Exam 1 Flashcards
What 4 changes happen to the cervix during pregnancy?
1) Estrogen causes hyperemia
2) A mucus plug forms
3) Chadwick’s sign: a blueish purple hue of the cervix
4) Goodell’s sign: softening of the cervix
What 3 changes happen to the vagina and vulva during pregnancy?
1) Increased discharge (leukorrhea)
2) Increased vascularity
3) Connective tissue changes
**What 3 changes happen to the uterus during pregnancy?
1) Hyperplasia and hypertrophy
2) Blood flow rises to increase perfusion for adequate fetal growth and metabolic waste removal
3) Braxton Hick’s contractions: sporadic contractions and relaxation that are not indicative of labor
**What is the pattern of uterine growth during pregnancy?
12 wks: above pubis symphysis
16 wks: between pubis symphysis and umbilicus
20 wks: at umbilicus
36 wks: xiphoid process
40 wks: descends slightly d/t fetal head dropping into pelvic cavity
What 2 changes occur to the ovaries during pregnancy?
1) progesterone is secreted from the corpus luteum for 6-8 weeks
2) ovulation stops
What does estrogen do to the breasts?
Increases mammary ductal tissue
What does progesterone do to the breasts?
Increases growth of lobules, lobes, and areola
What 3 changes happen to the areolae of the breast?
1) Size increases
2) Color darkens
3) Tubercles of montgomery
What is colostrum?
Form of breastmilk high in antibodies that is produced after birth
**What is vena cava syndrome?
It is decreased blood flow to the heart as the fetus/uterus presses on the inferior vena cava. Common in supine.
**What cardiovascular changes are common in pregnancy?
1) Myocardium enlarges d/t increased workload
2) Decreased vascular resistance which lowers BP causing orthostatic hypotension
3) Heart rate increases 15-20 BPM
4) Hypercoagulation d/t increased clotting factors increasing clot risk
5) Cardiac output increases by up to 50%
6) Blood volume increases by 45%
7) RBC size increases
8) Systolic murmur is common
**What is physiologic anemia?
It is anemia that occurs d/t increased plasma volume in the pregnant individual causing dilution of RBCs
What respiratory changes are common in pregnancy?
1) O2 use increase ~40%
2) The diaphragm has more pressure on it d/t the uterus
3) The elevated diaphragm reduce lung capacity slightly
4) Thoracic cavity expands 2-3in
5) Slight hyperventilation occurs but RR stays the same becuse breaths are deeper
6) Tidal volume increase to lower CO2
What are 2 ways progesterone affects the respiratory system in pregnancy?
1) Progesterone decreases airway resistance by relaxing smooth muscle
2) Progesterone increases sensitivity to CO2 to maintain a higher respiratory drive
How does estrogen cause epistaxis during pregnancy?
Estrogen increases mucus membrane vascularity. Therefore, there is more pressure in the capillaries within the nose. Risk factors like dry air or injury can make it bleed more easily
What changes happen to the mouth, esophagus, stomach, and colon during pregnancy?
1) Mouth: Hyperemia d/t estrogen and ptyalism (hypersalivation)
2) Esophagus: Esophageal tone decreases d/t progesterone relaxing SM, pyrosis (heartburn is more likely to occur)
** 3) Stomach:** GI tone decreases d/t progesterone relaxing SM; constipation is more likely
4) SI/LI: Delayed empyting to allow for higher aborption time; hemorrhoids more likely
Why is GFR increased in pregnancy?
1) Blood volume has increased
2) Progesterone relaxes smooth muscle increasing the amount of fluid into the kidneys
Why is urinary frequency higher in pregnancy?
1) Higher GFR
2) Pressure on the bladder from uterus
What are striae gravidarum?
Stretch marks that occur during pregnancy d/t serparation of connective tissue
How can nasuea and vomiting be relieved in pregnancy?
1) Small, frequent meals
2) Ginger tea
3) Taking vitamin B6 (for nasuea) and unisom (antihistamine that sedates) together
4) Ondansetron (Zofran)
5) Avoid strong odors
How can fatigue be relieved in pregnancy?
1) regular rest
2) proper nutrition
3) light exercise
4) sleep hygiene
How can back pain be relieved in pregnancy?
1) Proper body mechanics + posture
2) Prenatal yoga + stretching
3) Heat packs
How can heartburn be relieved in pregnancy?
1) small, frequent meals
2) avoid spicy and fatty foods
3) sleep with your head elevated
4) antacids as appropriate
How can edema be relieved in pregnancy?
1) elevate legs
2) compression stocking
3) Reduce sodium intake
4) Regular movement
How can constipation be relieved in pregnancy?
1) Increased fiber intake
2) Increased fluid intake
3) Regular activity
4) Stool softener like colace and metamucil (less miralax)
How can frequent urination be relieved in pregnancy?
1) Regular bathroom breaks
2) Pelvic floor exercises
3) Avoid caffiene
4) Less water before bed
How can skin irritation/changes be relieved during pregnancy?
1) Using moisturizing lotions + oils
2) Discuss normalcy of stretch marks
When is the first prenatal visit?
It usually occurs during the first trimester around 8 weeks
How often do prenatal visits occur?
1) Weeks 4-28: one visit/4 weeks
2) Weeks 28-36: one visit/2 weeks
3) Weeks 36-41: one visit weekly
How is Nargele’s Rule used to calculate due dates?
Step 1: Begin with the first day of the last menstrual period
Step 2: Subtract 3 months
Step 3: Add 7 days
Step 4: Add 1 year
Ex: LMP = january 15, 2024 - 3 months = October 15, 2023 + 7 days = October 22, 2024
Define preterm, late preterm, early preterm, and very preterm
1) Preterm: born before 37 weeks
2) Late preterm: 34-36 weeks
3) Moderate preterm: 32-34 weeks
4) Very preterm: <32 weeks
Define term, early term, full term, late term, and post-term
1) Term: between 37-42 weeks
2) Early term: 37-38 weeks + 6 days
3) Full term: 39-40 weeks + 6 days
4) Late term: 41-42 weeks + 6 days
5)Post-term: after 42 weeks
What is gravida and what is parity?
Gravida: the total number of pregnancies including current pregnancy
Parity: The number of births that reached past 20 weeks
What vital signs are taken at the initial visit?
1) BP
2) Pulse (HR)
3) RR/effort
4) Temperature
What physical exminations are done during the first OB visit?
1) breast
2) pelvis
3) abdominal
What bloodwork testing (10 items) is done during first OB visit?
1) CBC
2) Blood typing and Rh factor
3) Rubella titer
4) Hep B+C
5) HIV
6) Syphilis
7) Urinalysis
8) Glucose
9) Gonorrhea
10) Chlamydia
What vaccines are given before, during, and are contraindicated in pregnancy?
1) Prior: Ensure up to date
2)During: Tdap, Hep-B, Flu (IM), COVID, RSV
3)Contraindicated: Flu (mist), HPV, MMR, varicella
What screening tests are done prenatally (throughout pregnancy)?
1) Glucose: 24-28 weeks
2) Ultrasound: 8-12 weeks (dating scan), 20 weeks (anatomical scan)
3) Isoimmunization: Antibody test after 28 weeks in Rh-negative parent = Rhogam given
4) GBS Screening: 36 weeks; treat with penecillin during labor
What is considered an abortion when considering parity?
The number of pregnancies that ended before 20 weeks (miscarriage, spontaneous abortion)
Describe what GTPAL means
Gravida: Total # of pregnancies regardless of outcome including current one
**Term: ** # of pregnancies that resulted in delivery at 37+ weeks
**Preterm: ** # of pregnancies that resulted in delivery before 37 weeks
Abortions: # of pregnancies that ended before 20 weeks
Living children: # of living children
What genetic screening is done in the 1st and 2nd trimesters?
1) 1st: Labs and ultrasounds; noninvasive prenatal testing (screens for sex)
2) 2nd: Around 20 weeks = Anatomical ultrasound of entire fetal body to check for abnormalities
What is cholasma?
Increased skin pigmentation of facial skin d/t hormones
What is linea nigra?
A single, dark, verticle stretch mark that occurs during pregnancy d/t hormones
Why can acne occur more frequently during pregnancy?
Increased blood flow increased the activity of sebaceous and sweat glands
What is the effect of the hormone relaxin?
It can cause increased pelvic mobilization and instability
What is lordosis, a common occurence in pregnancy?
It is increased curvature of the lumbar region of the spine
What is diastasis recti?
When the abdominal muscle stretch and separate
How much can body water increase in pregnancy?
6-8L increase
Why is carpal tunnel more likely in pregnancy?
Increased water and blood flow can put pressure on the median nerve
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**1) **
**2) **
**3) **
**4) **
5)
**6) **
What is family planning?
The conscious decision on when to conceive
What are risk factors for unintended pregnancy?
1) poor/low-income
2) ages 18-24
3) cohabitation
4) low education
5) racial minority
What is the nurse’s role in contraception?
1) Option considerations (safety, availability, economical, acceptable, etc.)
2) Informed consent (how it works, advantages/disadvantages, side effects, etc.)
What are the child spacing reommendations?
12 months minimum, 18 preferred to fully recover
What is perfect use in contraception?
The failure rate w/o user error
What is typical use in contraception?
The failure rate based on typical use
What two hormones does combined birth control use?
Estrogen and progestin (progesterone)
What are the 3 combined birth control methods?
1) Combined pill
2) Ring (NuvaRing)
3) Patch (Ortho Evra)
What are contraindications for combined birth control?
1) History of blood clots
2) Migraine with aura
3) Breastfeeding
4) Hypertension
5) Smoking
6) Breast disease
7) Liver cirrhosis
8) Diabetic neuropathy
What does the ACHES blood clot assessment stand for?
A: Abdominal pain
C: Chest pain/shortness of breath
H: Headaches
E: Eyesight changes
S: Severe leg pain (calf), slurred speech
Combined BC Pills: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: Prevents ovulation, thickens cervical mucus, and thins uterine lining
Use: one pill daily taken at the same time, 21 day pack with 7 day break but you still take “false pills”
Impact on cycle: can regulate or lighten periods, or even eliminate them
Other: may induce nausea, weight gain, and headaches, can improve acne
Combined BC Patch: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: prevents ovulation
Use: apply patch to a clean, dry area of the skin for 1 week and replace 1 time each week; 1 non-patch week
Impact on cycle: regulate or lighten
Other: more visible, can irritate skin
Combined BC Ring: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: prevents ovulation
Use: insert ring into vagina for 3 weeks, remove for 1
Impact on cycle: lighten periods, alleviate period sx
Other: irritation/discharge, can leave ring in during sex
What are the benefits of progesterone only birth control methods?
1) Smokers can use them
2) Can be used in those with a history of blood clots
3) Can be used in those with migraine
4) Can be used while breastfeeding
5) Patient may stop having their period
What are 4 progesterone only birth control methods?
1) Depo-Provera shot
2) Mini pill (progestin only pill)
3) Implant (Nexplanon)
4) Intrauterine Device (IUD - Mirena, Kylena, Skyla)
Progestin Only BC Depo-Provera: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: stops ovulation and thickens cervical mucus
Use: IM injection every 12 weeks (3 months)
Impact on cycle: irregular or stops
Other: weight gain, headaches, mood changes, bone density loss with 2+ year use
Return to fertility: take 6 months after stopping for fertility to return after stopping
Progestin Only BC Mini Pill: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: prevents ovulation and thickens cervical mucus
Use: one pill at the same time every day w/o breaks (if dose is missed by 3 hours, use other BC means for 48 hours)
Impact on cycle: irregular, lighter, no periods
Other: headache, mood changes, breast tenderness
Progestin Only BC Implant (Nexplanon): Describe the MoA, use, impact on cycle, and any other important considerations
MoA: prevents ovulation
Use: small rod inserted into arm by provider
Impact on cycle: irregular bleeding on periods
Other: lasts up to 5 years, can decrease bone density
Progestin Only BC IUD: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: prevents ovulation and thickens cervical mucus
Use: uterine insertion by provider, lasts several years (3-8 years, 8 for mirena)
Impact on cycle: may lighten or stop cycle
Other: **if pregnancy does occur = likely ectopic; cramping/bleeding after insertion; possible pain, pelvic inflammatory disease, or uterine perforation
What progestin only birth control does not thicken cervical mucus?
The Nexplanon implant
What are the benefits to non-hormonal birth control?
1) No hormonal side effects
2) Immediately reversible
3) STI protection with barrier methods
4) Greater personal preferences
What are 3 non-hormonal birth controls methods?
1) Paragard IUD (Copper IUD)
2) Spermicides
3) Condoms
Non-hormonal BC Paragard (Copper) IUD: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: Copper is toxic to sperm preventing fertilization
Use: Inserted into uterus by healthcare provider; LASTS 12 YEARS
Impact on cycle: heavier periods and cramping
Other: can be used as emergency contraception
Non-hormonal BC Spermicides: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: intravaginal gel reduces sperm motility by attacking flagella
Use: place gel, foam, cream by use instructions into service
Impact on cycle: none
Other: only use 2x/day, 1 hour before
Non-hormonal BC Condom: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: creates barrier to prevent sperm from entering
Use: place over erect penis, new one for each act
Impact on cycle: no impact
Other: check expiration, only water/silicon-based lube, latix better
What are 3 natural family planning methods?
1) Abstinence
2) Fertility Awareness Method
3) Lactation Amenorrhea Method
Natural Family Planning - Abstinence: Describe the MoA, use, impact on cycle, and any other important considerations
MoA: Refraining from sexual activity
Use: 100% effective, long or short term
Impact on cycle: no impact on menstruation
Natural Family Planning - Fertility Awareness Method: Describe the MoA, use, impact on cycle, and any other important considerations
Moa: tracking menstrual cycle to identify fertile and infertile days while avoiding sex during fertile days; fertile 4 days before and 5-7 days after ovulation
Use: monitor basal body temp, cervical mucus, and cycle length
Impact on cycle: none, may increase your understanding
Other: consistency is key, risk for pregnancy, no cost
Natural Family Planning - Lactation Amenorrhea Method: Describe the MoA, use, impact on cycle, and any other important considerations
Moa: relies exclusively on breastfeeding to suppress ovulation
Use: breastfeed exclusively (no formula, or food) for first 6 months
Impact on cycle: delays return of cycle
Other: 6 month window, no guarantee of ovulation suppression once menses return
When is emergency contraception most effective?
When taken within 72 hours of intercourse (Plan B) or 120 hours (Ella/Paragard)
Emergency Contraception - Plan B +Ella: Describe the MoA, use, side effects, availability, and effectiveness
MoA: Plan B (levonorgestrel) works by preventing or delaying ovulation within 3 days (72 hours); Ella (upilristal acetate) prevents or delays ovulation within 5 days (120 hours)
Use: Take pill as prescribed or as instructed on box
Side effects: nausea, fatigue, headache, menstrual changes; Ella may have more persistent effects
Availability: Ella is prescription only; Plan B is OTC
Effectiveness: 89% (Plan B is less efffective for 164+ lbs, Ella is better for higher weight)
Why is Paragard a good option for emergency contraception for individuals who are a higher weight?
Because it’s effectiveness is not reduced by weight
What are the respective permanent birth control methods?
1) Tubal ligation (ovaries)
2) Vasectomy (Testies)
What is tubal ligation?
Cutting and tying of the fallopian tubes to prevent eggs from being fertilized
What is a vasectomy?
Cutting and sealing the vas deferens to prevent sperm from ejaculating
What is the effectiveness of sterilization?
99%
Are tubal ligation and vasectomies reversible?
They are possible, but costly, complicated, and not guaranteed
What are the benefits of permanent birth control methods?
They are permanent and do not require maintenance cost
Chlamydia: MoA, Transmission, Complications, Risk Factors,
Sx, Testing, Education, and Treatment
MoA: bacterial infection by c. trachomatis
Transmission: sexual intercourse, mother to baby
Complications: prelabor rupture of membranes, preterm labor, low birthweight, endometriosis
Risk Factors: multiple partners, unprotected sex
Sx: dysuria (painful urination), urinary frequency, spotting, vulvar itching, gray-white discharge
Testing: swab, NAAT
Education: take entire course of antibiotics, treat all partners
Treatment: pregnant = azithromycin; not pregnant = azithromycin or doxycycline; newborn = erythromycin ointment
Gonorrhea: MoA, Transmission, Complications, Risk Factors,
Sx, Testing, Education, and Treatment
MoA: bacterial infection by n. gonorrhea
Transmission: sexual intercourse, to infant at birth
Complications: preterm birth, miscarriage, neonatal sepsis, PID, neonatal growth problems
Risk Factors: multiple partners, unprotected sex
Sx: dysuria, lower abdominal pain, purulent discharge (yellow-green)
Testing: culture
Education: treat all partners
Treatment: ceftriaxone (IM single dose); azithromycin if suspected gonorrhea and chlamydia infection; erythromycin = newborn
Syphillis: MoA, Transmission, Complications, Risk Factors,
Sx, Testing, Education, and Treatment
MoA: T. pallidium bacteria
Transmission: oral, vaginal, anal, to fetus
Complications: brain and eye conditions, miscarriage, preterm labor, fetal transmission increases risk of rash, fever, irritability, disability, and death
Risk Factors: multiple partners, unprotected sex
Sx: 1) painless papular lesions called chancres
2) skin rash (reddish-brown) on palms + soles, fever
3) latent, no signs
4) damage to internal organs
Testing: blood test
Education: disease progression in stages, treat partners
Treatment: Benzathine penicillin G
Group B Streptococcus (GBS): MoA, Transmission, Complications, Risk Factors, Sx, Testing, Education, and Treatment
MoA: bacterial infection present in vaginal flora
Transmission: to fetus or at birth canal
Complications: preterm labor/birth, infant pneumonia, sepsis, meningitis, respiratory distress
Risk Factors: history of positive culture, intrauterine monitoring
Sx: prolonged PROM, low-birth weight, intrapartum fever
Testing: vaginal + rectal cultures @35-37 weeks
Education: antibiotic prophylaxis
Treatment: Given during labor = Penicillin G (Q4H), or ampicillin (Q4H)
Is Group B Streptococcus common?
Yes, 1 in 4 pregnant people test positive
How many days after Hep B contact can you have the vaccine?
14 days
Pelvic Inflammatory Disease (PID): MoA, Transmission, Complications, Risk Factors, Sx, Testing, Education, and Treatment
MoA: infection by various bacterial agents often at end or after menses - often caused by salpingitis (fallopian inflammation)
Transmission: N/A
Complications: infertility, ectopic pregnancy, pelvic pain
Risk Factors: multiple partners, history of STIs
Sx: pain, fever, irregular bleeding, vomiting, discharge, nausea, chills
Testing: clinical symptoms with tenderness and fever
Education: no sex until treatment is completed, avoid STIs
Treatment: ceftriaxone w/ doxycycline w/ or w/ or w/o metronidazole
What is the standard treatment for HIV?
Antiretroviral therapy (ART)
What is PReP and PEP?
PReP, pre-exposure prophylaxis, is taken with no HIV diagnosis, reduces HIV risk by 99%
PEP, post-exposure prophylaxis, is an emergency medication taken within 72 hours to prevent infection
What antibiotic is used in both trichomoniasis and bacterial vaginosis?
Metronidazole
What is the hallmark of bacterial vaginosis?
Fishy odor
How is candidiasis or yeast infection treated?
Antifungal like fluconazole
What is the treatment for HPV?
Prevent with vaccination up to 26 y/o or with cryotherapy to remove warts
What three STIs are transmitted through breastmilk?
HIV, Hep B, Cytomegalovirus
How is a UTI treated?
Trimethoprim-sulfamethoxazole (Bactrim)
What are the five TORCH infections?
T: Toxoplasmosis
O: Other (Hep B, Varicella, syphilis, etc.)
R: Rubella
C: Cytomegalovirus
H: Herpes simplex virus (HSV)
Can TORCH infections cross the placenta?
Yes
How are the TORCH infections acquired?
Toxoplasmosis can be acquired through cat feces, raw meat, gardening
Hepatitis can be acquired through sharing personal hygiene products and breast milk
Rubella is by skin contact
Cytomegalovirus is by droplets and body fluids (like breastmilk)
HSV is passed through contact with active sores
What are TORCH symptoms?
Toxoplasmosis: flu-like, malaise, muscle aches
Hep B: flu-like, malaise, jaundice
Rubella: skin rash, fever, joint and muscle pain
Cytomegalovirus: flu-like, headache, fatigue
HSV: blister/sores, fever, chills
How can you help prevent TORCH?
Toxoplasmosis: avoid handling cat litter, raw meat, and wash hands after gardening
Hep B: vaccination
Rubella: avoid large crowds, vaccine
Cytomegalovirus: good hand washing, especially after contact with young children
HSV: regular screenings, safe sex
How long is a typical menstrual cycle?
28 days
What 5 STIs are routinely tested at the first prenatal visit?
1) HIV
2) Syphilis
3) Hepatitis (B)
4) Chlamydia
5) Gonorrhea
Describe the 3 phases of the uterine cycle:
1) Menstrual phase: when the endometrial lining sheds (estrogen and progesterone low)
2) Proliferative phase: build up of thick inner lining for egg implantation (high estrogen)
3) Secretory phase: further preparation of the endometrium making it more vascular and glandular via progesterone from corpus luteum
Describe the 3 phases of the ovarian cycle:
1) Follicular: start of menses until ovulation; FSH stimulates dominant follicle
2) Ovulation: surge in LH triggering ovulation
3) Luteal: empty follicle become corpus luteum and secretes progesterone to help pregnancy; dies if no implantation
Describe the Five P’s in sexual health history:
Partners: “Are you currently having sex of any kind?”; “Are you safe?”
Practices: “What kind of sex have you had?”
Past history of STIs: “Have you ever been tested for STIs?”; “Have you ever tested positive for any STIs?”
Prevention of STIs: “Do you and your partner discuss prevention or testing?”
Pregnancy intentions: “Would you like to talk about ways to prevent pregnancy?”; “Are you or your partner using any contraceptive methods?”
What are two additional P questions to ask about in sexual health history?
PReP and Pleasure
How much folic acid should pregnant people take?
600mg to prevent neural tube defects
What preconception vaccines should be up to date?
1) Varicella (chicken-pox)
2) MMR
3) Hep. B
4) Influenza
Why is smoking detrimental while pregnant?
1) Reduced O2 delivery to the fetus
2) Low birth weight
3) Placental issues
4) Miscarriage
5) SIDs
What is the risk of not receiving adequate folic acid, iron, and calcium prenatally?
1) Lack of folic acid can lead to neural tube defects in fetus
2) Lack of iron can cause anemia (O2 low to mother and fetus)
3) Lack of calcium can lead to decreased bone mineral density in parent and fetus
What is primary, secondary, and tertiary prevention?
1) Primary: education, immunizations, modifying behaviors
2) Secondary: screenings, health fairs
3) Tertiary: treating disease, preventing complications, rehab
What is Expedited Partner Therapy (EPT)?
EPT is providing the patient seeking treatment with antibiotics or antivirals to deliver to their sexual partner(s) w/o them needing to come in to be examined.
What are the weight gain needs for those who are underweight, normal weight, overweight, and obese based on BMI during pregnancy?
Underweight: Gain = 28-40 lbs; <18.5 BMI
Normal weight: Gain = 25-35; 18.5-24.9 BMI
Overweight: Gain = 15-25; 25-29 BMI
Obese: Gain = 11-20 lbs; 30+ BMI
What two places does weight mainly go during pregnancy?
1) Fetus
2) Fat stores for delivering + breast feeding
How many extra k-cals does a prengnant person need to eat with a single fetus, two, and three fetuses?
Single = 340 calories
Twin = 600 calories
Triplets = 900 calories
What supplement should be taken with iron to helps its absorption?
Vitamin C
Why is omega 3 beneficial in pregnancy?
It helps with fetal brain development
How much fluid should be consumed per day while pregnant?
8-10 glasses
What food should be avoided during pregnancy?
1) Raw/undercooked foods
2) No deli meat unless heated
3) High mercury fish (shark, swordfish)
4) Unpasteurized products
5) Unwashed produce
6) No alcohol
How much should caffeine be limited to in pregnancy?
2 cups or 200-300mg
What is pica?
Pica is craving non-food substances or substances with no nutritional value like chalk or dirt = may indicate anemia.
When does the embryonic period occur?
3rd week to 8th week
What three layers does the embryo develop in the embryonic stage?
1) Ectoderm
2) Mesoderm
3) Endoderm
At which week are all major organ system in place?
8th week
What are teratogens and which fetal development period is impacted the most?
Substances that are harmful to developing fetuses. They causes the most harm during the embryonic period.
At week 4 compared to week 8, how big is the embryo?
Week 4: Poppy seed size
Week 8: Raspberry
At which week does the fetal period being?
9th week
What is gestational age?
Dating a pregnancy and describing how far along based on last menstrual period
What is the quickening?
Feeling fetal movement (weeks 13-16, butterfly feeling in weeks 17-20)
What is brown fat?
Fetal fat that helps maintain the baby’s temperature after deliver (17-20 weeks)
What is lanugo?
Lanugo is the soft, fine hair covering the fetus which helps vernix caseosa stick to the body. (17-20 weeks)
What is vernix caseosa?
It is the white, creamy substance covering the skin of the baby to help protect it from amniotic fluid exposure. (17-20 weeks)
What is surfactant?
A lipoprotein found in the lungs that helps to reduce surface tension of the water preventing atelectasis (21-24 weeks).
What fetal changes are seen in weeks 9-12?
1) Blood production moves to spleen from liver at week 12
2) Fetus produces urine into amniotic sac
3) Eyes close
4) Intestines move into abdomen
What fetal changes are seen in weeks 13-16?
1) Rapid length growth
2) Quickening
What fetal changes are seen in weeks 17-20?
1) Fetal movements feel like a butterfly
2) Vernix casoesa and lanugo develop
3) Brown fat develops
What fetal changes are seen in weeks 21-24?
1) Lungs produce surfactant
2) Some gas exchange can occur at 24 weeks
What fetal changes are seen in weeks 25-28?
1) Eyes reopen
2) Hair grows
3) Head shifts down toward pelvis**
What fetal change is seen in weeks 29-32?
1) Skin pigmentation
2) Good survivability if labor
What fetal changes are seen in weeks 33-38?
1) Large weight gains
2) Pulmonary system matures
3) Testies in scrotum
4) Brain develops more (best to wait until 40
weeks for best brain development)
What are 4 functions of the placenta?
1) Hormone production for pregnancy maintenance (progesterone)
2) Transport substances between circulations; acting as the respiratory organ w/ intervillious space
3) Metabolizes and synthesizes agents
4) Acts as immunologic barrier between parent and fetus
Describe the 3 main placental hormones and their function:
1) HCG: released from the corpus luteum at first, then taken over by the placenta at weeks 10-12. Causes positive pregnancy test.
2) Estrogen: stimulates uterine growth and blood supply; helps ductal system mature for lactation; vascular changes in the skin; increase in saliva production
3) Progesterone: maintains the endometrial layer for implantation; stimulates lobules/lobes for lactation; relaxes smooth muscle of the uterus to keep the fetus in; relaxes sphincter and ureters of parent
What is the function of the chorionic villus?
It acts as the interface for gas and nutrient exchange within the placenta while separating the mother and fetus’ blood.
How many arteries and veins does the chorionic villus/umbilicus have and what do they carry?
AVA: There are two arteries and one vein. The arteries carry deoxygenated blood and waste back to the placenta while the single artery carries oxygenated blood and nutrients to the fetus.
What is the “velamentous insertion” variation in placental development?
When the cord vessels branch out far on membranes leaving them prone to hemorrhage when membranes rupture during labor
What is Wharton’s Jelly?
It is the soft covering around the umbilicus to protect the blood supply from pressure
What is amniotic fluid composed of and what is its function?
Amniotic fluid is made of the urine from the fetus and fluid from the parent across the amnion.
It functions to protect the fetus and promote development
What 3 shunts does fetal circulation use?
1) Foramen ovale: allows blood flow from right to left atria bypassing the pulmonary artery
2) Ductus arteriosus: allows blood flow from the pulmonary artery to the aorta
3) Ductus venosus: allows blood flow from main vein to inferior vena cava bypassing the liver (50% of blood flow)
When do shunts close in neonates?
Weeks to months after birth
What are antigens?
Foreign substances that invades the body
What are antibodies including IgM and IgG?
1. Antibodies are made by your body to indentify a specific antigen.
2. IgM: made by the body during the innate immune response, primary reponse
3. IgG: antibodies made for immune “memory” and secondary immune response
What is Rhesus Factor (Rh)?
It is a protein found on red blood cells that naturally occurs in some people
How do you determine if you have Rhesus Factor (Rh)?
It is indicated after your blood type (ABO +/-). + means you have rhesus factor and - means you do not have Rh(d) proteins.
What pregnant individuals are at risk of Rh issues and why is it a problem?
Who: Individuals who are Rh-. Rh+ people already have the protein and will not produce antibodies regardless of Rh+/- fetus.
Why: Rh- pregnant individuals can produce anti-d antibodies if the fetus is Rh+. This is not a problem in the first pregnancy because IgM antibodies cannot cross placenta, but becomes a problem in any subsequent ones becuase anti-D antibodies (IgG) will cross the placenta and attack fetal RBCs. We have no way to determine if a fetus is + or -.
What is isoimmunization and how can it occur in Rh incompatabilities to create anti-D antibodies?
1) Isoimmunization is the antibody production from interaction with the same species
2) Isoimmunization occurs from mixing of fetal and maternal blood.
What are pre-pregnancy and perinatal risk factors for anti-D antibodies?
Pre-pregnancy: Blood transfusion and history of sharing needles or a needle stick.
Perinatal: Any trauma, abortion, placental abruption, antepartum bleeding, vaginal and cessarian births
What is hemolytic disease of the newborn and what are its complications?
Hemolysis of fetal blood cells destroyed by the parent’s antibodies, anti-D in Rh incompatability.
1) Intrauterine fetal demise
2) Cardiac abnormalities (fluid around heart)
3) Hydrops fetalis: cardiac failure and fluid buildup
4) Newborn non-physiologic jaundice: high levels of bilirubin d/t RBC hemolysis leading to kericterus: brain damage d/t high levels of bilirubin
How is Rh incompatability managed and what is the Indirect Coom’s Test?
1) 1st prental visit includes blood type for parents and Rh factor
2) Indirect Coom’s Test: test that looks for antibodies to RBC proteins (any agglutination)
3) If parent is Rh- = will always receive Rhogam
4) Multiple doses of Rhogam will be given over pregnancy
5) All newborns are screend for blood type and Rh factor
Describe Rhogam’s MoA, route, and 3 circumstances it is given in:
MoA: prevents pregnant person’s production of anti-Rh (anti-d) antibodies
Route: IM injection
When: 1) 28 weeks becuase of increase in blood volume in parent + fetus;
2) Within 72 hours (3 days) of delivery in Rh- woman and Rh+ newborn
3) Anytime there is trauma or suspected fetal-maternal hemorrhage
What are some nursing roles in Rh incompatability?
1) Provide education on Rh factor and what is means to be isoimmunized?
2) Anticipate Rhogam administration to Rh- pregnancy
3) Collect umbilical blood after birth to determine type and Rh status
Is Rhogam indicated for Rh+ individuals?
No, they are already natually have proteins and will not produce antibodies or they are already isoimmunized with antibodies
Is Rhogam required if the parent is Rh- and infant is Rh-?
No, a potpartum dose of Rhogam is not needed if the infant is Rh-
What is the priority nursing assessment in a RH- pregnant woman who has bleeding?
A) Notify provider
B) Start an IV
C) Assess source of bleeding
D) Administer Rhogam
What are the three most common bleeding conditions in early pregnancy?
1) Spontaneous abortion (miscarriage)
2) Ectopic pregnancy
3) Gestational tropoblastic disease/hydatiform mole (molar pregnancy)
What is light, moderate, and heavy bleeding on a pad?
1) Light: 1 in. stain/hour
2) Moderate: 1-4 in. stain/hour
3) Heavy: fully saturated w/in an hour
What is an abortion?
A loss of pregnancy before 20 weeks of gestation or weighing less than 500g
What is a spontaneous abortion?
Termination of the pregnancy w/o action taken by the pregnant person nor anyone else; occurs naturally
What kinds of induced abortions are there?
1) Elective: abortion performed at patient’s request
2) Therapeutic: abortion performed for maternal/fetal health
How many pregnancies end in spontaneous abortion?
10-15%
Which age group has the highest concern (%) of spontaneous abortion?
45 year olds have an 80% miscarriage rate
What is the main cause of spontaneous abortions?
Chromosomal abnormalities cause 50-60% of spontaneous abortions
What is the pathophysiology of spontaneous abortions?
1) Embryonic/fetal failure
2) Decrease in estrogen + progesterone
3) Uterine decidua (endometrium) sloughs off cuasing bleeding
4) Uterine irritability and expulsion of embryo/fetus and placenta
What are some risk factors of spontaneous abortion?
1) maternal/paternal age over 40
2) History of miscarriage
3) Obesity
4) Chronic disease (Hypertension, hypothyroidism, diabetes)
**Describe the following spontaneous abortion subgroups:
1) Threatened abortion
2) Inevitable abortion
3) Incomplete abortion
4) Complete abortion
5) Missed abortion
6) Recurrent abortion
1) Threatened: vaginal bleeding, closed cervix, other sx, abortion has not occurred
2) Inevitable: progressive bleeding, cervical dilation
3) Incomplete: some but not all products of conceptions expelled, active bleeding, cramping, cervix open
4) Complete: all uterine contents expelled, bleeding stopped, cervix closed
5) Missed: fetus dies but is retained in uterus, uterus stops growing
6) Recurrent: 3 or more consecutive pregnancy losses before 20 weeks
What is the primary goal in the management of spontaneous abortion and what is expectant, medical, and surgical management?
Goal: Ensure uterus is empty of products of conception
1) Expectant: await spontaneous/complete expulsion
2) Medical: medications to induce expulsion
3) Surgical: Dilation and curettage (D+C) in 1st trimester = suctioning; Dilation and evacuation (D+E) in later trimesters
What is an ectopic pregnancy?
Any implantation of a fertilized egg outside the uterus (most often in the fallopian tube).
What is the prevalence of ectopic pregnancies?
2%
What symptoms might indicate an ectopic pregnancy?
1) One-sided lower abdominal pain
2) Vaginal bleeding/spotting @5-6 weeks
3) Positive pregnancy test + pregnancy symptoms
What are risk factors for an ectopic pregnancy?
1) IUD in place
2) H/o PID and STIs
3) Smoking
4) Pelivc surgery
What is the pathophysiology of an ectopic pregnancy?
1) Ectopic implantation into tissue outside uterus
2) Faulty implantation causes hormonal fluctuation stimulating endometrium to withdaw and bleed
3) Embryo ruptures the tube
4) Internal hemorrhage
What is the most important part of ectopic pregnancy management and what are medical and surgical management?
The most important thing is to preserve the fallopian tube
1) Medical: Methotrexate stops the growth of the pregnancy and lets embryo be absorbed
2) Surgical: required if any hemorrhaging or if methotexate does not work
What is a hydatiform mole (molar pregnancy) and complete vs. partial?
1) Hydatiform mole: occurs when the trophoblast develops abnormally, it’s too big. It is characterized by proliferation and edema of chorionic villi w/ grape-like clusters
2) Complete: no fetal parts inside
3) Partial: fetal tissue and/or membranes present
Why is detailed follow-up necessary after a molar pregnancy?
Follow-up is necessary because it is a neoplastic disease that can possibly contribute to cancer.
What are the interventions for early pregnancy bleeding?
After your assessment:
1) Notify provider
2) Support for anxiety, fear, and loss
3) Help patient understand options
4) Educate regarding aftercare
What labs are drawn during early pregnancy bleeding?
1) CBC
2) Blood type + Rh antibody
3) HCG levels
What is placenta previa?
When the placenta covers or partially covers the cervix
What is the prevalence of placenta previa?
1 in 200-300 pregnancies
What are the risk factors for placenta previa?
1) Previous c-section or uterine surgery (scar tissue build up)
2) 35+ y/o
3) Smoking and cocaine use
What are the complications of placenta previa?
1) Bleeding in pregnancy, labor, or delivery
2) Preterm birth
3) Placenta accreta: placenta implants too deep into uterine wall
What are the symptoms of placenta previa?
1) Sudden, painless, bright red blood
2) Slight-moderate bleeding
How is placenta previa managed?
1) Pelvic rest: reduce activities that place pressure on pelvis (sex, tampons, straining on toilet, squatting, swimming)
2) Planned c-section for complete placenta previa @36 weeks
What is the nursing care for placenta previa?
1) DO NOT perform a vaginal exam
2) Listen to anxiety/fear
What is placental abruption?
When the placenta detaches from the uterine wall before birth causing concealed or external bleeding.
What is the prevalence of placental abruption?
0.5%-1% but 10-15% of all perinatal deaths
What are the risk factors for placental abruption?
1) Hypertension
2) Smoking and cocaine use
3) Multigravida (2+ pregnancies)
4) Abdominal trauma
5) Interpersonal violence
What is the pathophysiology of placental abruption?
1) Bleeding and formation of hematoma on maternal side of placenta
2) Clots expands furthering separation
3) Hematoma obliterates intervillious space harming gas and nutrient exchange
4) Fetal vessels are disrupted d/t separation and maternal bleeding
What are symptoms of placental abruption?
1) Vaginal bleeding
2) Abdominal/low back pain
3) Uterine irritability w/ low intensity but frequent contractions
4) High uterine resting tone (rigid)
5) Uterine tenderness (pain)
What is the diagnosis for placental abruption?
Fetal monitoring + ultrasound to r/o other bleeding
How is placental abruption managed?
1) mild w/ fetus <34 weeks = bedrest, tocolytics (prevent contractions), Rhogam
2) Severe = emergency c-section
What is the nursing care for placental abruption?
If you discover the abruption:
1) prepare for delivery if the bleeding is severe or non-reassuring vitals
2) Alert provider team
3) Fetal monitoring
4) IV access
What is type 1 vs type 2 diabetes?
Type 1: autoimmune beta cell destruction reducing insulin secretion
Type 2: peripheral insulin resistance and beta cell undersecretion of insulin
What are maternal and neonatal risks of diabetes?
Maternal: macrosomia (large birth weight), shoulder dystocia, neural tube/CV/kidney defects
Neonatal: hypoglycemia, hypocalcemia, hyperbilirubinemia, respiratory distress syndrome, risk to develop type 2 diabetes
What 2 pieces are there to fetal surveillance during gestational diabetes?
1) Ultrasound and echocardiogram @20-22 weeks to evaulate fetal body structure
2) 3rd trimester examine fetal kick, BPP, non-invasive stress tests, amniotic fluid volume, fetal growth
During pregnancy during which gestational age is GDM screened?
Weeks 24-28
What is the onset, prevalence, and characteristics of gestational diabetes?
Onset: Around 20 weeks
Prevalence: 7%
Characteristics: Hyperinsulinemia, hyperglycemia, mild fasting hypoglycemia
Why does insulin resistance occur in late pregnancy and what specifically leads leads to GDM?
Resistance: It occurs because the placenta grows releasing more hormones contributing to resistance.
Why GDM: GDM occurs if the mother’s pancreas cannot compensate by secreating more insulin.
Can glucose and insulin cross the placenta? What is the result for the fetus during and after pregnancy?
Glucose: crosses placenta
Insulin: cannot cross placenta
Prenatal: Hyperglycemia that can cause harm b/c of no insulin crossing from the parent
Postpartum: Hypoglycemia because the neonate’s body has tried to compensate with its own insulin, but there is no glucose coming from the parent.
What are risk factors for GDM?
1) Overweight (25-29.9) or obese (30+)
2) 25> y/o
3) Previous pregnancy with GDM
4) H/o glucose intolerance
5) First degree relative with diabetes
6) High risk ethnic or racial group (Hispanic, African American, Indigenous, Pacific Islander)
What is the screening process like from 24-28 weeks for GDM?
1) Glucose Challenge Test (GCT): 50g glucose load with blood draw done at 1 hour (no dietary restrictions prior to glucose load intake).
- If BG is equal to or greater than 130-140mg/dL = fail must do GTT
2) Glucose Tolerance Test (GTT): 100mg oral glucose load with blood draws @ fasting and 1, 2, and 3 hours.
- If fasting blood glucose, OR two of the 1, 2, or 3 hours tests are abnormal = fail = GDM positive
List GDM symptoms:
1) Increased thirst (polydipsia)
2) Increased urine output (polyuria)
3) Nausea
4) Dry mouth
5) Tired
List GDM maternal and fetal complications:
Maternal: macrosomia (large birth weight baby), shoulder dystocia, neural tube/CV/kidney defects, preeclampsia, c-section
Fetal: Hypocalcemia, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress
What is the nursing management for GDM and what are the glucose guidelines?
1) Diet modifications
2) Education (nutrition + moderate exercise)
3) Glucose level monitoring
- Fasting: <95mg/dL
- 1 hour post prandial: <= 140mg/dL
- 2 hour post prandial: <=120mg/dL
Which stage (gestational age) requires the highest insulin need for the mother?
40 weeks
How is GDM diagnosed?
Glucose tolerance test
When do the insulin needs of the parent drop, before or after pragnancy?
They sharply decline just after birth
What three pieces incorporate intrapartum glucose management?
1) Hourly glucose monitoring between 80-110mg/dL
2) IV access for insulin drip if needed
3) Fetal monitoring
What foods are high in iron?
Green leafy vegetables, eggs, lentils, red meat
What is the most common form of prenatal anemia?
Iron-deficiency anemia
Is iron supplementation recommended prenatally? Do prenatal vitamins have iron?
Yes, and most prenatal vitamins do not have iron, so separate supplemtation is needed.
What are risk factors for iron-deficiency anemia?
1) Poor diet
2) GI disease (Chron’s, Celiac)
3) Short intervals between pregnancies
What are complications of iron-deficiency anemia?
1) Low birth weight
2) Preterm delivery
3) Perinatal mortality
What is the nursing care for prental iron-deficiency anemia? What are the considerations of iron supplementation?
1) Identify abnormal labs = <11g/dL of iron
2) Supplement w/ ferrous sulfate 325mg BID
Considerations: Iron supplemtentation is irritating to the GI causing N/V and constipation. It should be taken with food to avoid this. Avoid taking it with calcium.
Describe chronic hypertension in pregnancy: When, BP value, causes, treatment, prevalence.
When: always diagnosed prior to 20 weeks (it’s a preexisting HTN disorder)
BP: equal to or greater than 140/90
Cause: genetic, diet, lifestyle, stress
Treatment: anti-hypertensives
Prevalence: 1% of all pregnancies
Describe gestational hypertension in pregnancy: When, BP value, causes, treatment, prevalence.
When: at or after 20 weeks on two occasions at least 4 hours apart with no proteinuria
BP: at or equal to 140/90
Cause: unknown
Treatment: anti-hypertensives
Prevalence: 5-6%, up to 50% of pregnancies with gestational hypertension develop preeclampsia.
Describe preeclampsia in pregnancy: When, BP value, causes, treatment, prevalence.
When: anytime before, during, or after pregnancy. With proteinuria present (protein/creatinine ratio of .3+ or 300mg+)
BP: equal to or greater than 140/90 on two or more occasions four hours apart or one time at equal to or greater than 160/110 once.
Cause: unknown etiology
Treatment: delivery of infant (must balance risks and benefits of timing, most w/o severe form deliver ~37 weeks)
Prevalence: 2-6%
What are the severe features in preeclampsia and how many symptoms are required for severe form diagnosis?
Only one symptom is required to be diagnosed with the severe form:
1) BP 160/110+
2) Abnormal liver function
3) Creatinine 1.1mg/dL+
4) new onset headache or visual changes unrelieved by Tylenol
5) Pulmonary edema
6) Thrombocytopenia (<100,000)
What are risk factors for developing preeclampsia?
1) H/o preeclampsia
2) Carrying 2+ fetuses at once
3) Chronic high BP
4) Kidney disease
5) Diabetes
6) Lupus
7) 35+ y/o
What are three ways to manage preeclampsia symptoms?
1) Medication (Labetolol= beta blocker, nifedipine = Ca2+ blocker, hydralazine = vasodilator)
2) Seizure profylaxis (magnesium sulfate)
3) Monitor BP at home with cuff
What are the nursing considerations for using Labetolol, Nifedipine, and Hydralazine
Labetolol: closely monitor BP + HR
Nifedipine: maternal hypotension, flushing, headache, diziness, and nausea; fetal hypotension possible, only PO
Hydralazine: Monitor BP + HR, cuatious use in heart failure, resuce IV
Magnesium sulfate: MoA, contraindications, side effects, reversal agent, normal Mg2+ range, Mg2+ toxicity effects
MoA: blocks Ach from being released by motor nuerons at neuromuscular junections acting as a CNS depressant; anticonvulsant
Contraindications: myocardial damage, impaired renal function
Side effects: respiratory depression, fetal intolerance, generalized weakness, flushing, sweating, lack of energy, thrombocytopenia
Reversal agent: calcium gluconate
Normal Mg2+ range: 1.7-2.2,
Therapuetic Mg2+ range: 5-9 (9+ = patellar reflex loss)
Mg2+ toxicity effects: facial drooping, slurred speech, hyporeflexia, loss of consciousness
Nursing assessment of magnesium sulfate watches for?
1) Fluid retention (Weight, I/O’s, edema)
2) Decreased BP (Mg2+ tox)
3) Breath sounds (respiratory depression)
4) Deep tendon reflex/clonus (hyporeflexia or hyperreflexia/shaking)
5) Neuro check (decreased consciousness)
6) Severe features (headache, visual changes, RUQ pain)
7) Labs (CBC, AST/ALT, platelet, proteinuria, Mg2+ levels)
Eclampsia: What is it, warning signs, when is it most common
Eclampsia: new onset of tonic-clonic, focal, or multi-focal seziures in pregnancy or postpartum w/ sx of preeclampsia
Warning signs: severe headache, hyperreflexia, blurred vision, photophobia
Most common: 80% occur during intrapartum period 48 hours after birth
What interventions are provided during eclamptic seizure and after?
During: A) keep airway patent (turn head, pillow under back), B) do not leave bedside (call for help), C) raise bed rails, D) record convulsant activity
After: A) do not leave patient until fully alert, B) monitor post-seizure status, C) suction as needed, D) administer O2 with nonrebreather to 10L/min if O2 sats are poor, E) IV fluids, F) Magnesium sulfate admin
What is HELLP syndrome, what are the symptoms, and when does it mainly occur?
HELLP: Hemolysis, elevated liver enzymes, and low platelets (more severe form of preeclampsia)
Sx: RUQ pain, general malaise (90%), N/V (50%)
When: mainly 3rd trimester
What is the nursing role in preeclampsia: environment, seizure precations, medications, and assessment?
Environment: calm, quiet, nonstimulating, lighting subdued
Seizure precautions: suction ready, O2 administration ready, call button ready
Emergency medications: Labetolol (beta blocker), Nifedipine (Ca2+ blocker), Hydralazine (vasodilator), magnesium sulfate (Ach binding)
Assess: BP, hyperreflexia, clonus, vision changes, headache, lung sounds, strict I/O’s.
