Ch 05 - Infertility, Contraception, & Abortion

Methods of Contraception

1. Coitus interruptus (withdrawal) 2. Fertility awareness methods (FAMs) - Rely on avoidance of intercourse during fertile periods - FAMs combine charting menstrual cycle with abstinence or other contraceptive methods - Natural family planning (period abstinence) - Calendar rhythm method

The nurse must evaluate a male patient's knowledge regarding the use of a condom. The nurse would recognize the need for further instruction if the patient states that he: A. Lubricates the condom with a spermicide containing nonoxynol-9. B. Leaves an empty space at the tip of the condom. C. Leaves a small amount of air in the tip. D. Removes his still-erect penis from the vagina while holding onto the base of the condom.

A. Lubricates the condom with a spermicide containing nonoxynol-9. Nonoxynol-9 is no longer recommended. Recent data suggest that frequent use of nonoxynol-9 may increase human immunodeficiency virus transmission and can cause genital lesions. An empty space at the tip of the condom is the correct instruction. Leaving a small amount of air at the tip of the condom is the correct instruction. Removing the condom while holding the base is the correct instruction.

24. While instructing a couple regarding birth control, the nurse should be aware that the method called natural family planning: a. Is the same as coitus interruptus, or "pulling out." b. Uses the calendar method to align the woman's cycle with the natural phases of the moon. c. Is the only contraceptive practice acceptable to the Roman Catholic church. d. Relies on barrier methods during fertility phases.

ANS: C Natural family planning is the only contraceptive practice acceptable to the Roman Catholic church. "Pulling out" is not the same as periodic abstinence, another name for natural family planning. The phases of the moon are not part of the calendar method or any method. Natural family planning is another name for periodic abstinence, which is the accepted way to pass safely through the fertility phases without relying on chemical or physical barriers.

22. A woman had unprotected intercourse 36 hours ago and is concerned that she may become pregnant because it is her "fertile" time. She asks the nurse about emergency contraception. The nurse tells her that: a. It is too late; she needed to begin treatment within 24 hours after intercourse. b. Preven, an emergency contraceptive method, is 98% effective at preventing pregnancy. c. An over-the-counter antiemetic can be taken 1 hour before each contraceptive dose to prevent nausea and vomiting. d. The most effective approach is to use a progestin-only preparation.

ANS: C To minimize the side effect of nausea that occurs with high doses of estrogen and progestin, the woman can take an over-the-counter antiemetic 1 hour before each dose. Emergency contraception is used within 72 hours of unprotected intercourse to prevent pregnancy. Postcoital contraceptive use is 74% to 90% effective at preventing pregnancy. Oral emergency contraceptive regimens may include progestin-only and estrogen-progestin pills. Women with contraindications to estrogen use should use progestin-only pills.

12. A woman is using the basal body temperature (BBT) method of contraception. She calls the clinic and tells the nurse, "My period is due in a few days, and my temperature has not gone up." The nurse's most appropriate response is: a. "This probably means that you're pregnant." b. "Don't worry; it's probably nothing." c. "Have you been sick this month?" d. "You probably didn't ovulate during this cycle."

ANS: D The absence of a temperature decrease most likely is the result of lack of ovulation. Pregnancy cannot occur without ovulation (which is being measured using the BBT method). A comment such as "Don't worry; it's probably nothing" discredits the client's concerns. Illness would most likely cause an increase in basal body temperature.

17. A woman currently uses a diaphragm and spermicide for contraception. She asks the nurse what the major differences are between the cervical cap and diaphragm. The nurse's most appropriate response is: a. "No spermicide is used with the cervical cap, so it's less messy." b. "The diaphragm can be left in place longer after intercourse." c. "Repeated intercourse with the diaphragm is more convenient." d. "The cervical cap can safely be used for repeated acts of intercourse without adding more spermicide later."

ANS: D The cervical cap can be inserted hours before sexual intercourse without the need for additional spermicide later. No additional spermicide is required for repeated acts of intercourse. Spermicide should be used inside the cap as an additional chemical barrier. The cervical cap should remain in place for 6 hours after the last act of intercourse. Repeated intercourse with the cervical cap is more convenient, because no additional spermicide is needed.

A 26-year-old woman is considering Depo-Provera as the form of contraception that is best for her since she does not like to worry about taking a pill every day. To assist this woman with decision making concerning this method of contraception, the nurse would tell her that Depo-Provera: A. Is a combination of progesterone and estrogen. B. Is a small adhesive hormonal birth control patch that is applied weekly. C. Thickens and decreases cervical mucus, thereby inhibiting sperm penetration and ovulation. D. Has an effectiveness rate in preventing pregnancy of 99% when used correctly.

C. Thickens and decreases cervical mucus, thereby inhibiting sperm penetration and ovulation. Depo-Provera is a progestin-only form of hormonal contraception. Depo-Provera is administered as an intramuscular injection. In addition to the changes in the cervical mucus, some but not all ovulatory cycles are suppressed, and formation of an endometrium capable of supporting implantation is inhibited. The effectiveness rate is 99% or greater over 5 years.

A woman is using the basal body temperature (BBT) method of contraception. She calls the clinic and tells the nurse, "My period is due in a few days, and my temperature has not gone up." The nurse's most appropriate response is: A. "This probably means you're pregnant." B. "Don't worry; it's probably nothing." C. "Have you been sick this month?" D. "You probably didn't ovulate during this cycle."

D. "You probably didn't ovulate during this cycle." Pregnancy cannot occur without ovulation (which is being measured using the BBT method). A comment such as this discredits the client's concerns. Illness would most likely cause an increase in BBT. The absence of a temperature decrease most likely is the result of lack of ovulation.

25. Which contraceptive method has a failure rate of less than 25%? a. Standard days c. Postovulation b. Periodic abstinence d. Coitus interruptus

ANS: A The standard days variation on the calendar method has a failure rate of 12%. The periodic abstinence method has a failure rate of 25% or higher. The postovulation method has a failure rate of 25% or higher. The coitus interruptus method has a failure rate of 27% or higher.

26. Which contraceptive method best protects against sexually transmitted infections (STIs) and human immunodeficiency virus (HIV)? a. Periodic abstinence b. Barrier methods c. Hormonal methods d. They all offer about the same protection.

ANS: B Barrier methods such as condoms best protect against STIs and HIV. Periodic abstinence and hormonal methods ("the pill") offer no protection against STIs or HIV.

1. Which test used to diagnose the basis of infertility is done during the luteal or secretory phase of the menstrual cycle? a. Hysterosalpingogram b. Endometrial biopsy c. Laparoscopy d. Follicle-stimulating hormone (FSH) level

ANS: B Endometrial biopsy is scheduled after ovulation, during the luteal phase of the menstrual cycle. A hysterosalpingogram is scheduled 2 to 5 days after menstruation to avoid flushing potentially fertilized ovum out through a uterine tube into the peritoneal cavity. Laparoscopy usually is scheduled early in the menstrual cycle. Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular.

28. With regard to the use of intrauterine devices (IUDs), nurses should be aware that: a. Return to fertility can take several weeks after the device is removed. b. IUDs containing copper can provide an emergency contraception option if inserted within a few days of unprotected intercourse. c. IUDs offer the same protection against sexually transmitted infections as the diaphragm. d. Consent forms are not needed for IUD insertion.

ANS: B The woman has up to 8 days to insert the IUD after unprotected sex. Return to fertility is immediate after removal of the IUD. IUDs offer no protection for sexually transmitted infections. A consent form is required for insertion, as is a negative pregnancy test.

Factors Associated with Infertility - Female

Assessment of female infertility - Ovarian factors - Tubal and peritoneal factors - Uterine factors - Vaginal-cervical factors - Other factors

An infertile woman is about to begin pharmacologic treatment. As part of the regimen, she will take purified follicle-stimulating hormone (FSH) (urofollitropin [Metrodin]). The nurse instructs her that this medication is administered in the form of a/an: A. Intranasal spray. B. Vaginal suppository. C. Intramuscular injection. D. Tablet.

C. Intramuscular injection. Intranasal spray is not the appropriate route for urofollitropin. Vaginal suppository is not the correct route for urofollitropin. Urofollitropin is given by IM injection; the dosage may vary. Urofollitropin cannot be given by tablet; it is given only by IM injection.

Abortion

Purposeful interruption of pregnancy before 20 weeks of gestation

First Trimester Abortion - Surgical

aspirate contents of uterus out, suck contents out, done after 10 weeks

Male Sterilization

- vasectomy - Tubal reconstruction (reanastomosis)- longer male has had vasectomy, less likely to have mobile sperm

Progestin-only contraceptives

- Oral progestins (minipill) - Injectable progestins - depo shot - Implantable progestins (Norplant) - 3 years

IUD

- Small, T-shaped device wrapped in copper inserted into the uterine cavity - Medicated intrauterine system loaded with progestational agent (Mirena) - IUD offers no protection against STIs or HIV - Change tubal transport time, doesn't allow for conception to occur, if conception occurs, usually doesn't allow for implantation

Barriers Methods

- Spermicides - Condoms, male (STI protection) - Vaginal sheath (STI protection) - Diaphragm - Cervical cap - no used in US - Contraceptive sponge

Fertility awareness methods (FAMs)

- Standard days method - Basal body temperature method - Cervical mucus ovulation-detection method - Symptothermal method - Predictor test kits for ovulation - indicate just prior to ovulation, not good for preventing pregnancy, good for getting pregnant - TwoDay method - Don't know - Breast-feeding

Female Sterilization

- Tubal occlusion - cauterize, put debris into tube and scaring occurs - Tubal reconstruction - ectopic common

Care Management

- A multidisciplinary approach to assist the woman in choosing an appropriate contraceptive method - Ideally the method should be safe, readily available, economical, acceptable, and simple to use - Contraceptive choice must meet personal, social, cultural, and interpersonal needs

Infertility Incidence

- Affects about 10% to 15% of reproductive-age couples - Four goals when providing care: 1. Provide the couple with accurate information 2. Assist in identifying the cause of infertility 3. Provide emotional support 4. Guide and educate about forms of treatment - Its a couple problem

Second Trimester Abortion

- Dilation and evacuation - aspiration - Cervical preparation with prostaglandins - Emotional considerations

Assisted reproductive therapies or ART

- In vitro fertilization-embryo transfer (IVF-ET) - Gamete intrafallopian transfer (GIFT) - Zygote intrafallopian transfer (ZIFT) - Ovum transfer (oocyte donation) - Therapeutic donor insemination (TDI) - Embryo hosting - Assisted embryo hatching

First Trimester Abortion

- Induced abortion performed in the first trimester is safest and less complex 1. Common complications: - Infection - from instrument placed into uterus - Retained products of conception - Excessive vaginal bleeding

6. In vitro fertilization-embryo transfer (IVF-ET) is a common approach for women with blocked fallopian tubes or unexplained infertility and for men with very low sperm counts. A husband and wife have arrived for their preprocedural interview. The husband asks the nurse to explain what the procedure entails. The nurse's most appropriate response is: a. "IVF is a type of assisted reproductive therapy that involves collecting eggs from your wife's ovaries, fertilizing them in the lab with your sperm, and transferring the embryo to her uterus." b. "A donor embryo will be transferred into your wife's uterus." c. "Donor sperm will be used to inseminate your wife." d. "Don't worry about the technical stuff; that's what we are here for."

ANS: A A woman's eggs are collected from her ovaries, fertilized in the laboratory with sperm, and transferred to her uterus after normal embryonic development has occurred. The statement, "A donor embryo will be transferred into your wife's uterus" describes therapeutic donor insemination. "Donor sperm will be used to inseminate your wife" describes the procedure for a donor embryo. "Don't worry about the technical stuff; that's what we are here for" discredits the client's need for teaching and is not the most appropriate response.

15. A woman who has a seizure disorder and takes barbiturates and phenytoin sodium daily asks the nurse about the pill as a contraceptive choice. The nurse's most appropriate response would be: a. "This is a highly effective method, but it has some side effects." b. "Your current medications will reduce the effectiveness of the pill." c. "The pill will reduce the effectiveness of your seizure medication." d. "This is a good choice for a woman of your age and personal history."

ANS: A Because the liver metabolizes oral contraceptives, their effectiveness is reduced when they are taken simultaneously with anticonvulsants. "Your current medications will reduce the effectiveness of the pill" is a true statement, but it is not the most appropriate response. The anticonvulsant will reduce the effectiveness of the pill, not the other way around. "This is a good choice for a woman of your age and personal history" does not teach the client that the effectiveness of the pill may be reduced because of her anticonvulsant therapy.

11. A woman has chosen the calendar method of conception control. During the assessment process it is most important that the nurse: a. Obtain a history of menstrual cycle lengths for the past 6 to 12 months. b. Determine the client's weight gain and loss pattern for the previous year. c. Examine skin pigmentation and hair texture for hormonal changes. d. Explore the client's previous experiences with conception control.

ANS: A The calendar method of conception control is based on the number of days in each cycle, counting from the first day of menses. The fertile period is determined after the lengths of menstrual cycles have been accurately recorded for 6 months. Weight gain or loss may be partly related to hormonal fluctuations, but it has no bearing on use of the calendar method. Integumentary changes may be related to hormonal changes, but they are not indicators for use of the calendar method. Exploring previous experiences with conception control may demonstrate client understanding and compliancy, but it is not the most important aspect to assess for discussion of the calendar method.

20. A woman is 16 weeks pregnant and has elected to terminate her pregnancy. The nurse knows that the most common technique used for medical termination of a pregnancy in the second trimester is: a. Dilation and evacuation (D&E). b. Instillation of hypertonic saline into the uterine cavity. c. Intravenous administration of Pitocin. d. Vacuum aspiration.

ANS: A The most common technique for medical termination of a pregnancy in the second trimester is D&E. It is usually performed between 13 and 16 weeks. Hypertonic solutions injected directly into the uterus account for less than 1% of all abortions because other methods are safer and easier to use. Intravenous administration of Pitocin is used to induce labor in a woman with a third-trimester fetal demise. Vacuum aspiration is used for abortions in the first trimester.

7. Nurses should be aware that infertility: a. Is perceived differently by women and men. b. Has a relatively stable prevalence among the overall population and throughout a women's potential reproductive years. c. Is more likely the result of a physical flaw in the woman than in her male partner. d. Is the same thing as sterility.

ANS: A Women tend to be more stressed about infertility tests and to place more importance on having children. The prevalence of infertility is stable among the overall population, but it increases with a woman's age, especially over age 40. Of cases with an identifiable cause, about 40% are related to female factors, 40% to male factors, and 20% to both partners. Sterility is the inability to conceive. Infertility is a state of requiring a prolonged time to conceive, or subfertility.

18. A woman was treated recently for toxic shock syndrome (TSS). She has intercourse occasionally and uses over-the-counter protection. On the basis of her history, what contraceptive method should she and her partner avoid? a. Cervical cap c. Vaginal film b. Condom d. Vaginal sheath

ANS: A Women with a history of TSS should not use a cervical cap. Condoms, vaginal films, and vaginal sheaths are not contraindicated for a woman with a history of TSS.

19. An unmarried young woman describes her sex life as "active" and involving "many" partners. She wants a contraceptive method that is reliable and does not interfere with sex. She requests an intrauterine device (IUD). The nurse's most appropriate response is: a. "The IUD does not interfere with sex." b. "The risk of pelvic inflammatory disease (PID) will be higher for you." c. "The IUD will protect you from sexually transmitted infections (STIs)." d. "Pregnancy rates are high with the IUDs."

ANS: B Disadvantages of IUDs include an increased risk of PID in the first 20 days after insertion and the risks of bacterial vaginosis and uterine perforation. The IUD offers no protection against STIs or the human immunodeficiency virus. Because this woman has multiple sex partners, she is at higher risk of developing an STI. The IUD does not protect against infection, as does a barrier method. Although "The IUD does not interfere with sex" may be correct, it is not the most appropriate response. The IUD offers no protection from STIs. The typical failure rate of the IUD ranges from 0.8% to 2%.

13. A married couple is discussing alternatives for pregnancy prevention and has asked about fertility awareness methods (FAMs). The nurse's most appropriate reply is: a. "They're not very effective, and it's very likely you'll get pregnant." b. "They can be effective for many couples, but they require motivation." c. "These methods have a few advantages and several health risks." d. "You would be much safer going on the pill and not having to worry."

ANS: B FAMs are effective with proper vigilance about ovulatory changes in the body and adherence to coitus intervals. They are effective if used correctly by a woman with a regular menstrual cycle. The typical failure rate for all FAMs is 25% during the first year of use. FAMs have no associated health risks. The use of birth control has associated health risks. In addition, taking a pill daily requires compliance on the client's part.

8. With regard to the assessment of female, male, and couple infertility, nurses should be aware that: a. The couple's religious, cultural, and ethnic backgrounds provide emotional clutter that does not affect the clinical scientific diagnosis. b. The investigation takes 3 to 4 months and a lot of money. c. The woman is assessed first; if she is not the problem, the male partner is analyzed. d. Semen analysis is for men; the postcoital test is for women.

ANS: B Fertility assessment and diagnosis take time, money, and commitment from the couple. Religious, cultural, and ethnic-bred attitudes about fertility and related issues always have an impact on diagnosis and assessment. Both partners are assessed systematically and simultaneously, as individuals and as a couple. Semen analysis is for men, but the postcoital test is for the couple.

30. Nurses, certified nurse-midwives, and other advanced practice nurses have the knowledge and expertise to assist women in making informed choices regarding contraception. A multidisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. Which action should the nurse take first when meeting with a new client to discuss contraception? a. Obtain data about the frequency of coitus. b. Determine the woman's level of knowledge about contraception and commitment to any particular method. c. Assess the woman's willingness to touch her genitals and cervical mucus. d. Evaluate the woman's contraceptive life plan.

ANS: B This is the primary step of this nursing assessment and necessary before completing the process and moving on to a nursing diagnosis. Once the client's level of knowledge is determined, the nurse can interact with the woman to compare options, reliability, cost, comfort level, protection from sexually transmitted infections, and a partner's willingness to participate. Although important, obtaining data about the frequency of coitus is not the first action that the nurse should undertake when completing an assessment. Data should include not only the frequency of coitus but also the number of sexual partners, level of contraceptive involvement, and partner's objections. Assessing the woman's willingness to touch herself is a key factor for the nurse to discuss should the client express interest in using one of the fertility awareness methods of contraception. The nurse must be aware of the client's plan regarding whether she is attempting to prevent conception, delay conception, or conceive.

4. A couple is trying to cope with an infertility problem. They want to know what they can do to preserve their emotional equilibrium. The nurse's most appropriate response is: a. "Tell your friends and family so they can help you." b. "Talk only to other friends who are infertile because only they can help." c. "Get involved with a support group. I'll give you some names." d. "Start adoption proceedings immediately because it is very difficult to obtain an infant."

ANS: C Venting negative feelings may unburden the couple. A support group may provide a safe haven for the couple to share their experiences and gain insight from others' experiences. Although talking about their feelings may unburden them of negative feelings, infertility can be a major stressor that affects the couple's relationships with family and friends. Limiting their interactions to other infertile couples may be a beginning point for addressing psychosocial needs, but depending on where the other couple is in their own recovery process, this may or may not help them. The statement about adoption proceedings is not supportive of the psychosocial needs of this couple and may be detrimental to their well-being

10. Although remarkable developments have occurred in reproductive medicine, assisted reproductive therapies are associated with a number of legal and ethical issues. Nurses can provide accurate information about the risks and benefits of treatment alternatives so couples can make informed decisions about their choice of treatment. Which issue would not need to be addressed by an infertile couple before treatment? a. Risks of multiple gestation b. Whether or how to disclose the facts of conception to offspring c. Freezing embryos for later use d. Financial ability to cover the cost of treatment

ANS: D Although the method of payment is important, obtaining this information is not the responsibility of the nurse. It is also of note that 14 states have mandated some form of insurance to assist couples with coverage for infertility. Risks of multiple gestation is indeed a risk of treatment of which the couple needs to be aware. To minimize the chance of multiple gestation, generally only three or fewer embryos are transferred. The couple should be informed that there may be a need for multifetal reduction. Nurses can provide anticipatory guidance on this matter. Depending on the therapy chosen, there may be a need for donor oocytes, sperm, embryos, or a surrogate mother. Couples who have excess embryos frozen for later transfer must be fully informed before consenting to the procedure. A decision must be made regarding the disposal of embryos in the event of death or divorce or if the couple no longer wants the embryos at a future time.

23. Which statement is true about the term contraceptive failure rate? a. It refers to the percentage of users expected to have an accidental pregnancy over a 5-year span. b. It refers to the minimum level that must be achieved to receive a government license. c. It increases over time as couples become more careless. d. It varies from couple to couple, depending on the method and the users.

ANS: D Contraceptive effectiveness varies from couple to couple, depending on how well a contraceptive method is used and how well it suits the couple. The contraceptive failure rate measures the likelihood of accidental pregnancy in the first year only. Failure rates decline over time because users gain experience.

29. Which statement is the most complete and accurate description of medical abortions? a. They are performed only for maternal health. b. They can be achieved through surgical procedures or with drugs. c. They are mostly performed in the second trimester. d. They can be either elective or therapeutic.

ANS: D Medical abortions are performed through the use of medications (rather than surgical procedures). They are mostly done in the first trimester, and they can be either elective (the woman's choice) or therapeutic (for reasons of maternal or fetal health).

Factors Associated with Infertility - Male

Assessment of male infertility - Hormonal factors - Testicular factors - Factors associated with sperm transport - men may build antibodies to own sperm - Idiopathic male infertility

Care Management - Male

Test or examination - Semen analysis - ejaculate into cup - Hormone analysis - Scrotal ultrasound

Elective Abortion

preformed at the women's request

Therapeutic Abortion

preformed for reasons of maternal or fetal health or disease

Contraception

- Intentional prevention of pregnancy - Birth control is the device or practice to decrease the risk of conceiving - Family planning is the conscious decision on when to conceive or avoid pregnancy - May still be at risk for pregnancy - Nearly half of all U.S. pregnancies are unplanned - unplanned doesn't mean unwanted

Combined estrogen-progestin contraceptives (COCs)

- Oral contraceptives and side effects - Transdermal contraceptive system - Vaginal ring 3weeks in, one week out - If given estrogen, must give progesterone - end up with carcinoma if not given together - Not put on estrogen if had thrombus before - one missed pill, taken soon as possible - two missed pills, up back up method 7 days - three or missed pills, restart package

Plan of care and implementation

- Psychosocial considerations 1. Nonmedical treatments - Herbal alternative methods - not good evidence 2. Medical therapy - make eggs mature, make women shed endometrium at appropriate time 3. Surgical therapies - Assisted reproductive therapies (ART)

Reproductive alternatives

- Surrogacy - illegal in Michigan - Preimplantation genetic diagnosis - Adoption - Cryopreservation of human embryos - freezing of embryos

Emergency contraception

- Used within 72 hours of unprotected intercourse - Five methods available in the United States - High doses of estrogen or COCs (three options) - Doesn't allow for implantation - Two days of levonorgestrel - Insertion of the copper intrauterine device (IUD)

First Trimester Abortion - Medical

- early part of trimester, prior to 8 weeks - Methotrexate and misoprostol - stop duplication of cells - Mifepristone and misoprostol - cause uterus to contract, RU486 blocks progesterone (not used in US)

31. You (the nurse) are reviewing the educational packet provided to a client about tubal ligation. What is an important fact you should point out? Choose all that apply. a. "It is highly unlikely that you will become pregnant after the procedure." b. "This is an effective form of 100% permanent sterilization. You won't be able to get pregnant." c. "Sterilization offers some form of protection against sexually transmitted infections (STIs)." d. "Sterilization offers no protection against STIs." e. "Your menstrual cycle will greatly increase after your sterilization."

ANS: A, D A woman is unlikely to become pregnant after tubal ligation, although it is not 100% effective. It does not offer any protection against STIs. Sterilization offers no protection against STIs. Typically the menstrual cycle remains the same after a tubal ligation.

14. A male client asks the nurse why it is better to purchase condoms that are not lubricated with nonoxynol-9 (a common spermicide). The nurse's most appropriate response is: a. "The lubricant prevents vaginal irritation." b. "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; it has also been linked to an increase in the transmission of human immunodeficiency virus and can cause genital lesions." c. "The additional lubrication improves sex." d. "Nonoxynol-9 improves penile sensitivity."

ANS: B "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; it has also been linked to an increase in the transmission of human immunodeficiency virus and can cause genital lesions" is a true statement. Nonoxynol-9 may cause vaginal irritation, has no effect on the quality of sexual activity, and has no effect on penile sensitivity.

15. A woman who has a seizure disorder and takes barbiturates and phenytoin sodium daily asks the nurse about the pill as a contraceptive choice. The nurse's most appropriate response would be: a. "This is a highly effective method, but it has some side effects." b. "Your current medications will reduce the effectiveness of the pill." c. "The pill will reduce the effectiveness of your seizure medication." d. "This is a good choice for a woman of your age and personal history."

ANS: B Because the liver metabolizes oral contraceptives, their effectiveness is reduced when they are taken simultaneously with anticonvulsants. "Your current medications will reduce the effectiveness of the pill" is a true statement, but it is not the most appropriate response. The anticonvulsant will reduce the effectiveness of the pill, not the other way around. "This is a good choice for a woman of your age and personal history" does not teach the client that the effectiveness of the pill may be reduced because of her anticonvulsant therapy.

5. A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is the most appropriate when instructing the client in which herbal preparations to avoid while trying to conceive? a. "You should avoid nettle leaf, dong quai, and vitamin E while you are trying to get pregnant." b. "You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to conceive." c. "You should not take anything with vitamin E, calcium, or magnesium. They will make you infertile." d. "Herbs have no bearing on fertility."

ANS: B Herbs that a woman should avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, golden seal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. Nettle leaf, dong quai, and vitamin E are all remedies that promote fertility. Vitamin E, calcium, and magnesium may promote fertility and conception. Although most herbal remedies have not been proven clinically to promote fertility, women should avoid the following herbs while trying to conceive: licorice root, yarrow, wormwood, ephedra, fennel, golden seal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle.

16. Injectable progestins (DMPA, Depo-Provera) are a good contraceptive choice for women who: a. Want menstrual regularity and predictability. b. Have a history of thrombotic problems or breast cancer. c. Have difficulty remembering to take oral contraceptives daily. d. Are homeless or mobile and rarely receive health care.

ANS: C Advantages of DMPA include a contraceptive effectiveness comparable to that of combined oral contraceptives with the requirement of only four injections a year. Disadvantages of injectable progestins are prolonged amenorrhea and uterine bleeding. Use of injectable progestin carries an increased risk of venous thrombosis and thromboembolism. To be effective, DMPA injections must be administered every 11 to 13 weeks. Access to health care is necessary to prevent pregnancy or potential complications.

3. A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses, but the sperm seem to be clumped together. What additional test is needed? a. Testicular biopsy b. Antisperm antibodies c. Follicle-stimulating hormone (FSH) level d. Examination for testicular infection

ANS: C The woman has irregular menstrual cycles. The scenario does not indicate that she has had any testing related to this irregularity. Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular. Determination of blood levels of prolactin, FSH, luteinizing hormone (LH), estradiol, progesterone, and thyroid hormones may be necessary to diagnose the cause of irregular menstrual cycles. A testicular biopsy would be indicated only in cases of azoospermia (no sperm cells) or severe oligospermia (low number of sperm cells). Antisperm antibodies are produced by a man against his own sperm. This is unlikely to be the case here, because the husband has already produced children. Examination for testicular infection would be done before semen analysis. Furthermore, infection would affect spermatogenesis.

21. A woman will be taking oral contraceptives using a 28-day pack. The nurse should advise this woman to protect against pregnancy by: a. Limiting sexual contact for one cycle after starting the pill. b. Using condoms and foam instead of the pill for as long as she takes an antibiotic. c. Taking one pill at the same time every day. d. Throwing away the pack and using a backup method if she misses two pills during week 1 of her cycle.

ANS: C To maintain adequate hormone levels for contraception and to enhance compliance, clients should take oral contraceptives at the same time each day. If contraceptives are to be started at any time other than during normal menses or within 3 weeks after birth or abortion, another method of contraception should be used through the first week to prevent the risk of pregnancy. Taken exactly as directed, oral contraceptives prevent ovulation, and pregnancy cannot occur. No strong pharmacokinetic evidence indicates a link between the use of broad-spectrum antibiotics and altered hormone levels in oral contraceptive users. If the client misses two pills during week 1, she should take two pills a day for 2 days, finish the package, and use a backup method the next 7 consecutive days.

9. In their role of implementing a plan of care for infertile couples, nurses should: a. Be comfortable with their sexuality and nonjudgmental about others to effectively counsel their clients. b. Know about such nonmedical remedies as diet, exercise, and stress management. c. Be able to direct clients to sources of information about what herbs to take that might help and which ones to avoid. d. Do all of the above plus be knowledgeable about potential drug and surgical remedies.

ANS: D Nurses should be open to and ready to help with a variety of medical and nonmedical approaches.

27. With regard to the noncontraceptive medical effects of combined oral contraceptive pills (COCs), nurses should be aware that: a. COCs can cause toxic shock syndrome if the prescription is wrong. b. Hormonal withdrawal bleeding usually is a bit more profuse than in normal menstruation and lasts a week. c. COCs increase the risk of endometrial and ovarian cancer. d. The effectiveness of COCs can be altered by some over-the-counter medications and herbal supplements.

ANS: D The effectiveness of COCs can be altered by some over-the-counter medications and herbal supplements. Toxic shock syndrome can occur in some diaphragm users, but it is not a consequence of taking oral contraceptive pills. Hormonal withdrawal bleeding usually is lighter than in normal menstruation and lasts a couple of days. Oral contraceptive pills offer protection against the risk of endometrial and ovarian cancers.

2. A man smokes two packs of cigarettes a day. He wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant. The nurse's most appropriate response is: a. "Your sperm count seems to be okay in the first semen analysis." b. "Only marijuana cigarettes affect sperm count." c. "Smoking can give you lung cancer, even though it has no effect on sperm." d. "Smoking can reduce the quality of your sperm."

ANS: D Use of tobacco, alcohol, and marijuana may affect sperm counts. "Your sperm count seems to be okay in the first semen analysis" is inaccurate. Sperm counts vary from day to day and depend on emotional and physical status and sexual activity. Therefore a single analysis may be inconclusive. A minimum of two analyses must be performed several weeks apart to assess male fertility. Use of tobacco, alcohol, and marijuana may affect sperm counts.

A male client asks the nurse why it is better to purchase condoms that are not lubricated with nonoxynol-9 (a common spermicide). The nurse's most appropriate response is: A. "The lubricant prevents vaginal irritation." B. "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; also it has been linked to an increase in the transmission of human immunodeficiency virus (HIV) and can cause genital lesions." C. "The additional lubrication improves sex." D. "Nonoxynol-9 improves penile sensitivity."

B. "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; also it has been linked to an increase in the transmission of human immunodeficiency virus (HIV) and can cause genital lesions." Nonoxynol-9 may cause vaginal irritation. This is a true statement. Nonoxynol-9 has no effect on the quality of sexual activity. Nonoxynol-9 has no effect on penile sensitivity.

A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is the most appropriate when instructing the woman in which herbal preparations to avoid while trying to conceive? A. "You should avoid nettle leaf, dong quai, and vitamin E while you are trying to get pregnant." B. "You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to conceive." C. "You should not take anything with vitamin E, calcium, or magnesium. They will make you infertile." D. "Herbs have no bearing on fertility."

B. "You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to conceive." Nettle leaf, dong quai, and vitamin E promote fertility. Herbs that a woman should avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. Vitamin E, calcium, and magnesium may promote fertility and conception. Although most herbal remedies have not been proven clinically to promote fertility, women should avoid the following herbs while trying to conceive: licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle.

A married woman has made the decision to use a diaphragm as her primary method of birth control. The clinic nurse should provide which instructions regarding care of, insertion, and removal of the diaphragm? (Select all that apply.) A. Remove the diaphragm by catching the rim from below the dome. B. Avoid using mineral oil body products. C. On insertion, direct the diaphragm down toward the space below cervix. D. Wash diaphragm monthly with mild soap and water. E. A dusting of cornstarch is appropriate after drying the diaphragm.

B. Avoid using mineral oil body products. C. On insertion, direct the diaphragm down toward the space below cervix. D. Wash diaphragm monthly with mild soap and water. E. A dusting of cornstarch is appropriate after drying the diaphragm. The diaphragm should not be removed by trying to catch the rim from below the dome. Oil-based products can cause the breakdown of the rubber. The diaphragm should be inserted into the vagina, directing it inward and downward as far as it will go to the space behind and below the cervix. The diaphragm should be washed after each use with mild soap and water. Cornstarch may be used. Avoid use of scented talc, body powder, and baby powder because they can weaken the rubber.

Semen analysis is a common diagnostic procedure related to infertility. In instructing a male patient regarding this test, the nurse would tell him to: A. Ejaculate into a sterile container. B. Obtain the specimen after a period of abstinence from ejaculation of 2 to 5 days. C. Transport specimen with container packed in ice. D. Ensure that the specimen arrives at the laboratory within 30 minutes of ejaculation.

B. Obtain the specimen after a period of abstinence from ejaculation of 2 to 5 days. The male must ejaculate into a clean container or a plastic sheath that does not contain a spermicide. An ejaculated sample should be obtained after a period of abstinence to get the best results. He should avoid exposing the specimen to extremes of temperature, either heat or cold. The specimen should be taken to the laboratory within 2 hours of ejaculation.

Discharge instructions after tubal ligation should include: (Select all that apply.) A. Being prepared for significant mood swings due to hormonal influences. B. Expecting heavier menstrual periods. C. Using two forms of birth control to prevent pregnancy. D. Not expecting change in sexual functioning; may enjoy more. E. Using condoms to prevent sexually transmitted infections.

D. Not expecting change in sexual functioning; may enjoy more. E. Using condoms to prevent sexually transmitted infections. Patient teaching regarding what to expect after tubal ligation includes: • You should expect no change in hormones and their influence. • Your menstrual period will be about the same as before the sterilization. • You may feel pain at ovulation. • The ovum disintegrates within the abdominal cavity. • It is highly unlikely that you will become pregnant. • You should not have a change in sexual functioning; you may enjoy sexual relations more because you will not be concerned about becoming pregnant. • Sterilization offers no protection against sexually transmitted infections. Therefore you may need to use condoms.

Care Management - Female

Test or examination - Evaluation of the anatomy - Detection of ovulation - Hormone analysis - parts of cycle - Ultrasonography - Endometrial biopsy - take part of endometrium, look at proiferating - Hysterosalpingography - shoot dye up cervix and watch movement of it through tubes - Laparoscopy - look at endometrium tissue