Physiological aspects of antepartum care ch4

Question 1

physiological progression of pregnancy

Answer 1

• Pregnancy results in maternal physiological adaptations involving every body system each change meant to protect woman and or fetus and based in the maintenance of the pregnancy the development of the fetus in preparation for labor and birth

Question 2

Importance of nurses knowledge

Answer 2

nurses must have basic information on physics Physiology of pregnancy understanding critical for risk assessment and implementation of appropriate nursing interventions to reduce risk but also for providing effective patient education and anticipatory guidance grounded in knowledge of the normal physical changes in pregnancy and resulting common normal discomforts

Question 3

Physiological changes

Breasts

Answer 3

-increased estrogen progesterone levels initially produced by corpus luteum then by placenta , increased blood supply to breasts -tenderness feeling of fullness tingling sensation , increase in weight of breast by 400 grams , enlargement of breasts nipples areola and Montgomery follicles (small glands in the aerial around the nipple ), strai-due to stretching of skin to accommodate enlarging breast tissue , prominent veins due to two fold increase in blood flow . • increased prolactin produced by anterior pituitary -increased growth of mammary glands increase in lactiferous ducts and alveolar system , production of colostrum yellow secretion richen antibodies begins to be produced as early as 16 weeks

Question 4

Uterus , Cervix and Vagina

Answer 4

increased levels of estrogen and progesterone -hypertrophie of uterine wall , softening of vaginal muscle and connective tissue and preparation for expansion of tissue , uterus contract ability increases in response to increased estrogen levels leading to Braxton Hicks contractions , hypertrophie of cervical glands leads to formation of mucus plug(protective barrier between uterus fetus and vagina) , increased vascularity and hypertrophy of vaginal and cervical glands leads to increase in Leukorrhea, cessation of menstrual cycle (amenorrhea) and ovulation.
•enlargement and stretching of uterus to accommodate developing fetus and placenta -increase uterine size 20 times that of non pregnant uterus , weight of uterus increases from 70 grams to 1100 grams , capacity increases from 10 milliliters to 5000 milliliters 80% of that to uteroplacental
.•expanded circulatory volume leads to increased vascular congestion -blood flow to uterus is 500 to 600 milliliters per minute at term ,
goodells sign- softening of cervix ,
hagars sign-softening of lower uterine segment , chadwicks sign blueish coloration of cervix vaginal mucosa and vulva
• acid pH of vagina -acid environment inhibits growth of bacteria , acid environment allows growth of candida Albicans leading to increased risk of candidiasis- yeast infection

Question 5

Cardiovascular System

Answer 5

• Decrease in peripheral vascular resistance -decrease in blood pressure
• increase in blood volume by 40% to 45% -hypervolemia of pregnancy
• increasing cardiac output by 40% -increased heart rate Of 15 to 20 beats per minute
• BMR increased 10% to 20% by 3rd trimester -increased stroke volume of 25% to 30%
• increase in peripheral dilation -systolic murmurs , load and wide S1 split , load S2 , obvious S3 , increase in heart size
• increase in RBC count by 30% -In response to increased oxygen requirements of pregnancy RBC volume increases up to 33% with iron supplementations up to 18% without supplementation -physiological anemia of pregnancy
• Increase in plasma volume by 50%-Peaking at 32 to 34 weeks staying until term
-hemodilution is caused by increase in plasma volume being relatively larger than the increase in RBCS which results in decreased hemoglobin and hematocrit values=anemia ;
• Cardiac work is eased as the decrease in blood viscosity facilitates placental perfusion
• iron deficiency anemia=hemoglobin less than 11 grams per deciliter and hematocrit less than 33% maternal iron stores are insufficient to meet demands for iron in fetal development blood volume increases by 1500 milliliters to support uteroplacental demands and maintenance of pregnancy this is referred to as hypervolemia of pregnancy heart enlarges do too these factors
• hypercoagulation occurs during pregnancy to decrease risk of postpartum hemorrhage changes place women at risk for thrombosis and coagulopathies -Plasma fibrin increase of 40% fibrinogen increase of 50% coagulation inhibiting factors decrease
• increase in WBC count -values up to 16,000 mm3 in the absence of infection
• increase demand for iron and fetal development -iron deficiency anemia hemoglobin less than 11 grams per deciliter and hematocrit less than 33%
• plasma fibrin increase of 40% ,fibrinogen increase of 50% , decreasing coagulation inhibiting factors , protective of inevitable blood loss during birth - hypercoagulability
• Blood pressure decrease in first trimester due to a decrease in peripheral vascular resistance blood pressure returns to normal by term
• a systolic heart murmur or a third heart sound Gallup may be heard by mid pregnancy
• peripheral dilation increased
• supine hypotensive syndrome supine hypotensive syndrome is a hypotensive condition resulting from a woman lying on her back in mid to late pregnancy in superimposition enlarged uterus compresses inferior vena cava leading to a significant drop in cardiac output and blood pressure that results in the woman feeling dizzy and faint
• increased Venous pressure and decreased blood flow to extremities due to compression of iliac veins and inferior vena cava -edema of lower extremities varicosities and legs and vulva hemorrhoids
• in supine position enlarged uterus compresses inferior vena cava causing reduced blood flow back to right atrium and a drop in cardiac output and blood pressure -supine hypotensive syndrome
• Cardiac output increases 30 to 50% peaks at 25 to 30 weeks

Question 6

Respiratory System

Answer 6

• hormones of pregnancy stimulate respiratory center and act on lung tissue to increase and enhance respiratory function , increase of oxygen consumption by 15% to 20% - increase in title volume by 35% to 50% , slight increase in respiratory rate , increase in inspiratory capacity , decrease in expiratory volume , slight hyperventilation , slight respiratory alkalosis .
• estrogen progesterone and prostaglandins cause vascular engorgement and smooth muscle relaxation -dyspnea , nasal and sinus congestion , epistaxis (nose bleeds)
• upward displacement of diaphragm by enlarging uterus -shift from abdominals to thoracic breathing
• estrogen causes a relaxation of the ligaments and joints of the ribs , slight decrease in lung capacity -chest and thorax expand to accommodate thoracic breathing and upward displacement of diaphragm
• Increased oxygen demand is due to 15% increase in metabolic rate and 20% increased consumption of oxygen there is a 40 to 50% increase in minute ventillation mostly due to increase in title volume rather than in respiratory rate pulmonary function is not compromised in a normal pregnancy
• slight respiratory alkalosis -decrease in PCO 2 leads to increase in pH more alkaline and decrease in bicarbonate this change promotes transport of CO2 away from the fetus
• Diaphragm is displaced upward about four centimeters , increased chest circumference of 6 centimeters increase in kostal angle of greater than 90 degrees , these changes may contribute to physiological dyspnea that is common during pregnancy .

Question 7

Renal System

Answer 7

• increased cardiac output an increased blood and plasma volume lead to increased renal blood flow of 50 to 80% in first trimester and then decreases , increased progesterone levels which cause a relaxation of smooth muscles -urinary frequency and incontinence and increased risk of UTI
• dilation of renal pelvis and ureters , ureters become elongated with decreased motility , decreased bladder tone with increased bladder capacity -increased risk of UTI
• pressure of enlarging uterus on renal structures , displacement of bladder and 3rd trimester -urinary frequency and nocturia
• increased glomerular filtration rate -increased urinary output
• increased renal excretion of glucose and protein -glucosuria and proteinuria -Occurs in small amounts related to exceeded tubal reabsorption threshold of protein and glucose due to increased volume small amount of protein area and glucosuria can be normal important to assess and monitor for pathology
• shift in fluid and electrolyte balance the need that’s increased for these results in all .. of regulating mechanisms like renin angiotensin aldosterone system and anti diuretic hormone
• In supine and upright maternal position blood pools lower body decrease in cardiac output GFR and urine output causing excess sodium and fluid retention
• a left lateral recumbent maternal position can maximize cardiac output renal plasma volume and urine output stabilize fluid and electrolyte balance minimize dependent edema maintain optimal blood pressure
• renal system secretes both maternal and fetal waste products
• Bladder capacity increases bladder tone decreases due to progesterone effect on smooth muscle of bladder relaxation and stretching
• urinary stasis -progesterone reduces tone of renal structures allowing pooling of urine stasis promotes bacterial growth and increases the woman’s risk for your UTI’s and pyelonephritis
• Hyperemia bladder and Aretha related to increased vascularity results in pelvic congestion edamatous mucosa is easily traumatized
• Urinary frequency urgency an nocturia begin early pregnancy continue varying degrees through pregnancy primarily a result of systemic hormonal changes and anatomical changes in renal system UTI’s are common in pregnancy and may be asymptomatic symptoms of UTI urinary frequency discaria urgency sometimes pus or blood in urine if left untreated it can lead to pyelonephritis or premature labor
• decreased renal flow in 3rd trimester -dependent edema
• increased vascularity -hyperemia of Bladder and urethra

Question 8

Gastrointestinal System

Answer 8

• A third of women with nausea and vomiting experience significant distress 60% of cases resolved by 12 weeks gestation 90% have symptom improvement by 16 weeks gestation NVP
• increased levels of HCG and altered carbohydrate metabolism -nausea and vomiting during early pregnancy
• Uterine enlargement displaces stomach liver and intestines as pregnancy progresses by end of pregnancy the appendix is situated high and to the right along the costal margin GI tract relaxation and slowing of processes contributes to heartburn bloating and Constipation
• hemorrhoids varicosities and ** canal common due to increased venous pressure and are exacerbated by Constipation 3040% of pregnant women experience hemorrhoidal discomfort puritis and or bleeding gallstones progesterone induced relaxation of smooth muscle results distention of Gallbladder slows emptying of bile bile stasis elevated levels of cholesterol contribute to formation of gallstones
• pruritis-Abdominal Pruritis maybe early sign of Cholestasis
• ptyalism-Increase in saliva
• bleeding gums periodontal disease increased vascularity of gums can result in gingivitis
• increased progesterone levels slow stomach emptying and relax esophageal sphincter -reflux of gastric contents into lower esophagus resulting in heartburn
• increase progesterone levels relax smooth muscle to slow the digestive process and movement of stool -bloating flatulence and Constipation
• increased progesterone levels decreased muscle tone of Gallbladder and result in prolonged emptying time -increased risk of gallstone formation and Cholestasis
• changes in sense of taste and smell -increased or decrease in appetite , nausea , pica:abnormal craving for and ingestion of non food substances such as clay or starch
• displacement of intestines by uterus -flatulence abdominal distention abdominal cramping and pelvic heaviness
• increased levels of estrogen lead to increased vascular congestion of mucosa -gingivitis bleeding gums increased risk of periodontal disease

Question 9

Musculoskeletal system

Answer 9

• increased progesterone and relaxin levels lead to softening of joints and increased joint mobility resulting in widening and increased mobility of the sacroiliac and symphysis pubis -altered gate waddle gate , facilitates birthing process , low back pain or pelvic discomfort , pelvis tilts forward leading to shifting of center of gravity that results in change in posture and walking style increasing lordosis , increased risk of falls due to shift in center of gravity and change in gait and posture
• lordosis-Abnormal curvature anterior curvature of lumbar spine
• Diastasis recti separation of rectus abdominis muscle in the midline caused by the abdominal distention at benign condition that can occur in 3rd trimester \
• distension of abdomen related to expanding uterus reduced abdominal tone and increased breast size -round ligament spasm
• increased estrogen and relaxing levels lead to increased elastic city and relaxation of ligaments -increased risk of joint pain and injury
• abdominal muscles stretched due to enlarging uterus -diastasis recti

Question 10

Integumentary system

Answer 10

• estrogen and progesterone levels stimulate increased melanin deposition causing light Brown to dark Brown pigmentation -linea nigra , melasma (chloasma), increased pigmentation of nipples areola vulva scars and moles
• Melasma or mask of pregnancy brownish pigmentation of skin appears over cheeks nose and forehead occurs in 50 to 70% of pregnant women more common and darker skinned women usually occurs after 16th week and is exacerbated by some exposure stretch marks due to growth plus estrogen relaxing an adreno corticoids may result in tearing of subcutaneous connective tissue slash collagen
• increased blood flow increased BMR progesterone induced increase in body temperature and vasomotor instability -hot flashes facial flushing alternating sensation of hot and cold , increased perspiration -increased thyroid activity
• increased action of adrenocorticosteroids Leads to cutaneous elastic tissues becoming fragile -striae gravidarum(stretch marks) On abdomen thighs breast and buttocks
• increased estrogen levels lead to color and vascular changes -angiomas (spider nevi), Palmar erythema: pinkish red modeling over palms of hands and redness of fingers
• increased androgens lead to increase in sebaceous gland secretions -increased oiliness of skin an increase of acne

Question 11

Endocrine system

Answer 11

Include alterations in pituitary adrenal thyroid parathyroid and pancreatic functioning
• Placenta after full development produces most hormones of pregnancy such as estrogen progesterone human placental lactogen and relax him each hormone plays a role in Physiology of pregnancy resulting in specific alterations in nearly all body systems to support maternal physiological needs maintenance and progression of the pregnancy and fetal growth and development
• decreased follicle stimulating hormone -amenorrhea
• increased progesterone -maintains pregnancy by relaxation of smooth muscles leading to decreased uterine activity which results in decreased risk of spontaneous abortions , decreases gastrointestinal motility and slows digestive processes
• increased estrogen -facilitates uterine and breast development , facilitates increase in vascularity , facilitates hyperpigmentation , alters metabolic processes and fluid and electrolyte balance
• increased prolactin -facilitates lactation
• increased oxytocin -stimulates uterine contractions , stimulates the milk let down or ejection reflex in response to breastfeeding
• increased HCG -maintenance of corpus luteum until placenta becomes fully functional
• human placental lactogen /human chorionic somatomammotropin- facilitates breast development , alters carbohydrate protein and fat metabolism , facilitates fetal growth by altering maternal metabolism ;acts as an insulin antagonist
• hyperplasia an increased vascularity of thyroid -enlargement of thyroid , heat intolerance and fatigue
• increased BMR related to fetal metabolic activity -depletion of maternal glucose stores leads to increased risk of maternal hypoglycemia
• increased need for glucose due to developing fetus -increased production of insulin
• increase in circulating cortisol -increase in maternal resistance to insulin leads to increase risk of hyperglycemia

Question 12

Neurological System

Answer 12

Headache, Syncope

Question 13

Three parts of the Uterus

Answer 13

fundus or upper portion , isthmus or lower segment , cervix the lower narrow part or neck ; the external part of the cervix interfaces with the vagina .

Question 14

Cervical os

Answer 14

• the cervical OS is the opening of the cervix that dilates during labor to allow passage of fetus
•

Question 15

Uterine changes

Answer 15

• before pregnancy the elastic muscular organ is size and shape of a small pair and weighs 40 to 50 grams
• dream pregnancy uterine wall thins as uterus expands , mid pregnancy the uterine fundus reaches the level of umbilicus abdominally
• end of pregnancy enlarged uterus contains full term fetus Phil’s abdominal cavity has altered the placement of the lungs and rib cage and abdominal organs

Question 16

Braxton hicks Contractions

Answer 16

• Braxton Hicks contractions are intermittent painless and physiological uterine contractions begin in 2nd trimester some women don’t feel them until 3rd trimester these contractions are irregular with no pattern as uterus enlarges they are more noticeable that term uterus weighs 1100 to 1200 grams

Question 17

Vagina

Answer 17

-elastic muscular canal
• in pregnancy vascularity increases due to more circulatory needs , increase in vaginal discharge -leukorrhea-in response to estrogen induced hypertrophie of the vaginal glands , relaxation of vaginal wall imperil Neil body to allow stretching of tissues for birthing , acid pH changes which inhibits growth of bacteria but allows overgrowth of candida albicans-Risk for yeast infection

Question 18

Ovaries

Answer 18

• corpus luteum usually degrades after ovulation when eggs not fertilized is maintained during first few months of pregnancy by high levels of HCG -in beginning of pregnancy it produces progesterone to maintain endometrium allows for implantation and establishment of pregnancy by 6 to 7 weeks placenta produces progesterone corpus luteum degenerates

Question 19

Immune system

Answer 19

every aspects of body’s immune system undergoes adaptation during pregnancy to maintain tenuous balance between preserving maternal fetal well being through normal immune responses and making necessary alterations of maternal immune system required to maintain the pregnancy involves maternal immune system becoming tolerant of the foreign fetal system so fetus is not rejected and is protected from infection immune cheat function changes in pregnancy are far reaching and beyond the scope of this chapter relatively new body of science that is not fully understood

Question 20

Patient education about pregnancy related changes

Answer 20

discuss reasons for breast changes encourage women to wear properly fitted support bra
• Explain possibility of breast leaking colostrum
• educate on Braxton Hicks contractions and contraction patterns that should be reported to provider
• discuss self care measures to prevent yeast infections
• educate on cause of supine and orthostatic hypotension give advice on self care measures to prevent a hypotensive event
• encourage woman to include iron rich foods take iron supplementations to prevent anemia
• instruct women in prevention and relief measures for dependent edema and varicosities
• educate reassure about normal respiratory changes suggest symptom relief measures
• encourage women to stand stretch take a deep breath periodically through day
• educate women on reasons for increased frequency of urination during 1st and 3rd trimesters
• teach signs and symptoms of UTI
• encourage UTI prevention measures like emptying bladder frequently wiping front to back washing hands before and after urination urinating before and after intercourse and maintaining adequate hydration with at least 8 glasses of liquid a day
• teach and encourage kegel exercises instruct women to wear a perineal pad if needed
• reassure of normalcy and self limiting nature of nausea and vomiting suggest measures to prevent or relieve it
• advised to maintain good oral hygiene continue routine preventative dental care
• advise encourage women to eat high fiber diet adequate hydration physical activity
• instruct on preventative and relief measures for heartburn flatulence causation and hemorrhoids
• discuss musculoskeletal system changes during pregnancy
• encourage good posture and body mechanics
• teach symptom relief measures for back or ligament pain
• encourage gentle abdominal strengthening exercises
• offer reassurance as skin pigmentation and or other changes occur
• discuss normalcy of striae stretch marks in pregnancy and encourage good weight control
• suggest maintaining skin comfort with daily bathing lotions oatmeal baths non binding clothing
• advised to limit sun exposure and wear sunscreen

Question 21

Preconception healthcare

Answer 21

broad term refers to process of identifying social behavioral environmental and biomedical risks to a woman’s fertility and pregnancy outcome and reducing risks through education counseling and appropriate intervention when possible before conception -obesity, smoking etc..

Question 22

Components of health history and risk factor assessment in preconception care

Answer 22

identifying information age gravida address race ethnicity religion marital family status occupation education
• health status prior and present health status
• disease complications : history of or current medical conditions diseases surgeries including blood transfusions history of physical or sexual abuse medication used prescription over the counter complementary allergies immunizations
• family medical- current health status genetic medical conditions and diseases
• reproductive menstrual obstetric gynecological contraceptive sexual
• Self care lifestyle safety behaviors
• psychosocial -mental health social
• cultural -beliefs values practices primary language
• environmental -home workplace
• financial -basic needs related to food and housing resources and health insurance

Question 23

Routine physical examination and screening

Answer 23

-two primary components of a preconception health care visit are physical examination and relevant health screening in form of laboratory or diagnostic testing
• physical examination includes height weight measurements to calculate BMI assess for healthy weight
• comprehensive physical exam including breast and pelvic exam

Question 24

laboratory and diagnostic tests

Answer 24

• laboratory and diagnostic tests include serum blood tests to determine blood type RH factor complete blood count cholesterol glucose IgG rubella HIV and syphilis , urinalysis, cultures for sexually transmitted infections , Papanicolaou smear pap smear To screen for cervical cancer , tubercule and skin test , and other testing based on history and physical exam findings

Question 25

Preconception anticipatory guidance and education

Answer 25

anticipatory guidance is the provision of information and guidance to women and families enabling them to be knowledgeable and prepared as process of pregnancy and childbirth unfolds spans topics from health maintenance self care lifestyle choices to contraception and safety behaviors
-nurse is key in providing this aspect of care imperative that a woman’s age sexual orientation culture religion an additional values and beliefs are acknowledged and respected and info is incorporated appropriately into nurses teaching plan

Question 26

Preconception education goals

Answer 26

• preconception education goals are to provide women with information she can use to enhance her health before becoming pregnant when a woman seeks care specifically because she’s planning for a future pregnancy emphasis is more placed on counseling and anticipatory guidance related to preparation and planning for pregnancy topics include nutrition vitamin supplements such as folic acid exercise self care contraception cessation timing of conception and modifying behaviors to reduce risks

Question 27

Nutrition/weight

Answer 27

-maintaining a healthy way especially important for planning a pregnancy -BMI calculated based on height and weight represents measure of body fat number of women in childbearing years were overweight or obese is grown over the last three decades maternal obesity prior to conception has been linked to childhood obesity in their offspring increased infant mortality and an increased risk of fetal congenital abnormalities

Question 28

Obesity risks

Answer 28

• Obesity increases women’s risk for infertility during pregnancy it’s associated with increased perinatal morbidity and mortality from a variety of causes :increased risks for antepartum complications like hypertension cardiac dysfunction proteinuria sleep apnea non alcoholic fatty liver disease just stational diabetes mellitus and preeclampsia obese gravida’s are 40% more likely to experience still birth
• obese pregnant women -Our increased risk I was cesarian delivery failed trial of Labor endometritis , Wound rupture or dehiscence and Venous thrombosis and postpartum hemorrhage
• fetus of obese gravida’s are at increased risk of macrosomia and impaired growth
• An overweight or obese pre pregnancy weight increases risk for poor maternal and neonatal outcomes may have far reaching complication implications for long term health and development of chronic disease

Question 29

Underweight pre-pregnancy

Answer 29

• underweight pre pregnancy weight and or inadequate weight gain increases risk or poor fetal growth and low birth weight women who are either significantly over or underweight should be counseled about potential issues with infertility and associated risk during and after pregnancy referral for dietary counseling is and planning is recommended as needed to achieve a healthier weight before conception

Question 30

Nutrition education

Answer 30

• Nutritional education for women of childbearing years should include -education on diet and physical activity and their role in reproductive health , advise on the importance of achieving and maintaining a healthy weight prior to conception , encouragement to make nutritious food choices with emphasis on fresh fruits vegetables and protein sources low fat or nonfat dairy foods whole grains small amounts of healthy fats , help in choosing appropriate foods and serving sizes

Question 31

Prenatal Vitamins

Folic acid

Answer 31

• Folic acid -lowers risk of neural tube defects
• Cdc 1992- recommends daily folic acid supplements0.4 mg daily for childbearing age women.
• Benefits of folic acid greatest between 1 mon b4 pregnancy and thru first trimester-period of neural tube development.
• Due to unplanned pregnancies- and tube closes very early, many don’t know they are pregnant till later- so recommended 0.4-0.8 mg folic acid daily
• during pregnancy women with no previous NTDS are recommended to take 0.6 milligrams per day of folic acid
• For women with previous pregnancy affected by an NTD 4 milligrams per day is recommended from one month before conception through first trimester of pregnancy after that .4 milligrams per day for the remainder of pregnancy is recommended

Question 32

Calcium , magnesium and Vitamin D

Answer 32

• Calcium magnesium and vitamin D contribute to bone health osteoporosis prevention through life including during childbearing years

Question 33

Iron Supplementation

Answer 33

• iron supplementation is prescribed during pregnancy but there’s controversy about benefit of this practice as a routine recommendation —woman who is anticipating a short time between pregnancies is at risk for iron deficiency anemia
• mega doses of vitamins and minerals are not advised may be toxic to developing fetus

Question 34

Exercise

Answer 34

• exercise -recommended to have exercise program prior to pregnancy my want to talk with providers about types of exercise

Question 35

Self care

Answer 35

many don’t know they’re pregnant until they are one to two weeks pregnant already council preconception women to decrease risk behaviors and eliminate exposure to substances that could be harmful should Avoid illicit drugs alcohol tobacco and excessive use of caffeine , medications contraindicated for pregnancy , environmental toxins
• encourage women to -use safe sex practices to prevent STI’s , seat belt in car , smoke alarms carbon monoxide detectors , adequate sleep relaxation , apply sunscreen when outdoors , Maintain good oral health , discuss use of complementary or alternative medicine modalities with health care provider

Question 36

Contraception Cessation

Answer 36

– 2-3 normal periods before conception, some like depo can take months to a year to conceive after stopping.

Question 37

Preconception counseling

Answer 37

• provide info about cycle and when to conceive, Gain information that helps them positively affect their overall health and reduce perinatal risk

Question 38

Critical component:Zika virus

Answer 38

• Zika virus infection is an infection spread primarily through infected mosquitoes but can be sexually transmitted from a person affected by the virus even when symptoms are not present. A pregnant woman can transmit this to her fetus causing birth defects such as microcephaly impaired growth or visual abnormalities or hearing deficits there is no cure for zika virus And there is no vaccine

Question 39

Nursing actions in preconception care

Answer 39

• Nursing actions in preconception care provide comfort and privacy ,use therapeutic communication techniques , obtain a health history and conduct a review of systems , provide teaching about procedures , assist with physical and pelvic exams and obtaining specimens ,provide anticipatory guidance and education related to plan of care and appropriate follow up and assess the patient’s understanding , provide education recommendations and referrals to help women make appropriate behavioral lifestyle or medical changes based on history or physical examination

Question 40

Patient education -preconception care and healthcare

Answer 40

preconception care is not limited to single visit to a health professional but is a process of care that is designed to meet the needs and improve the health of women during the different stages of their reproductive life
• All women and men of reproductive age are candidates for preconception care ,

Question 41

Preconception care for men

Answer 41

• CDC recommends when conceive is planned man should have medical evaluation to prevent and identify disease and provide preconception education –Counseling to avoid certain risks , counseling men to engage in healthy behaviors

Question 42

Diagnosis of pregnancy

Answer 42

• Diagnosis of pregnancy is based on combination of the presumptive probable and positive changes or signs of pregnancy and info is obtained through history physical and pelvic exams and lab and diagnostic studies

Question 43

Presumptive signs of pregnancy

Answer 43

• Presumptive signs of pregnancy ; include all subjective signs of pregnancy physiological changes perceived by the woman
• Amenorrhea-absence of ministration
• nausea and vomiting coming from weeks two through 12
• rest changes begin to appear at two to three weeks enlargement tenderness tingling increased vascularity
• fatigue common during 1st trimester
• urination frequency related to pressure of enlarging uterus on bladder decreases as uterus moves upward out of pelvis
• quickening a woman’s first awareness of fetal movement occurs around 18 to 20 weeks gestation and primigravida’s (between 14 and 16 weeks in multigravida’s)
• These changes could have causes outside of pregnancy and are not considered diagnostic

Question 44

Probably signs of pregnancy

Answer 44

• probable signs of pregnancy -are objective signs of pregnancy and include all physiological and anatomical changes that can be perceived by health care provider
• chadwicks sign -blueish purple coloration of the vaginal mucosa cervix and vulva seen at 6-8 weeks
• goodells sign -softening of the cervix and vagina would with increased leukorrheal discharge palpated at 8 weeks
• hagar’s sign -softening of the lower uterine segment palpated at six weeks
• uterin growth and abdominals growth
• skin hyperpigmentation -melasma-cholasma-also referred to as the mask of pregnancy ;brownish pigmentation over the forehead temples cheek and or upper lip -linea nigra dark line that runs from umbilicus to the pubis -nipples and areola become darker more evident in primigravidas and dark haired women
• ballottement a light tap of the examining finger on the cervix causes fetus to rise in the amniotic fluid and then rebound to its original position occurs at 16 to 18 weeks –
• positive pregnancy test results -laboratory tests are based on detection presence of HCG in maternal urine or blood -tests are extremely accurate but not 100% can be both false positive and false negative results ‘cause of this a positive pregnancy test is considered a probable rather than a positive sign of pregnancy -a maternal blood pregnancy test can detect HCG levels before a missed. -A urine pregnancy test is best performed using a first morning urine specimen highest concentration of HCG becomes positive about four weeks after conception -home pregnancy test accurate but not 100% are simple to perform use enzymes rely on color change when an gluten nation occurs indicating a pregnancy home test can be performed at time of missed mentor. Or as early as one week before missed. If a negative result occurs the instruction suggests the test be repeated in one week if menstrual period has not begun
• These changes could also have causes other than pregnancy and are not considered diagnostic that presumptive and probable signs of pregnancy are important components of the assessment and confirming a pregnancy early in gestation before any positive signs of pregnancy a combination of presumptive and probable science is used to make a practical diagnosis of pregnancy

Question 45

Positive signs of pregnancy

Answer 45

• Positive signs of pregnancy are objective signs of pregnancy that only can be attributed to the fetus ;auscultation of the fetal heart by 10 to 12 weeks gestation with a Doppler , observation and palpation of fetal movement by the examiner after about 20 weeks gestation , sonographic visualization of the fetus cardiac movement noted at 4 to 8 weeks

Question 46

Sonographic diagnosis of pregnancy

Answer 46

• sonographic diagnosis of pregnancy ; ultrasound using vaginal probe can confirm pregnancy slightly earlier than with transabdominal method with trans vaginal ultrasound gestation ilsac is visible by 4.5 to 5 weeks gestation an fetal cardiac movement can be observed as early as four weeks gestation ultrasound has increasingly become a routine and expected part of prenatal care indications for ultrasound examination of an early pregnancy for purposes of diagnosis include : pelvic pain or vaginal bleeding in first trimester ,history of repeated pregnancy loss or ectopic pregnancy implantation of a fertilized Ovum outside uterus , uncertain menstrual history , discrepancy between actual size and expected size of pregnancy based on history .

Question 47

Pregnancy

Answer 47

• Pregnancy -antepartum or prenatal. Begins with first day of last menstrual period and ends with onset of Labor known as intrapartal period

Question 48

Trimesters

Answer 48

• three trimesters of pregnancy ;1st trimester -first day of last menstrual period through 14 completed weeks , 2nd trimester -15 weeks through 28 completed weeks , 3rd trimester -29 weeks through 40 completed weeks

Question 49

Due date calculation

Answer 49

• due date calculation -also known as estimated date of delivery EDD calculation of EDD is best accomplished with a known and certain LMP if LMP is unknown other tools are used to determine most accurate EDD possible :physical examination to determine uterine size , first auscultation of fetal heart rate with a Doppler and or a fetoscope (stethoscope for auscultation of fetal heart tones ), date of quickening , ultrasound examination , history of assisted reproduction

Question 50

Naegeles rule

Answer 50

• Naegeles rule- is the standard formula for determining an ivd based on the LMP :first day of LMP -three months +seven days , two factors influence accuracy of this rule -regularity of a woman’s menstrual cycles , length of a woman’s menstrual cycles -results may not be accurate if minstrel cycles are not regular or are greater than 28 days apart . most women give birth within three weeks before or two weeks after their EDD

Question 51

Full term, early term, late term

Answer 51

• length of pregnancy is approximately 280 days or 40 weeks from first day of LMP
• window for full term gestation is between 38 and 42 weeks from the LMP , infant mortality is lowest for deliveries between 39 weeks 0 days and 41 weeks 6 days , early term is between 37 weeks 0 days and 38 weeks 6 days , late term births between 41 weeks 0 days and 41 weeks 6 days , postterm 42 weeks 0 days and beyond.

Question 52

Gestational age

Answer 52

• Gestational age-refers to number of completed weeks of fetal development embryologists date fetal age and development from time of conception known as conceptual or embryological age which is usually two weeks less -this book will be using just stational age based on time since last menstrual period and not time since conception
• weeks of gestation -Once EDD is determined pregnancy is counted in terms of weeks of gestation beginning with first day of LMP and ending with 40 completed weeks , the just stational wheel is 1 tool for quickly and easy easily calculating the EDD, but it is less reliable than naegeles rule.

Question 53

Prenatal assessment terminology

Answer 53

• Prenatal assessment terminology -G/P gravida anpara are terms used in describing numbers of pregnancies and births , gravida refers to total number of times a woman has been pregnant , para refers to number of births after 20 weeks gestation whether live births or stillbirths there is no reference to number of fetuses delivered with this system -Twins count as one delivery , pregnancy that ends before 20 weeks gestation is considered an abortion

Question 54

GTPAL

Answer 54

• GTPAL (gravida , term , para , abortion , living ) -G -total number of times pregnant , T -number of term infants born (between 38 and 42 weeks gestation ), P number of pre term infants born between 20 and 37 6 /7weeks , A- number of abortions either spontaneous or induced before 20 weeks gestation or less than 500 grams at birth , L- the number of children currently living , M -is sometimes added representing pregnancies with multiple gestations (GTPALM)

Question 55

Nulligravida

Answer 55

woman who has never been pregnant or given birth

Question 56

Primigravida

Answer 56

a woman who is pregnant for first time

Question 57

Multigravida

Answer 57

a woman who is pregnant for at least the second time

Question 58

Antepartal nursing care

Answer 58

• antepartal nursing care - Care the nurses provide to women before during and after birth is fundamental to well being of them and their newborns

Question 59

Prenatal , Prenatal assessment

Answer 59

• prenatal assessment -prenatal. Entire period a woman is pregnant through the birth of baby prenatal care (PNC) is health care related to pregnancy also referred to as Antenatal care.

Question 60

Nursing interactions

Answer 60

• Nursing interactions nurse places emphasis on health education and health promotion involving the woman in her care , integrated view of health inherent in nursing care for the childbearing woman and her family contributes to a unique situation in which the anti portal patient has ready access to health information individualized woman centered support and guidance to help achieve the healthiest possible pregnancy and best possible outcome

Question 61

Adequate prenatal care

Answer 61

• adequate prenatal care -‘s a comprehensive process in which problems associated with pregnancy are identified and treated three basic components of adequate prenatal care have been identified early and continuing risk assessment , health promotion , an medical and psychosocial intervention with follow up , aim is to detect any potential problems early prevent them if possible and direct women to appropriate specialists or hospitals if necessary , prenatal care also provides an opportunity to prevent and manage concurrent diseases through integrated service delivery - prenatal nursing care and interventions also contribute to women and families ability to make informed choices about health care of the entire family throughout the childbearing cycle based on info provided by nurse and integrated with families personal values preferences and beliefs one of the healthy people 2020 objectives is to increase the proportion of women who receive early inadequate prenatal care from 70 to 78%

Question 62

Family centered maternity care

Answer 62

• family centered maternity care is based on a view that pregnancy and childbirth are normal life events alaih transition that is not primarily medical but rather developmental

Question 63

Initial prenatal visit

Answer 63

• initial prenatal visit -parallels a preconception health care visit includes info about health health history of father of the baby (blood type RH status current health status history of any chronic or past medical problems genetic history occupation lifestyle factors impacting health and his involvement in the woman’s life and with her pregnancy )
• early initiation of prenatal care is encouraged for optimization of maternal health and infectious disease screening

Question 64

Prenatal visits

Answer 64

• the focus of patient education and anticipatory guidance shifts towards pregnancy related health concerns but basic components of visit and the emphasis on health maintenance and health promotion remain the same prenatal visits also include specific assessment of the pregnancy and fetal status some components are uniform across all prenatal visits and others are specific to one or more trimesters of the pregnancy
• subsequent prenatal visits are more abbreviated than the initial visit with nursing care and interventions focused on current pregnancy status and patient needs always with emphasis on patient education and anticipatory guidance
• the number of prenatal care visits in low risk women in developed countries is 7 to 12 per pregnancy , current guidelines on frequency of prenatal visits his monthly up to 28 weeks gestation then every two to three weeks between 28 and 36 weeks gestation and then weekly from 36 weeks gestation until delivery

Question 65

Goals of prenatal care

Answer 65

• Goals of prenatal care -maintenance of maternal fetal health -accurate determination of just stational age - ongoing assessments of risk status an implementation of risk appropriate intervention -build report with child bearing family referrals to appropriate resources

Question 66

Nursing actions

Answer 66

• nursing actions -provide comfort privacy and use therapeutic communication techniques -demonstrate sensitivity thord patient related to the personal nature of interview and conversation -obtain womans identifying information (initial prenatal visit ) -obtain complete health history -initial prenatal visit -or an interval history -subsequent visits -, conduct a review of systems initial prenatal visit , obtain blood pressure temperature pulse respirations weight height and BMI initial prenatal visit , assess for absence or presence of edema, provide anticipatory guidance for patient before and during the physical exam , assist with physical and pelvic exam as needed , assist with obtaining specimens for laboratory or diagnostic studies as ordered and assess urine specimen for protein glucose and ketones , provide teaching about procedures as needed , provide anticipatory guidance related to the plan of care and appropriate follow up including how and when to contact care provider with warning signs or symptoms , Provide teaching appropriate for the woman her family and her just stational age assess womans understanding of the teaching provided allow time for the woman to ask questions , document according to agency protocol all findings interventions and education provided , assess for intimate partner violence - culture assessment is an important part of prenatal care the nurse should assess woman’s belief values and behaviors that relate to pregnancy and childbearing this includes info about ethnic background religious preferences language communication style common etiquette practices and expectations of the health care system

Question 67

First trimester- initial prenatal assessment

Answer 67

• 1st trimester during initial prenatal visit woman learns frequency of follow up visits and what to expect from her prenatal visits as the pregnancy progresses , if woman presents late for prenatal care and is in her second or third trimester at her initial prenatal visit the nurse may need to modify typical patient education content to meet current needs of the patient and her family , at every prenatal care encounter it’s imperative that nurse provides a relaxed environment for women and her family where they feel comfortable asking questions and sharing personal details about their lives relating to health of woman fetus and developing family
• intimate partner violence - information is on module

Question 68

Components of initial prenatal assessment

Answer 68

• components of initial prenatal assessment -history of current pregnancy -first day of LMP and degree of certainty about the date , regularity frequency and length of menstrual cycles , recent use or cessation of contraception , women’s knowledge of conception date , signs and symptoms of pregnancy whether the pregnancy was intended , woman’s response to being pregnant
• obstetric ull history detail about all previous pregnancies :GT PAL , whether abortions if any were spontaneous or induced , dates of pregnancies, length of gestation, type of birth experiences induced or spontaneous labours vaginal or cesarean births the use of four steps or vacuum assist type of pain management , complications with pregnancy labor or birth , neonatal outcomes including apgar scores birthweight neonatal complications feeding method health and development since birth , pregnancy loss and grieving status,
• Physical and pelvic examinations - the bimanual component of pelvic examination enables examiner to internally palpate the dimensions of the enlarging uterus when gestational age is uncertain decision may be made to perform an ultrasound examination of pregnancy to determine the EDD., clinical pelvimetry (measurement of dimensions of Bony pelvis through palpation during internal pelvic examination) may be performed during initial pelvic examination however routine is not recommended
• assessment of uterine growth -uterine growth after 10 to 12 weeks is assessed by measuring height of the fundus with use of a centimeter measuring tape the zero point of tape is placed on the synthesis pubis and tape is then extended to top of the fundus measurement should approximately equal number of weeks pregnant instruct women to empty her bladder before the measurement because a full bladder can displace the uterus , maternal position an examiner uniformity are variables that render this evaluation somewhat imprecise but it’s useful as a gross measure of progressive fetal growth well as well as able to help identify pregnancy that is growing outside optimal or normal range either too large or too small for gestational age this serves as a screening tool for fetal growth
• assessment of fetal heart tones with an ultrasound Doppler in the first trimester initially heard by 10 and 12 weeks gestation the normal fetal heart rate baseline is between 1:10 and 160 beats per minute

Question 69

Comprehensive laboratory and diagnostic studies

Answer 69

• comprehensive laboratory and diagnostic studies -laboratory studies are ordered or obtained at the initial prenatal visit to establish baseline values for follow-up in comparison as pregnancy progresses , ultrasound might be performed during 1st trimester to confirm intrauterine pregnancy viability and gestational age

Question 70

Warning danger signs of first trimester

Answer 70

• Warning danger signs of the 1st trimester -abdominal cramping or pain indicates possible threatened abortion UTI or appendicitis ,vaginal spotting or bleeding indicates possible threatened abortion ,absence of fetal heart tone indicates possible missed abortion, dysuria frequency and urgency indicate possible UTI , fever or chills indicate possible infection , prolonged nausea and vomiting indicate possible hyperemesis gravidarum increased risk of dehydration .

Question 71

Nutritional assessment and education

Answer 71

• Nutritional assessment and education -about 40% of pregnant women in Western countries gain more than recommended during pregnancy -obesity during pregnancy has been linked to adverse fetal outcomes as well as childhood and adult obesity in their offspring , nutrition should be discussed at all prenatal visits to reinforce importance of appropriate weight gain as both excessive and inadequate weight gain in pregnancy are associated with poor perinatal outcomes
• discuss appetite cravings or food aversions
• obtain a 24 hour diet recall and review for obvious deficiencies
• based on women’s prepregnancy BMI and IOM guidelines :assist woman to set weight gain goals with a recommended weight gain of between one and 5 pounds during the first trimester , discussed distribution of weight gain during pregnancy, encourage the woman to eat a variety of unprocessed foods from all food groups including fresh fruits vegetables whole grains lean meats or beans and low fat dairy products,
• encourage the woman to drink 8 to 10 glasses of fluid per day Ann limit caffeine to 200 milligrams per day
• certain types of fish King mackerel orange roughy Marlin shark swordfish and tilefish should be avoided due to high levels of Mercury however most other fish and seafood are safe as long as fully cooked tuna is safe but limit white albacore tuna to 6 ounces per week
• advise on prevention of foodborne illnesses -wash hands frequently before and after handling food use warm water and soap, Thoroughly rinse all raw vegetables and fruits before eating, cook eggs and all meats poultry or fish thoroughly and sanitize all dishes utensils cutting boards in areas that contact these during food preparation, discard cooked food left out at room temperature for more than two hours,
• foods to avoid unpasteurized juices or dairy products, raw sprouts of any kind unpasteurized soft cheese like Brie cambert or fetayeah refrigerated smoked seafood , unheated deli meats or hot dogs, raw eggs, raw fish and shellfish, teas with camel meal peppermint licorice or Raspberry leaf

Question 72

Initial prenatal labs with rationale

Answer 72

• initial prenatal labs with rationale
• blood type and RH factor with antibody screening to identify isoimmunization patients found to be orange negative should be re screened in 2nd trimester and given rho gam at 28 weeks and again after delivery if infant is RH positive
• HCT or HGB blood volume in pregnancy increases more than red cell volume and hematocrit typically falls therefore HCT or HGB levels should be monitored for signs of anemia , anemia is often caused by iron deficiency and should be treated with supplemental iron taken in addition to routine prenatal vitamins a normal term pregnancy requires approximately 1 gram of iron an amount not adequately supplied in the diet
• rubella to determine if the mother is acceptable or immune if susceptible she should receive vaccination postpartum
• varicella to determine if mother is acceptable or immune if suseptable she should receive vaccination postpartum
• Venereal disease research laboratory or rapid plasma regain to check for Sarah logical evidence of syphilis so treatment can be initiated as soon as possible to avoid vertical transmission and the sequelae of congenital syphilis
• gonorrhea and CLA Medea test to identify and treat infection
• urine culture to identify and treat UTI including asymptomatic bacteriuria which is associated with a 25% risk of pyelonephritis if left untreated
• Hepatitis B surface antigen to identify women whose infants need immuno prophylaxis post delivery to minimize risk of congenital infection and carrier status
• HIV serology anti retroviral therapy during gestation and around the time of delivery can decrease risk of vertical transmission to less than 2% HIV positive women should be counseled on risk and benefits of treatment and mode of delivery
• women aged 21 to 29 years should have cytology screening every three years women aged 30 to 65 years should have human papilloma virus an cytology Co screening every five years or cytology alone every three years
• discussion of prenatal screening for chromosome abnormalities genetic disease and birth defects should be performed and documented in the patient’s medical record topics to be addressed include:
prenatal screening and diagnostic tests for chromosome abnormalities options include first trimester screening , quad screen, and integrated sequential screening. Alpha fetal protein AFP alone is not an acceptable screening strategy for chromosome abnormalities , AFP for neural tube defect screening, cystic fibrosis carrier screening is offered to caucasians and discussed with other patients as they desire, hemoglobin Electrophoresis for patients at risk of sickle cell trait thalassemia or other hemoglobinopathies include African American patients and patients of Mediterranean or Asian ancestry, tay sachs and canavan and familial dysautonomia for patients of Eastern European Jewish ancestry, tuberculosis skin test for patients at risk for example recent immigrants from developing countries inmates residents of mental institutions or group homes .

Question 73

Migrant women

Answer 73

• migrant women - pregnancy can be an entry point into health care system for immigrant women though they are less likely to access maternal care services than their non immigrant counterparts in a review reported that immigrants were more likely to receive inadequate prenatal care initiate prenatal care late in pregnancy and have fewer than the recommended number of prenatal appointments in current systematic review of qualitative research in case migrant women had pregnancy expectations strongly rooted in home beliefs values and practices that were supported by family husbands and friends it is recommended that strategies be implemented to increase cultural sensitivity within the HCS and recognize a need for awareness that immigrant women may be isolated in their new country and need additional assistance to navigate an unfamiliar system, for example findings indicate women with support from community an from providers were more likely to be receptive to the care and accept new practices if they understood their benefit or if the practice was supported by someone they knew

Question 74

Patient education first trimester

Answer 74

• patient education -1st trimester patient education –
• general information about physical changes
• general information about common discomforts of pregnancy relief measures for normal discomforts in early pregnancy are discussed based on patient need
• general information about fetal development by end of 1st trimester fetus is 3 inches in length and weighs 1 to 2 ounces all organ systems are present head is large and heartbeat is audible with Doppler
• general health maintenance health promotion information –
• avoid exposure to tobacco alcohol and recreational drugs
• avoid exposure to environment hazards with teratogenic effects
• obtain input from care provider before using medications complementary and alternative medicine and nutritional supplements
• reinforce safety behaviors
• recognize need for additional rest
• maintain daily hygiene
• decrease risk for UTI’s and vaginal infections by wiping from front to back wearing cotton underwear maintaining adequate hydration voiding after intercourse and not douching
• maintain good oral hygiene gently brushing of teeth and flossing continue routine preventative dental care
• exercise 30 minutes each day avoid risk for trauma to abdomen over avoid overheating and maintain adequate hydration while exercising
• establish daily kegl exercise routine to maintain pelvic floor muscle strength and decrease risk of urinary incontinence and uterine prolapse
• travel is safe and low risk pregnancy need to stop more frequently to stretch and walk to to decrease risk of thrombophlebitis take copy of prenatal record
• use coping strategies for stress such as relaxation exercises and meditation
• communicate with partner regarding changes in sexual responses sexual responses slash desires change throughout pregnancy couples need to talk openly about these changes and explore different sexual positions that accommodate the changes of pregnancy
• warning danger signs that need to be reported to the care provider

Question 75

Second trimester visits

Answer 75

• Second trimester-Subsequent or return prenatal visits begin with a chart review from the previous visit(s) and an interval history. This history includes information about the pregnancy since the previous prenatal visit
• ● Focused physical assessment
• ● Vital signs
• ● Vital signs within normal limits; slight decrease in blood pressure toward end of second trimester
• ● Weight
• ● Average weight gain per week depending on prepregnancy BMI (see Box 4–2)
• ● Urine dipstick for glucose, albumin, and ketones
• ● Mild proteinuria and glucosuria are normal.
• ● FHR ● Able to auscultate FHR with Doppler; rate 110 to 160 bpm (Fig. 4–10)
• ● Fetal movement
• ● Assess for quickening (when the woman feels her baby move for the first time).
• ● Leopold’s maneuvers (palpation of the abdomen) to identify the position of the fetus in utero (Chapter 8)
• ● Examiner able to palpate fetal parts.
• ● Presence of edema
• ● Slight lower-body edema is normal due to decreased venous return.
• ● Upper-body edema, especially of the face, is abnormal and needs further evaluation.
• ● Fundal height measurement
• ● Fundal height should equal weeks of gestation.
• ● Confirm established due date:
• ● Quickening occurs around 18 weeks’ gestation (usually between 18 and 20 weeks of gestation, but sometimes as early as 14 to 16 weeks of gestation in a multigravida and occasionally as late as 22 weeks of gestation in some primigravidas).
• ● Ultrasound around 20 weeks’ gestation to confirm EDD and scan fetal anatomy

Question 76

Laboratory and diagnostic studies

Answer 76

• ● Laboratory and diagnostic studies:
• ● Triple screen, quad screen, or penta screen blood tests at 15 to 23 weeks of gestation (Chapter 6): Screening tests for neural tube defect and trisomy 21 are not diagnostic. Amniocentesis offered if screening tests are positive.
• ● Screening for gestational diabetes: 1-hour glucose challenge test recommended between 24 and 28 weeks; 3-hour glucose tolerance test (GTT) is ordered if 1-hour screen is elevated.
• ● Hemoglobin and hematocrit between 28 and 32 weeks to identify anemia and the need for an iron supplement. This is the time in pregnancy when the hemoglobin and hematocrit are likely to be at their lowest, so the result provides the care provider with valuable information for management of late pregnancy.
• ● Syphilis serology if prevalent or as indicated
• ● Antibody screen for Rh-negative women
• ● All pregnant women should be offered prenatal assessment for chromosomal abnormalities by screening or diagnostic testing regardless of age or other risk factors (ACOG, 2016).
• ● Administer anti-D immunoglobulin (i.e., RhoGAM) to Rh-negative women with negative antibody screen results.
• ● Anti-D immunoglobulin is administered at 28 weeks’ gestation to help prevent isoimmunization and the resulting risk of hemolytic disease in fetuses in subsequent pregnancies.

Question 77

Rhogam

Answer 77

• Rhogam-Lab screening during an initial prenatal visit includes blood type and Rh factor with antibody screening to identify isoimmunization. Patients found to be Rh negative should be rescreened in the second trimester and given RhoGAM at 28 weeks and again after delivery if the infant is Rh positive.
• ● Indication: Administered to Rh-negative women prophylactically at 28 weeks’ gestation to prevent isoimmunization from potential exposure to Rh-positive fetal blood during the normal course of pregnancy. Also administered with likely exposure to Rh-positive blood, such as with pregnancy loss, amniocentesis, or abdominal trauma. If the infant is Rh positive, another dose is given within 72 hours after delivery.
• ● Action: Prevents production of anti-Rh(D) antibodies in Rh(D)-negative women exposed to Rh(D)-positive blood. Prevention of antibody response and hemolytic diseases of the newborn (erythroblastosis fetalis) in future pregnancies of women who have conceived a Rh(D)-positive fetus.
• ● Adverse reactions: Pain at intramuscular (IM) site; fever
• ● Route/dosage: One vial standard dose (300 mcg) IM at 28 weeks’ gestation. Use cautiously in patients with preexisting idiopathic thrombocytopenic purpura (ITP) anemia.

Question 78

Warning danger signs of 2nd trimester

Answer 78

• Warning/Danger Signs of the Second Trimester
• • Abdominal or pelvic pain indicates possible preterm labor (PTL), UTI, pyelonephritis, or appendicitis.
• • Absence of fetal movement once the woman has been feeling daily movement indicates possible fetal distress or death.
• • Prolonged nausea and vomiting indicates possible hyperemesis gravidarum; at risk for dehydration.
• • Fever and chills indicates possible infection.
• • Dysuria, frequency, and urgency indicate possible UTI.
• • Vaginal bleeding indicates possible infection, friable cervix due to pregnancy changes, placenta previa, abruptio placenta, or PTL.

Question 79

Patient education topics during second trimester

Answer 79

• Patient education topics during the second trimester should include the following:
• ● Information on fetal development during the second trimester
• ● At 20 weeks’ gestation, the fetus is 8 inches long, weighs 1 pound, and is relatively long and skinny.
• ● General health maintenance/health promotion topics
• ● Nutritional follow-up and reinforcement
• ● Recommend increase in daily caloric intake by 340/kcal/day during second trimester (IOM, 2006).
• ● Offer counseling and guidance on dietary intake or physical activity as needed.
• ● Information on physical changes during the second trimester (see Table 4–1)
• ● Relief measures for normal discomforts commonly experienced during the second trimester (see Table 4–5)
• ● Reinforce warning/danger signs that need to be reported to care provider.
• • Signs and symptoms of PTL:
● Rhythmic lower abdominal cramping or pain
● Low backache
● Pelvic pressure
● Leaking of amniotic fluid
● Increased vaginal discharge
● Vaginal spotting or bleeding
• ● Signs and symptoms of hypertensive disorders: ● Severe headache that does not respond to usual relief measures
● Visual changes
● Facial or generalized edema
• ● Information about the benefits and risks of procedures and tests with goal of enabling the woman to make informed decisions about what procedures she will choose based on her knowledge of the available options coupled with her and her family’s values and beliefs.

Question 80

Third trimester assessment/visit

Answer 80

• Third trimester assessment/visit- includes all aspects of the second trimester assessment and may also include a pelvic examination to identify cervical change, Assessment of pregnancy in the third trimester becomes more frequent and involved than in previous return visits as the pregnancy advances and the fetus nears term
• ● Chart review
• ● Interval history
• ● Focused assessment (e.g., fundal height)
• ● Assessment of fetal well-being
● Auscultation of FHR
● Record woman’s assessment of “kick counts”
● Daily fetal movement count (kick counts) is a maternal assessment of fetal movement by counting fetal movements in a period of time to identify potentially hypoxic fetuses. Maternal perception of fetal movement was one of the earliest tests of fetal well-being The pregnant woman is instructed to palpate the abdomen and track fetal movements daily by tracking fetal movements for 1 or 2 hours.
● In the 2-hour approach recommended by the American College of Obstetricians and Gynecologists (ACOG), maternal perception of at least 10 distinct fetal movements within 2 hours is considered reassuring; once movement is achieved, counts can be discontinued for the day.
● In the 1-hour approach, the count is considered reassuring if it equals or exceeds the established baseline; in general, 4 movements in 1 hour is reassuring.
● Define fetal movements or kick counts to include kicks, flutters, swishes, or rolls.
● Instruct mother to keep journal or documentation of the time it takes to feel fetal movement
. ● Instruct mother to perform counts at same time every day.
● Instruct mother to monitor time intervals it takes and to contact HCP immediately for deviations from normal (i.e., no movements or decreased movements).
● Decreased fetal activity should be reported to the provider, as further evaluation of the fetus, such as a nonstress test or biophysical profile, is indicated.
● Pelvic examination to identify cervical change, depending on weeks of gestation and maternal symptoms
• ● Leopold’s maneuvers to identify the position of the fetus in utero (Chapter 8)
• ● Screening for Group B Streptococcus (GBS)
● One-quarter to one-third of women are colonized with GBS in the lower gastrointestinal or urogenital tract (typically asymptomatic).
● GBS infection in a newborn, either early onset (first week of life) or late onset (after first week of life), can be invasive and severe, with potential long-term neurological sequelae.
● Vaginal and rectal swab cultures are done at 35 to 37 weeks’ gestation to determine presence of GBS bacterial colonization before the onset of labor to anticipate intrapartum antibiotic treatment needs

Question 81

Laboratory tests and screening/ additional discussion topics

Answer 81

• ● Laboratory tests and screening \
● 1-hour glucose test at 24 to 28 weeks’ gestation (may have already been done in second trimester)
● Hemoglobin and Hematocrit (H & H) (if not recently done in second trimester)
● Repeat gonorrhea culture (GC), chlamydia, syphilis test by rapid plasma reagin (RPR) if indicated and not screened in second trimester, HIV, and hepatitis B surface antigen (HBsAg) tests as indicated
• ● Travel limitations may be suggested in the last month.
• ● Discussion of preparation for labor and birth
● Attend childbirth classes
● Discuss the method of labor pain management
● Develop birth plan; list preferences for routine procedures
• ● Signs of impending labor
• ● Discussion of true versus false labor
• ● Instruction on when to contact the doctor or midwife
• ● Instructions on when to go to the birthing unit
• ● Discussion on parenting and infant care
● Attend parenting classes
● Select the method of infant feeding
● Select the infant health care provider
● Prepare siblings

Question 82

Warning danger signs of third trimester

Answer 82

• Warning/Danger Signs of the Third Trimester
• • Abdominal or pelvic pain (PTL, UTI, pyelonephritis, appendicitis)
• • Decreased or absent fetal movement (fetal hypoxia or death)
• • Prolonged nausea and vomiting (dehydration, hyperemesis gravidarum)
• • Fever, chills (infection) • Dysuria, frequency, urgency (UTI)
• • Vaginal bleeding (infection, friable cervix due to pregnancy changes or pathology, placenta previa, placenta abruptio, PTL)
• • Signs/symptoms of PTL: Rhythmic lower abdominal cramping or pain, low backache, pelvic pressure, leaking of amniotic fluid, increased vaginal discharge
• • Signs/symptoms of hypertensive disorders: Severe headache that does not respond to usual relief measures, visual changes, facial or generalized edema.

Question 83

Patient education in third trimester

Answer 83

• Patient education for women in the third trimester should include the following:
• ● Information about fetal growth during the third trimester
• ● At term fetus is about 17 to 20 inches in length, weighs between 6 and 8 pounds, has increased deposits of subcutaneous fat, and has established sleep and activity cycles.
• ● General health maintenance/health promotion topics
• ● Nutritional follow-up and reinforcement
• ● Recommend increase in daily caloric intake by 452/kcal/day during third trimester (IOM, 2006).
• ● Offer counseling and guidance on dietary intake or physical activity as needed.
• ● Information on physical changes during the third trimester (Table 4–4).
• ● Relief measures for normal discomforts commonly experienced during the third trimester (Table 4–5).
• ● Reinforce warning/danger signs that need to be reported to care provider.
• look at pgs 94, 95 and 96 paste into mod or notes and constipation concept map.