscle aches, and headache accompanied by dysuria and the appearance of multiple painful blister-like lesions
>HSV-2 can have adverse effects of both mother and fetus; primary infection in first trimester is associated with congenital infection and increased risk of pregnancy loss; in neonate 60% mortality rate, and those that survive suffer neurological damage
-no cure for genital herpes, although several anti-viral agents are available but safety of these medications during pregnancy is not firmly established

Question 92

Cervical Cancer

Answer 92

recommendation that screening via Papanicolaou testing to be performed on all young adults beginning at 21

Question 93

Preparing the Patient for the Physical Exam

Answer 93

• be given adequate private time to prepare for exam
• void if necessary
• room should be warm
• a cover for for the patient and a gown for her to wear
• ensure privacy for the patient; put a “do not disturb —exam in progress” sign affixed to the closed door

Question 94

What should Happen before the physical examination begins

Answer 94

• patient should receive an explanation of what the examination will involve and what she is expected to do
• obtain her consent to be examined
• collect all equipment needed, along with any teaching literature that the patient should receive

Question 95

Demonstrating professionalism during the physical examination

Answer 95

to convey respect and minimize the transmission of infection the nurse should

• ensure that the fingernails are short and all jewelry items that may cause skin trauma have been removed
• wash hands thoroughly in the patients presence
• develop habit of always washing the hands when entering and leaving the patients room

Question 96

A successful Physical examination involves what?

Answer 96

• proceed in the same order each time (head to toe) to reduce the likelihood of unintentionally omitting any component
• organized in a manner that reduces the movements the patient must make
• less threatening to the patient when less invasive procedures are performed first
• use good communication skills and to advocate for and treat the patient with respect

Question 97

How does the general assessment begin?

Answer 97

by simply observing the woman
-information that can be obtained includes overall health/nutritional status; posture; ease of movement and gait; appearance (clothing and cleanliness); affect and speech pattern; eye contact; and general orientation to place, person, and time
>then obtain anthropometric measurements (height and weight); prepregnant weight
>check vital signs (BP and HR may be elevated for first prenatal visit)

Question 98

Obtaining Information and Promoting Good Nutrition

Answer 98

-nurses goal: promote appropriate weight gain during pregnancy through healthy nutrition
-use a 24-hour diet recall form; helps provide info on food prep/cooking preferences and nutritional intake
-woman’s caloric needs increase by 300 per day
-educate woman that prenatal vitamins are an option to ensure that their daily needs are being met, but mega-doses of vitamins can be harmful
>woman’s need for folic acid doubles

Question 99

The general physical examination consists of?

Answer 99

ears, nose, mouth, and throat, cardio-respiratory, musculoskeletal, and neurological function with an in depth evaluation of maternal physical adaptation to the pregnancy

Question 100

The Focused Obstetric Examination Consists of?

Answer 100

• Head, Neck, and Lungs
• The Skin
• The breasts
• The abdomen
• uterine size and fetal position
• fetal heart auscultation
• the vagina and pelvis

Question 101

Focused Obstetric Examination: Head, Neck, and Lungs

Answer 101

-sitting position
-head to toe
-begin with general evaluation of skin and hair
-hair can be healthier during pregnancy
-hair loss common postpartum; can be indicative of vitamin or mineral deficiency
-increased level of estrogen responsible for hypertrophy of gingival tissue, nasal stuffiness, and increased tendency for nosebleeds
-thyroid gland palpated; enlargement is common because of increased vascularity and hyperplasia of glandular tissue; the size and position are documented with presence of nodules or swelling
-anterior and posterior lung sounds are auscultated
-cardiac rhythm and rate are evaluated for adventitious sounds
>many experience systolic heart murmurs because of an increase in blood volume; may be heard clearer when woman holds breath; beginning late in second trimester, the gravid uterus causes an upward and lateral displacement of the heart and the PMI
>as pregnancy advances the patient’s breathing becomes thoracic in nature (rather than abdominal) because of enlarged uterus

Question 102

Focused Obstetric Examination: The Skin

Answer 102

> evaluated for color consistent with ethnic background and for lesions or indicators of drug abuse (e.g. skin scratches, bruising or trace marks, nasal discharge or irritated mucosa, and constricted or dilated pupils)

• chloasma (the mask of pregnancy)
• hyperpigmentation of the areolae, vulva, abdomen, and linea (linea nigra)

Question 103

Focused Obstetric Examination: The Breasts

Answer 103

-recumbent position (on side)
-depending on gestational age, advisable to place a wedge under one of her hips to prevent compression of the vena cava from the gravid uterus (supine hypotension syndrome)
-inspection reveals nodularity, striae, and enlargement and hyperpigmentation of the nipples and Montgomery tubercles
>areas of indentation and skin puckering = not normal
-Colostrum, a precursor of breast milk, may be expressed from the nipples as early as the first trimester
>the lymph odes should not be palpable

Question 104

Promoting Breast Comfort During Pregnancy

Answer 104

-wear a firm, supporting bra

Question 105

Focused Obstetric Examination: The Abdomen

Answer 105

abdominal shape is assessed and inspected for the presence of scars (previous surgery should be documented), linea nigra, striae gravidarum, or signs of injury (e.g. bruising)
-may able to feel fetal movements

Question 106

Abdominal Palpation

Answer 106

used to evaluate the uterine size, to determine fetal position, and later in pregnancy to determine whether the presenting part has engaged into the maternal pelvis
-use of Leopold Maneuvers

Question 107

Fundal Height

Answer 107

an indication of uterine size; periodic measurements of the fundal height should correlate with fetal growth
-correlates to the weeks of gestation from approximately 22 to 34 weeks of gestation
>12 weeks the fundus should be at the level of the symphysis pubis
>20 weeks the fundus should be at the umbilicus
>fundus can be measured by using a tape measure or finger breadths in combination with known maternal landmarks

Question 108

How to Measure Fundal Height by Tape Measure

Answer 108

usually initiated around 22 weeks gestation
-the end of the measuring tape with the zero mark is held on the superior border of the symphysis pubis
-using the abdominal midline as a guide, the tape is stretched over the contour of the abdomen on top of the fundus (McDonald’s Method)
>the measurement (in cm) is recorded and equals week of gestation

Question 109

Approximate Fundal Height in Relation to Weeks of Pregnancy

Answer 109

• 12 weeks= level of symphysis pubis
• 16 weeks= halfway between the symphysis pubis and the umbilicus
• 20 weeks= 1-2 finger breadths below the umbilicus (or at umbilicus)
• 24 weeks= 1-2 finger breadths above the umbilicus
• 28-30= one-third of the way between the umbilicus and the xiphoid process
• 32 weeks= two-thirds of the way between the umbilicus and the xiphoid process
• 36 weeks= at the xiphoid process
• 38 weeks= 1-2 finger breadths below the xiphoid process
• 40 weeks= 3-4 finger breadths below the xiphoid process

Question 110

Leopold Maneuvers

Answer 110

used in abdominal palpation

• a four-part clinical assessment method of observation and palpation to determine the lie, presentation, and position of the fetus
• helps aid in locating fetal heart sounds

Question 111

Fetal Heart Auscultation

Answer 111

determining fetal presentation facilitates fetal heart auscultation
-FHR is heard most clearly directly over the fetal upper back (the maternal right or left lower abdominal quadrants)
-normal FHR= 110-160 bpm
>if a slower HR, the maternal pulse should first be evaluated to determine if the two heart rates are synchronous; if they are, the maternal pulse as inadvertently been auscultated through the abdomen and an attempt should be made to locate the fetal pulse; if differ, the nurse should position the patient on her left side and seek assistance
>oxygen may be administered by mask and patient should take slow deep breaths; nurse continue to monitor FHR and provide explanations and reassurance to patient

Question 112

Devices used to listen to the fetal heart

Answer 112

-Pinard stethoscope
-fetoscope
-doppler ultrasound stethoscope
>do not rely on technology, nurses should use clinical skills

Question 113

Nonstress Test

Answer 113

provides an evaluation of the FHR in response to fetal movement and/or uterine activity
-test may be ordered in high-risk pregnancies because of maternal or fetal factors

Question 114

Fetal Positon

Answer 114

Fetal heart tone intensity varies according to the fetal position
RSA= right sacrum anterior
LSA= left sacrum anterior
ROP= right occipitoposterior
LOP= left occipitoposterior 
RMA= right mentum anterior
LMA= left mentum anterior
ROA= right occipitoanterior 
LOA= left occipitoanterior

Question 115

Focused Obstetric Examination: The Vagina and Pelvis

Answer 115

vaginal examination usually performed at the initial prenatal visit following assessment of maternal abdomen

• explain to patient what to expect and to help her to verbalize and fears
• obtain permission to conduct a vaginal exam
• demonstrate awareness of patients feelings: remain respectful and gentle, showing equipment that will be used with demonstration of how it works, and ensuring privacy with appropriate drapes
• eye-to-eye contact
• involve patient in exam (mirror can be placed so woman can view cervix and see Chadwick’s sign)
• 4 components to examination

Question 116

Components of the Examination of the Vagina: 1 part

Answer 116

1. assessment of the external genitalia
   - information regarding secondary sexual characteristics by observing patterns of hair growth
   - check for pediculosis (pubic lice)
   - signs of infection (redness, edema, offensive discharge)
   - presence of lesions, condylomata (human papillomavirus), vesicles (herpes), ulceration (syphilitic chancre), or inflammation need to be recognized and investigated
   - bruising or tenderness may be present as a result of trauma or abuse
   - observation of perineal body may show evidence of a previous episiotomy or perineal tear

Question 117

Components of the Examination of the Vagina: 2nd part

Answer 117

2. visual inspection of the vaginal mucosa and cervix along with the collection of specimens such as Papanicolaou test (Pap test), cultures for gonorrhea or Chlamydia, and if indicated, wet smear slides to determine the cause of vaginal discharge
   >appropriate sized speculum; constructed of metal or plastic ; two types (Grave’s speculum; useful for multiparous woman and the more narrow, Pedersen speculum; used for children, woman who have never been sexually active, nulliparous women, and some postmenopausal
   >speculum is inserted into the vagina at an oblique angle, then rotated to a horizontal angle and gently advanced downward against the posterior vaginal wall; once in position, the speculum blades are opened to allow visualization of the cervix
   -cervix and vaginal mucosa are inspected for color and for the presence of inflammation, lesions, ulcerations, or erosion

Question 118

Components of the Examination of the Vagina: 3rd Part

Answer 118

includes clinical pelvimetry and the bimanual examination
>Bimanual examination= evaluation of uterine shape, position, and size
-normal uterus= anteverted (tipped forward); as it enlarges, the uterus becomes more midline and globular in shape; size of the uterus should be equal to the estimated weeks of gestation
-if larger= miscalculation of the date of conception, multiple pregnancy, hydatidiform mole, uterine fibroid tumors, or hydramnios (increase in volume of amniotic fluid
-if smaller= miscalculation of dates or missed abortion
>the manual examination provides an ideal time to evaluate vaginal and perineal muscle tone and to determine the presence of cystocele (bladder prolapse), urethrocele (urethral prolapse), or rectocele (rectal prolapse)
-Practice Kegel exercises to help maintain perineal muscle tone
>Rectovaginal Examination is performed after Bimanual examination

Question 119

Rectovaginal Examination

Answer 119

part of the third part of the vaginal exam
-performed after bimanual exam
-examiner removes hand from the vagina and dons a clean pair of gloves
-a water-based lubricant is applied to the fingertips of the dominant hand
-the index finger is reinserted into the vagina; middle finger inserted into the rectum
>the rectal finger is advanced forward as the abdomen is depressed with the non-dominant hand
-palpation of the tissue between the examining fingers allows for assessment of the strength and irregularity of the posterior vaginal wall
-the fingers are withdrawn and any stool present on the glove may be tested for occult blood

Question 120

Components of the Examination of the Vagina: 4th part

Answer 120

clinical evaluation of the pelvis (clinical pelvimetry)
-goal= recognize any abnormality in shape or size that may be associated with a difficult or traumatic vaginal birth
>4 pelvic types= gynecoid, the android (male), anthropoid (non-Caucasian races), and the platypelloid
-internal pelvic measurements= provide diameters of the inlet and outlet through which the fetus must pass during birth
>measurements most commonly made: diagonal conjugate, true conjugate (conjugate vera), and the ischial tuberosity diameter
-performed by physician, nurse midwife, or advanced practice nurse

Question 121

Diagonal conjugate

Answer 121

distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis
-lithotomy position
-indicates the anteroposterior diameter of the pelvic inlet– most narrow diameter and the one most likely to create a problem with misfit of the fetal head
>if greater than 12.5 cm, the pelvic inlet is considered to be adequate for childbirth

Question 122

Components of Subsequent Prenatal Examinations

Answer 122

usually not as in-depth but should be designed to recognize any deviations from normal so that appropriate investigation can be made and care managed accordingly

• review woman’s overall health status
• maternal well-being
• fetal well-being
• patient teaching

Question 123

Subsequent Prenatal Examinations: Review woman’s overall health status

Answer 123

• signs/symptoms of pregnancy
• discomforts of pregnancy
• changes in medications/over-the-counter/herbal/ homeopathic
• psychological assessment (emotional or psychological distress) including factors such as affect, sleep patterns, and diet

Question 124

Subsequent Prenatal Examinations: Maternal Well-Being

Answer 124

> Record Vital signs
-ensure BP is recorded using appropriate size cuff and under same condition each visit (e.g. maternal position)
Maternal Weight
-weight gain = 1 pound per week during second and third trimesters
-excessive weight gain= fluid retention
-weight loss= maternal disease or inadequate dietary intake: nursing assessment needed
Evaluate for Edema: dependent edema especially in hot weather and at the end of the day is normal finding
Where indicated, check for reflexes and clonus (involuntary muscle contractions)
-any signs of preterm labor such as uterine contractions or backache
-ensure patient knows indicators of preterm labor and knows how to seek medical advice
Assess for signs of domestic/intimate partner abuse

Question 125

Subsequent Prenatal Examinations: Fetal Well-Being

Answer 125

listen to fetal heart tones; can be heard from 12-14 weeks gestation with a Doppler stethoscope; normal= 110-160 bpm
>Discuss pattern and frequency of fetal movements
-encourage patient to monitor and record fetal movements daily
-educate patient on importance of fetal movements as an indicator of general fetal well-being
-report a decrease in fetal movements
>Evaluate uterine growth
-measure fundal height
-document findings and evaluate pattern of growth
-weeks of gestation are equivalent to measurement in centimeters (cm): McDonalds Method (measure from the top of the symphysis pubis to fundus, from approximately 24-34 weeks gestation)
-measurement less than expected= intrauterine growth restriction, oligohydramnios, or incorrect dates
-measurement greater than expected= multiple pregnancy, macrosomic infant, hydramnios (too much amniotic fluid), or incorrect dates

Question 126

Subsequent Prenatal Visit: Patient Teaching

Answer 126

• education r/t stage of pregnancy (e.g. physical changes to expect; danger signs that need to be reported such as vaginal bleeding or fluid loss, abdominal pain, or visual disturbances)
• attendance in prenatal education classes
• tour of facility where patient intends to give birth
• later in pregnancy, focus of education needs to include preparation for care of the infant (e.g. car seats, male circumcision, and immunizations) so parents make informed decisions
• screening and laboratory tests: ultrasound, prenatal screening, screening for gestational diabetes, Rh screening, Hemoglobin/Hematocrit, Group B Streptococcus screening
• confirm patients contact information and ensure return appointment
• provide time to ask questions and confirm understanding; she has no other concerns that needs to be addressed

Question 127

Screening for Gestational Diabetes

Answer 127

-offered around 24-28 weeks gestation
-patient drinks solution containing 50 g of glucose and then blood drawn 1 hour later
>results be below 140 mg/dL

Question 128

Rh Screening

Answer 128

Rh(D) negative woman= check for Rh antibodies and if negative, 300 mcg of Rh(D) immune globulin (RhoGAM) is prescribed at 28-32 weeks gestation

Question 129

Adolescence at Greatest Risk For Pregnancy

Answer 129

• adolescence who lack support, security, and love of a family home
• incarcerated juveniles

Question 130

Four developmental tasks a teenager has to meet to successfully adapt and fulfill the role of being a mother

Answer 130

• gain acceptance of pregnancy
• set goals
• view self as mother
• grow up

Question 131

Considerations in the older Gravida: Chronic medical conditons

Answer 131

for woman over 35

• preexisting diabetes and hypertension
• benign uterine leiomyomas (fibroid tumors) occur with greater frequency in woman over age 35 and may interfere with cervical dilation during labor and cause postpartum hemorrhage
• vaginal bleeding, preeclampsia, multiple gestation, gestational diabetes, preterm labor, dysfunctional labor, and C-section are increased during labor
• fetus at greater risk fir low birth weight, macrosomia, chromosomal abnormalities, and congenital malformations

Question 132

Considerations in the older Gravida: detrimental lifestyle habits

Answer 132

alcohol, drug and tobacco use

Question 133

Considerations in the older Gravida: physical examination

Answer 133

• focus on identification of breast abnormalities and circulatory problems
• continue with monthly breast self-examination because the incidence of breast cancer is increased in the older woman
• inspection of the lower extremities; varicosities are common in older woman
• first trimester, assess presence of fetal heart sounds; incidence of hydatidiform mole is increase in woman over 40

Question 134

Screening for Fetal Chromosomal Abnormalities

Answer 134

• offered a screening test for down syndrome
• child affected by down syndrome increases with maternal age
• provide information concerning the tests

Question 135

Summary Points of the Chapter

Answer 135

• education and involvement in prenatal care empowers patients and their families to make informed decisions
• the first prenatal visit includes a health history, physical examination, and laboratory testing; establishing good rapport through effective communication is essential in creating an environment to which the patient is likely to return
• Prenatal follow up visits are shorter than the initial assessment, but they are important in monitoring maternal-fetal health and in providing anticipatory guidance for the patient and family
• early and ongoing prenatal care is key to an optimal maternal-fetal outcome; families should be involved in activities for health promotion and educated about strategies for self-care during the childbearing year
• the diagnosis of pregnancy is based on three types of signs: presumptive, probable, and positive; presumptive and probable signs may be caused by conditions other than pregnancy; positive signs can have no other cause
• the teenage pregnant patient is at risk for a number of obstetric complications including anemia, preeclampsia, and preterm birth
• factors including education, culture, spiritual beliefs, and family support and income impact the occurrence of adolescent pregnancy
• preconception and prenatal care for the woman over 35 focuses on the recognition and management of chronic medical problems and strategies to promote a healthy lifestyle