Promotion of women's health during pregnancy: Ch 19

Question 1

What vaccinations are important concerning pregnancy?

Answer 1

Hep B- should be vaccinated during pregnancy if not immune.
inluenza- should be vaccined with inactive form- NOT the live one
HPV- vaccination should ideally be given prior to coitarche; contraindicated during pregnancy
rubella- if not immune, mom should be cautioned to avoid anyone with a rash or viral illness and should be vaccinated after giving birth

Question 2

What are presumptive signs/ symptoms of pregnancy?

Answer 2

Signs or symptoms frequently reported with pregnancy, although not conclusive for pregnancy. Include amenorrhea, breast tenderness and enlargement, Chadwick’s sign, fatigue, hyperpigmentation, chloasma, linea nigra, fetal movements (quickening), urinary frequency, nausea, vomiting.

Question 3

What are probable signs/ symptoms of pregnancy?

Answer 3

Signs or symptoms that are more reliable indicators of pregnancy, often noted on the physical examination or with laboratory testing. Include abdominal enlargement, ballottment, Braxton- hicks contractions, Goodell’s sign, Hegar’s sign, palpitation of fetal contours, positive pregnancy test, uterine enlargment

Question 4

What are positive signs/ symptoms of pregnancy?

Answer 4

Signs or symptoms that provide absolute confirmation of pregnancy, when noted. Include auscultation of fetal heart rate, palpitation of fetal movements, radiologic and/ or ultrasonic verification of gestation

Question 5

What hormone is detected in pregnancy tests? How does the level of this hormone fluctuate throughout pregnancy?

Answer 5

Human chorionic gonadotropin (hCG) is detected in pregnancy at about the time of implantation. Levels in normal pregnancy usually double every 1.4 to 2.0 days. Levels peak at approximately 60 to 90 days postfertilization, and then decrease to plateau at 16 weeks of pregnancy.

Question 6

What can help determine the viability of a pregnancy?

Answer 6

Quantitative, serial measurements of serum beta-subunit hCG (β-hCG); Serum and urine tests specific for β-hCG have accuracy rates of 99 percent, with few false positives.

Question 7

What does the initial prenatal visit include?

Answer 7

Confirmation of pregnancy with a β-hCG urine test, auscultate fetal heart tones (FHTs), or perform ultrasound; if all three are negative but pregnancy is still suspected, retest using a radioimmunoassay β-hCG serum test.
Thorough history and physical, determine expected date of delivery, routine labs, risk assessment, give prenatal educational materials/ anticipatory guidance and teaching

Question 8

What is included in routine blood work to be done on all prenatal patients? (19.3)

Answer 8

ABO blood group/Rh factor identification/antibody screen
Complete blood cell count with indices (Hb, Hct, MCV, MCH, MCHC)
Rubella titer
Syphilis screening/VDRL, RPR
Hepatitis B surface antigen
Urinalysis and urine culture
Chlamydia screening
Cervical cytology (if indicated by routine screening guidelines)
HIV antibody screening
Hb—hemoglobin
Hct—hematocrit
HIV—human immunodeficiency virus
MCHC—mean corpuscular hemoglobin concentration
MCH—mean corpuscular hemoglobin
MCV—mean corpuscular volume
RPR—rapid plasma reagin
VDRL—Venereal Disease Research Laboratories test

Question 9

When is the risk of miscarriage highest?

Answer 9

First trimester

Question 10

When should patients schedule the first visit?

Answer 10

It is common to have women schedule a first OB visit between 8 and 10 weeks, and sometimes earlier if they are planning genetic testing (i.e., chorionic villus sampling [CVS])

Question 11

What should be done at the visits during weeks 12- 16?

Answer 11

Review lab findings. Offer and order appropriate genetic testing as indicated. Follow-up on and address any medical or pregnancy risk factors. Provide anticipatory guidance related to fetal development and changes to expect as the pregnancy progresses. Counsel the client on lifestyle factors such as healthy nutrition, weight gain, and exercise.

Question 12

What should be done at visits during weeks 16- 20?

Answer 12

Assess for fetal movements (quickening), which typically occur between 16 and 20 weeks of gestation. Offer and order appropriate genetic screening tests. US evaluation can be done to confirm gestational age and assess fetal anatomy. Encourage the woman and her partner or support person(s) to enroll in prenatal childbirth education classes. Continue to provide anticipatory guidance and screen for risk factors.

Question 13

What should be done at visits during weeks 24- 28?

Answer 13

If Rh negative, reevaluate the antibody screen titer. Perform glucose screening for gestational diabetes. Administer RhoGAM (Rh immune globulin) as indicated. Retest H & H. Evaluate the client for risk of preterm labor and consider a cervical assessment including cervical position, consistency, length, and dilation, if indicated.

Question 14

When should you instruct the patient to start performing fetal movement counts (FMCs) daily?

Answer 14

around 28 weeks’ gestation

Question 15

How should we instruct patients to perform daily FMCs?

Answer 15

Note the start time, the client may lie in the left lateral position; however, a seated or standing position may also be used.
Place a hand over the abdomen to palpate movement.
Remain in this position until you have counted 10 fetal movements.
Record the end time.

Question 16

How long should it take for 10 fetal movements?

Answer 16

2 hours; if it is less then biophysical fetal assessment is indicated

Question 17

What should be done at visits during weeks 28- 35?

Answer 17

Encourage the client to begin the process of finding a health care provider for the infant. Assess the client’s breasts and discuss preparation for breastfeeding. Discuss the importance of daily fetal movement as an indicator of fetal well-being. Reassess the client for risk of preterm labor; assess the cervix as indicated. May begin assessing fetal presentation and position with Leopold’s maneuvers.

Question 18

What should be done at visits during weeks 35- 37?

Answer 18

Review with the client the signs and symptoms of labor; provide a handout listing them. Obtain a vaginal/anorectal culture for group B streptococcus. Assess for active herpes simplex virus outbreak, in those with positive history. For women at or beyond 36 weeks who are at risk for recurrent genital herpes infection, suppressive antiviral therapy may be considered. (acyclovir 400 mg twice a day or valacyclovir 500 mg twice daily until delivery). Retest for chlamydia, gonorrhea, syphilis, and/or HIV in those with infections earlier in pregnancy or those at high risk for STIs.

Question 19

What should be done at visits during weeks 37- 40?

Answer 19

Assess fetal position and presentation. Review and negotiate the client’s birth expectations. Forward a copy of the client’s prenatal records to the hospital labor area, as indicated. Document the client’s choice of a pediatrician. Initiate fetal surveillance as indicated. A cervical examination may be performed per the protocol of the institution. Review client plans for postpartum contraception, and reinforce preparation for breastfeeding. Ensure that client has made plans for infant car seat. Review signs of postpartum depression and discuss available resources should client need them.

Question 20

What should be done at visits during weeks 40 and beyond?

Answer 20

Prepare the client for postdate pregnancy protocol. Perform a cervical assessment and consider membrane sweeping if no contraindications exist, such as cervicitis, low-lying placenta or placenta previa, unknown fetal lie, and vaginal bleeding. Institute fetal surveillance, such as ultrasound, to evaluate amniotic fluid volume; nonstress testing; and semiweekly office visits, according to practice protocol.

Question 21

What are major milestones during first trimester and when do they occur?

Answer 21

fetal heart movements- 6 weeks’ gestation
closure of the neural tube- 7 weeks’ gestation
rapid head and brain growth beginning in the 7th week.

Question 22

Common physical changes during pregnancy- skin

Answer 22

Increased vascularity; increased pigmentation of face (chloasma), areola, abdomen (linea nigra), and genitalia; striae of breasts and abdomen.

Question 23

Common physical changes during pregnancy- head

Answer 23

Mild changes in scalp; excessive oiliness or dryness.

Question 24

Common physical changes during pregnancy- eyes

Answer 24

Mild corneal edema and thickening.

Question 25

Common physical changes during pregnancy- mouth

Answer 25

Edematous gums; increased gingivitis.

Question 26

Common physical changes during pregnancy- Respiration/cardiovascular

Answer 26

Physiologic dyspnea of pregnancy; progressive elevation of the diaphragm; hand/pedal edema; leg and vulvar varicosities and hemorrhoids. Exaggerated heart sounds, particularly functional systolic murmurs.

Question 27

Common physical changes during pregnancy- breasts

Answer 27

Increased fullness, tenderness, enlargement, and excretion of colostrum are common by the third trimester.

Question 28

Common physical changes during pregnancy- abdomen

Answer 28

Distention secondary to flatus and increased uterine size; diminished bowel sounds as peristaltic movements are slowed; enlarging uterus, which displaces abdominal organs.

Question 29

Common physical changes during pregnancy- Genitalia/reproduction: external

Answer 29

Increased pigmentation; pubic hair may lengthen. Near term, pelvic congestion and overall swelling of labia majora are common; vulvar varicosities may be noted.

Question 30

Common physical changes during pregnancy- Genitalia/reproduction: vagina

Answer 30

Rugation of vaginal mucosa is prominent.

Question 31

Common physical changes during pregnancy- Genitalia/reproduction: cervix

Answer 31

Chadwick’s and Goodell’s signs are noted. May soften, dilate, and efface close to term.

Question 32

What is Chadwick’s sign?

Answer 32

bluish/purple color of cervix

Question 33

What is Goodell’s sign?

Answer 33

softening with growth of cervical glands

Question 34

Common physical changes during pregnancy- Genitalia/reproduction: uterus

Answer 34

6 weeks’ gestation- Hegar’s sign
12 weeks- fundus is noted at the symphysis pubis
16 weeks- the fundus is midway between the symphysis and the umbilicus.
20 weeks- uterine fundus can be palpated at the umbilicus and measures 20 cm (Uterine enlargement occurs in linear fashion- 1 cm per week).
36 weeks- fundus is just below the xiphoid process and measures approximately 36 cm; the fundal height may decrease slightly or plateau near term (lightening). Measurement may then no longer correspond with week of gestation. The uterus maintains a globular/ovoid shape throughout pregnancy.

Question 35

What is Hegar’s sign?

Answer 35

softening of the lower uterine segment

Question 36

Common physical changes during pregnancy- Genitalia/reproduction: adnexa

Answer 36

Discomfort may be noted with exam due to stretching of the round ligaments throughout pregnancy. The ovaries are not palpable once the uterus fills the pelvic cavity at 12 to 14 weeks’ gestation.

Question 37

Common physical changes during pregnancy- Genitalia/reproduction: urinary

Answer 37

The bladder may be palpable; frequency and incontinence are common, particularly with multiparity.

Question 38

Common physical changes during pregnancy- Genitalia/reproduction: rectal

Answer 38

Increased vascular congestion with resulting hemorrhoids is often noted.

Question 39

Common physical changes during pregnancy- Genitalia/reproduction: musculoskeletal

Answer 39

Increased relaxation of pelvic structures, lordosis, sciatica, and discomfort at the symphysis pubis are common. Pain from round ligament syndrome often noted.

Question 40

Common physical changes during pregnancy- Genitalia/reproduction: endocrine

Answer 40

May have mildly enlarged thyroid; however, diffusely enlarged thyroid nodularity or increased firmness is abnormal.

Question 41

What are the recommendations for total weight gain during pregnancy for underweight, normal, overweight, and obese women?

Answer 41

underweight (BMI < 18.5)- 28-40lbs
normal weight (BMI 18.5- 24.9)- 25- 35lbs
overweight- (BMI 25- 25.9)- 15- 25lbs
obese (BMI 30+)- 11- 20lbs

Question 42

What are the danger signs/ symptoms of the first trimester?

Answer 42

spotting or bleeding; cramping; painful urination; severe vomiting and/or diarrhea; fever higher than 100.4°F; symptoms of vaginal infection or STIs; persistent or severe low abdominal pain (unilateral, bilateral, or midline); and lightheadedness or dizziness (particularly if accompanied by shoulder pain). If a woman experiences any abdominal trauma, this should be reported to her health care provider. Additionally, women and their partners should be counseled to report any new onset or exacerbations of depression and/or anxiety symptoms.

Question 43

Additional prenatal tests performed on the basis of the pt history (19.4)

Answer 43

Blood chemistry
Cystic fibrosis screen
Cytomegalovirus titer
Diabetes screening
Genetic risk screening and/or testing, such as quad screen, amniocentesis, or chorionic villus sampling
Glucose tolerance tests
Group B streptococcus culture
Hemoglobin electrophoresis
Herpes culture
Lead level
Quantitative beta-hCG
Serum iron studies
Thyroid studies
Tuberculin skin test (PPD)
Urine culture
Ultrasonography to evaluate gestational age, fetal anatomy, and/or placental location
Varicella titer