Ch 45 Disorders of the Female Reproductive System

A nurse who works on a urology-gynecology ward of a hospital is coming on shift and will be caring for a 34-year-old woman who has been admitted overnight for the treatment of a large endometriosis. What interventions should the nurse most realistically anticipate providing over the course of the shift and the next several days? A) Providing pain control; preparing the client for a laparoscopic procedure or hysterectomy. B) Administration of packed red blood cells to compensate for low hemoglobin; administering hormone therapy. C) Assisting with a Pap smear; administration of high-dose corticosteroids. D) Administration of male androgens to minimize endometrial hyperplasia; facilitating a dilation and curettage.

Ans: A Feedback: Pain control is central to treatment of endometriosis, and surgical treatment is ideally performed laparoscopically, though hysterectomy is sometimes indicated. Bleeding is not a common symptom of endometriosis, and neither corticosteroids nor male androgens are common treatments.

While teaching a class on female cancers, the instructor emphasizes to the nursing students that many patients with ovarian cancer may display: A) abdominal pain, bloating, feeling full quickly after ingesting food. B) pain after intercourse, bleeding irregularities, perineal tenderness. C) colicky low abdominal pain, adnexal mass present without palpation. D) lower abdominal pain localized to one side, referred shoulder pain.

Ans: A Feedback: Symptoms that are believed to have a strong correlation to ovarian cancer include abdominal pain, increased abdominal size or bloating, and difficulty in eating or feeling full quickly after ingesting food. Pain and bleeding after intercourse are usually associated with an inflammatory process. Colicky low abdominal pain and adnexal mass are associated with cancer of the fallopian tube. Localized abdominal pain to one side with referred shoulder pain is common in ectopic pregnancy.

A 57-year-old woman has been diagnosed with atrophic vaginitis and has expressed surprise to her care provider, citing a lifetime largely free of gynecological health problems. She has asked what may have contributed to her problem. How can the care provider best respond? A) "The lower levels of estrogen since you've begun menopause make your vagina prone to infection." B) "Vaginitis is not usually the direct result of any single problem, but rather an inevitability of the vaginal dryness that accompanies menopause." C) "This type of vaginitis is most commonly a symptom of a latent sexually transmitted infection that you may have contracted in the distant past." D) "The exact cause of this problem isn't known, but it can usually be resolved with a diet high in probiotic bacteria."

Ans: A Feedback: The lack of vaginal epithelial regeneration after menopause predisposes older woman to vaginitis. It is not necessarily a result of vaginal dryness and is not likely sexually transmitted. The etiology is not unknown, and diet alone is unlikely to resolve the problem.

A 70-year-old woman who delivered four children during her reproductive years has weakened pelvic floor muscles. Which of her following anatomical structures is least susceptible to inappropriate herniation into her vagina? A) Peritoneum B) Uterus C) Bladder D) Rectum

Ans: A Feedback: While displacement of the uterus, bladder, and rectum can result in uterine prolapse, cystocele, and rectocele, the peritoneum is unlikely to prolapse into the vagina.

A 31-year-old woman and her husband have presented to their family physician due to their inability to conceive a child after trying for the last 18 months. Which of the following will the nurse practitioner want to specifically rule out as potential contributing factors? Select all that apply. A) Cryptorchidism in the husband B) Slow maturation of the endothelial lining after ovulation C) Low levels of LH and FSH in the wife D) Large amounts of clear, stretchy cervical mucus E) Sexually transmitted diseases like gonorrhea or chlamydial infection.

Ans: A, B, C, E Feedback: Cryptorchidism, luteal phase defects, low pituitary hormone levels, and an inability of the tubes to pick up an ovum can all contribute to infertility. A large amount of clear, stretchy cervical mucus is a normal finding. Cervical cultures for gonorrhea, chlamydial infection, and mycoplasmal infection should be obtained and treatment instituted as needed.

Prior to performing a laparoscopy, a patient exhibiting which of the following clinical manifestations would be treated with oral antibiotic therapy for suspected pelvic inflammatory disease (PID)? Select all that apply. A) Lower abdominal pain. B) Tenderness when cervix is touched during bimanual exam. C) Feeling of fullness and bloating in abdomen. D) Purulent cervical drainage noted on tissue after voiding. E) Elevated white cell count. Ans: A, B, D, E

Ans: A, B, D, E Feedback: The symptoms of PID include lower abdominal pain, which may start just after a menstrual period; dyspareunia; back pain; purulent cervical discharge; adnexal tenderness; and cervical motion tenderness on bimanual examination with no other apparent cause. Fever, increased erythrocyte sedimentation rate, and elevated WBC are commonly seen.

Following a workup that included endocrine studies (FSH/LH, prolactin, testosterone, DHEAS levels), a 22-year-old college student complaining of abnormal bleeding has been diagnosed with dysmenorrhea due to alterations in her hormone levels. The nurse should anticipate that she will likely be prescribed: Select all that apply. A) oral contraceptives. B) estrogen only. C) prostaglandin synthetase inhibitors. D) anxiolytic medications. E) androgens.

Ans: A, C Feedback: The treatment of dysfunctional bleeding of a nonhormonal nature is usually treated with oral contraceptives or cyclic progesterone therapy. Prostaglandin synthetase inhibitors are prescribed for dysmenorrhea. Anxiolytic drugs treat mood changes of PMS.

A 60-year-old woman who is 11 years menopausal has presented to the emergency department stating, "I haven't had my period in years, but lately I've been bleeding again, and quite heavily in the last few days." The care team needs to rule out endometrial cancer. How should they best explain the most accurate plan for confirming or ruling out the diagnosis? A) "We're going to book a CT scan for you as soon as possible so that we can see what is inside your uterus." B) "We're going to have to open your cervix with a speculum and take scrapings from the wall of your uterus." C) "We are going to order blood work that will measure your hormone levels." D) "We can do a Pap smear right now, and we will get the results as soon as we can."

Ans: B Feedback: D&C is a more accurate diagnostic procedure for endometrial cancer than CT, Pap smear, or blood work analysis.

A 31-year-old patient with breast cancer is concerned about being prescribed a hormonal medication to help block the effects of estrogen on the growth of breast cancer cells. The nurse should provide education about which of the following likely medications? A) Trastuzumab (Herceptin), a biologic therapy B) Nolvadex (Tamoxifen), a nonsteroidal antiestrogen C) Progesterone, a hormone. D) Arimidex (anastrozole), an aromatase inhibitor.

Ans: B Feedback: Hormone therapy is used to block the effects of estrogen on the growth of breast cancer cells. Tamoxifen is a nonsteroidal antiestrogen that binds to estrogen receptors and blocks the effects of estrogens on the growth of malignant cells in the breast. Herceptin is used to stop the growth of breast tumors that express the HER2/neu receptor on their cell surface. Arimidex, an aromatase inhibitor, blocks the enzyme that converts androstenedione and testosterone to estrogen in the peripheral tissues. This reduces the circulating estrogen levels in postmenopausal women.

Which of the following sexually active women most likely faces the highest risk of developing an ectopic pregnancy? A) A 14-year-old who experienced menarche 2 years prior. B) A 42-year-old who has decided to try to have one more child and has had her tubal ligation reversed. C) A 27-year-old who stopped using medroxyprogesterone contraceptive injection (Depo-Provera) several months ago. D) A 22-year-old who has a history of anorexia nervosa and who has a body mass index (BMI) of 12.0 (normal weight = 18.5 to 24.9).

Ans: B Feedback: Previous tubal ligation is an identified risk factor for ectopic pregnancy. Young age, use of injectable contraception, and low BMI are not specifically associated with ectopic pregnancy.

After a long and frustrating course of constant vaginal pain, a 38-year-old woman has diagnosed with generalized vulvodynia by her gynecologist. What treatment plan is her physician most likely to propose? A) Alternative herbal therapies coupled with antifungal medications B) Antidepressant and antiepileptic medications C) Lifestyle modifications aimed at accommodating and managing neuropathic pain D) Narcotic analgesia and nonsteroidal anti-inflammatory medications

Ans: B Feedback: Treatment of vulvodynia necessitates a long-term, chronic pain approach; antidepressants and antiepileptic medications are often used. Alternative therapies, standard analgesic regimens, and simple lifestyle modifications are less likely to be effective.

While educating a mother about the benefits of giving her child the human papilloma virus (HPV) vaccine, gardisil, which of the following statements will the nurse need to clarify for the parent? Select all that apply. The vaccine is: A) best administered before the child becomes sexually active. B) 100% effective against development of cervical cancer for her life span. C) effective against the two most common strains of genital warts. D) only recommended for females between the ages of 9 and 26. E) recommended prior to exposure to HPV, and if the child has genital warts, they are already exposed.

Ans: B, D Feedback: The HPV vaccine has decreased the risk of cervical cancer by 97%. Gardisil is one type of HPV vaccine to prevent infection with the HPV subtypes 16, 18, 9, and 11. This vaccine has been approved for girls and boys between 9 and 26 years of age (prior to becoming sexually active) to prevent HPV 6 and 11 genital warts. The vaccine targets the two strains of HPV (16 and 18) responsible for 70% of the cervical cancer. There is no treatment that is 100% effective against cervical cancer.

A 15-year-old female has presented to her family physician complaining of frequent discomfort around the time of her period. She has subsequently been diagnosed with primary dysmenorrhea. Which of the following treatments is most likely to be effective? A) Investigation and resolution of her hypothalamic-pituitary-ovarian disorder B) Hormone therapy aimed at resolving her estrogen deprivation C) Pain control with prostaglandin synthetase inhibitors D) Dilation and curettage

Ans: C Feedback: Because she has been diagnosed with primary rather than secondary dysmenorrhea, treatment of a specific underlying condition is not indicated. Treatment will likely focus on adequate pain control. D&C is not a relevant intervention.

Following a visit to her campus medical clinic motivated by persistent abdominal pain and dyspareunia, a 20-year-old female college student has been referred for a diagnostic workup to rule out pelvic inflammatory disease. Her elevated white cell and C-reactive protein levels lead her care provider to suspect pelvic inflammatory disease (PID). What follow-up question is most likely to help with the differential diagnosis? A) "Are you using tampons during your period or do you normally use pads?" B) "What does your daily hygiene routine usually consist of?" C) "How many sexual partners have you had?" D) "Have you ever had a therapeutic abortion in the past?"

Ans: C Feedback: Having multiple sex partners is a factor that has been identified in the development of PID. The use of tampons, inadequate hygiene, and a history of TA are less likely to predispose to PID.

A 23-year-old woman has been referred to a fertility clinic after 1 year of attempting to become pregnant. Her diagnostic workup has resulted in a diagnosis of polycystic ovary syndrome (PCOS). What will the first line of treatment most likely consist of? A) Estrogen-progesterone hormone therapy and the administration of clomiphene B) Surgical resection of the ovaries using laparoscopy C) Lifestyle modifications to include weight loss by lowering calories and fat consumption D) Temporary use of oral contractive agents

Ans: C Feedback: Lifestyle modifications are the treatment of choice for PCOS. Hormone therapy, surgery, and use of oral contraceptives are less likely to be a primary treatment option.

A patient who is still breast-feeding her infant has arrived at the clinic complaining of sore breasts. The physician has diagnosed mastitis. Which of the following statements made by the patient will require correction by the nurse? A) "They tell me this is usually caused by a Staph infection." B) "I need to make sure to wash my hands thoroughly before touching my breasts." C) "I need to stop breast-feeding until all my antibiotics have been taken." D) "A clogged duct in my breast has become clogged."

Ans: C Feedback: Mastitis is inflammation of the breast. It most frequently occurs during lactation but also can result from other conditions. In the lactating woman, inflammation results from an ascending infection that travels from the nipple to the ductile structures. The most common organism isolated is Staphylococcus. The offending organism originates from the suckling infant's nasopharynx or the mother's hands. Infection and inflammation cause obstruction of the ductile system. The breast becomes hard and, inflamed. It is advisable for the mother to continue breast-feeding during antibiotic therapy to prevent this.

A 28-year-old female has been told she has atypical glandular cells following Pap smear. The physician will likely recommend which procedure that can be performed in his office to remove the abnormal zone and provide a specimen for further histological evaluation? A) Cone biopsy B) Intracavitary irradiation C) Trachelectomy D) Loop electrosurgical excision procedure (LEEP)

Ans: D Feedback: Because adenocarcinoma of the cervix is being detected more frequently, especially in women younger than 35 years of age, a Pap smear result of atypical glandular cells warrants further evaluation. The LEEP has taken the place of cone biopsies in most situations and is now the first-line management for CIN II/III. This outpatient procedure allows for the simultaneous diagnosis and treatment of dysplastic lesions found on colposcopy. In skilled hands, this wire can remove the entire transformation zone, providing adequate treatment for the lesion while obtaining a specimen for further histological evaluation. Cone biopsy is a surgical procedure that removes a cone-shaped wedge of cervix. Trachelectomy is removal of the cervix, and intracavitary irradiation is a form of brachytherapy to treat cervical cancer.

A college student has come to the health clinic complaining of heavy bleeding during and between her menstrual periods. The nurse practitioner will document this as: A) dyspareunia. B) amenorrhea. C) polymenorrhea. D) menometrorrhagia.

Ans: D Feedback: Menometrorrhagia is heavy bleeding during and between menstrual periods. Polymenorrhea is frequent menstruation with periods less than 21 days apart. Amenorrhea is absence of menstruation. Dyspareunia is pain following intercourse.

Staff at a women's health center are being briefed by their supervisor on the latest recommendations for breast cancer screening. Which of the following guidelines should staff pass on to their clients? A) "Breast self-exam should be ideally performed around the time of the month that you think you're ovulating." B) "The most important thing you can do to identify breast cancer early is to perform regular, systematic self-exams." C) "All postmenarche females should get a clinical exam by a trained professional on an annual basis." D) "Screening mammography and clinical exams are the cornerstones of breast cancer screening."

Ans: D Feedback: Self-exam has recently been deemphasized by the American Cancer Society with emphasis now placed on mammography and trained exam. If done, self-exam should be performed around the time of menses, and clinical exams every 3 years are believed to be sufficient for women under 40.

Which of the following women is most likely to have a sexually transmitted infection as a contributing factor to her health problem? A) A 29-year-old woman with a diagnosis of localized vulvodynia B) A 40-year-old who is being treated for vaginal cancer C) A 32-year-old who is undergoing diagnostics to rule out endometriosis D) A 41-year-old with a diagnosis of mucopurulent cervicitis

Ans: D Feedback: While C. albicans, T. vaginalis, Neisseria gonorrhoeae, Gardnerella vaginalis, Chlamydia trachomatis, Ureaplasma urealyticum, and herpes simplex virus can all contribute to cervicitis. C. trachomatis is the organism most commonly associated with mucopurulent cervicitis. Vulvodynia, vaginal cancer, and endometriosis are less likely to have a sexually transmitted etiology.