Unit 1

Question 1

What is infant mortality rate?
What are the leading cause of infant death in the US?
Factors leading to infant death include…

Answer 1

of infant deaths following live birth divided by total number of live births

Leading causes of infant deaths in US: Congenital malformations, preterm birth and LBW (most significant factor), SIDS
Factors leading to infant death include.
- Limited maternal education (low education level)
- Young maternal age (teen mom, very inexperienced, usually not a lot of support)
- Unmarried status (also associated with not having a lot of support)
- Poverty
- Lack of prenatal care
- Smoking
- Poor nutrition
- Alcohol use
- Poor overall maternal health

Question 2

Define:
Low birth weight:
Very low birth weight:
Preterm birth:

Answer 2

Low birth weight (LBW) - weight less than 5.5 pounds, or 2,500 grams
Very low birth weight (VLBW) - weight less than 3.3 pounds, or 1,500 grams
Preterm birth (PTB) - live infant birth before 37 weeks

Question 3

Causes associated with PTB and LBW infants

Answer 3

• Social causes: poverty, not having prenatal care, being of a racial or ethnic minority
• Behavioral causes: maternal stress can increase risk of PTB (usually extreme stress), substance abuse, smoking
• Physiologic cause: health problems in the mom that indicates an earlier delivery (hypertension or diabetes)
• Poor Nutrition
• Teen Pregnancy

Question 4

What is maternal mortality rate?
3 major causes:
Risks:

Answer 4

of maternal deaths divided by total # of live births

Moms that die within one year window of giving birth, specifically deaths associated with that birth or pregnancy (e.g., postpartum hemorrhage, cardiomyopathy during pregnancy leading to heart failure)
3 major causes:
- Hypertensive disorders (preeclampsia, eclampsia)
- Infection
- Hemorrhage
More maternal death in moms that are younger than 20 and older moms (35+), moms that lack prenatal care, moms with low education level, unmarried/single moms, and moms in a racial or ethnic minority
Disparities in African American women having higher levels of maternal mortality (lack of access)

Question 5

What is maternal morbidity?
Pregnancy complications include…
What greatly increases the risk for complications in pregnancy?

Answer 5

Pregnancy complications that lead to long-term problems
- Acute renal failure
- Cardiomyopathy (can lead to heart failure)
- Amniotic fluid embolism (Rare; a bubble of amniotic fluid goes to the lung; usually happens right at delivery)
- Cerebrovascular accident
- Eclampsia (developing a seizure disorder after having preeclampsia)
- Pulmonary embolism
- Liver failure
- Shock
- Septicemia
- Complications of anesthesia
Obesity greatly increases the risk for complications in pregnancy (diabetes, hypertension); it also increases risk of miscarriage, birth defects

Question 6

Risks of Teen Pregnancy include…

Answer 6

Increased risk of adverse outcomes for both mother and infant
- Maternal death
- Risk for STIs (see more STIs in younger women)
- Greater risk of cephalopelvic disproportion (CPD) (issues with baby’s head fitting through mom’s pelvis)
Less likely to receive prenatal care (not as much social support, poor, lack of transportation, more likely to abuse drugs)
More likely to have PTB and LBW infant

Question 7

Prenatal genetic testing options include…
Which tests are screening and which are diagnostic?

Answer 7

• Maternal serum screening: Offered to all moms; it is a blood test; It is a sensitive test, but it is only a screening test. This test is looking for neural tube defects and trisomy 13, 18, 21
• Fetal Ultrasound: Used as a screening test; a lot of physical anomalies associated with genetic disorders can be seen on ultrasound
• NIPT (Non-invasive prenatal testing): Serum blood test; screening test
• Amniocentesis and Chorionic Villus Sampling: diagnostic test that confirms a genetic disorder

Question 8

What is carrier testing?

Answer 8

Identifies individuals who have a gene mutation for an autosomal recessive condition
Sickle cell anemia, Cystic fibrosis, Tay-Sachs disease

Question 9

What is predictive testing?
Presymptomatic testing?
Predispositional testing?

Answer 9

Predictive: used to clarify genetic status of asymptomatic family members
Presymptomatic: symptoms will definitely appear if the patient has the mutation (if they live long enough). Ex: Huntington’s Disease - autosomal dominant mutation
Predispositional: tests for a genetic mutation that, if present, increases the predisposition for that problem or disease. Ex: BRCA 1, + results do not mean there is a 100% risk of developing the condition (breast cancer)

Question 10

Describe newborn screening

Answer 10

Mandatory state-supported public health program
Screens for over 50 disorders
Cystic fibrosis, Tay-Sachs, PKU, Galactosemia, Congenital hypothyroidism, Sickle cell anemia
If it comes back abnormal, the infant will have follow-up with pediatrician

Question 11

What is trisomy 21?
What are the common characterisitcs?
What is a big risk factor for trisomy 21?

Answer 11

Down’s Syndrome: one of the more common genetic disorders; affects the 21st pair of chromosomes -> extra chromosome; 1 in 691 babies are affected
Characteristics:
- All individuals have some degree of intellectual disability
- Upward slant of eyes
- Small skin folds in inner corner of eyes (epicanthal folds)
- Flat facial profile, depressed nasal bridge and small nose (seen on ultrasound)
- Small, low-set ears
- Enlarged tongue
- Small deep crease across center of palms (simian crease)
- Hypotonia - low muscle tone
- Hyperflexibility (joints are extremely flexible “floppy baby”)
- Also will see a shorter, webbed neck
- Typically small babies
BIG risk factor of Down Syndrome -> older moms (35+)

Question 12

Describe Trisomy 18
What are the common characteristics?

Answer 12

“Edward syndrome”: 1 in every 3,000 live births
- Severe mental retardation
- CNS abnormalities
- Craniofacial abnormalities
- Cleft lip/cleft palate
- Really small mouth and jaw; the babies themselves are very small
- Cardiac malformations are common
- Rocker bottom feet and clenched fist (will see on ultrasound)
- Classic: rocker bottom feet + clenched fist + cardiac defect + cleft lip/palate
- Poor prognosis: sometimes baby does not make it through the delivery or is stillborn; a lot of babies die in the first year

Question 13

Describe Trisomy 13
What are the common characteristics?

Answer 13

“Patau syndrome”: 1 in every 10,000 live births
- Holoproscencephaly: fusion of developing eyes (“cyclops appearance”)
- CNS abnormalities
- Cardiac abnormalities
- Cleft lip and palate
- Malformations in the extremities (can also be seen on ultrasound)
- These babies usually die in utero; sometimes are stillborn
- Very poor prognosis: usually “kept comfortable” in the hospital or go home on palliative care

Question 14

What is Turner Syndrome?
What are the characteristics?

Answer 14

Monosomy X (45 X): only one copy of “X”
Affects females only
- Lack of secondary sex characteristics (they do not go through puberty or develop pubic hair)
- Juvenile external genitalia
- Underdeveloped ovaries (they are infertile)
- Short stature
- Webbed neck
- Low-set ears
- Impaired intelligence
- A lot of times these babies abort spontaneously in utero

Question 15

What is Klinefelter syndrome?
What are the characteristics?

Answer 15

Trisomy XXY (47 XXY) - an extra copy of “X”
Affects males only
- Usually tall
- Underdeveloped secondary sex characteristics (don’t develop hair on body, deep voice)
- Small testes (they are usually infertile)
- Learning disabilities

Question 16

Multiple roles for nurses in genetic counseling include:

Answer 16

Identify families in need of genetic counseling
Make referrals to specialists
Provide information about genetics
Clarify genetics information received during counseling session or from other sources
Provide emotional support

Question 17

Describe the anatomy of the breasts and how they change in relation to a woman’s menstrual cycle

Answer 17

• Each breast contains several lobes; each lobe is divided into further lobule; each lobule is a cluster of acini (sacs lined with epithelial cells that make milk)
• Breasts have an abundant vascular supply; this explains why the vascularity of breasts increases during pregnancy, also explains why breast cancer metastasizes quickly
• Breasts change in size and nodularity in response to cyclic ovarian changes
• Increasing levels of estrogen and progesterone 3-4 days before menstruation increase breasts’ vascularity, induce growth of ducts and acini, and promote water retention
• Nodules may develop just before and during menstruation, when the breast is most active.
• Physiologic alterations in breast size reach minimal level 5 to 7 days after menstruation stops (best time for breast self-exam)

Question 18

Describe the process of breast self-exam
- When to do it, where, what to do

Answer 18

• Best time: when there’s no tenderness or swelling, 5-7 days after the period has ended.
• Recommended it is done in the shower
• The goal is to cover the entire breast tissue
• East to West: Go all the way from the midaxillary line all the way to the sternum (this is all fair game for breast tissue)
• North to South: Start at collarbone all the way down to where you feel ribs
• Lie down and put a pillow under your shoulder. Place your arm behind your head
• Use the finger pads of your three middle fingers on your other hand to feel for lumps or thickening. Use circular motions. Press firmly enough to know how your breast feels.
• Use light pressure to feel the tissue just under the skin, medium pressure for a little deeper, and firm pressure to feel the breast tissue close to the chest and ribs.
• Move around the breast in a set way, such as using an up-and-down or vertical line pattern.
• Check breasts standing in front of a mirror. See if there are any changes in the way your breasts look: dimpling of the skin, changes in the nipple, or redness or swelling.
• Check the area between the breast and the underarm, and the underarm itself. Examine the area above the breast to the collarbone and to the shoulder while you are standing or sitting up with your arms lightly raised.
• A part of the breast more prone to breast cancer: outer upper quadrant; part of the breast that goes into the armpit; 50% of breast cancers

Question 19

What are some health risks in the childbearing years?

Answer 19

• Age: risk to pregnancies at both ends of the spectrum
• Socioeconomic status and culture: affects outcomes of birth negatively (maternal mortality)
• Substance use and abuse
• Nutrition: obesity and malnutrition have negative consequences; more complications in obese pregnant women; malnutrition leads to LBW babies
• Lack of exercise
• Stress: can induce anxiety, depression, cardiac issues, BP issues, GI issues; can impact pregnancy negatively, especially extreme stress which can lead to PTB
• Sexual practices: unsafe sex can lead to ectopic pregnancy, infertility
• Medical conditions: HTN and diabetes can negatively affect a pregnancy
• Gynecologic conditions: STIs, endometriosis can lead to long term consequences: pain, infertility; also vaginal infections, fibroids (can lead to miscarriage, PTB)
• Environmental and workplace hazards: being exposed to chemicals and radiation
• Violence against women (and intimate partner violence): under-reported and increases in pregnancy; fearful of reporting; important to screen women at well visits and maternal visits

Question 20

What are important things to note in the health history of a woman

Answer 20

• Menstrual history: When did you start your period? How old were you? When was your last period? How frequent is your cycle? How long do they last? Any pain associated with your period? Do you bleed heavy, moderate, light?
• Obstetric history: Have you ever been pregnant? How many times? Miscarriages? Abortions? Outcome of the pregnancy (live birth, complications, length of labor)?
• Menopause: Esp for women in mid-40s. Any menopausal symptoms such as hot flashes, mood swings, night sweats, vaginal dryness? Have periods started to slow down or become infrequent?
• Preventative care: When was the last pap smear, mammogram, colonoscopy (if over 50)? Dexa scan (if over 50)?
• Urinary symptoms: Frequency, urgency, burning, incontinence? Can happen as women age, a lot of that comes from trauma to the tissues from childbirth and symptoms will come later.
• Vaginal problems or discharge: Any sores? Pain with sex? Normal discharge is clear to white. Anything outside of that is probably abnormal.
• Sexual activity: Are you sexually active? How many partners?
• Contraception : Are you on contraception? Are you satisfied with the current method of contraception?
• STIs: In contact with any partners that may have STIs? Do you use protection to prevent STIs?

Question 21

During health history and review of symptoms: what to assess for current health status?

Answer 21

Reason for seeking care?
• Use of safety measures: seat belts, bicycle helmets, designated driver
• Exercise and leisure activities: regularity
• Sleep patterns: length and quality
• Sexuality: Is she sexually active? With men, women, or both? Risk-reducing sex practices?
• Diet, including beverages: 24-h dietary recall; caffeine: coffee, tea, cola, or chocolate intake
• Nicotine, alcohol, illicit or recreational drug use: type, amount, frequency, duration, and reactions
• Environmental and chemical hazards: home, school, work, and leisure setting; exposure to extreme heat or cold, noise, industrial toxins such as asbestos or lead, pesticides, diethylstilbestrol (DES), radiation, cat feces, or cigarette smoke

Question 22

During health history and review of systems: how to assess history of present illness?

Answer 22

Onset of the problem, the setting in which it developed, its manifestations, and any treatments received are noted.
The woman’s state of health before the onset of the present problem is determined.
If the problem is long standing, the reason for seeking attention at this time is elicited
Symptoms:
• Location
• Quality or character
• Quantity or severity
• Timing (onset, duration, frequency)
• Setting
• Factors that aggravate or relieve
• Associated factors
• Woman’s perception of the meaning of the symptom

Question 23

During health history and review of systems: how to assess past health?

Answer 23

• Infectious diseases: measles, mumps, rubella, whooping cough, chickenpox, rheumatic fever, scarlet fever, diphtheria, polio, tuberculosis (TB), hepatitis
• Chronic disease and system disorders: arthritis, cancer, diabetes, heart, lung, kidney, seizures, thyroid, stroke, ulcers, sickle cell anemia
• Adult injuries, accidents
• Hospitalizations, operations, blood transfusions
• Obstetric history
• Allergies: medications, previous transfusion reactions, environmental allergies
• Immunizations: diphtheria, pertussis, tetanus, polio, hepatitis B, varicella, influenza, pneumococcal vaccine, last TB skin test, measles, mumps, rubella (MMR)
• Last date of screening tests: Pap test, mammogram, stool for occult blood, sigmoidoscopy or colonoscopy, H&H, rubella titer, urinalysis, cholesterol test; electrocardiogram; last vision, dental, hearing examination
• Current medications: name, dose, frequency, duration, reason for taking, and compliance with prescription medications; home remedies, OTC drugs, herbal supplements, or recreational drugs used over a 24-hour period

Question 24

During health history and review of systems: how to assess family history? how to screen for abuse?

Answer 24

Family history:
- Information about the ages and health of family members: age, health or death of parents, siblings, spouse, children.
- Check for history of diabetes; heart disease; hypertension; stroke; respiratory, renal, or thyroid problems; cancer; bleeding disorders; hepatitis; allergies; asthma; arthritis; TB; epilepsy; mental illness; human immunodeficiency virus infection, etc
Screening for abuse:
- Has she ever been hit, kicked, slapped, or forced to have sex against her wishes?
- Has she been verbally or emotionally abused?
- Does she have a history of childhood sexual abuse?
- If yes, has she received counseling or does she need referral?
- Does she feel safe in her current relationship?
- Does she feel safe in her home?
- Are there any signs of being trafficked?

Question 25

Review of Systems: Women’s Health
• General:
• Skin:
• Lymph nodes:
• Head:
• Eyes:
• Ears:
• Nose and sinuses:
• Mouth, throat, and neck:
• Breasts:
• Respiratory:
• Cardiovascular:
• Gastrointestinal:
• Genitourinary:
• Sexual health and sexual activity:
• Peripheral vascular:
• Endocrine:
• Hematologic:
• Musculoskeletal:
• Neurologic:
• Mental status:
• Functional assessment:

Answer 25

• General: weight change, fatigue, weakness, fever, chills, or night sweats
• Skin: skin, hair, and nail change; itching, bruising, bleeding, rashes, sores, lumps, or moles
• Lymph nodes: enlargement, inflammation, pain, suppuration (pus), or drainage
• Head: trauma, vertigo (dizziness), convulsive disorder, syncope (fainting); headache: location, frequency, pain type, nausea and vomiting, or visual symptoms present
• Eyes: glasses, contact lenses, blurriness, tearing, itching, photophobia, diplopia, inflammation, trauma, cataracts, glaucoma, or acute visual loss
• Ears: hearing loss, tinnitus (ringing), vertigo, discharge, pain, fullness, recurrent infections, or mastoiditis
• Nose and sinuses: trauma, rhinitis, nasal discharge, epistaxis, obstruction, sneezing, itching, allergy, or smelling impairment
• Mouth, throat, and neck: hoarseness, voice changes, soreness, ulcers, bleeding gums, goiter, swelling, or enlarged nodes
• Breasts: masses, pain, lumps, dimpling, nipple discharge, fibrocystic changes, or implants; breast self-examination practice; date of last mammogram
• Respiratory: shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, pleurisy, asthma, bronchitis, emphysema, or TB; date of last chest x-ray
• Cardiovascular: hypertension, rheumatic fever, murmurs, angina, palpitations, dyspnea, tachycardia, orthopnea, edema, chest pain, cough, cyanosis, cold extremities, ascites, intermittent claudication (leg pain caused by poor circulation to the leg muscles), phlebitis, or skin color changes
• Gastrointestinal: appetite, nausea, vomiting, indigestion, dysphagia, abdominal pain, ulcers, hematochezia (bleeding with stools), melena (black, tarry stools), bowel-habit changes, diarrhea, constipation, bowel movement frequency, food intolerance, hemorrhoids, jaundice, or hepatitis; sigmoidoscopy, colonoscopy, barium enema, ultrasound
• Genitourinary: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infection, or urethral discharge; menstrual history (e.g., age at menarche, length and flow of menses, last menstrual period [LMP], dysmenorrhea, intermenstrual bleeding, age at menopause or signs of menopause), dyspareunia, discharge, sores, itching
• Sexual health and sexual activity: with men, women, or both; contraceptive use; sexually transmitted infections
• Peripheral vascular: coldness, numbness and tingling, leg edema, claudication, varicose veins, thromboses, or emboli
• Endocrine: heat and cold intolerance, dry skin, excessive sweating, polyuria, polydipsia, polyphagia, thyroid problems, diabetes, or secondary sex characteristic changes
• Hematologic: anemia, easy bruising, bleeding, petechiae, purpura, or transfusions
• Musculoskeletal: muscle weakness, pain, joint stiffness, scoliosis, lordosis, kyphosis, range-of-motion instability, redness, swelling, arthritis, or gout
• Neurologic: loss of sensation, numbness, tingling, tremors, weakness, vertigo, paralysis, fainting, twitching, blackouts, seizures, convulsions, loss of consciousness or memory
• Mental status: moodiness, depression, anxiety, obsessions, delusions, illusions, or hallucinations
• Functional assessment: ability to care for self

Question 26

Nursing implications for special needs women

Answer 26

• Women with disabilities: Physical or intellectual disability -> can be hard for them to make good decisions about their sexual health, they can be taken advantage of. They may have to bring someone with them, but we want to talk to the patient privately and treat them the same as any other patient
• Abused women : Look for signs of physical and sexual abuse -> bruising in various stages of healing, male partner that is very overbearing and won’t leave. With sexual abuse, a GYN exam can be triggering for the woman -> always explain what you are about to do before it happens.
• Adolescents: How that first GYN visit goes determines their future compliance with visits and screenings. Establish rapport with young patients before probing and asking personal questions.
• Midlife and older women: Assessing sexual health is still important; Closer to menopause, vaginal dryness can be associated with painful sex. Ask about menopause symptoms, make sure they are getting cancer screenings. Once a woman has gone through menopause, she should NOT have ANY vaginal bleeding, this is a red flag for endometrial cancer

Question 27

Describe physical examination of female reproductive system
External and internal examination

Answer 27

External inspection and palpation: inspect the external genitalia
Internal exam (“Pelvic”)
- Speculum: can be plastic and thrown away after use or metal and cleaned afterward; in teens or a woman not sexually active, it is better to use pediatric speculum.
- Collection of specimens, including PAP: may get a wet prep if woman is experiencing abnormal discharge to look at under a microscope
- Vaginal Exam
Bimanual palpation: Internally palpates the structures -> ovaries, uterus; for size, tenderness, checks for masses

Question 28

How often should a woman get a PAP smear?

Answer 28

• First exam should be by 21 years; regardless of sexual activity
• Ages 21-65: every 3 years
  OR
• Start at 21, every 3 years, then at ages 30-65: every 5 years IF PAP testing plus HPV testing done
• After age 65 and 3 consecutive negative results: discontinue screening
• After total hysterectomy FOR BENIGN REASONS: discontinue screening
• IF hysterectomy was done to treat cancer, they would still need to get screening done (swab where the cervix was)
• More frequent screening needed if history of abnormal pap
• Done in early pregnancy if woman is not up to date on pap smears

Question 29

What patient teaching should be done for a pap smear?

Answer 29

Patient teaching: if women are scheduled for a pap, they need to understand that they cannot use vaginal cream or have sex for 48 hours prior to the pap; they could still have the exam, just not the pap smear, because the results would be thrown off

Question 30

Where is the pap smear done?

Answer 30

Transformation zone -squamocolumnar junction - area where squamous cells of vagina are meeting the columnar cells of the cervix - area where there is a lot of cellular division, where lesions will usually start