Module 1 Lesson 4 (Maternity Client: Antepartum Care)

Discomforts of pregnancy: ankle edema

Edema usually occurs in the second and third trimesters as a result of vasodilation, venous stasis, and increased venous pressure below the uterus. - Interventions The client should elevate her legs at least twice a day. Advise the client to sleep in the lateral position. Supportive stockings should be worn. The client should avoid sitting or standing in one position for long periods.

The third through eighth weeks after conception are called the

Embryonic stage

Priority points

Fertilization occurs in the upper region of the fallopian tubes. Most substances in maternal blood can be transferred to the fetus. The umbilical cord contains two arteries and one vein. Positive signs of pregnancy include auscultation of the fetal heart rate, active fetal movements palpable by the examiner, and the outline of the fetus on ultrasound. The gravid uterus partially occludes the vena cava and descending aorta when the mother lies in a supine position, sometimes resulting in supine hypotensive syndrome; this may be prevented or corrected by positioning the mother in a lateral position. During the second and third trimesters (weeks 18-30), fundal height in centimeters approximately equals the fetus's age in weeks, plus or minus 2 cm. An increase of about 300 calories per day is needed during pregnancy. An increase of about 500 calories per day is needed during lactation. A diet high in folic acid and folic acid supplementation are important. The pregnant woman should drink at least eight to ten 8-oz (235ml) glasses of fluid each day, of which four to six glasses should be water. The non-stress test reveals whether the fetal heart rate accelerates when the fetus moves. The contraction stress test is used to evaluate the response of the fetal heart to recurrent short interruptions in placental blood flow and oxygen supply that occur with uterine contractions.

Positive signs/symptoms of pregnancy

Fetal heart rate, detectable with an electronic device (Doppler transducer) at 10 to 12 weeks and with a nonelectronic device (fetoscope) at 20 weeks of gestation Active fetal movements palpable by examiner Outline of fetus on ultrasound

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 16

Fetus is 11.5 to 13.5 cm long. Fetus weighs 100 g. Active movements are present. Skin is transparent. Lanugo hair begins to develop. Skeletal ossification takes place.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 20

Fetus is 16 to 18.5 cm long. Fetus weighs 300 g. Lanugo covers the entire body. Fetus has fingernails and toenails. Muscles are developed. Enamel and dentin are being deposited. Heartbeat is detectable with a regular (nonelectronic) fetoscope.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 24

Fetus is 23 cm long. Fetus weighs 600 g. Hair on head is well formed. Skin is reddish and wrinkled. Reflex hand grasp is functioning. Vernix caseosa covers the entire body. Fetus can hear.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 28

Fetus is 27 cm long. Fetus weighs 1100 g. Limbs are well flexed. Brain is developing rapidly. Eyelids open and close. Lungs are developed sufficiently to provide gas exchange (lecithin forming). If born at this time, neonate can breathe.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 32

Fetus is 31 cm long. Fetus weighs 1800 to 2100 g. Bones are fully developed. Subcutaneous fat has accumulated. Lecithin-to-sphingomyelin (L/S) ratio is 1.2:1.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 36

Fetus is 35 cm long. Fetus weighs 2200 to 2900 g. Skin is pink and the body rounded. Skin is less wrinkled. Lanugo is disappearing. L/S ratio is higher than 2:1.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 40

Fetus is 40 cm long. Fetus weighs 3200 g or more. Skin is pinkish and smooth. Lanugo remains on the upper arms and shoulders. Vernix caseosa coverage decreases. Fingernails extend beyond fingertips. Sole (plantar) creases run down to the heels. Testes are in the scrotum. Labia majora are well developed.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 12

Fetus is 6 to 9 cm long. Fetus weighs 19 g. Face is well formed. Limbs are long and slender. Kidneys begin to form urine. Spontaneous movements occur. Heartbeat is detectable with a Doppler transducer between 10 and 12 weeks. Sex is visually recognizable.

Types of Pelvises: Platypelloid

Flat, with an oval inlet Wide transverse diameter but short anteroposterior diameter, making outlet inadequate for labor and birth

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 1

Free floating blastocyst

PHYSIOLOGICAL MATERNAL CHANGES: renal system

Frequency of urination increases in the first and third trimesters as a result of pressure of the enlarging uterus on the bladder. This reduces bladder capacity. Diminished bladder tone is caused by hormonal changes. The renal threshold for glucose may be reduced.

Discomforts of pregnancy: fatigue

Generally a result of hormonal changes, fatigue usually occurs in the first and third trimesters. - Interventions Recommend that the client arrange for frequent rest periods throughout the day. The client should get regular exercise. Teach client to perform muscle-relaxation and strengthening exercises for the legs and hip joints. The client should avoid eating and drinking foods containing stimulants throughout pregnancy.

Gestation

Gestation lasts approximately 280 days. Use Nagele's rule to calculate the estimated date of delivery (EDD) or estimated date of confinement (EDC). (For Nagele's rule to be accurate, the woman must have a regular 28-day menstrual cycle.)

Gravida

Gravida is used to refer to the number of pregnancies or to the pregnant woman herself. Gravidity is the state of being pregnant. A nulligravida is a woman who has never been pregnant. A primigravida is a woman who is pregnant for the first time. A multigravida is a woman in at least her second pregnancy.

Discomforts of pregnancy: heartburn

Heartburn, which occurs in the second and third trimesters, results from an increased progesterone level, decreased gastrointestinal motility and esophageal reflux, and displacement of the stomach by the enlarging uterus. - Interventions Client should eat small, frequent meals. Advise client to sit upright for 30 minutes after a meal. Milk should be drunk between meals. Fatty and spicy foods should be avoided. Teach client to perform tailor-sitting exercises. Client should take antacids only if they are recommended by the primary health care provider or nurse-midwife.

Discomforts of pregnancy: increase vaginal discharge

Increased discharge, which may occur in all three trimesters, results from hyperplasia of vaginal mucosa and increased mucus production. - Interventions Proper cleansing and hygiene are important. The client should wear cotton underwear. Douching should be avoided. The client should be advised to consult the primary health care provider or nurse-midwife if infection is suspected.

Discomforts of pregnancy: N/V

Occurs in the first trimester Results from increased hCG levels and changes in carbohydrate metabolism - Interventions Eating dry crackers before arising Eating small, frequent, low-fat meals during the day Drinking liquids between meals rather than at meals Avoiding fried foods and spicy foods Acupressure (some types may require a prescription) Herbal remedies, only if approved by the primary health care provider or nurse-midwife (select to learn more about complementary therapies for nausea)

Fertilization

Occurs in the upper region of the fallopian tubes within 12 hours of ovulation and 2 to 3 days of insemination, which are the average durations of viability for the ovum and sperm, respectively. - Once the ovum is fertilized, its membrane undergoes changes that prevent the entry of other sperm. - Sperm carry an X and a Y chromosome: XY is male, XX female.

Fetal environment: chorion

Outer membrane Becomes vascularized and forms the fetal part of the placenta

Types of Pelvises: Anthropoid

Oval Adequate outlet and normal or moderately narrow pubic arch

PHYSIOLOGICAL MATERNAL CHANGES: respiratory system

Oxygen consumption increases by 15% to 20%. Diaphragm is elevated because of the enlarged uterus. Respiratory rate remains unchanged, but shortness of breath may be experienced by the pregnant woman.

Parity

Parity is the number of births (not the number of fetuses—e.g., twins) carried past 20 weeks' gestation, whether or not the fetuses were born alive. A nullipara is a woman who has not had a birth at more than 20 weeks of gestation. A primipara is a woman who has had one birth that occurred after the 20th week of gestation. A multipara is a woman who has had two or more pregnancies resulting in viable offspring.

Diagnostic tests: Non stress test (NST)

Performed to assess placental function and oxygenation Used to determines fetal well-being Enables evaluation of FHR in response to fetal movement - Implementation External ultrasound transducer and the tocodynamometer (a.k.a. the "toco") are applied to the mother, and a tracing of at least 20 minutes duration is obtained so that the FHR and the uterine activity may be observed. Obtain baseline blood pressure and recheck pressure frequently. Position mother in the lateral position to avoid vena cava compression. The mother may be asked to press a button every time she feels fetal movement; the monitor records each point of fetal movement, and the record is used as a reference against which to assess FHR response. (Reactive, nonreactive, unsatisfactory)

Fetal circulation: fetal circulation bypass

Present because of the fetus' nonfunctioning lungs, bypasses must close after birth to allow blood to flow through the lungs and the liver. The ductus arteriosus connects the pulmonary artery to the aorta, bypassing the lungs. The ductus venosus connects the umbilical vein and inferior vena cava, bypassing the liver. The foramen ovale is the opening between right and left atria of heart, bypassing the lungs.

Lab tests

- Blood Type and Rh Factor Vials of blood ABO typing is performed to determine the woman's blood type. Rh factor typing is conducted to determine the presence or absence of Rh antigen (Rh-positive or Rh-negative). If the client is Rh negative and has a negative result on antibody screening, she will need repeat antibody screens and should receive Rh immune globulin at 28 weeks' gestation. Rh factor type is important to determine because if the mother is Rh-negative and delivers an Rh-positive fetus, an antigen-antibody reaction can occur that causes the destruction of fetal red blood cells. - Rubella Titer If the client has a negative titer, indicating susceptibility to the rubella virus, she should receive the appropriate immunization after delivery. The client must be using effective birth control at the time of the immunization and must be counseled not to become pregnant for 3 months (or as recommended by the primary health care provider) after immunization. - Hemoglobin and Hematocrit Hemoglobin and hematocrit levels drop during gestation as a result of increased plasma volume. An increase in the hematocrit level may indicate the development of gestational hypertension. A decrease in the hemoglobin level to less than 10 g/dL (Hgb 100 mmol/L) or in the hematocrit level to less than 35% for females indicates anemia. - Papanicolaou Smear This test may be better known by some as the Pap smear. The Pap smear is performed during the initial prenatal examination to screen for cervical neoplasia. - Hepatitis B Surface Antigen Screening for hepatitis B infection is recommended for all women because of the prevalence of the disease in the general population. - Urinalysis and Urine Culture A urine specimen for glucose and protein determinations should be obtained at every prenatal visit. Glycosuria is a common result of the decreased renal threshold that occurs during pregnancy. Persistent glycosuria may indicate diabetes. White blood cells in the urine may indicate infection. Ketonuria may result from insufficient food intake or vomiting. Levels of 2+ to 4+ protein in the urine may indicate infection or preeclampsia.

Lab tests: STIs

- Gonorrhea Culture is performed during the initial prenatal examination and may be repeated during the third trimester in high-risk clients. - Syphilis Screening is performed during the initial prenatal examination and may be repeated during the third trimester in high-risk clients. - Herpes Culture is indicated for clients with a history of the disease and in those with active lesions and is performed to determine the route of delivery. Weekly cultures may be performed beginning at the 35th or 36th week of pregnancy and continued until delivery. - Chlamydia Culture is indicated if the client is in a high-risk group: adolescents, those who have had multiple sex partners, and those with a history of sexually transmitted infections. Culture is indicated if an infant or infants from previous pregnancies have exhibited neonatal conjunctivitis or pneumonia.

PHYSIOLOGICAL MATERNAL CHANGES: reproductive system

- Ovaries Maturation of new follicles is blocked. Ovum production ceases. - Vagina Hypertrophy and thickening of the muscle occurs. Vaginal secretions increase; usually these are thick, white, and acidic. - Breasts Size increases. Nipples become more pronounced. Areolas become darker. Superficial veins become prominent. Hypertrophy of the Montgomery follicles occurs. Colostrum may leak from the breast. - Uterus Enlarges from a weight of 60 g to 1000 g Irregular contractions occur - Cervix Becomes shorter, more elastic, and larger in diameter Endocervical glands secrete a thick mucus plug, which is expelled from the canal when dilation begins Increased vascularization causes softening and the violet discoloration known as the Chadwick sign, which occurs at approximately 4 weeks of gestational age

PHYSIOLOGICAL MATERNAL CHANGES: Cardiovascular system

Circulating blood and plasma volumes increase. Physiological anemia occurs as the plasma increase exceeds the increase in red blood cell production. Iron requirements are increased. The heart is elevated and moved to the left because of displacement of the diaphragm as the uterus enlarges. Pulse may increase by about 10 beats per minute. Blood pressure may decline in the second trimester. Retention of sodium and water may occur.

The fetal period starts ____ weeks after conception and lasts through the end of gestation.

9

Diagnostic tests: nitrazine test

A Nitrazine test strip is used to detect the presence of amniotic fluid in vaginal secretions, which have a pH of 4.5 to 5.5 and do not affect the yellow Nitrazine strip or swab. Amniotic fluid has a pH of 7.0 to 7.5 and turns the yellow Nitrazine strip blue. - Implementation Position the client in the dorsal lithotomy position. Touch the test tape to the fluid. Assess the test tape for a blue-green, blue-gray, or deep-blue color, all of which indicate that the membranes have probably ruptured.

PHYSIOLOGICAL MATERNAL CHANGES: integumentary system

A dark streak, or linea nigra, may appear down the midline of the abdomen. Chloasma (the "mask of pregnancy"), a blotchy brownish hyperpigmentation, may appear over the forehead, cheeks, and nose. Reddish-purple stretch marks (striae) may appear on the abdomen, breasts, thighs, and upper arms. Vascular spider nevi may appear on the neck, chest, face, arms, and legs. The rate of hair growth may slow.

Discomforts of pregnancy: backache

A result of an exaggerated lumbosacral curve caused by the enlarged uterus, backache generally occurs in the second and third trimesters. - Interventions The client should be encouraged to rest. Good body mechanics and improved posture will help alleviate pain. Low-heeled shoes should be worn. The client should be taught pelvic rocking and abdominal breathing exercises. Sleeping on a firm mattress may help relieve pain.

A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? 4 days 10 days 14 days 21 days

ANS = 10 Rationale: Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.

A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? Checking the woman's blood pressure Calling the obstetrician to the examining room Placing a cool cloth on the woman's forehead Assisting the client into a lateral recumbent position

ANS = Assisting the client Rationale: When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Signs/symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.

A nurse prepares to teach a pregnant woman to perform tailor-sitting exercises. Which instruction should the nurse provide to the client? Lie flat on the back and place both feet against a wall. Position self on the hands and knees and arch the back five times in a 30-second period. Sit with the legs straight, press the knees toward the floor, and hold the position for 10 seconds. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes.

ANS = Bend the knees Rationale: Tailor-sitting exercises are useful in alleviating heartburn and shortness of breath or dyspnea. The woman sits on the floor, bends her knees, places the soles together, uses her thigh muscles to press the knees to the floor, and holds the position for 5 to 15 minutes. The other options are incorrect descriptions of this exercise.

A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? Gravida 2, para 4 Gravida 3, para 5 Gravida 4, para 2 Gravida 5, para 3

ANS = G4 P2 Rationale: Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.

Janice Casey, 27 years old, is pregnant for the third time. She is in her first trimester. Janice's husband has accompanied her to the maternity clinic, and he tells the nurse that he is going to be with Janice throughout labor and delivery. The nurse, obtaining an obstetric history from Janice, notes that her menstrual periods are regular and that her last period was on August 25, 2016. Janice tells the nurse that she has one son, born at 40 weeks' gestation, and one daughter, born at 36 weeks' gestation. She says that these pregnancies progressed normally, without complications. Janice has no history of medical or surgical problems. Her temperature is 98° F (36.7° C), her apical pulse is 80 beats/min, respirations are 18 breaths/min, and blood pressure is 120/78 mm Hg. Janice asks the nurse about her expected date of delivery. Using Nagele's rule, what does the nurse calculate the estimated date of delivery (EDD)? May 25, 2017 May 31, 2017 June 1, 2017 July 1, 2017 The nurse completes Janice's obstetric history. How does the nurse record Janice's history of gravidity and parity? Gravida 2, para 2 Gravida 3, para 2 Gravida 3, para 3 Gravida 2, para 3 At 30 weeks' gestation, Janice is seen in the maternity clinic for a follow-up visit. The nurse checks the fundal height. Which measurement does the nurse expect to see? 20 cm 26 cm 30 cm 34 cm During the 30-week follow-up visit, the nurse assesses Janice and asks, "How are you feeling these days?" Which of these statements from Janice would indicate that further assessment is needed? Select all that apply. "I spend so much time going to the bathroom!" "I haven't been sleeping well for several days." "I've noticed that I get out of breath after I vacuum the floors." "Since yesterday I've noticed that the baby isn't moving as much." "I've noticed that my fingers and face have been swollen when I wake up in the morning." Janice comes to the clinic for her 39-week visit. (Refer to Janice's record by refering "Chart" below.) Based on the data recorded (refer to medical record), the nurse concludes that one condition may be a problem. What is it? Vital Signs Blood pressure 162/110 mm Hg Temperature: 98.4° F Pulse 92 beats/min Respirations 14 breaths/min Subjective Data "I've had a headache for the last few days." "My vision seems blurry lately." "I've had to take off my rings because my fingers are swollen." Objective Data Urine dipstick: proteinuria +2; glucose negative Bilateral ankle edema, +2 Edema of face and fingers Fundal height 38.5 cm Fetal heart tones (FHTs): 140 beats/min Deep tendon reflexes: 2+ Eclampsia Mild preeclampsia Severe preeclampsia Chronic hypertension

ANS = June 1 Rationale: For Nagele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse subtracts 3 months from the first day of the last menstrual period, adds 7 days, and then adjusts the year as necessary. Subtracting 3 months from August 25, 2016, yields May 25, 2016. Adding 7 days yields June 1, 2016. Adding 1 year to June 1, 2016 brings the EDD to June 1, 2017. ANS = G3 P2 Rationale: Gravida refers to the number of pregnancies, including the current one. Parity is the number of births (not the number of fetuses, e.g., twins) carried past 20 weeks at delivery, whether or not the fetus was born alive. Because this is the client's third pregnancy, her gravidity is 3. Because Janice is in her first trimester of this pregnancy and also has one son who was born at 40 weeks' gestation and one daughter who was born at 36 weeks' gestation, her parity is 2. ANS = 30 Rationale: From 22 weeks to term, the fundal height, which is measured in centimeters, is roughly equal (plus or minus 2 cm) to the gestational age of the fetus in weeks. Therefore, because this client is at 30 weeks' gestation, her fundal height would be 30 (plus or minus 2 cm). If fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause of the unexpectedly large uterine size. If fundal height is less than expected on the basis of gestational age, the estimated date of delivery must be confirmed. If the dates are accurate, further assessment may be necessary to determine whether the fetus' growth is inadequate. ANS = "Since yesterday..." + "Ive noticed that my fingers..." Rationale: During the second and third trimesters of pregnancy, certain signs and symptoms may indicate complications. Any change in the pattern or frequency of fetal movements should be investigated immediately to detect or rule out fetal jeopardy. Swelling of the face or fingers may indicate a hypertensive condition or preeclampsia. Discomforts that are expected during this trimester of pregnancy include insomnia, frequent urination (caused by impingement of the enlarging uterus on the bladder, resulting in reduced bladder capacity), and shortness of breath (resulting from limitation of diaphragm movement by the enlarging uterus). ANS = severe preeclampsia Rationale: A client experiencing severe preeclampsia will have a blood pressure of 160/110 mm Hg or higher on two separate occasions and will have 2+ to 3+ proteinuria on dipstick testing. Headaches, blurred vision, and facial and finger edema may also be present. Chronic hypertension would have been detected before pregnancy or before 20 weeks of gestation. Mild preeclampsia presents with a blood pressure of 140/90 mm Hg, minimal or no headache, no vision problems, and proteinuria of less than 2+ on dipstick testing. Eclampsia is an emergency that is characterized by seizure activity and sometimes coma.

A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. Perform the exercise while urinating. Perform the exercise once only after urinating. Repeat the contraction-relaxation cycle 30 times a day. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.

ANS = Repeat and contract Rationale: Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.

A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? The procedure will take about 2 hours. The obstetrician will locate the fetus with the use of the Leopold's maneuvers. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.

ANS = The client may feel pressure Rationale: Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Leopold's maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted

A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? The umbilical cord holds two veins and one artery. Fetal blood circulation takes place strictly in the placenta. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.

ANS = The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. Rationale: The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.

A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. What is the best response the nurse should give to the client? To increase her daily intake of high-fiber foods That this is a normal occurrence during pregnancy To take the iron supplement every other day instead of every day To start taking an oral laxative daily until the constipation resolves

ANS = To increase her daily intake of high-fiber foods Rationale: The best response is for the client to increase her daily intake of high-fiber foods. Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the primary health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.

A non-stress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? Fetal well-being has been established. A contraction stress test will be scheduled. Placental function and oxygenation are adequate. The results are inadequate and the non-stress test must be repeated.

ANS = a contraction stress test will be scheduled Rationale: A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if non stress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.

Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? The result of the Rh factor screen is normal. Because the Rh factor is not present, no additional testing is necessary. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.

ANS = because the Ph factor is not present, the client will need to receive Rh immune globulin at about 28 weeks gestation Rationale: If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.

A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nagele's Rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? October 17, 2016 November 17, 2016 September 17, 2016 December 17, 2017

ANS = nov 17 Rationale: For Nagele's Rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.

A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? The client is definitely pregnant. The nurse-midwife noted softening of the cervix. The client exhibits a presumptive sign of pregnancy. The nurse-midwife noted a violet coloration of the cervix.

ANS = softening cervix Rationale: In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.

A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? She should cover the discoloration with makeup. She should come to the clinic immediately to be checked. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen.

ANS = this is a normal skin change Rationale: Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign/symptom is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.

A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? She must come to the clinic to be checked. This is an expected occurrence during pregnancy. This is frequently the first sign of a breast infection. She should notify the nurse-midwife of this finding.

ANS = this is an expected occurrence Rationale: Colostrum, the creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples as early as 16 weeks' gestation. This is an expected occurrence during pregnancy. It is not necessary for the client to notify the nurse-midwife or to report to the clinic to be checked. It is not a sign/symptom of infection.

A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? Week 1 Week 5 Week 8 Week 9

ANS = week 5 Rationale: By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore, the other options are incorrect.

PHYSIOLOGICAL MATERNAL CHANGES: ambivalence

Ambivalence may occur early in pregnancy, even when the pregnancy is planned. Mother may experience dependence-independence conflict and ambivalence related to role changes and increased financial responsibilities. Partner may experience ambivalence related to assuming the new role, increased financial responsibilities, and anticipation of having to share the partner's attention with the child. Factors that may be related to acceptance of a pregnancy are the woman's readiness for the experience and identification with the motherhood role.

Presumptive signs/symptoms

Amenorrhea Nausea and vomiting Increased size and feeling of fullness in breasts Pronounced nipples Urinary frequency Quickening Fatigue Discoloration and thickening of the vaginal mucosa

Diagnostic tests: amniocentesis

Amniotic fluid is aspirated between 15 and 20 weeks of pregnancy to enable detection of genetic disorders and metabolic defects and to aid assessment of fetal lung maturity. - Implementation Obtain informed consent. If the client is less than 20 weeks pregnant, she should have a full bladder to support the uterus; if amniocentesis is being performed after 20 weeks' gestation, the client should have an empty bladder to minimize the chance of puncture. Prepare the client for ultrasonography, which is performed to locate the placenta and avoid puncture. Obtain baseline vital signs and fetal heart rate (FHR); monitor every 15 minutes. Position the client supine during the exam and on the left side after the procedure. Instruct the client to notify the primary health care provider or nurse-midwife if chills or fever develops, fluid leaks from the needle-insertion site, fetal movement decreases, or uterine contractions occur. Rh-negative women may be given RhoGAM to counter risks related to the procedure.

Discomforts of pregnancy: SOB and dyspnea

Breathing difficulties may occur in the second and third trimesters as a result of pressure on the diaphragm. - Interventions The client should plan frequent rest periods. Sleeping with the head elevated or sleeping on the side may bring relief. The client should avoid overexertion. Teach client to perform tailor-sitting exercises (refer image on right).

PHYSIOLOGICAL MATERNAL CHANGES: skeletal system

Center of gravity changes. Postural changes occur as the increased weight of the uterus exerts a forward pull on the bony pelvis.

PHYSIOLOGICAL MATERNAL CHANGES: body image changes

Changes in a woman's perception of her image during pregnancy occur gradually and may be either positive or negative. Physical changes and signs/symptoms the woman experiences during pregnancy contribute to her body image. Cultural beliefs may affect how the woman views body changes.

Nutrition: Lactose intolerance

Clients need to incorporate sources of calcium other than dairy products into their dairy patterns regularly.

Discomforts of pregnancy: constipation

Constipation, which usually occurs in the second and third trimesters, is caused by decreased intestinal motility or the displacement of the intestines or as a result of iron supplementation. - Interventions Advise client to eat high-fiber foods. The client should drink sufficient fluids. Advise client to exercise regularly. Laxatives or enemas should not be used until client has consulted with the primary health care provider or nurse-midwife.

Fetal circulation: umbilical cord

Cord contains two arteries and one vein. Arteries carry deoxygenated blood and waste products from the fetus. Vein carries oxygenated blood and provides oxygen and nutrients to the fetus.

Nutrition: Pica

Refers to eating nonfood substances; cultural values such as beliefs regarding the effect of a material on the mother or fetus may make pica a common practice; iron deficiency may occur.

Fetal environment: amnion

Inner membrane that encloses the amniotic cavity - Appears around the second week of embryonic development - Forms a fluid-filled sac that surrounds the embryo and, later, the fetus

PHYSIOLOGICAL MATERNAL CHANGES: metabolic and endocrine activity

Metabolic function and basal metabolic rate increase. Body weight increases. Thyroid gland enlarges slightly and thyroid activity increases. Parathyroid increases in size. Water retention is increased, contributing to weight gain.

PHYSIOLOGICAL MATERNAL CHANGES: GI

Nausea and vomiting may occur as a result of the secretion of human chorionic gonadotropin (hCG). hCG is a hormone produced by the placenta after implantation and is detected in some pregnancy tests. The presence of hCG generally subsides by the third month. Constipation is caused by decreased gastrointestinal (GI) motility or pressure of the uterus or results from iron supplementation. Flatulence and heartburn occur because of decreased GI motility and slowed emptying of the stomach. Hemorrhoids result from increased venous pressure. Gum tissue may become swollen and bleed easily. Ptyalism (excessive secretion of saliva) may occur.

Diagnostic tests: Doppler blood flow analysis

Noninvasive Doppler ultrasonography is used to study the blood flow in the fetus and placenta.

Types of Pelvises: Gynecoid

Normal female pelvis Transversely rounded or blunt Most favorable for successful labor and birth

Discomforts of pregnancy: breast tenderness

Tenderness, which may occur in all three trimesters, is caused by increased levels of estrogen and progesterone. - Interventions Encourage the client to wear a supportive bra. The use of soap on the nipples and areolar areas should be avoided to help prevent drying.

Fetal environment: amniotic fluid

Surrounds, cushions, and protects the fetus and permits fetal movement Maintains the body temperature of the fetus Consists largely of fetal urine and is therefore a measure of fetal kidney function Drunk, swallowed, and urinated into by the fetus and breathed into the fetus' lungs

Discomforts of pregnancy: syncope and supine hypotension

Syncope usually occurs in the first trimester; supine hypotension occurs particularly in the second and third trimesters. - These problems may be hormonally triggered or caused by increased blood volume, anemia, fatigue, sudden position changes, or lying supine (the weight of the enlarged uterus places pressure on the inferior vena cava). - Interventions Sitting with the feet elevated and changing positions slowly helps prevent syncope. Changing the position to the lateral recumbent (right or left side) to relieve the pressure of the uterus on the inferior vena cava may help prevent supine hypotension.

Nutrition

The average weight gain during pregnancy is 25 to 35 lb (11 to 16 kg) for women of normal prepregnancy weight. An increase of about 300 calories per day is needed during pregnancy. Caloric needs are greater in the last two trimesters than in the first. An increase of about 500 calories per day is needed during lactation. The client should be encouraged to consume a diet high in folic acid and to take a folic acid supplement; a diet rich in folic acid is necessary for all women of childbearing age to prevent neural-tube defect in the fetus during the first trimester of pregnancy. The client should drink at least eight to ten 8-oz (235ml) glasses of fluid each day, four to six of them water. Sodium is not restricted unless specifically prescribed by the primary health care provider or nurse-midwife. Cultural considerations in nutrition must be taken into account.

Monitoring fetal movement: kick count

The client sits quietly or lies on the left side and counts fetal kicks for a set period as instructed. Instruct the client to notify the primary health care provider or nurse-midwife if she counts fewer than 10 kicks in a 12-hour period or as instructed by the primary health care provider or nurse-midwife.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 5

The embryo is 0.4 to 0.5 cm long. The embryo weighs 0.4 g. Double heart chambers are visible. The heart beats. Limb buds begin to form.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 2-3

The embryo is 1.5 to 2 mm long. Lung buds appear. Blood circulation begins. The heart is tubular. The neural plate becomes the brain and spinal cord.

FETAL DEVELOPMENT: EMBRYONIC STAGE: week 8

The embryo is 3 cm long. The embryo weighs 2 g. The eyelids begin to fuse. The circulatory system through the umbilical cord is well established. Every organ system is present.

Fetal circulation: fetal heart rate

The fetal heart rate (FHR) depends on gestational age: 160 to 170 beats/min in the first trimester but slowing with fetal growth to 120 to 160 beats/min near or at term. The FHR is approximately twice the maternal heart rate.

Fundal height

The fundal height is measured to help gauge the fetus' gestational age. During the second and third trimesters (weeks 18-30), fundal height in centimeters approximately equals the fetus' age in weeks, plus or minus 2 cm. At 16 weeks, the fundus can be found halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

PHYSIOLOGICAL MATERNAL CHANGES: emotional liability

The pregnant woman may experience frequent changes in emotional state or extremes in emotional states. Such changes are common, but the mother may feel that they are abnormal.

Nutrition: Vegetarianism

potential deficiencies include energy; protein, vitamin B12, zinc, iron, calcium, omega-3 fatty acids, and vitamin D (if limited exposure to sunlight).

Implantation

The zygote propels itself down the fallopian tube, toward the uterus. Implantation in the uterine wall occurs 6 to 10 days after ovulation.

Discomforts of pregnancy: urine urgency and frequency

These problems, caused by the pressure of the uterus on the bladder, usually occur in the first and third trimesters. - Interventions The client should drink 2 quarts (2 liters) of fluid during the day. Encourage the client to void at regular intervals. Sleeping on the side may relieve pressure on the bladder. Perineal pads may be worn, if necessary. Kegel exercises will help strengthen bladder control.

Diagnostic tests: a-Fetoprotein (AFP) screening

This assay is used to assess the quantity of fetal serum proteins; an increased level is associated with an open neural tube (e.g., spina bifida) and abdominal wall defects; it is also used to detect Down syndrome. - Implementation Explain that the AFP level is determined with the use of a single maternal blood sample drawn at 16 to 18 weeks' gestation. If the level is increased and the gestation is of less than 18 weeks, a second sample is drawn. In the presence of an increased AFP level, ultrasound is performed to rule out fetal abnormalities or multiple gestation.

Diagnostic tests: ultrasonography

This imaging modality is used to outline and identify fetal and maternal structures; it also helps confirm gestational age and estimated date of delivery. - Implementation The woman may need to drink water to fill her bladder before the procedure to help obtain a better image of the fetus. Inform the client that the test presents no known risks to her or to the fetus.

Diagnostic tests: biophysical profile

This noninvasive assessment of the fetus includes fetal breathing movements, fetal movements, fetal tone, amniotic fluid index, and fetal heart rate patterns, all assessed through the use of a non-stress test. Normal fetal biophysical activities indicate that the central nervous system is functional and that the fetus is not hypoxemic.

Fetal environment: placenta

This organ develops by the third month of gestation to permit exchange of nutrients and waste products between fetus and mother; also produces hormones to maintain pregnancy. Placenta depends on maternal circulation. Large particles such as bacteria cannot pass through the placenta, but nutrients, drugs, antibodies, and viruses can. In the third trimester, transfer of maternal immunoglobulin to the fetus provides passive immunity to certain diseases for the first few months after birth. By week 8, genetic testing may be performed.

Diagnostic tests: Fern test

This simple test is used to determine whether amniotic fluid is leaking. - Implementation Position the client in the dorsal lithotomy position. Instruct the client to cough, which will cause fluid to leak from the uterus if the membranes have ruptured. Under sterile technique, a specimen is obtained from the external portion of the cervix and vaginal pool, then examined on a slide under a microscope. A fernlike pattern, caused by the salts in the amniotic fluid, indicates the presence of amniotic fluid.

Diagnostic tests: Chorionic Villus Sampling (CVS)

This test, which involves the aspiration of a small sample of chorionic villus tissue at 10 to 13 weeks' gestation, is performed for the purpose of detecting genetic abnormalities. - Implementation Obtain informed consent. Instruct the client to drink water to fill her bladder before the procedure to aid in positioning the uterus for catheter insertion. Instruct the client to report bleeding, infection, or leakage of fluid at the insertion site after the procedure. Because CVS increases the risk of Rh sensitization, Rh-negative women may be given Rho(D) immune globulin (RhoGAM).

Prenatal concerns: diagnostic tests: Contraction stress test

Used to assess placental oxygenation and function Helps determine fetus' ability to tolerate labor and reveals fetal well-being Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions Performed if non stress test findings are abnormal (nonreactive) - Implementation External fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded Uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved Frequent maternal blood-pressure readings are performed, and the mother is monitored closely while increasing doses of oxytocin are given (Negative, positive, equivocal, unsatisfactory)

Discomforts of pregnancy: hemorrhoids

Usually occurring in the second and third trimesters, hemorrhoids are the result of increased venous pressure or constipation. - Interventions A warm sitz bath may relieve discomfort. The client should sit on a soft pillow. Advise client to eat high-fiber foods and avoid constipation. The client should drink sufficient fluids. Exercise, such as walking, should be increased. Ointments, suppositories, or compresses may be prescribed by the primary health care provider or nurse-midwife.

Discomforts of pregnancy: leg cramps

Usually occurring in the second and third trimesters, leg cramps result from altered calcium-phosphorus balance, pressure of the uterus on nerves, or fatigue. - Interventions The client should get regular exercise, especially walking. Dorsiflexing the foot of the affected leg relieves pain (refer to image on right). Increasing calcium intake may help prevent cramps.

Probable signs

Uterine enlargement Hegar sign (refer image) Goodell sign Chadwick sign Ballottement (refer image) Positive result on pregnancy test for human chorionic gonadotropin (hCG)

Types of Pelvises: Android

Wedge-shaped or angulated Seen in males Not favorable for labor Narrow pelvic planes conducive to slow descent and mid pelvis arrest

Diagnostic tests: percutaneous umbilical blood sampling

When fetal blood sampling is necessary, a needle is inserted directly into the fetal umbilical vessel under ultrasound guidance. Fetal heart rate monitoring is necessary for 1 hour after the procedure; a follow-up ultrasound to check for bleeding or hematoma formation is performed 1 hour after the procedure.