Chapter 11 OB
The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective?
"I will need to take iron supplementation throughout my pregnancy even if I am not anemic." Iron is recommended for all pregnant women because it is almost impossible for the pregnant woman to get what is required from diet alone, especially after 20 weeks' gestation when the requirements of the fetus increase. Pregnant women can get many nutrients from seafood including phosphorus, but there are specific recommendations about types of fish to avoid because of the risk of mercury poisoning. Milk production actually requires higher levels of zinc, which can be obtained from a healthy diet. Calcium requirements do not increase above prepregnancy levels during pregnancy because calcium absorption is enhanced during pregnancy. It can be unsafe for the pregnant woman to eat anything she wants and gain too much weight. A woman who gains too much weight during pregnancy is at risk for delivering a macrosomic baby.
A 28-year-old client in her first trimester of pregnancy reports conflicting feelings. She expresses feeling proud and excited about her pregnancy while at the same time feeling fearful and anxious of its implications. Which action should the nurse do next?
Inform the client this is a normal response to pregnancy that many women experience. The maternal emotional response experienced by the client is ambivalence. Ambivalence, or having conflicting feelings at the same time, is universal and is considered normal when preparing for a lifestyle change and new role. Pregnant women commonly experience ambivalence during the first trimester.
In preparing for a prenatal class to discuss the hormonal changes during pregnancy, which information would the nurse most likely include?
Over-the-counter antacids can be used to treat acid reflux with the health care provider's knowledge. Elevated progesterone levels cause smooth muscle relaxation, which can result in relaxation of the cardiac sphincter and reflux of the stomach contents into the lower esophagus. OTC antacids will usually relieve the symptoms but should be discussed with the health care provider first. The hormonal changes are necessary for the pregnancy to continue, and the woman will return to her usual nonpregnant hormonal levels after the baby is born. Taking hormonal replacement therapy is not recommended. Using herbs should be done only with the knowledge of the health care practitioner due to the side effects and contraindications of some herbs during pregnancy. Some herbs will cause a spontaneous abortion.
A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition?
Place the client in the left lateral position. The symptoms experienced by the client indicate supine hypotension syndrome. When the pregnant woman assumes a supine position, the expanding uterus exerts pressure on the inferior vena. The nurse should place the client in the left lateral position to correct this syndrome and optimize cardiac output and uterine perfusion. Elevating the client's legs, placing the client in an orthopneic position, or keeping the head of the bed elevated will not help alleviate the client's condition.
The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?
Positive home pregnancy test
A client in her first trimester reports frequent urination and asks the nurse for suggestions. The nurse should teach the client that the urination is most likely related to which cause?
Pressure on the bladder from the uterus
Amanda's menstrual period is two weeks late. She has been feeling tired and has had bouts of nausea in the morning. What classification of pregnancy symptoms is Amanda experiencing?
Presumptive The most common presumptive sign of pregnancy is a missed menstrual period, or amenorrhea. Other presumptive signs include nausea, fatigue, swollen, tender breasts, and frequent urination.
A 28-year-old primigravida client with diabetes mellitus, in her first trimester, comes to the health care clinic for a routine visit. The client reports frequent episodes of sweating, giddiness, and confusion. What should the nurse tell the client about these experiences?
increased secretion of insulin occurs in the first trimester Increased secretion of insulin in the maternal body in the first trimester is due to the rise in serum levels of estrogen, progesterone, and other hormones. During the second half of pregnancy, tissue sensitivity to insulin progressively decreases, producing hyperglycemia and hyperinsulinemia. Use of insulin needs to be increased not reduced as pregnancy advances. Insulin resistance becomes maximal not minimal in the latter half of the pregnancy.
The nurse is teaching a pregnant woman about breast feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as being released when the newborn sucks at the breast?
oxytocin
The nurse is teaching a prenatal class about preparing for their expanding families. What is helpful advice from the nurse?
"The hormones of pregnancy may cause anxiety or depression postpartum." The "raging hormones"of pregnancy can keep the woman slightly out of touch with her usual methods of coping. Although she may normally interact and communicate in quite mature ways, during a pregnancy, she may become depressed, anxious, withdrawn, or angry as she accomplishes her own developmental tasks. Siblings often react to a pregnancy by regression in behavior and attitude because they fear that they will be replaced or unloved. In addition to anticipatory guidance concerning the alterations in family structure and functioning, prenatal preparation for first-time parents involves learning the basics of infant care and preparing for infant feeding, particularly for women who plan to breastfeed.
The nurse is teaching a prenatal class about preparing for their expanding families. What is helpful advice from the nurse?
"The hormones of pregnancy may cause anxiety or depression postpartum." The "raging hormones"of pregnancy can keep the woman slightly out of touch with her usual methods of coping. Although she may normally interact and communicate in quite mature ways, during a pregnancy, she may become depressed, anxious, withdrawn, or angry as she accomplishes her own developmental tasks. Siblings often react to a pregnancy by regression in behavior and attitude because they fear that they will be replaced or unloved. In addition to anticipatory guidance concerning the alterations in family structure and functioning, prenatal preparation for first-time parents involves learning the basics of infant care and preparing for infant feeding, particularly for women who plan to breastfeed.
A pregnant client reports an increase in a thick, whitish vaginal discharge. Which response by the nurse would be most appropriate?
"This discharge is normal during pregnancy." During pregnancy, the vaginal secretions become more acidic, white, and thick. Most women experience an increase in a whitish vaginal discharge, called leukorrhea, during pregnancy. The nurse should inform the client that the vaginal discharge is normal except when it is accompanied by itching and irritation, possibly suggesting Candida albicans infection, a monilial vaginitis, which is a very common occurrence in this glycogen-rich environment. Monilial vaginitis is a benign fungal condition and is treated with local antifungal agents. The client need not refrain from sexual activity when there is an increase in a thick, whitish vaginal discharge.
A client in her second trimester of pregnancy is anxious about the blotchy, brown pigmentation appearing on her forehead and cheeks. She also reports increased pigmentation on her breasts and genitalia. Which statement by the nurse is most appropriate?
"This is called facial melasma and should fade after the birth." The skin and complexion of pregnant women undergo hyperpigmentation, primarily as a result of estrogen, progesterone, and melanocyte stimulating hormone levels. The increased pigmentation that occurs on the breasts and genitalia also develops on the face to form the "mask of pregnancy," or facial melasma (cholasma). This is a blotchy, brownish pigment that covers the forehead and cheeks in dark-haired women. The nurse would inform the client that this is a normal occurrence in pregnancy and should fade after birth.
Amanda is about 16 weeks pregnant and is concerned because she feels her "abdomen" contracting. She calls the primary care provider's office and speaks to the nurse. What is the nurse's most appropriate response to Amanda's concern?
"What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy." Braxton Hicks contractions are the painless, intermittent, "practice" contractions of pregnancy.
A woman's prepregnant weight is within the normal range. During her second trimester, the nurse would determine that the woman is gaining the appropriate amount of weight when her weight increases by which amount per week?
1 lb (.45 kg) The recommended weight gain pattern for a woman whose prepregnant weight is within the normal range would be 1 lb (.45 kg) per week during the second and third trimesters. Underweight women should gain slightly more than 1 lb (.45 kg) per week. Overweight women should gain about 2/3 lb (.30 kg) per week.
A woman comes to the clinic for her first prenatal checkup. The woman has a body mass index (BMI) of 22. The nurse would anticipate that this client should gain approximately how much weight during her pregnancy?
25 to 35 lbs (11 to 16 kg) A woman with a BMI of 18.5 to 24.9 is of normal weight and should gain 25 to 35 pounds (11 to 16 kg) during the pregnancy. For a woman who is underweight (BMI <18.5), the total weight gain range is 28 to 40 pounds (13 to 18 kg). For a woman who is overweight (BMI = 25-29.9), total weight gain range should be 15 to 25 pounds (7 to 11 kg). For a woman who is obese (BMI = 30 or higher), the total weight gain range should be 11 to 20 pounds (5 to 9 kg).
The nursing instructor is preparing to illustrate the various changes between the nonpregnant and pregnant female body. The instructor should point out the blood volume in the pregnant woman can increase by what percentage?
40% to 45% The pregnant female can experience a blood volume increase by approximately 40% to 45% above prepregnancy levels by the end of the third trimester.
A 17-year-old client arrives for an annual examination and reports no changes since the last exam; however, the nurse assesses a postive Chadwick sign, slightly enlarged uterus, and subsequent positive urine pregnancy test. Which task should the nurse prioritize to assist this client who is denying any possibility that she is pregnant?
Accepting the pregnancy Acceptance of pregnancy is multi-factorial, and how the woman responds to the pregnancy is certainly influenced by her age and if the pregnancy was planned. As a teenager, she may not have been trying to get pregnant and may not want to accept the role and experience. Baby and parenthood decisions should all occur later.
A woman tells the nurse that she is going to use a home pregnancy test to determine whether she is pregnant. Which precautions should the nurse give her?
Arrange for prenatal care if the test is positive. Home pregnancy testing can be accurate as soon as a period is missed; it should not take the place of prenatal care.
A pregnant client in her third trimester, lying supine on the examination table, suddently grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?
Blood is trapped in the vena cava in a supine position. Supine hypotension syndrome, or an interference with blood return to the heart, occurs when the weight of the fetus rests on the vena cava. Cerebral arteries should not be affected. Mean arterial pressure is high enough to maintain perfusion of the uterus in any orientation. The sympathetic nervous system will not be affected by the supine position.
A nurse is assessing a pregnant client. The nurse understands that hormonal changes occur during pregnancy. Which hormones would the nurse most likely identify as being inhibited during the pregnancy?
FSH and LH During pregnancy, FSH and LH are both inhibited as there is no need to develop a follicle and release an ovum. There is an increase in the secretion of T4 and MSH. There is a decrease in the production of GH and MSH but not an inhibition.
Some women are lactose intolerant. Lactose intolerance occurs more frequently in individuals of African, Hispanic, Native American, Ashkenazic Jewish, and Asian descent. What is the major concern for a lactose intolerant woman who is pregnant?
Calcium deficiency Calcium deficiency is a major concern for the pregnant woman who is lactose intolerant. There are several ways to address this concern. Some lactose-intolerant individuals are able to tolerate cooked forms of milk, such as pudding or custard. Cultured or fermented dairy products, such as buttermilk, yogurt, and some cheeses may also be tolerated. A chewable lactase tablet may be taken with milk. Lactase-treated milk is available in most supermarkets and may be helpful. Other options are to drink calcium-enriched orange juice or soy milk or to take a calcium supplement. If the woman is infrequently exposed to sunlight, she will need a vitamin D supplement (Marchiano & Ural, 2005).
A client presents to the clinic because she thinks she may be pregnant. On examination, the nurse notes that the client's cervix and vaginal mucosa appear a bluish-purple color. The nurse interprets this finding as which sign?
Chadwick's sign Common probably signs of pregnancy include a bluish-purple coloration of the vaginal mucosa and cervix (Chadwick's sign), softening of the lower uterine segment or isthmus (Hegar's sign), and softening of the cervix (Goodell's sign). There is no such thing as Braxton's sign; however, there are the Braxton Hicks contractions, which occur throughout the pregnancy preparing the uterus for delivery.
During a routine antepartal visit, a pregnant woman reports a white, thick, vaginal discharge. She denies any itching or irritation. Which action would the nurse do next?
Tell the woman that this is entirely normal.
The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?
Darkened breast areolae As part of the pigment changes that occur with pregnancy, breast areolae become darker. The breast tissue should not be softer or slacker than before. There should not yet be any lymph enlargement, and the nipples should not have fissures.
A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet?
Fortified cereals The best source to recommend are the fortified cereals to meet the amino acid needs necessary for the development of her infant's nervous system during pregnancy. She should be encouraged to include fortified cereals to meet these needs. The carrots, sweet potatoes, mangoes, nuts, and seeds will add other nutrients to her diet. A vegan will not eat milk and cheese, as they are animal products.
A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she has been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely?
Fundal height has dropped since the last recording. Between 38 and 40 weeks of gestation, the fundal height drops as the fetus begins to descend and engage into the pelvis. Because it pushes against the diaphragm, many women experience shortness of breath. By 40 weeks, the fetal head begins to descend and engage into the pelvis. Although breathing becomes easier because of this descent, the pressure on the urinary bladder now increases, and women experience urinary frequency. The fundus reaches its highest level at the xiphoid process at approximately 36, not 39, weeks. By 20 weeks' gestation, the fundus is at the level of the umbilicus and measures 20 cm. At between 6 and 8 weeks of gestation, the cervix begins to soften (Goodell sign) and the lower uterine segment softens (Hegar's sign).
A client in her second trimester of pregnancy reports discomfort during sexual activity. Which instruction should a nurse provide?
Modify sexual positions to increase comfort. The nurse should instruct the client to change sexual positions to increase comfort as the pregnancy progresses. Although the nurse should also encourage her to engage in alternative, noncoital modes of sexual expression, such as cuddling, caressing, and holding, the client need not restrict herself to such alternatives. It is not advisable to perform frequent douching, because this is believed to irritate the vaginal mucosa and predispose the client to infection. Using lubricants or performing stress-relieving and relaxation exercises will not alleviate discomfort during sexual activity.
The nurse is teaching a pregnant teenager the importance of proper nutrition and adequate weight gain throughout the pregnancy. What is the best response when the client refuses to eat due to fear of possible weight gain?
The infant will be small and could have problems. Women who gain less than 16 pounds (7,257 g) are at risk for giving birth to small infants, which is associated with poor neonatal outcomes. The infant may not quickly gain weight but continue to slowly put on weight.
A nurse is leading a discussion in a prenatal class for a group of primigravida clients. Which factor would the nurse include when explaining the changes that are expected to occur in the uterus during the pregnancy?
The uterus changes from a pear-shaped organ to an oval one. The uterus starts as a pear-shaped organ and becomes oval as length increases over width. Uterine growth is primarily related to an increase in size of the myometrial cells. The uterus remains in the pelvic cavity for the first 3 months, after which it progressively ascends into the abdomen. The uterus reaches its highest level at the xiphoid process at approximately 36 weeks. Between 38 to 40 weeks, fundal height drops as the fetus begins to descend and engage into the pelvis.
The nurse is caring for a woman in a prenatal clinic who thinks she might be pregnant. Which assessment is a probable sign of pregnancy?
a positive pregnancy test Most probable signs of pregnancy are objective signs; laboratory testing is probable, not positive, because error can occur.
During pregnancy, one of progesterone's actions is to allow sodium to be "wasted" or lost in the urine. The nurse would expect to see which hormone increased to help counteract this loss?
aldosterone Aldosterone is secreted by the adrenal glands, and it normally regulates the absorption of sodium in the kidney. During pregnancy, aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. ADH (antidiuretic hormone) is secreted by the kidneys and aids in resorption of fluids in the kidneys. Glycogen assists in the balancing of blood glucose, breaking down to glucose when needed by the body. Cortisol is important in helping the body handle stress.
Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to:
detect fetal heart sounds with a Doppler. Fetal heart sounds are audible with a Doppler at 10 to 12 weeks of gestation but cannot be heard through a stethoscope until 18 to 20 weeks of gestation. Fetal movements can be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around 20 weeks' gestation. The fetal outline is also palpable around 20 weeks of gestation.
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply.
breast changes amenorrhea morning sickness Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). Probable signs are signs that appear in the first and early second trimesters, seen via objective criteria, but can also be indicators of other conditions (e.g., hydatidiform mole). Positive signs affirm that proof exists that there is a developing fetus in any trimester and are objective criteria seen by a trained observer or diagnostic study, (e.g., ultrasound.)
During a prenatal visit, the nurse inspects the skin of the client's abdomen. Which would the nurse identify as an abnormal finding?
bruising Bruising would not be a normal finding. Evidence of bruising might suggest domestic violence. Linea nigra, striae, and darkening of the umbilicus are normal findings.
During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called?
couvade syndrome Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partner. This phenomenon is called couvade syndrome.
A nurse who has been caring for a pregnant client understands that the client has pica and has been regularly consuming soil. For which condition should the nurse monitor the client?
iron-deficiency anemia Pica is characterized by a craving for substances that have no nutritional value. Consumption of these substances can be dangerous to the client and her developing fetus. The nurse should monitor the client for iron-deficiency anemia as a manifestation of the client's compulsion to consume soil. Consumption of ice due to pica is likely to lead to tooth fractures. The nurse should monitor for inefficient protein metabolism if the client has been consuming laundry starch as a result of pica. The nurse should monitor for constipation in the client if she has been consuming clay.
A woman in her third trimester shows the nurse a narrow, brown line that has formed on her abdomen, running from her belly button down to her pubic region. She expresses concern about this and asks the nurse whether it is normal. The nurse explains that this is a normal occurrence of pregnancy and that it results from the release of melanocyte-stimulating hormone from the pituitary, causing the appearance of extra pigmentation on the skin. What is the name of this phenomenon?
linea nigra Extra pigmentation generally appears on the abdominal wall because of melanocyte-stimulating hormone from the pituitary. A narrow, brown line (linea nigra) may form, running from the umbilicus to the symphysis pubis and separating the abdomen into right and left halves. The other answers are other changes that occur in the integumentary system during pregnancy, including melasma (darkened or reddened areas on the face), diastasis (separation of the rectus muscles under the skin), and striae gravidarum (stretch marks; pink or reddish streaks on the sides of the abdominal wall and sometimes on the thighs).
The nurse is teaching a pregnant woman about breast feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as being released when the newborn sucks at the breast?
oxytocin Oxytocin is responsible for milk ejection during breast-feeding. Its secretion is stimulated by stimulation of the breasts via sucking or touching. Secretion of follicle-stimulating hormone is inhibited during pregnancy. The secretion of antidiuretic hormone has no effect on breast-feeding. Cortisol secretion regulates carbohydrate and protein metabolism and is helpful in times of stress.
The nurse is preparing to teach a community class to a group of first-time parents. Which information should the nurse include concerning what the pregnant woman's partner may experience as a normal response?
physical symptoms similar to the mother Couvade syndrome is the occurrence of physical symptoms by the partner, similar to the physical symptoms of the mother. Other emotional symptoms may occur, but they are typically on a person-to-person basis.
Early in pregnancy, frequent urination results mainly from which cause?
pressure on the bladder from the uterus Early in pregnancy, the expanding uterus presses on the bladder. Later, it rises above the bladder so pressure is relieved.
A client who is entering her third trimester comes to the prenatal clinic for a follow-up examination. When assessing the breasts, which findings would the nurse expect? Select all that apply.
prominent veins hyperpigmentation of the nipple increased sensitivity Normal breast findings include prominent veins, nodular breasts, increased sensitivity to touch, and hyperpigmentation of the nipples and areolae. Warmth would suggest possible infection.
A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation and enlargement of the birth canal. What is this hormone?
relaxin Relaxin, secreted by the corpus luteum of the ovary as well as the placenta, is responsible for helping to inhibit uterine activity and to soften the cervix and the collagen in joints. Softening of the cervix allows for dilatation at birth; softening of collagen allows for laxness in the lower spine and so helps enlarge the birth canal. The effect of estrogen is to cause breast and uterine enlargement. Progesterone has a major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breasts for lactation. Human placental lactogen (hPL), also known as human chorionic somatomammotropin, serves as an antagonist to insulin, making insulin less effective, thereby allowing more glucose to become available for fetal growth.
The nurse is assessing a pregnant woman on a routine prenatal visit. Which breast assessment finding will the nurse document as a normal and expected finding?
tingling sensations and tenderness Normal changes in the breasts associated with pregnancy include tingling sensations and tenderness, enlargement of the breast and nipples, hyperpigmentation of the areola and nipples, enlargement of Montgomery tubercles, prominence of superficial veins, development of striae, and expression of colostrum in the second and third trimesters.
The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?
ultrasound picture of her fetus
The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?
ultrasound picture of her fetus A positive sign of pregnancy is visualization of the fetus by ultrasound at 6+ weeks. Amenorrhea is a presumptive sign and can be caused by a variety of factors. Positive hCG in the blood and uterine growth are both probable signs but can be caused by hydatidiform or tumors.
A client in her 39th week of gestation reports swelling in the legs after standing for long periods of time. The nurse recognizes that this factor increases the client's risk for which condition?
venous thrombosis