OB review define

group B step

) is a bacterial infection that can be passed to a fetus during labor and delivery.

physiological reproductive

- Uterus increases in size and changes shape and position. Ovulation and menses cease during pregnancy.

creating a postpartum nutritional plan

A lactating woman's nutritional plan includes the following instructions: ◯◯ Increase protein and calorie intake while adhering to a recommended, well-balanced diet. ◯◯ Increase oral fluids, but avoid alcohol and caffeine. ◯◯ Avoid food substances that do not agree with the newborn (foods that may cause altered bowel function). ◯◯ The client should take calcium supplements if she consumes an inadequate amount of dietary calcium. ●● A nutritional plan for a woman who is not breastfeeding should include resumption of a previously recommended well-balanced diet.

abruptio placenta

Abruptio placenta is the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 weeks of gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death. ●● Coagulation defect, such as disseminated intravascular coagulopathy (DIC), is often associated with moderate to severe abruption.

infertility female

Age - age greater than 35 years may affect fertility. ◯◯ Duration of infertility - more than 1 year of coitus without contraceptives. ◯◯ Medical history - atypical secondary sexual characteristic such as abnormal body fat distribution or hair growth, which is indicative of an endocrine disorder. ◯◯ Surgical history - particularly, pelvic and abdominal procedures. ◯◯ Obstetric history - past episodes of spontaneous abortions. ◯◯ Gynecologic history - abnormal uterine contours or any history of disorders that may contribute to the formation of scar tissue that can cause blockage of ovum or sperm. ◯◯ Sexual history - intercourse frequency, number of partners across the lifespan, and any history of STIs. ◯◯ Occupational/environmental exposure risk assessment - exposure to hazardous teratogenic materials in the home or at a place ofemployment. ◯◯ Weight - overweight or underweight.

instruct the client to adhere and maintain during pregnancy

An increase of 340 calories/day is recommended during the second trimester. An increase of 452 calories/day is recommended during the third trimester. ◯◯ If the client is breastfeeding during the postpartum period, an additional intake of 330 calories/day is recommended during the first 6 months, and an additional intake of 400 calories/day is recommended during the second 6 months. ◯◯ Increasing protein intake is essential to basic growth. Also, the intake of foods high in folic acid is crucial for neurological development and the prevention of fetal neural tube defects. Foods high in folic acid include leafy vegetables, dried peas and beans, seeds, and orange juice. Breads, cereals, and other grains are fortified with folic acid. Increased intake of folic acid is encouraged for clients who wish to become pregnant and clients of childbearing age. It is recommended that 600 mcg of folic acid should be taken during pregnancy. Current recommendations for clients who are lactating include consuming 500 mcg of folic acid. ◯◯ Iron supplements are often added to the prenatal plan to facilitate an increase of the maternal RBC mass. Iron is best absorbed between meals and when given with a source of vitamin C. Milk and caffeine interfere with the absorption of iron supplements. Food sources of iron include beef liver, red meats, fish, poultry, dried peas and beans, and fortified cereals and breads. A stool softener may need to be added to decrease constipation experienced with iron supplements. ◯◯ Calcium, which is important to a developing fetus, is involved in bone and teeth formation. ■■ Sources of calcium include milk, calcium-fortified soy milk, fortified orange juice, nuts, legumes, and dark green leafy vegetables. Daily recommendation is 1,000 mg/day for pregnant and nonpregnant women over the age of 19, and 1,300 mg/day for those under 19 years of age. ◯◯ 2 to 3 L of fluids is recommended daily. Preferred fluids are water, fruit juice, and milk. ◯◯ Caffeine intake should be limited to 300 mg/day. The equivalent of 500 to 750 mL/day of coffee may increase the risk of a spontaneous abortion or fetal intrauterine growth restriction. ◯◯ It is recommended that women abstain from alcohol consumption during pregnancy.

prenatal care routine lab test

Blood type, Rh factor, and presence of irregular antibodies ›› Determines the risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. Indirect Coombs' test identifies clients sensitized to Rh-positive blood. For clients who are Rh-negative and not sensitized, the indirect Coombs' test is repeated between 24 to 28 weeks of gestation. CBC with differential, Hgb, and Hct ›› Detects infection and anemia. Hgb electrophoresis ›› Identifies hemoglobinopathies (sickle cell anemia and thalassemia). Rubella titer ›› Determines immunity to rubella. Hepatitis B screen ›› Identifies carriers of hepatitis B. Group B Streptococcus (GBS) ››Obtained at 35 to 37 weeks of gestation. Urinalysis with microscopic examination of pH, specific gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, and human chorionic gonadotropin ›› Identifies pregnancy, diabetes mellitus, gestational hypertension, renal disease, and infection. One-hour glucose tolerance (Oral ingestion or IV administration of concentrated glucose with venous sample taken 1 hr later [fasting not necessary]) ›› Identifies hyperglycemia; done at initial visit for at-risk clients, and at 24 to 28 weeks of gestation for all pregnant women (> 140 mg/dL requires follow up). Three-hour glucose tolerance (Fasting overnight prior to oral ingestion or IV administration of concentrated glucose with a venous sample taken 1, 2, and 3 hr later) ›› Used in clients with elevated 1-hr glucose test as a screening tool for diabetes mellitus. A diagnosis of gestational diabetes requires two elevated blood-glucose readings. Papanicolaou (PAP) test›› Screening tool for cervical cancer, herpes simplex type 2, and/or human papillomavirus. Vaginal/cervical culture ›› Detects streptococcus ß-hemolytic, bacterial vaginosis, or sexually transmitted infections (gonorrhea and chlamydia). PPD (tuberculosis screening), chest x-ray after 20 weeks of gestation with PPD test ›› Identifies exposure to tuberculosis. Venereal disease research laboratory (VDRL) ›› Syphilis screening mandated by law. HIV ›› Detects HIV infection (the Centers for Disease Control and Prevention and the American Congress of Obstetricians and Gynecologists recommend testing all clients who are pregnant unless the client refuses testing). Toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes virus (TORCH) screening when indicated ›› Screening for a group of infections capable of crossing the placenta and adversely affecting fetal development. Maternal serum alpha-fetoprotein (MSAFP) ›› Screening occurs between 15 to 22 weeks of gestation. Used to rule out Down syndrome (low level) and neural tube defects (high level). The provider may decide to use a more reliable indicator and opt for the Quad screen instead of the MSAFP at 16 to 18 weeks of gestation. This includes AFP, inhibin-A, a combination analysis of human chorionic gonadotropin, and estriol.

physiological musculoskeletal

Body alterations and weight increase necessitate an adjustment in posture. Pelvic joints relax.

physiological cardiovascular

Cardiac output and blood volume increase (45 to 50% at term) to meet the greater metabolic needs. Heart rate increases during pregnancy.

condoms

Condoms Definition ›› A thin flexible sheath worn on the penis during intercourse to prevent semen from entering the uterus. Client Instructions ›› A man places a condom on his erect penis, leaving an empty space at the tip for a sperm reservoir. ›› Following ejaculation, a man withdraws his penis from the woman's vagina while holding the rim of the condom to prevent any semen spillage to the woman's vulva or vaginal area. ››May be used in conjunction with spermicidal gel or cream to increase effectiveness. Advantages ›› Protects against STIs and involves the male in the birth control method. Disadvantages ›› High rate of noncompliance. ››May reduce spontaneity of intercourse. ›› The penis must be erect to apply a condom. ›› If the penis is withdrawn while still erect, this can interfere with sexual intercourse. Risks/possible complications/contraindications ›› Condoms can rupture or leak, thus potentially resulting in an unwanted pregnancy. ›› Condoms have a one-time usage, which creates a replacement cost. ›› Condoms made of latex should not be worn by those who are sensitive or allergic to latex. ››Only water-soluble lubricants should be used with latex condoms to avoid condom breakage.

contraception

Contraception refers to strategies or devices used to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy. ●● A nurse should assess clients' need/desire for contraception, as well as their preferences. A thorough discussion of benefits, risks, and alternatives of each method should be discussed. ●● Sexual partners often make a joint decision regarding a desired preference (vasectomy or tubal ligation). Postpartum discharge instructions should include the discussion of future contraceptive plans. ●● Expected outcomes for family planning methods consist of preventing pregnancy until a desired time. ●● Nurses should support clients in making the decision that is best for their individual situations. ●● Methods of contraception include natural family planning, barrier, hormonal, and intrauterine methods, as well as surgical procedures.

Intrauterine device (IUD)

Definition ›› A chemically active T-shaped device that is inserted through a woman's cervix and placed in the uterus by the provider. Releases a chemical substance that damages sperm in transit to the uterine tubes and prevents fertilization. Client Instructions ›› The device must be monitored monthly by clients after menstruation to ensure the presence of the small string that hangs from the device into the upper part of the vagina to rule out migration or expulsion of the device. Advantages ›› An IUD can maintain effectiveness for 1 to 10 years. ›› Contraception can be reversed. ›› Does not interfere with spontaneity. ›› Safe for mothers who are breastfeeding. ›› It is 99% effective in preventing pregnancy. Disadvantages ›› An IUD can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy. ›› A client should report to the provider late or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal or foul-smelling vaginal discharge, fever, chills, a change in string length, or if IUD cannot be located. ›› An IUD does not protect from STIs. Risks/possible complications/contraindications ›› Best used by women in a monogamous relationship due to the risks of STIs. ››May cause irregular menstrual bleeding. ›› A risk of bacterial vaginosis, uterine perforation, or uterine expulsion. ››Must be removed in the event of pregnancy

and spermicide

Definition ›› A dome-shaped cup with a flexible rim made of latex or silicone that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim. Client Instructions ›› A female client should be fitted with a diaphragm properly by a provider. ›› A client must be refitted by the provider every 2 years, if there is a 7 kg (15 lb) weight change, full-term pregnancy, or second-term abortion. ›› Requires proper insertion and removal. Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. The diaphragm must remain in place for at least 6 hr after coitus. ›› Spermicide must be reapplied with each act of coitus. ›› A client should empty her bladder prior to insertion of the diaphragm. Advantages ›› This barrier method eliminates surgery and gives a woman more control over contraception. Disadvantages ›› Diaphragms are inconvenient, interfere with spontaneity, and require reapplication with spermicidal gel, cream, or foam with each act of coitus to be effective. ›› Requires a prescription and a visit to a provider. ››Must be inserted correctly to be effective. Risks/possible complications/contraindications ›› A diaphragm is not recommended for clients who have a history of toxic shock syndrome (TSS), or frequent, recurrent urinary tract infections. ›› Increased risk of acquiring TSS. ›› TSS is caused by a bacterial infection. Signs and symptoms include high fever, a faint feeling and drop in blood pressure, watery diarrhea, headache, and muscle aches. ›› Proper hand hygiene aids in prevention of TSS, as well as removing diaphragm promptly at 6 hr following coitus. ›› Diaphragms made of latex should not be worn by those who are sensitive or allergic to latex.

Male sterilization (vasectomy)

Definition ›› A surgical procedure consisting of ligation and severance of the vas deferens. Procedure ›› The cutting of the vas deferens in the male as a form of permanent sterilization. Reinforce the need for alternate forms of birth control for approximately 20 ejaculations or 1 week to several months to allow all of the sperm to clear the vas deferens. This will ensure complete male infertility. Client Instruction ›› Following the procedure, scrotal support and moderate activity for a couple of days is recommended to reduce discomfort. ›› Sterility is delayed until the proximal portion of the vas deferens is cleared of all remaining sperm (approximately 20 ejaculations). ›› Alternate forms of birth control must be used until the vas deferens is cleared of sperm. ›› Follow up is important for sperm count. Advantages ›› A vasectomy is a permanent contraceptive method. ›› Procedure is short, safe, and simple. ›› Sexual function is not impaired. Disadvantages ›› Requires surgery. ›› Considered irreversible in the event that a client desires conception. Risks/ possible complications/contraindications ›› Complications are rare, but may include bleeding, infection, and anesthesia reaction.

Female sterilization (Bilateral tubal ligation salpingectomy)

Definition ›› A surgical procedure consisting of severance and/or burning or blocking the fallopian tubes to prevent fertilization. Procedure ›› The cutting, burning, or blocking of the fallopian tubes to prevent the ovum from being fertilized by the sperm. Advantages ›› Permanent contraception. ›› Sexual function is unaffected. Disadvantages ›› A surgical procedure carrying risks related to anesthesia, complications, infection, hemorrhage, or trauma. ›› Considered irreversible in the event that a client desires conception. Risks/ possible complications/contraindications ›› Risk of ectopic pregnancy if pregnancy occurs.

calendar method

Definition ›› A woman records her menstrual cycle by calculating her fertile period based on the assumption that ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoids intercourse during that period. Also taken into account is the timing of intercourse with this method because sperm are viable for 48-120 hr, and the ovum is viable for 24 hr. Client Instructions›› Accurately record the number of days in each cycle counting from the first day of menses for a period of at least six cycles. ›› The start of the fertile period is figured by subtracting 18 days from the number of days in the woman's shortest cycle. ›› The end of the fertile period is established by subtracting 11 days from the number of days of the longest cycle. For example: »»Shortest cycle, 26 - 18 = 8th day »»Longest cycle, 30 - 11 = 19th day »»Fertile period is days 8 through 19. ›› Refrain from intercourse during these days to avoid conception. Advantages›Most useful when combined with basal body temperature or cervical mucus method. ›› Inexpensive Disadvantages ›› Not a very reliable technique. ›› Requires accurate record keeping. ›› Requires compliance in regard to abstinence during fertile periods. Risks/possible complications/ contraindications ›› Various factors can affect and change the time of ovulation and cause unpredictable menstrual cycles. ›› Risk of pregnancy.

Injectable progestins (Depo-Provera)

Definition ›› An intramuscular injection given to a female client every 11 to 13 weeks. Client Instructions ›› Start of injections should be during the first 5 days of a client's menstrual cycle and every 11 to 13 weeks thereafter. Injections in postpartum nonbreastfeeding women should begin within 5 days following delivery. For breastfeeding women, injections should start in the sixth week postpartum. ›› Advise clients to keep follow-up appointments. ›› A client should maintain an adequate intake of calcium and vitamin D. Advantages ›› Very effective and requires only four injections per year. ›› Does not impair lactation. Disadvantages ›› Can prolong amenorrhea. ›› Irregular or unpredictable bleeding or spotting. ›› Increases the risk of thromboembolism. ›› Decreases bone mineral density (loss ofcalcium). ›› Does not protect against STIs. ›› Should only be used as a long-term method of birth control (more than 2 years) if other birth control methods are inadequate. Risks/possible complications/contraindications ›› Avoid massaging injection site following administration to avoid accelerating medication absorption, which will shorten the duration of its effectiveness

Contraceptive vaginal ring

Definition ›› Contains etonogestrel and ethinyl estradiol that is delivered at continuous levels vaginally. Client Instructions ›› A client inserts the ring vaginally. ›› Requires ring replacement after 3 weeks, and placement of new vaginal ring within 7 days. Insertion should occur on the same day of the week monthly. Advantages ›› Vaginal ring does not have to be fitted. ›› Decreases the risk of forgetting to take the pill. Disadvantages ›› Vaginal ring does not protect against STIs. ›› Poses the same side effects as oral contraceptives. ›› Some clients report discomfort during intercourse. Risks/possible complications/ contraindications ›› Blood clots, hypertension, stroke, heart attack. ›› Vaginal irritation, increased vaginal secretions, headache, weight gain, and nausea.

Transdermal contraceptive patch

Definition ›› Contains norelgestromin (progesterone) and ethinyl estradiol, which is delivered at continuous levels through the skin into subcutaneous tissue. Client Instructions ›› A client applies the patch to dry skin overlying subcutaneous tissue of the buttock, abdomen, upper arm, or torso, excluding breast area. ›› Requires patch replacement once a week. ›› Patch is applied the same day of the week for 3 weeks with no application of the patch on the fourth week. Advantages ››Maintains consistent blood levels of hormone. ›› Avoids liver metabolism of medication because it is not absorbed in the gastrointestinal tract. ›› Decreases risk of forgetting daily pill. Disadvantages ›› Patch does not protect against STIs. ›› Poses same side effects as oral contraceptives. ›› Skin reaction may occur from patch application. Risks/possible complications/contraindications ›› Same as those of oral contraceptives ›› Avoid applying of patch to skin rashes or lesions

Symptom-Based Method (cervical mucus)

Definition ›› Fertility awareness method based on ovulation. Ovulation occurs approximately 14 days prior to the next menstrual cycle, which is when a woman is fertile. Following ovulation, the cervical mucus becomes thin and flexible under the influence of estrogen and progesterone to allow for sperm viability and motility. The ability for the mucus to stretch between the fingers is greatest during ovulation. This is referred to as spinnbarkeit sign. Client Instructions›› Engage in good hand hygiene prior to and following assessment. ›› Begin examining mucus from the last day of the menstrual cycle. ››Mucus is obtained from the vaginal introitus. It is not necessary to reach into the vagina to the cervix. ›› Do not douche prior to assessment. Advantages ›› A woman can become knowledgeable in recognizing her own mucus characteristics at ovulation, and self-evaluation can be very accurate. ›› Self-evaluation of cervical mucus can also be diagnostically helpful in determining the start of ovulation while breastfeeding, in noting the commencement of menopause, and in planning a desired pregnancy. Disadvantages ›› Some women may be uncomfortable with touching their genitals and mucus and, therefore, will find this method objectionable. Risks/possible complications/ contraindications ›› Assessment of cervical mucus characteristics may be inaccurate if mucus is mixed with semen, blood, contraceptive foams, or discharge from infections. ›› Risk of pregnancy

Combined oral contraceptives

Definition ›› Hormonal contraception containing estrogen and progestin, which acts by suppressing ovulation, thickening the cervical mucus to block semen, and altering the uterine decidua to prevent implantation. Client Instructions››Medication that requires a prescription and follow-up appointments with the provider. ››Medication requires consistent and proper use to be effective. ›› A client is instructed in observing for side effects and danger signs of medication. Signs include chest pain, shortness of breath, leg pain from a possible clot, headache, or eye problems from a stroke, or hypertension. ›› In the event of a client missing a dose, the nurse should instruct the client that if one pill is missed, take one as soon as possible; if two or three pills are missed, instruct the client to follow the manufacturer's instructions. Instruct the client on the use of alternative forms of contraception or abstinence to prevent pregnancy until regular dosing is resumed. Advantages ›› Highly effective if taken correctly and consistently. ››Medication can alleviate dysmenorrhea by decreasing menstrual flow and menstrual cramps. ›› Reduces acne.Disadvantages ››Oral contraceptives do not protect against STIs. ›› Birth control pills can increase the risk of thromboses, breast tenderness, scant or missed menstruation, stroke, nausea, headaches, and hormone-dependent cancers. ›› Exacerbates conditions affected by fluid retention such as migraine, epilepsy, asthma, kidney, or heart disease. Risks/possible complications/contraindications ››Women with a history of blood clots, stroke, cardiac problems, breast or estrogen‑related cancers, pregnancy, or smoking (if over 35 years of age), are advised not to take oral contraceptive medications. ››Oral contraceptive effectiveness decreases when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics.

Essure

Definition ›› Insertion of small flexible agents through the vagina and cervix into the fallopian tubes. This results in the development of scar tissue in the tubes preventing conception. ›› Examination must be done after 3 months to ensure fallopian tubes are blocked. Client Instruction ›› Normal activities may be resumed by most clients within 1 day of the procedure. Advantages ››Quick procedure that requires no general anesthesia. ›› Nonhormonal means of birth control. ›› Essure is 99.8% effective in preventing pregnancy. ›› Rapid return to normal activities of daily living. Disadvantages ›› Not reversible. ›› Not intended for use in the client who is postpartum. ›› Delay in effectiveness for 3 months. Therefore, an alternative means of birth control should be used until confirmation of blocked fallopian tubes occurs. ›› Changes in menstrual patterns. Risks/possible complications/contraindications ›› Perforation can occur ›› Unwanted pregnancy can occur if a client has unprotected sexual intercourse during the first 3 months following the procedure. ›› Increased risk of ectopic pregnancy if pregnancy occurs.

minipill

Definition ›› Oral progestins that provide the same action as combined oral contraceptives. Client Instructions›› A client should take the pill at the same time daily to ensure effectiveness secondary to a low dose of progestin.›› A client cannot miss a pill.›› A client may need another form of birth control during the first month of use to prevent pregnancy. Advantages ›› The minipill has fewer side effects when compared with a combined oral contraceptive. ›› Considered safe to take while breastfeeding. Disadvantages ›› Less effective in suppressing ovulation than combined oral contraceptives. ›› Pill increases occurrence of ovarian cysts. ›› Pill does not protect against STIs. ›› Users frequently report breakthrough, irregular, vaginal bleeding, and decreased libido. ›› Increases appetite Risks/possible complications/contraindications ››Oral contraceptive effectiveness decreases when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics.

Implantable progestin etonogestrel (Implanon)

Definition ›› Requires a minor surgical procedure to subdermally implant and remove a single rod containing etonogestrel on the inner side of the upper aspect of the arm. Client Instructions ›› Avoid trauma to the area of implantation. Advantages ›› Effective continuous contraception for 3 years. ›› Reversible. ›› Can be used by mothers who are breastfeeding after 4 weeks postpartum. Disadvantages ›› Etonogestrel can cause irregular menstrual bleeding. ›› Etonogestrel does not protect against STIs. ››Most common side effect is irregular and unpredictable menstruation. ›› Headache. Risks/possible complications/contraindications ›› Increased risk of ectopic pregnancy if pregnancy occurs.

Basal body temperature

Definition ›› Temperature can drop slightly at the time of ovulation. This can be used to facilitate conception, or be used as a natural contraceptive. Client Instructions ›› A woman is instructed to measure oral temperature prior to getting out of bed each morning to monitor ovulation. Advantages ›› Inexpensive, convenient, and no side effects Disadvantages ›› BBT reliability can be influenced by many variables that can cause inaccurate interpretation of temperature changes, such as stress, fatigue, illness, alcohol, and warmth or coolness of sleeping environment. Risks/possible complications/ contraindications ›› Risk of pregnancy

coitus interruptus

Definition ››Man withdraws penis from vagina prior to ejaculation. Client Instructions ›› Be aware of fluids leaking from the penis. Advantages ›› Possible choice for monogamous couples with no other option for birth control, such as those opposed to birth control due to religious conviction. Disadvantages ››Most ineffective method of contraception. ›› No protection against STIs. Risks/possible complications/contraindications ››Male partner's control can make this an effective method. ›› Leakage of fluid that contains spermatozoa prior to ejaculation can be deposited in vagina. ›› Risk of pregnancy.

Emergency oral contraceptive

Definition ››Morning after pill that prevents fertilization from taking place. Client Instructions ›› Pill is taken within 72 hr after unprotected coitus. ›› A provider will recommend an over-the-counter antiemetic to be taken 1 hr prior to each dose to counteract the side effects of nausea that can occur with high doses of estrogen and progestin. ›› Advise a woman to be evaluated for pregnancy if menstruation does not begin within 21 days. ›› Provide client with counseling about contraception and modification of sexual behaviors that are risky. ›› Is considered a form of "emergency birth control." Advantages ›› Pill is not taken on a regular basis. ›› Can be obtained without a prescription by women 17 years and older. Disadvantages ›› Nausea, heavier than normal menstrual bleeding, lower abdominal pain, fatigue, and headache. ›› Does not provide long-term contraception. ›› Does not terminate an established pregnancy. ›› Does not protect against STIs. Risks/possible complications/ contraindications ›› Contraindicated if a client is pregnant or has undiagnosed abnormal vaginal bleeding. ›› If menstruation does not start within 1 week of expected date, a client may be pregnant.

nursing interventions for infertility

Encourage couples to express and discuss their feelings and recognize infertility as a major life stressor.Assist the couple to consider options, and provide education to assist in decision-making. ●● Explain role of genetic counselor, reproductive specialist, geneticist, and pharmacist in providing psychosocial and medical care. ●● Monitor for adverse effects associated with medications to treat female and male infertility. ●● Advise that the use of medications to treat female infertility may increase the risk of multiple births by more than 25%. ●● Provide information regarding assisted reproductive therapies (in vitro fertilization and embryo transfer, intrafallopian gamete transfer, surrogate parenting, and reproductive alternatives such as adoption). ●● Make referrals to grief and infertility support groups.

plan of care for a pregnant client

Expected Outcomes ›› The client will consume the recommended dietary allowances/nutrients during her pregnancy. Interventions ›› The nurse assesses the client's dietary journal on the next prenatal visit. ›› The nurse provides educational materials regarding nutritional benefits to the mother and her newborn. ›› The nurse provides encouragement and answers questions that the client has regarding her dietary plans. ›› The nurse weighs the client and monitors for signs of inadequate weight gain. ›› The nurse makes a referral if needed. Evaluation of the Plan ›› Is there adequate weight gain? ›› Is the client compliant with the nursing plan of care?

physiological renal

Filtration rate increases secondary to the influence of pregnancy hormones and an increase in blood volume and metabolic demands. The amount of urine produced remains the same. Urinary frequency is common during pregnancy.

genetic counseling

Genetic counseling may be recommended by the provider if there is a family history of birth defects. ●● Identify clients who are in need of genetic counseling, such as a client who has a sickle cell trait orsickle cell anemia, or a client older than 35. Make referrals to genetic specialists as necessary. ●● Prenatal assessment of genetic disorders (amniocentesis) can pose potential risks to the fetus. ●● Provide and clarify information pertaining to the risk of or the occurrence of genetic disorders within a family preceding, during, and following a genetic counseling session.

GTPAL

Gravidity ◯◯ Term births (38 weeks or more) ◯◯ Preterm births (from viability up to 37 weeks) ◯◯ Abortions/miscarriages (prior to viability) ◯◯ Living children

lab test for spontaneous abortion

Hgb and Hct, if considerable blood loss ■■ Clotting factors monitored for disseminated intravascular coagulopathy (DIC) - a complication with retained products of conception ■■ WBC for suspected infection ■■ Serum human chorionic gonadotropin (hCG) levels to confirm pregnancy

risk factors group b strep

History of positive culture with previous pregnancy ●● Risk factors for early-onset neonatal GBS ◯◯ Maternal age less than 20 years ◯◯ African American or Hispanic ethnicity ◯◯ Positive culture with pregnancy ◯◯ Prolonged rupture of membranes ◯◯ Preterm delivery ◯◯ Low birth weight ◯◯ Use of intrauterine fetal monitoring ◯◯ Intrapartum maternal fever (38° C [100.4° F])

infertility

Infertility is defined as an inability to conceive despite engaging in unprotected sexual intercourse for a prolonged period of time or at least 12 months. ●● Common factors associated with infertility may include decreased sperm production, endometriosis, ovulation disorders, and tubal occlusions. ●● Partners who experience infertility may experience stress related to: ◯◯ Physical inability to conceive ◯◯ Expense ◯◯ Effect on the couple's relationship ◯◯ Lack of family support ●● Infertility assessments, diagnostic procedures, and genetic counseling may be undertaken.

physiological respiratory

Maternal oxygen needs increase. During the last trimester, the size of the chest may enlarge, allowing for lung expansion, as the uterus pushes upward. Respiratory rate increases and total lung capacity decreases.

measurement for calculating delivery date

Measurement of fundal height in centimeters from the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation). ◯◯ Approximates the gestational age

infertility male

Mumps during adolescence ◯◯ Substance use (alcohol, cigarettes, heroin, marijuana [cannabis]) ◯◯ Exposure to hazardous teratogenic materials in home or work environment

physiological gastrointestinal

Nausea and vomiting may occur due to hormonal changes and/or an increase of pressure within the abdominal cavity as the pregnant client's stomach and intestines are displaced within the abdomen. Constipation may occur due to increased transit time of food through the gastrointestinal tract and, thus, increased water absorption.

gonorrhea

Neisseria gonorrhoeae is the causative agent of gonorrhea. Gonorrhea is a bacterial infection that is primarily spread by genital-to-genital contact. However, it also can be spread by anal-to-genital contact or oral-to-genital contact. It can also be transmitted to a newborn during delivery. Women are frequently asymptomatic

diagnostic procedure and nursing management contraction stress test

Nipple stimulated CST consists of a woman lightly brushing her palm across her nipple for 2 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins. The same process is repeated after a 5-min rest period. ◯◯ Analysis of the FHR response to contractions (which decrease placental blood flow) determines how the fetus will tolerate the stress of labor. A pattern of at least three contractions within a 10-min time period with duration of 40 to 60 seconds each must be obtained to use for assessment data. ◯◯ Hyperstimulation of the uterus (uterine contraction longer than 90 seconds or more frequent than every 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is unsuccessful. ●● Oxytocin (Pitocin) administration CST is used if nipple stimulation fails and consists of the IV administration of oxytocin to induce uterine contractions. ◯◯ Contractions started with oxytocin may be difficult to stop and can lead to preterm labor. ●● Indications for the use of a contraction stress test during pregnancy ◯◯ Potential diagnoses ■■ High-risk pregnancies (gestational diabetes mellitus, postterm pregnancy) ■■ Nonreactive stress test ◯◯ Client presentation ■■ Decreased fetal movement ■■ Intrauterine growth restriction ■■ Postmaturity ■■ Gestational diabetes mellitus ■■ Gestational hypertension■■ Maternal chronic hypertension ■■ History of previous fetal demise ■■ Advanced maternal age ■■ Sickle-cell disease ●● Interpretation of findings ◯◯ A negative CST (normal finding) is indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR. ◯◯ A positive CST (abnormal finding) is indicated with persistent and consistent late decelerations on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable deceleration may indicate cord compression, and early decelerations may indicate fetal head compression. Based on these findings, the provider may determine to induce labor or perform a cesarean birth. View Image: Positive CST ●● Nursing Actions ◯◯ Preparation of client ■■ Obtain a baseline of the FHR, fetal movement, and contractions for 10 to 20 min, and document. ■■ Explain the procedure to the client, and obtain informed consent. ■■ Complete an assessment without artificial stimulation if contractions are occurring spontaneously. ◯◯ Ongoing care ■■ Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. The client should stop when a uterine contraction begins. ■■ Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus. ◯◯ Interventions ■■ Initiate IV oxytocin administration if nipple stimulation fails to elicit a sufficient uterine contraction pattern. If hyperstimulation of the uterus and/or preterm labor occurs, do the following: ☐☐ Monitor for contractions lasting longer than 90 seconds and/or occurring more frequently than every 2 min. ☐☐ Provide administration of tocolytics as prescribed. ☐☐ Maintain bed rest during the procedure. ☐☐ Observe the client for 30 min afterward to see that contractions have ceased and preterm labor does not begin. ●● Complications ◯◯ Potential for preterm labor

nursing care gonorrhea

Nursing Care ◯◯ Provide client education regarding disease transmission. ◯◯ Identify and treat all sexual partners. ●● Medications ◯◯ Ceftriaxone (Rocephin) IM and azithromycin (Zithromax) PO for gonorrhea ■■ One dose prescription ■■ Broad-spectrum antibiotic ■■ Bactericidal action ◯◯ Client Education ■■ Instruct the client to take entire prescription as prescribed. ■■ Instruct the client to repeat the culture to assess for medication effectiveness. ■■ Educate the client regarding safe sex practices.

placenta previa

Placenta previa occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface. View Image: Placenta Previa ●● Placenta previa is classified into three types dependent on the degree to which the cervical os is covered by the placenta. ◯◯ Complete or total - when the cervical os is completely covered by the placental attachment ◯◯ Incomplete or partial - when the cervical os is only partially covered by the placental attachment ◯◯ Marginal or low-lying - when the placenta is attached in the lower uterine segment but does not reach the cervical os

indications for the use of PUBS

Potential diagnoses ■■ Fetal blood type, RBC, and chromosomal disorders ■■ Karyotyping of malformed fetuses ■■ Fetal infection ■■ Altered acid-base balance of fetuses with IUGR ●● Interpretation of findings ◯◯ Evaluates for isoimmune fetal hemolytic anemia and assesses the need for a fetal blood transfusion. ●● Nursing actions ◯◯ Administer medication as prescribed. ◯◯ Offer support. ●● Complications ◯◯ Cord laceration ◯◯ Preterm labor ◯◯ Amnionitis ◯◯ Hematoma ◯◯ Fetomaternal hemorrhage

indications; chorionic villus sampling

Potential diagnoses ■■ Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality (cannot determine spina bifida or anencephaly) ◯◯ Client education ■■ Instruct the client to drink plenty of fluid to fill the bladder prior to the procedure to assist in positioning the uterus for catheter insertion. ■■ Provide ongoing education and support. ●● Complications ■■ Spontaneous abortion (higher risk with CVS than with amniocentesis) ■■ Risk for fetal limb loss ■■ Miscarriage ■■ Chorioamnionitis and rupture of membranes ●● Miscellaneous ◯◯ The advantage of an earlier diagnosis should be weighed against the increased risk of fetal anomalies and death.

prenatal care

Prenatal care involves nursing assessments and client education for expectant mothers. When providing prenatal care, nurses must take into account cultural considerations. ●● Prenatal education encompasses information provided to a client who is pregnant. Major areas of focus include assisting the client in self-care of the discomforts of pregnancy, promoting a safe outcome to pregnancy, and fostering positive feelings by the pregnant woman and her family regarding the childbearing experience. ●● Prenatal care dramatically reduces infant and maternal morbidity and mortality rates by early detection and treatment of potential problems. A majority of birth defects occur between 2 and 8 weeks of gestation.

high risk pregnancy; quad maker and alpha fetoprotein screening

Quad marker screening - a blood test that ascertains information about the likelihood of fetal birth defects. It does not diagnose the actual defect. It may be performed instead of the maternal serum alpha-fetoprotein yielding more reliable findings. Includes testing for: ■■ Human chorionic gonadotropin (hCG) - a hormone produced by the placenta ■■ Alpha-fetoprotein (AFP) - a protein produced by the fetus ■■ Estriol - a protein produced by the fetus and placenta ■■ Inhibin-A - a protein produced by the ovaries and placenta

nageles rule

Take the first day of the woman's last menstrual cycle, subtract 3 months, and then add 7 days and 1 year, adjusting for the year as necessary.

physiological endocrine

The placenta becomes an endocrine organ that produces large amounts of hCG, progesterone, estrogen, human placental lactogen, and prostaglandins. Hormones are very active during pregnancy and function to maintain pregnancy and prepare the body for delivery.

high risk pregnancy; chorionic villus sampling

assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance and analyzed. ◯◯ CVS is a first-trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities. CVS can be performed at 10 to 12 weeks of gestation, and rapid results with chromosome studies are available in 24 to 48 hr following aspiration.

probably signs of pregnancy

changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus). Signs can be caused by physiological factors other than pregnancy (pelvic congestion, tumors). ◯◯ Abdominal enlargement related to changes in uterine size, shape, and position ◯◯ Hegar's sign - softening and compressibility of lower uterus ◯◯ Chadwick's sign - deepened violet-bluish color of cervix and vaginal mucosa ◯◯ Goodell's sign - softening of cervical tip ◯◯ Ballottement - rebound of unengaged fetus ◯◯ Braxton Hicks contractions - false contractions; painless, irregular, and usually relieved by walking ◯◯ Positive pregnancy test ◯◯ Fetal outline felt by examiner

presumptive signs of pregnancy

changes that the woman experiences that make her think that she may be pregnant. These changes may be subjective symptoms or objective signs. Signs also may be a result of physiological factors other than pregnancy (peristalsis, infections, and stress). ◯◯ Amenorrhea ◯◯ Fatigue ◯◯ Nausea and vomiting ◯◯ Urinary frequency ◯◯ Breast changes - darkened areolae, enlarged Montgomery's glands ◯◯ Quickening - slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation ◯◯ Uterine enlargement

Gestational trophoblastic disease (GTD)

is the proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like clusters. The embryo fails to develop beyond a primitive state and these structures are associated with choriocarcinoma, which is a rapidly metastasizing malignancy. Two types of molar growths are identified by chromosomal analysis. ●● In the complete mole, all genetic material is paternally derived. ◯◯ The ovum has no genetic material or the material is inactive. ◯◯ The complete mole contains no fetus, placenta, amniotic membranes, or fluid. ◯◯ There is no placenta to receive maternal blood; therefore, hemorrhage into the uterine cavity occurs and vaginal bleeding results. ◯◯ Approximately 20% of complete moles progress toward a choriocarcinoma●● In the partial mole, genetic material is derived both maternally and paternally. ◯◯ A normal ovum is fertilized by two sperm or one sperm in which meiosis or chromosome reduction and division did not occur. ◯◯ A partial mole often contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood, but congenital anomalies are present. ◯◯ Approximately 6% of partial moles progress toward a choriocarcinoma.

nonstress test

most widely used technique for antepartum evaluation of fetal well-being performed during the third trimester. It is a noninvasive procedure that monitors response of the FHR to fetal movement. A Doppler transducer, used to monitor the FHR, and a tocotransducer, used to monitor uterine contractions, are attached externally to a client's abdomen to obtain tracing strips. The client pushes a button attached to the monitor whenever she feels a fetal movement, which is then noted on the tracing. This allows a nurse to assess the FHR in relationship to the fetal movement. ●● Indications for the use of an NST during pregnancy ◯◯ Potential diagnoses for: ■■ Assessing for an intact fetal CNS during the third trimester. ■■ Ruling out the risk for fetal death in clients who have diabetes mellitus. Used twice a week or until after 28 weeks of gestation. ◯◯ Client presentation ■■ Decreased fetal movement ■■ Intrauterine growth restriction ■■ Postmaturity ■■ Gestational diabetes mellitus ■■ Gestational hypertension ■■ Maternal chronic hypertension ■■ History of previous fetal demise ■■ Advanced maternal age ■■ Sickle cell disease ■■ Isoimmunization ●● Interpretation of findings ◯◯ The NST is interpreted as reactive if the FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/min for at least 15 seconds and occurs two or more times during a 20-min period. View Image: Reactive NST ◯◯ Nonreactive NST indicates that the fetal heart rate does not accelerate adequately with fetal movement. It does not meet the above criteria after 40 min. If this is so, a further assessment, such as a contraction stress test (CST) or biophysical profile (BPP), is indicated. ●● Nursing actions ◯◯ Preparation of client ■■ Seat the client in a reclining chair, or place in a semi-Fowler's or left-lateral position. ■■ Apply conduction gel to the client's abdomen. ■■ Apply two belts to the client's abdomen, and attach the FHR and uterine contraction monitors ◯◯ Ongoing care ■■ Instruct the client to press the button on the handheld event marker each time she feels the fetus move. ■■ If there are no fetal movements (fetus sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus. ●● Miscellaneous ◯◯ Disadvantages of a NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications, and chronic smoking.

Gravidity

number of pregnancies. ◯◯ Nulligravida - a woman who has never been pregnant ◯◯ Primigravida - a woman in her first pregnancy ◯◯ Multigravida - a woman who has had two or more pregnancies ◯◯ Parity - number of pregnancies in which the fetus or fetuses reach viability (approximately 20 weeks) regardless of whether the fetus is born alive ■■ Nullipara - no pregnancy beyond the stage of viability ■■ Primipara - has completed one pregnancy to stage of viability ■■ Multipara - has completed two or more pregnancies to stage of viability

positive signs of pregnancy

signs that can be explained only by pregnancy. ◯◯ Fetal heart sounds ◯◯ Visualization of fetus by ultrasound ◯◯ Fetal movement palpated by an experienced examiner

aminocentesis

the aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus. It may be performed after 14 weeks of gestation.

high risk pregnancy; percutaneous umbilical blood sampling

the most common method used for fetal blood sampling and transfusion. This procedure obtains fetal blood from the umbilical cord by passing a fine-gauge, fiber-optic scope (fetoscope) into the amniotic sac using the amniocentesis technique. The needle is advanced into the umbilical cord under ultrasound guidance, and blood is aspirated from the umbilical vein. Blood studies from the cordocentesis may consist of: ◯◯ Kleihauer-Betke test that ensures that fetal blood was obtained. ◯◯ CBC count with differential. ◯◯ Indirect Coombs' test for Rh antibodies. ◯◯ Karyotyping (visualization of chromosomes). ◯◯ Blood gases.

spontaneous miscarriage assessment

type, cramps, bleeding, tissue passed, cervical opening pg 66 ›› Threatened ››With or without slight cramps ›› Spotting to moderate ›› None ›› Closed ›› Inevitable ››Moderate ››Mild to severe ›› None ›› Dilated with membranes or tissue bulging at cervix ›› Incomplete ›› Severe ›› Continuous and severe ›› Partial fetal tissue or placenta ›› Dilated with tissue in cervical canal or passage of tissue ›› Complete ››Mild ››Minimal ›› Complete expulsion of uterine contents ›› Closed with no tissue in cervical canal ››Missed ›› None ›› Brownish discharge ›› None, prolonged retention of tissue ›› Closed ›› Septic ›› Varies ››Malodorous discharge ›› Varies ›› Usually dilated ›› Recurrent ›› Varies ›› Varies ›› Yes ›› Usually dilated

biophysical profile

uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. ●● BPP assesses fetal well-being by measuring the following five variables with a score of 2 for each normal finding, and 0 for each abnormal finding for each variable. ◯◯ Reactive FHR (reactive nonstress test) = 2; nonreactive = 0. ◯◯ Fetal breathing movements (at least 1 episode of greater than 30 seconds duration in 30 min) = 2; absent or less than 30 seconds duration = 0. ◯◯ Gross body movements (at least 3 body or limb extensions with return to flexion in 30 min) = 2; less than 3 episodes = 0. ◯◯ Fetal tone (at least 1 episode of extension with return to flexion) = 2; slow extension and flexion, lack of flexion, or absent movement = 0. ◯◯ Qualitative amniotic fluid volume (at least 1 pocket of fluid that measures at least 2 cm in 2 perpendicular planes) = 2; pockets absent or less than 2 cm = 0. ●● Interpretation of findings ◯◯ Total score of 8 to 10 is normal; low risk of chronic fetal asphyxia ◯◯ 4 to 6 is abnormal; suspect chronic fetal asphyxia ◯◯ < 4 is abnormal; strongly suspect chronic fetal asphyxia ●● Potential diagnoses ◯◯ Nonreactive stress test ◯◯ Suspected oligohydramnios or polyhydramnios ◯◯ Suspected fetal hypoxemia and/or hypoxia ●● Client presentation ◯◯ Premature rupture of membranes ◯◯ Maternal infection ◯◯ Decreased fetal movement ◯◯ Intrauterine growth restriction ●● Nursing Actions ◯◯ Prepare the client following the same nursing management principles as those used for an ultrasound.

summary of causes of bleeding during pregnancy

›› First trimester ›› Spontaneous abortion ›› Vaginal bleeding, uterine cramping, and partial or complete expulsion of products of conception ›› Ectopic pregnancy ›› Abrupt unilateral lower-quadrant abdominal pain with or without vaginal bleeding ›› Second trimester ›› Gestational trophoblastic disease ›› Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea and increased emesis, no fetus present on ultrasound, and scant or profuse dark brown or red vaginal bleeding ›› Third trimester ›› Placenta previa ›› Painless vaginal bleeding ›› Abruptio placenta ›› Vaginal bleeding, sharp abdominal pain, and tender rigid uterus

diagnostic and therapeutic procedures spontaneous abortion

■■ Ultrasound - to determine the presence of a viable or dead fetus, or partial or complete products of conception within the uterine cavity. ■■ Examination of the cervix - to observe whether it is opened or closed. ■■ Dilation and curettage (D&C) - to dilate and scrape the uterine walls to remove uterine contents for inevitable and incomplete abortions. ■■ Dilation and evacuation (D&E) - to dilate and evacuate uterine contents after 16 weeks of gestation. ■■ Prostaglandins and oxytocin (Pitocin) - to augment or induce uterine contractions and expulse the products of conception.

preprocedure, intra, post for an aminocentesis

● Preprocedure for an amniocentesis ◯◯ Nursing actions ■■ Explain the procedure to the client, and obtain informed consent. ◯◯ Client education ■■ Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture. ●● Intraprocedure ◯◯ Nursing actions ■■ Obtain client's baseline vital signs and FHR, and document prior to the procedure. ■■ Assist client into a supine position, and place a wedge under her right hip to displace the uterus off the vena cava, and place a drape over the client exposing only her abdomen. ■■ Prepare client for an ultrasound to locate the placenta. ■■ Cleanse client's abdomen with an antiseptic solution prior to the administration of a local anesthetic by the provider. ◯◯ Client education ■■ Advise the client that she will feel slight pressure as the needle is inserted. She should continue breathing because holding her breath will lower the diaphragm against the uterus and shift the intrauterine contents. ●● Postprocedure ◯◯ Nursing actions ■■ Monitor the client's vital signs, FHR, and uterine contractions throughout and 30 min following the procedure. ■■ Have the client rest for 30 min. ■■ Administer RhO(D) immune globulin (RhOGAM) to the client if she is Rh-negative (standard practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization). ◯◯ Client education ■■ Advise the client to report to her provider if she experiences fever, chills, leakage of fluid, or bleeding from the insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure. ■■ Encourage the client to drink plenty of liquids and rest for the 24 hr postprocedure.

Verifying Possible Pregnancy Using Serum and Urine Pregnancy Testing

● Serum and urine tests provide an accurate assessment for the presence of human chorionic gonadotropin (hCG). hCG production can start as early as the day of implantation and can be detected as early as 7 to 10 days after conception. ●● Production of hCG begins with implantation, peaks at about 60 to 70 days of gestation, declines until around 80 days of pregnancy, and then gradually increases until term. ●● Higher levels of hCG can indicate multifetal pregnancy, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), or a genetic abnormality such as Down syndrome. Lower blood levels of hCG may suggest a miscarriage. ●● Some medications (anticonvulsants, diuretics, tranquilizers) can cause false-positive or false-negative pregnancy results. ●● Urine samples should be first-voided morning specimens.

nutrition during pregnancy

●● Adequate nutritional intake during pregnancy is essential to promoting fetal and maternal health. ●● Recommended weight gain during pregnancy is usually 11.2 to 15.9 kg (25 to 35 lb). The general rule is that clients should gain 1 to 2 kg (2.2 to 4.4 lb) during the first trimester and after that, a weight gain of approximately 0.4 kg (1 lb) per week for the last two trimesters. Underweight woman are advised to gain 28 to 40 lb; overweight women, 15 to 25 lb. ●● It is important for the nurse to evaluate the pregnant client's nutritional choices, possible risk factors, and diet history. The nurse also should review specific nutritional guidelines for at-risk clients. Assistance is given to clients to develop a postpartum nutritional plan.

risk factors to ensure adequate nutrition during pregnancy

●● Age, culture, education, and socioeconomic issues may affect adequate nutrition during pregnancy. Also, certain conditions specific to each client may inhibit adequate caloric intake. ◯◯ Adolescents may have poor nutritional habits (a diet low in vitamins and protein, not taking prescribed iron supplements). ◯◯ Vegetarians may have low protein, calcium, iron, zinc, and vitamin B12. ◯◯ Nausea and vomiting during pregnancy. ◯◯ Anemia. ◯◯ Eating disorders such as anorexia nervosa or bulimia nervosa. ◯◯ Pregnant clients diagnosed with the appetite disorder pica (craving to eat nonfood substances such as dirt or red clay). This disorder may diminish the amount of nutritional foods ingested. ◯◯ Excessive weight gain can lead to macrosomia and labor complications. ◯◯ Inability to gain weight may result in low birth weight of the newborn. ◯◯ Financially unable to purchase/access food. Therefore, the nurse should advise the client about the Women, Infants and Children (WIC) programs, which are federally funded state programs for pregnant women and their children (up to 5 years old).

chlamydia

●● Chlamydia is a bacterial infection caused by Chlamydia trachomatis. It is the most common STI. The infection is often difficult to diagnose because it is typically asymptomatic. According to current guidelines from the Centers for Disease Control and Prevention, all women and adolescents ages 20 to 25 who are sexually active should be screened for STIs.

risk factors for spontaneous abortion

●● Chromosomal abnormalities (account for 50%) ●● Maternal illness, such as type 1 diabetes mellitus ●● Advancing maternal age ●● Premature cervical dilation ●● Chronic maternal infections ●● Maternal malnutrition ●● Trauma or injury ●● Anomalies in the fetus or placenta ●● Substance use ●● Antiphospholipid syndrome

risk factors candida albicans

●● Diabetes mellitus ●● Oral contraceptives ●● Recent antibiotic treatment

ectopic pregnancy

●● Ectopic pregnancy is the abnormal implantation of a fertilized ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage. ●● Ectopic pregnancy is the second most frequent cause of bleeding in early pregnancy and a leading cause of infertility.

HIV/AIDS

●● HIV is a retrovirus that attacks and causes destruction of T lymphocytes. It causes immunosuppression in a client. HIV is transmitted from the mother to a neonate perinatally through the placenta and postnatally through the breast milk. ●● Routine laboratory testing in the early prenatal period includes testing for HIV. Early identification and treatment significantly decreases the incidence of perinatal transmission. ●● Testing is recommended in the third trimester for clients who are at an increased risk, and rapid HIV testing should be done if a client is in labor and her HIV status is unknown. ●● Procedures, such as amniocentesis and an episiotomy, should be avoided due to the risk of maternal blood exposure. ●● Use of internal fetal monitors, vacuum extraction, and forceps during labor should be avoided because of the risk of fetal bleeding. ●● Administration of injections and blood testing should not take place until the first bath is given to the newborn.

risk factors hiv/aids

●● IV drug use ●● Multiple sexual partners ●● Bisexuality ●● Maternal history of multiple STIs ●● Blood transfusion (rare occurrence)

indications for quad maker and alpha fetoprotein screening

●● Indications ◯◯ Client presentation ■■ Preferred at 16-18 weeks gestation ■■ Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality ●● Interpretation of findings ◯◯ Low levels of AFP may indicate a risk for Down syndrome. ◯◯ High levels of AFP may indicate a risk for neural tube defects. ◯◯ Higher levels than the expected reference range of hCG and Inhibin-A indicates a risk for Down syndrome. ◯◯ Lower levels than the expected reference range of estriol may indicate a risk for Down syndrome. ●● Description of procedure ◯◯ Maternal serum alpha-fetoprotein (MSAFP) is a screening tool used to detect neural tube defects.fClients who have abnormal findings should be referred for a quad marker screening, genetic counseling, ultrasound, and an amniocentesis. ●● Indications ◯◯ Potential diagnoses ■■ All pregnant clients, preferably between 16-18 weeks of gestation ●● Interpretation of findings ◯◯ High levels may indicate a neural tube defect or open abdominal defect. ◯◯ Lower levels may indicate Down syndrome. ●● Nursing Actions ◯◯ Preparation of a client ■■ Discuss testing with the client. ■■ Draw blood sample. ■■ Offer support and education as needed

risk factors GTD

●● Low carotene or animal fat intake ●● Age - early teens or over age 40 ●● Ovulation stimulation with clomiphene (Clomid)

risk factors abruptio placenta

●● Maternal hypertension (chronic or gestational) ●● Blunt external abdominal trauma (motor-vehicle crash, maternal battering) ●● Cocaine use resulting in vasoconstriction ●● Previous incidents of abruptio placenta ●● Cigarette smoking ●● Premature rupture of membranes ●● Multifetal pregnancy

dietary complications during pregnancy

●● Nausea and constipation are common during pregnancy. ◯◯ For nausea, tell the client to eat dry crackers or toast, and avoid alcohol, caffeine, fats, and spices. Also avoid drinking fluids with meals, and DO NOT take a medication to control nausea without first checking with her provider. ◯◯ For constipation, increase fluid consumption, and include extra fiber in the diet. Fruits, vegetables, and whole grains all contain fiber. ●● Maternal phenylketonuria (PKU) is a maternal genetic disease in which high levels of phenylalanine pose a danger to the fetus. ◯◯ It is important for the client to resume the PKU diet for at least 3 months prior to pregnancy and continue the diet throughout pregnancy. ◯◯ The diet includes foods that are low in phenylalanine. Foods high in protein, such as fish, poultry, meat, eggs, nuts, and dairy products, must be avoided due to high phenylalanine levels. ◯◯ The client's blood phenylalanine levels are monitored during pregnancy. ◯◯ These interventions can prevent fetal complications such as mental retardation and behavioral problems.

nursing assessment in prenatal care

●● Nurses play an integral role in assessing a client's current knowledge, previous pregnancies, and birthing experiences. ●● Nursing assessment in prenatal care includes obtaining information regarding: ◯◯ Reproductive and obstetrical history (contraception use, gynecological diagnoses, and obstetrical difficulties). ◯◯ Medical history, including the woman's immune status (rubella and hepatitis B). ◯◯ Family history, such as genetic disorders. ◯◯ Any recent or current illnesses or infections. ◯◯ Current medications, including substance use and alcohol consumption. The nurse should display a nonjudgmental, matter-of-fact demeanor when interviewing a client regarding substance abuse and observe for signs and symptoms such as lack of grooming. ◯◯ Psychosocial history (a client's emotional response to pregnancy, adolescent pregnancy, spouse, support system, history of depression, domestic violence issues). ◯◯ Any hazardous environmental exposures; current work conditions. ◯◯ Current exercise and diet habits as well as lifestyle. ●● A nurse ascertains what a client's goals are for the birthing process. The nurse should discusses birthing methods, such as Lamaze, and pain control options (epidural, natural childbirth).

patient centered care placenta previa

●● Nursing Actions ◯◯ Assess for bleeding, leakage, or contractions. ◯◯ Assess fundal height. ◯◯ Perform Leopold maneuvers (fetal position and presentation). ◯◯ Refrain from performing vaginal exams (may exacerbate bleeding). ◯◯ Administer IV fluids, blood products, and medications as prescribed. ■■ Corticosteroids, such as betamethasone (Celestone), promote fetal lung maturation if delivery is anticipated (cesarean birth). ◯◯ Have oxygen equipment available in case of fetal distress. ●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Bed rest ■■ Nothing inserted vaginally

patient centered care GTD

●● Nursing Actions ◯◯ Measure fundal height. ◯◯ Assess vaginal bleeding and discharge. ◯◯ Assess gastrointestinal status and appetite. ◯◯ Monitor for signs and symptoms of preeclampsia. ◯◯ Administer medications as prescribed. ■■ RhO(D) immune globulin (RhoGAM) to the client who is Rh-negative ■■ Chemotherapeutic medications for findings of malignant cells indicating choriocarcinoma ◯◯ Advise client to save clots or tissue for evaluation. ●● Health Promotion and Disease Prevention ◯◯ Client education ■■ Provide client education and emotional support. ■■ Offer referral for client and partner to pregnancy loss support group. ■■ Instruct the client to use reliable contraception as a component of follow-up care. ■■ Reinforce the importance of follow-up because of the increased risk of choriocarcinoma

patient centered care spontaneous abortion

●● Nursing Actions ◯◯ Observe color and amount of bleeding (counting pads). ◯◯ Perform a pregnancy test. ◯◯ Maintain client on bed rest; inform client of risk for falls due to sedative medications if prescribed. ◯◯ Avoid vaginal exams. ◯◯ Assist with an ultrasound. ◯◯ Administer medications and blood products as prescribed. ◯◯ Determine how much tissue has passed and save passed tissue for examination. ◯◯ Assist with termination of pregnancy (D&C, D&E, prostaglandin administration) as indicated. ●● Medications ◯◯ Analgesics and sedatives ◯◯ Prostaglandin - administered into the amniotic sac or as a vaginal suppository ◯◯ Oxytocin (Pitocin) ◯◯ Broad-spectrum antibiotics - in septic abortion ◯◯ RhO(D) immune globulin (RhoGAM) - suppresses immune response of clients who are Rh-negative ●● Nursing Considerations ◯◯ Use the lay term "miscarriage" with clients because the medical term "abortion" can be misunderstood. ◯◯ Provide client education and emotional support. ◯◯ Provide referral for client and partner to pregnancy loss support groups.●● Health Promotion and Disease Prevention ◯◯ Discharge instructions ■■ Notify the provider of heavy, bright red vaginal bleeding; elevated temperature; or foul-smelling vaginal discharge. ■■ A small amount of discharge is normal for 1 to 2 weeks. ■■ Take prescribed antibiotics. ■■ Refrain from tub baths, sexual intercourse, or placing anything into the vagina for 2 weeks. ■■ Avoid becoming pregnant for 2 months.

patient centered care abruptio placenta

●● Nursing Actions ◯◯ Palpate the uterus for tenderness and tone. ◯◯ Assess FHR pattern. ◯◯ Administer IV fluids, blood products, and medications as prescribed. ■■ Corticosteroids to promote fetal lung maturity ◯◯ Administer oxygen 8 to 10 L/min via face mask. ◯◯ Assess urinary output and monitor fluid balance. ●● Client Education ◯◯ Provide emotional support for the client and family.

patient centered care ectopic pregnancy

●● Nursing Actions ◯◯ Replace fluids, and maintain electrolyte balance. ◯◯ Provide client education and psychological support. ◯◯ Administer medications as prescribed. ◯◯ Prepare the client for surgery and postoperative nursing care. ◯◯ Provide referral for client and partner to pregnancy loss support group. ●● Nursing Considerations ◯◯ Obtain serum hCG and progesterone levels, liver and renal function studies, CBC, and type and Rh. ●● Health Promotion and Disease Prevention ◯◯ Client education ■■ Instruct the client who is prescribed methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication. ■■ Advise the client to protect herself from sun exposure (photosensitivity

nursing care group b strep

●● Nursing Care ◯◯ Administer intrapartum antibiotic prophylaxis (IAP). ■■ Client who delivered previous infant with GBS infection ■■ Client who has GBS bacteriuria during current pregnancy ■■ Client who has a GBS-positive screening during current pregnancy ■■ Client who has unknown GBS status who is delivering at less than 37 weeks of gestation ■■ Client who has maternal fever of 38° C (100.4° F) ■■ Client who has rupture of membranes for 18 hr or longer

teamwork and collaboration chlamydia

●● Nursing Care ◯◯ Instruct the client to take the entire prescription as prescribed. ◯◯ Identify and treat all sexual partners. ◯◯ Clients who are pregnant should be retested 3 weeks after completing the prescribed regimen. ●● Medications ◯◯ Azithromycin (Zithromax) and amoxicillin (Amoxil) are prescribed during pregnancy. ■■ Broad-spectrum antibiotic ■■ Bactericidal action ■■ Nursing Care ☐☐ Administer erythromycin (Romycin) to all infants following delivery. This is the medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal, thus it provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. ■■ Client Education ☐☐ Instruct the client to take all prescriptions as prescribed. ☐☐ Educate the client about the possibility of decreasing effectiveness of oral contraceptives

nursing care candida albicans

●● Nursing Care ◯◯ Medications ■■ Fluconazole (Diflucan) ☐☐ Antifungal agent ☐☐ Fungicidal action ☐☐ Over-the-counter treatments, such as clotrimazole (Monistat), are available to treat candidiasis. However, it is important for the provider to diagnosis candidiasis initially. ●● Health Promotion and Disease Prevention ◯◯ Client Education ■■ Instruct the client to avoid tight-fitting clothing. ■■ Instruct the client to wear cotton-lined underpants. ■■ Instruct the client to limit wearing damp clothing. ■■ Instruct the client to void before and after intercourse and avoid douching. ■■ Instruct the client to increase dietary intake of yogurt with active cultures.

teamwork and collaboration torch

●● Nursing Care ◯◯ Monitor fetal well-being. ◯◯ Educate the client on prevention practices, including correct hand hygiene and cooking meat properly. Clients should be instructed to avoid contact with contaminated cat litter. ●● Medications ◯◯ Administer antibiotics as prescribed. ◯◯ Treatment of toxoplasmosis includes sulfonamides or a combination of pyrimethamine and sulfadiazine (potentially harmful to the fetus, but parasitic treatment is essential). ●● Health Promotion and Disease Prevention ◯◯ Client Education ■■ For rubella, vaccination of women who are pregnant is contraindicated because rubella infection may develop. These women should avoid crowds of young children. Women with low titers prior to pregnancy should receive immunizations. ■■ Because no treatment for cytomegalovirus exists, tell the client to prevent exposure by frequent hand hygiene before eating, and avoiding crowds of young children. ■■ Emphasize to the client the importance of compliance with prescribed treatment. ■■ Provide client with emotional support.

assessment group b strep

●● Objective Data ◯◯ Physical Assessment Findings ■■ Positive GBS may have maternal and fetal effects, including premature rupture of membranes, preterm labor and delivery, chorioamnionitis, infections of the urinary tract, and maternal sepsis. ◯◯ Laboratory Tests ■■ Vaginal and rectal cultures are performed at 36 to 37 weeks of gestation

nursing assessment and interventions

●● Obtain subjective and objective dietary information. ◯◯ Journal of client's food habits, eating pattern, and cravings ◯◯ Nutrition-related questionnaires ◯◯ Client's weight on first prenatal visit and follow-up visits ◯◯ Laboratory findings, such as Hgb and iron levels ●● Determine client's caloric intake. ◯◯ Have client record everything eaten. The nurse, dietician, or client can identify the caloric value of each item. This record can provide better objective data about the client's nutrition status.

how does prenatal care begin

●● Prenatal care begins with an initial assessment and continues throughout pregnancy. In an uneventful pregnancy, prenatal visits are scheduled monthly for 7 months, every 2 weeks during the eighth month, and every week during the last month. ◯◯ At the initial prenatal visit: ■■ Determine estimated date of birth based on the last menstrual period. ■■ Obtain medical and nursing history to include social supports, and review of systems (to determine risk factors). ■■ Perform a physical assessment to include a client's baseline weight, vital signs, and pelvic examination. Assess for costovertebral angle tenderness to identify kidney infection. ■■ Obtain initial laboratory tests. ◯◯ Ongoing prenatal visits include the following: ■■ Monitoring weight, blood pressure, and urine for glucose, protein, and leukocytes. ■■ Monitoring for the presence of edema. ■■ Monitoring fetal development. ☐☐ FHR can be heard by Doppler at 10 to 12 weeks of gestation or heard with an ultrasound stethoscope at 16 to 20 weeks of gestation. Listen at the midline, right above the symphysis pubis, by holding the stethoscope firmly on the abdomen. ☐☐ Measure fundal height after 12 weeks of gestation. View Video: Measuring Fundal Height ☐☐ Begin assessing for fetal movement between 16 and 20 weeks of gestation. ■■ Providing education for self-care to include management of common discomforts and concerns of pregnancy (nausea and vomiting, fatigue, backache, varicosities, heartburn, activity, sexuality). ◯◯ Perform or assist with Leopold maneuvers to palpate presentation and position of the fetus. ◯◯ Assist the provider with the gynecological examination. This examination is performed to determine the status of a client's reproductive organs and birth canal. Pelvic measurements determine whether the pelvis will allow for the passage of the fetus at delivery. ■■ The nurse has the client empty her bladder and take deep breaths during the examination to decrease discomfort. ◯◯ Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for clients who are Rh-negative.

risk factors placenta previa

●● Previous placenta previa ●● Uterine scarring (previous cesarean birth, curettage, endometritis) ●● Maternal age greater than 35 to 40 years ●● Multifetal gestation ●● Multiple gestations or closely spaced pregnancies ●● Smoking

normal physiological changes during pregnancy

●● Recognizing changes during pregnancy is helpful for both clients and nurses. The nurse and provider assess findings during the client's initial prenatal visit. ●● Signs of pregnancy are classified into three groups. ◯◯ Presumptive ◯◯ Probable ◯◯ Positive ●● Calculating delivery date, number of pregnancies, and evaluating the physiological status of a client who is pregnant are performed.

risk factors ectopic pregnancy

●● Risk factors for an ectopic pregnancy include any factor that compromises tubal patency (STIs, assisted reproductive technologies, tubal surgery, and contraceptive intrauterine device [IUD]).

infertility diagnostic procedures

●● Semen analysis - In 40% of couples who are infertile, inability to conceive is due to male infertility. This test is the first in an infertility workup because it is less expensive and less invasive compared with female infertility testing. It may need to be repeated. ●● Pelvic examination - assesses for uterine or vaginal anomalies. ●● Hormone analysis - evaluate hypothalamic-pituitary-ovarian axis to include serum prolactin, FSH, LH, estradiol, progesterone, and thyroid hormones. ●● Endometrial biopsy - evaluates endometrial response, secretory, and luteal phase of menstrual cycle. ●● Postcoital test - evaluates coital technique and mucus secretions. ●● Ultrasonography - a transvaginal or abdominal ultrasound procedure performed to visualize female reproductive organs. ●● Hysterosalpingography - outpatient radiological procedure in which dye is used to assess the patency of the fallopian tubes. Assess for history of allergies to iodine and seafood. ●● Hysteroscopy - a radiographic procedure in which the uterus is examined for signs of defect, distortion, or scar tissue that may impair successful impregnation. ●● Laparoscopy - a procedure where gas insufflation under general anesthesia is used to observe internal organs.

spontaneous abortion

●● Spontaneous abortion is when a pregnancy is terminated before 20 weeks of gestation (the point of fetal viability) or a fetal weight less than 500 g. ●● Types of abortion are clinically classified according to clinical manifestations and whether the products of conception are partially or completely retained or expulsed. Types of abortions include threatened, inevitable, incomplete, complete, and missed

assessment GTD

●● Subjective Data ◯◯ Excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels ●● Objective Data ◯◯ Physical assessment findings ■■ Rapid uterine growth more than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells. ■■ Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks and may be accompanied by passage of vesicles. ■■ Symptoms of preeclampsia that occur prior to 24 weeks of gestation. ◯◯ Laboratory Tests ■■ Serum level of hCG persistently high compared with expected decline after weeks 10 to 12 of pregnancy. ◯◯ Diagnostic and Therapeutic Procedures ■■ An ultrasound reveals a dense growth with characteristic vesicles, but no fetus in utero. ■■ Suction curettage is done to aspirate and evacuate the mole. ■■ Following mole evacuation, the client should undergo a baseline pelvic exam and ultrasound scan of the abdomen. ■■ Serum hCG analysis following molar pregnancy to be done weekly for 3 weeks, then monthly for 6 months up to a year to detect GTD.

assessment hiv/aids

●● Subjective Data ◯◯ Fatigue and influenzalike symptoms ●● Objective Data ◯◯ Physical assessment findings ■■ Diarrhea and weight loss ■■ Lymphadenopathy and rash ■■ Anemia ◯◯ Laboratory Tests ■■ Obtain informed maternal consent prior to testing. Testing begins with an antibody screening test, such as enzyme immunoassay. Confirmation of positive results is confirmed by Western blot test or immunofluorescence assay. ■■ Use rapid HIV antibody test (blood or urine sample) for a client in labor. ■■ Screen the client for STIs such as gonorrhea, chlamydia, syphilis, and hepatitis B. ■■ Obtain frequent viral load levels and CD4 cell counts throughout the pregnancy

assessment placenta previa

●● Subjective Data ◯◯ Painless, bright red vaginal bleeding during the second or third trimester ●● Objective Data ◯◯ Uterus soft, relaxed and nontender with normal tone ◯◯ Fundal height greater than usually expected for gestational age ◯◯ Fetus in a breech, oblique, or transverse position ◯◯ Reassuring FHR ◯◯ Vital signs within normal limits ◯◯ Decreasing urinary output may be a better indicator of blood loss ●● Laboratory Tests ◯◯ Hgb and Hct for blood loss assessment ◯◯ CBC ◯◯ Blood type and Rh ◯◯ Coagulation profile ◯◯ Kleihauer-Betke test (used to detect fetal blood in maternal circulation) ●● Diagnostic Procedures ◯◯ Transabdominal or transvaginal ultrasound for placement of the placenta ◯◯ Fetal monitoring for fetal well-being assessment

assessment abruptio placenta

●● Subjective Data ◯◯ Sudden onset of intense localized uterine pain with dark red vaginal bleeding ●● Objective Data ◯◯ Area of uterine tenderness may be localized or diffuse over uterus and boardlike ◯◯ Contractions with hypertonicity ◯◯ Fetal distress ◯◯ Signs of hypovolemic shock ●● Laboratory Tests ◯◯ Hgb and Hct decreased ◯◯ Coagulation factors decreased ◯◯ Clotting defects (disseminated intravascular coagulation) ◯◯ Cross and type match for possible blood transfusions ◯◯ Kleihauer-Betke test (used to detect fetal blood in maternal circulation) ●● Diagnostic Procedures ◯◯ Ultrasound for fetal well-being and placental assessment ◯◯ Biophysical profile to ascertain fetal well-being

assessment torch

●● Subjective Data ◯◯ Toxoplasmosis findings similar to influenza or lymphadenopathy ◯◯ Malaise, muscle aches, (flulike symptoms) ◯◯ Rubella joint and muscle pain ◯◯ Cytomegalovirus has asymptomatic or mononucleosis-like manifestations●● Objective Data ◯◯ Physical assessment findings ■■ Manifestations of toxoplasmosis include fever and tender lymph nodes. ■■ Manifestations of rubella include rash, mild lymphedema, fever, and fetal consequences, which include miscarriage, congenital anomalies, and death. ■■ Herpes simplex virus initially presents with lesions and tender lymph nodes. Fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction. ◯◯ Laboratory Tests ■■ For herpes simplex, obtain cultures from women who have HSV or are at or near term. ◯◯ Diagnostic Procedures ■■ A TORCH screen is an immunologic survey that is used to identify the existence of these infections in the mother (to identify fetal risks) or in her newborn (detection of antibodies against infections). ■■ Prenatal screenings

assessment for ectopic pregnancy

●● Subjective Data ◯◯ Unilateral stabbing pain and tenderness in the lower-abdominal quadrant. ◯◯ Delayed (1 to 2 weeks), lighter than usual, or irregular menses. ◯◯ Scant, dark red, or brown vaginal spotting occurs 6 to 8 weeks after last normal menses; red, vaginal bleeding if rupture has occurred. ◯◯ Referred shoulder pain due to blood in the peritoneal cavity irritating the diaphragm or phrenic nerve after tubal rupture. ◯◯ Report of faintness and dizziness related to amount of bleeding in abdominal cavity. ●● Objective Data ◯◯ Signs of hemorrhage and shock (hypotension, tachycardia, pallor) ●● Laboratory Tests ◯◯ Serum levels of progesterone and hCG elevated rules out ectopic pregnancy.●● Diagnostic and Therapeutic Procedures ◯◯ Transvaginal ultrasound showing an empty uterus ◯◯ Caution used if vaginal and bimanual examination undertaken ◯◯ Rapid surgical treatment ■■ Salpingostomy is done to salvage the fallopian tube if not ruptured. ■■ Laparoscopic salpingectomy (removal of the tube) is performed when the tube has ruptured. ■■ Medical management if rupture has not occurred and tube preservation desired. ☐☐ Methotrexate (MTX) - inhibits cell division and embryo enlargement, dissolving the pregnancy

assessment chlamydia

●● Subjective Data ◯◯ Vaginal spotting ◯◯ Vulvar itching ◯◯ Postcoital bleeding and dysuria ●● Objective Data ◯◯ Physical Assessment Findings ■■ White, watery vaginal discharge ◯◯ Laboratory Tests ■■ Endocervical culture

assessment candida albicans

●● Subjective Data ◯◯ Vulvar itching ●● Objective Data ◯◯ Physical Assessment Findings ■■ Thick, creamy, white vaginal discharge ■■ Vulvar redness ■■ White patches on vaginal walls ■■ Gray-white patches on the tongue and gums (neonate) ◯◯ Laboratory Tests ■■ Wet prep ◯◯ Diagnostic Procedures ■■ Potassium hydroxide (KOH) prep ■■ Presence of hyphae and pseudohyphae indicates positive findings.

assessment gonorrhea

●● Subjective Data (Male) ◯◯ Urethral discharge ◯◯ Painful urination ◯◯ Frequency ●● Subjective Data (Female) ◯◯ Lower abdominal pain ◯◯ Dysmenorrhea●● Objective Data - Male/Female ◯◯ Physical Assessment Findings ■■ Urethral discharge ■■ Yellowish-green vaginal discharge ■■ Reddened vulva and vaginal walls ■■ If gonorrhea is left untreated, it can cause pelvic inflammatory disease, heart disease, and arthritis. ◯◯ Laboratory Tests ■■ Urethral and vaginal cultures ■■ Urine culture

assessment for spontaneous abortion

●● Subjective and Objective Data ◯◯ Backache and abdominal tenderness ◯◯ Rupture of membranes, dilation of the cervix ◯◯ Fever ◯◯ Signs and symptoms of hemorrhage such as hypotension and tachycardia

torch infections

●● TORCH is an acronym for a group of infections that can negatively affect a woman who is pregnant. These infections can cross the placenta and have teratogenic affects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus.

risk infections torch

●● Toxoplasmosis is caused by consumption of raw or undercooked meat or handling cat feces. The symptoms are similar to influenza or lymphadenopathy. Other infections can include hepatitis A and B, syphilis, mumps, parvovirus B19, and varicella-zoster. These are some of the most common and can be associated with congenital anomalies. ●● Rubella (German measles) is contracted through children who have rashes or neonates who are born to mothers who had rubella during pregnancy. ●● Cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, a virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal. ●● The herpes simplex virus (HSV) is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions.

assessment of fetal well-being

●● Ultrasound - a procedure lasting approximately 20 min that consists of high-frequency sound waves used to visualize internal organs and tissues by producing a real-time, three-dimensional image of the developing fetus and maternal structures (FHR, pelvic anatomy). An ultrasound allows for early diagnosis of complications, permits earlier interventions, and thereby decreases neonatal and maternal morbidity and mortality. There are three types of ultrasound: external abdominal, transvaginal, and Doppler. ◯◯ External abdominal ultrasound - a safe, noninvasive, painless procedure whereby an ultrasound transducer is moved over a client's abdomen to obtain an image. An abdominal ultrasound is more useful after the first trimester when the gravid uterus is larger. ◯◯ Internal transvaginal ultrasound - an invasive procedure in which a probe is inserted vaginally to allow for a more accurate evaluation. An advantage of this procedure is that it does not require a full bladder. ■■ It is especially useful in clients who are obese and those in the first trimester to detect an ectopic pregnancy, identify abnormalities, and to establish gestational age. ■■ A transvaginal ultrasound also may be used in the third trimester in conjunction with abdominal scanning to evaluate for preterm labor. ◯◯ Doppler ultrasound blood flow analysis - a noninvasive external ultrasound method to study the maternal-fetal blood flow by measuring the velocity at which RBCs travel in the uterine and fetal vessels using a handheld ultrasound device that reflects sound waves from a moving target. It is especially useful in fetal intrauterine growth restriction (IUGR) and poor placental perfusion, and as an adjunct in pregnancies at risk because of hypertension, diabetes mellitus, multiple fetuses, or preterm labor. ●● Indications for the use of an ultrasound during pregnancy ◯◯ Potential diagnoses for: ■■ Confirming pregnancy ■■ Confirming gestational age by biparietal diameter (side-to-side) measurement ■■ Identifying multifetal pregnancy■■ Site of fetal implantation (uterine or ectopic) ■■ Assessing fetal growth and development ■■ Assessing maternal structures ■■ Confirming fetal viability or death ■■ Ruling out or verifying fetal abnormalities ■■ Locating the site of placental attachment ■■ Determining amniotic fluid volume ■■ Fetal movement observation (fetal heartbeat, breathing, and activity) ■■ Placental grading (evaluating placental maturation) ■■ Adjunct for other procedures (e.g., amniocentesis, biophysicalClient presentation ■■ Vaginal bleeding evaluation ■■ Questionable fundal height measurement in relationship to gestational weeks ■■ Reports of decreased fetal movements ■■ Preterm labor ■■ Questionable rupture of membranes

bleeding during pregnancy

●● Vaginal bleeding during pregnancy is always abnormal and must be investigated to determine the cause. It can impair both the outcome of the pregnancy and the mother's life. ●● The primary causes of bleeding are summarized in the following table according to common causes during each trimester of pregnancy.

health promotion and disease prevention hiv/aids

◯ Discharge instructions ■■ Instruct the client not to breastfeed. ■■ Discuss HIV and safe sexual relations with the client. ■■ Refer client and infant to providers specializing in the care of clients who have HIV.

meds hiv/aids

◯ Retrovir (Zidovudine) ■■ Antiretroviral agent ■■ Nucleoside reverse transcriptase inhibitor ◯◯ Nursing considerations ■■ Administer retrovir at 14 weeks of gestation, throughout the pregnancy, and before the onset of labor or cesarean birth. ■■ Administer retrovir to the infant at delivery and for 6 weeks following birth.

interpretation of aminocentesis

◯◯ Alpha-fetoprotein (AFP) can be measured from the amniotic fluid between 16 and 18 weeks of gestation and may be used to assess for neural tube defects in the fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum. ■■ High levels of AFP are associated with neural tube defects, such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), or omphalocele (abdominal wall defect). High AFP levels also may be present with normal multifetal pregnancies. ■■ Low levels of AFP are associated with chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydatidiform mole). ◯◯ Tests for fetal lung maturity may be performed if gestation is less than 37 weeks, in the event of a rupture of membranes, for preterm labor, or for a complication indicating a cesarean birth. Amniotic fluid is tested to determine whether the fetal lungs are mature enough to adapt to extrauterine life, or if the fetus will likely have respiratory distress. Determination is made whether the fetus should be removed immediately or if the fetus requires more time in utero with the administration of glucocorticoids to promote fetal lung maturity. ■■ Fetal lung tests ☐☐ Lecithin/sphingomyelin (L/S) ratio - a 2:1 ratio indicating fetal lung maturity (2.5:1 or 3:1 for a client who has diabetes mellitus). ☐☐ Presence of phosphatidylglycerol (PG) - absence of PG is associated with respiratory distress

expected vital signs in pregos

◯◯ Blood pressure measurements are within the prepregnancy range during the first trimester. ◯◯ Blood pressure decreases 5 to 10 mm Hg for both the diastolic and the systolic during the second trimester. ◯◯ Blood pressure should return to the prepregnancy baseline range after approximately 20 weeks of gestation. ◯◯ Position of the pregnant woman also may affect blood pressure. In the supine position, blood pressure may appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which decreases venous blood flow to the heart. Maternal hypotension and fetal hypoxia may occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome. Signs and symptoms include dizziness, lightheadedness, and pale, clammy skin. Encourage the client to engage in maternal positioning on the left-lateral side, semi-Fowler's position, or, if supine, with a wedge placed under one hip to alleviate pressure to the vena cava. ◯◯ Pulse increases 10 to 15/min around 20 weeks of gestation and remains elevated throughout the remainder of the pregnancy. ◯◯ Respirations increase by 1 to 2/min. Respiratory changes in pregnancy are attributed to the elevation of the diaphragm by as much as 4 cm, as well as changes to the chest wall to facilitate increased maternal oxygen demands. Some shortness of breath may be noted.

complications with amiocentesis

◯◯ Complications ■■ Amniotic fluid emboli ■■ Maternal or fetal hemorrhage ■■ Fetomaternal hemorrhage with Rh isoimmunization ■■ Maternal or fetal infection ■■ Inadvertent fetal damage or anomalies involving limbs ■■ Fetal death ■■ Inadvertent maternal intestinal or bladder damage ■■ Miscarriage or preterm labor ■■ Premature rupture of membranes ■■ Leakage of amniotic fluid ◯◯ Nursing actions ■■ Monitor the client's vital signs, temperature, respiratory status, FHR, uterine contractions, and vaginal discharge for amniotic fluid or bleeding. ■■ Administer medication as prescribed. ■■ Offer support and reassurance

body image changes in pregos

◯◯ Due to physical and psychological changes that occur, the pregnant woman requires support from her provider and family members. ◯◯ In the first trimester of pregnancy, physiological changes are not obvious. Many women look forward to the changes so that pregnancy will be more noticeable. ◯◯ During the second trimester, there are rapid physical changes due to the enlargement of the abdomen and breasts. Skin changes also occur, such as stretch marks and hyperpigmentation. These changes can affect a woman's mobility. She may find herself losing her balance and feeling back or leg discomfort and fatigue. These factors may lead to a negative body image. The client may make statements of resentment toward the pregnancy and express anxiousness for the pregnancy to be over soon.

expected physical assessment findings in pregos

◯◯ Fetal heart tones are heard at a normal baseline rate of 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS. ◯◯ The client's heart changes in size and shape with resulting cardiac hypertrophy to accommodate increased blood volume and increased cardiac output. Heart sounds also change to accommodate the increase in blood volume with a more distinguishable splitting of S1 and S2, with S3 more easily heard following 20 weeks of gestation. Murmurs also may be auscultated. Heart size and shape should return to normal shortly after delivery. ◯◯ Uterine size changes from a uterine weight of 50 to 1,000 g (0.1 to 2.2 lb). By 36 weeks of gestation, the top of the uterus and the fundus will reach the xiphoid process. This may cause the pregnant woman to experience shortness of breath as the uterus pushes against the diaphragm. ◯◯ Cervical changes are obvious as a purplish-blue color extends into the vagina and labia, and the cervix becomes markedly soft. ◯◯ Breast changes occur due to hormones of pregnancy, with the breasts increasing in size and the areolas darkening. ◯◯ Skin changes ■■ Chloasma - Pigmentation increases on the face. ■■ Linea nigra - Dark line of pigmentation from the umbilicus extending to the pubic area. ■■ Striae gravidarum - Stretch marks most notably found on the abdomen and thighs.

common discomforts of pregnancy

◯◯ Nausea and vomiting may occur during the first trimester. The client should eat crackers or dry toast 30 min to 1 hr before rising in the morning to relieve discomfort. Instruct the client to avoid having an empty stomach and ingesting spicy, greasy, or gas-forming foods. Encourage the client to drink fluids between meals. ◯◯ Breast tenderness may occur during the first trimester. The client should wear a bra that provides adequate support. ◯◯ Urinary frequency may occur during the first and third trimesters. The client should empty her bladder frequently, decrease fluid intake before bedtime, and use perineal pads. The client is taught how to perform Kegel exercises (alternate tightening and relaxation of pubococcygeal muscles) to reduce stress incontinence (leakage of urine with coughing and sneezing). ◯◯ Urinary tract infections (UTIs) are common during pregnancy because of renal changes and the vaginal flora becoming more alkaline. ■■ UTI risks can be decreased by encouraging the client to wipe the perineal area from front to back after voiding; avoiding bubble baths; wearing cotton underpants; avoiding tight-fitting pants; and consuming plenty of water (8 glasses per day). ■■ The client should urinate before and after intercourse to flush bacteria from the urethra that are present or introduced during intercourse. ■■ Advise the client to urinate as soon as the urge occurs because retaining urine provides an environment for bacterial growth. ■■ Advise the client to notify her provider if her urine is foul-smelling, contains blood, or appears cloudy. ◯◯ Fatigue may occur during the first and third trimesters. The client is encouraged to engage in frequent rest periods. ◯◯ Heartburn may occur during the second and third trimesters due to the stomach being displaced by the enlarging uterus and a slowing of gastrointestinal tract motility and digestion brought about by increased progesterone levels. The client should eat small frequent meals, not allow the stomach to get too empty or too full, sit up for 30 min after meals, and check with her provider prior to using any over-the-counter antacids. ◯◯ Constipation may occur during the second and third trimesters. The client is encouraged to drink plenty of fluids, eat a diet high in fiber, and exercise regularly. ◯◯ Hemorrhoids may occur during the second and third trimesters. A warm sitz bath, witch hazel pads, and application of topical ointments will help relieve discomfort. ◯◯ Backaches are common during the second and third trimesters. The client is encouraged to exercise regularly, perform pelvic tilt exercises (alternately arching and straightening the back), use proper body mechanics by using the legs to lift rather than the back, and use the side-lying position. ◯◯ Shortness of breath and dyspnea may occur because of the enlarged uterus, which limits inspiration. The client should maintain good posture, sleep with extra pillows, and contact her provider if symptoms worsen.◯◯ Leg cramps during the third trimester may occur due to the compression of lower-extremity nerves and blood vessels by the enlarging uterus. This can result in poor peripheral circulation as well as an imbalance in the calcium/phosphorus ratio. The client should extend the affected leg, keeping the knee straight, and dorsiflex the foot (toes toward head). Application of heat over the affected muscle or a foot massage while the leg is extended can help relieve cramping. The client should notify her provider if frequent cramping occurs. ◯◯ Varicose veins and lower-extremity edema can occur during the second and third trimesters. The client should rest with her legs elevated, avoid constricting clothing, wear support hose, avoid sitting or standing in one position for extended periods of time, and not sit with her legs crossed at the knees. She should sleep in the left-lateral position and exercise moderately with frequent walking to stimulate venous return. ◯◯ Gingivitis, nasal stuffiness, and epistaxis (nosebleed) can occur as a result of elevated estrogen levels causing increased vascularity and proliferation of connective tissue. The client should gently brush her teeth, observe good dental hygiene, use a humidifier, and use normal saline nose drops or spray. ◯◯ Braxton Hicks contractions, which occur from the first trimester onward, may increase in intensity and frequency during the third trimester. Inform the client that a change of position and walking should cause contractions to subside. If contractions increase in intensity and frequency (true contractions) with regularity, the client should notify her provider. ◯◯ Supine hypotension occurs when a woman lies on her back and the weight of the gravid uterus compresses her vena cava. This reduces blood supply to the fetus. The client may experience feelings of lightheadedness and faintness. Teach the client to lie in a side-lying or semi-sitting position with her knees slightly flexed.

preparation for pregnancy and birth

◯◯ Nurses provide anticipatory teaching to the pregnant client and her family about the following: ■■ Physical and emotional changes during pregnancy and interventions that can be implemented to provide relief. ■■ Signs and symptoms of complications to report to the provider. ■■ Birthing options available to enhance the birthing process. ◯◯ Maternal adaptation to pregnancy and the attainment of the maternal role - whereby the idea of pregnancy is accepted and assimilated into the client's way of life - includes hormonal and psychological aspects. ■■ Emotional lability is experienced by many women with unpredictable mood changes and increased irritability, tearfulness, and anger alternating with feelings of joy and cheerfulness. This may result from hormonal changes. ■■ A feeling of ambivalence about the pregnancy, which is a normal response, may occur early in the pregnancy and resolve before the third trimester. It consists of conflicting feelings (joy, pleasure, sorrow, hostility) about the pregnancy. These feelings can occur simultaneously, whether the pregnancy was planned or not. ◯◯ The nurse anticipates reviewing prenatal education topics with a client based on her current knowledge and previous pregnancy and birth experiences. The client's readiness to learn is enhanced when the nurse provides teaching during the appropriate trimester based on learning needs. Using a variety of educational methods, such as pamphlets and videos, and having the client verbalize and demonstrate learned topics will ensure that learning has taken place.

ectopic pregnancy

◯◯ Ovum may implant in the fallopian tubes or abdominal cavity due to the presence of endometrial tissue. ◯◯ As ovum increases in size, fallopian tube may rupture, and extensive bleeding occurs, resulting in surgical removal of the damaged tube. ◯◯ If ectopic pregnancy is identified prior to rupture of the tube, surgical removal of the products of conception may be performed, or methotrexate (Rheumatrex) is prescribed to dissolve the pregnancy. ◯◯ Client faces increased risk of recurrence of an ectopic pregnancy and infertility.

medications group b strep

◯◯ Penicillin G or ampicillin (Principen) is most commonly prescribed for GBS. ■■ Administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus every 4 hr. The client may be prescribed ampicillin 2 grams IV initially, followed by 1 g every 4 hr. ■■ Bactericidal antibiotic is used to destroy the GBS.● Health Promotion and Disease Prevention ◯◯ Client Education ■■ Instruct the client to notify the labor and delivery nurse of GBS status.

indications for the use of an aminocentesis during pregnancy

◯◯ Potential diagnoses ■■ Previous birth with a chromosomal anomaly ■■ A parent who is a carrier of a chromosomal anomaly ■■ A family history of neural tube defects ■■ Prenatal diagnosis of a genetic disorder or congenital anomaly of the fetus ■■ Alpha fetoprotein level for fetal abnormalities ■■ Lung maturity assessment ■■ Fetal hemolytic disease ■■ Meconium in the amniotic fluid

client education - health promotion pregos

◯◯ Preconception and prenatal education emphasizes healthy behaviors that promote the health of the pregnant woman and her fetus. ■■ A client is instructed to avoid all over-the-counter medications, supplements, and prescription medications unless the provider who is supervising her care has knowledge of this practice. ■■ Alcohol (birth defects) and tobacco (low birth weight) are contraindicated during pregnancy. ■■ Substance use of any kind is to be avoided during pregnancy and lactation. Strategies to reduce or eliminate substance use are reviewed. ◯◯ The nurse educates a client about the following: ■■ Need for flu immunization ■■ Smoking cessation ■■ Treatment of current infections ■■ Genetic testing and counseling ■■ Exposure to hazardous materials ◯◯ Exercise during pregnancy yields positive benefits and should consist of 30 min of moderate exercise (walking or swimming) daily if not medically or obstetrically contraindicated. ■■ Avoid the use of hot tubs or saunas. ■■ Consume at least 2 to 3 L of water each day from food and beverage sources.

other causes of bleeding during pregnancy

◯◯ Precurrent premature dilation of the cervix ■■ Painless bleeding with cervical dilation leading to fetal expulsion ◯◯ Preterm labor ■■ Pink-stained vaginal discharge, uterine contractions becoming regular, cervical dilation and effacement

nursing actions for an ultrasound

◯◯ Preparation of client ■■ Explain the procedure to the client and that it presents no known risk to her or her fetus. ■■ Advise the client to drink 1 to 2 quarts of fluid prior to the ultrasound to fill the bladder, lift and stabilize the uterus, displace the bowel, and act as an echolucent to better reflect sound waves to obtain a better image of the fetus. ■■ Assist the client into a supine position with a wedge placed under her right hip to displace the uterus (prevents supine hypotension). ◯◯ Ongoing care ■■ Apply an ultrasonic/transducer gel to the client's abdomen before the transducer is moved over the skin to obtain a better fetal image, ensuring that the gel is at room temperature or warmer. ■■ Allow the client to empty her bladder at the termination of the procedure. ●● Nursing actions for a transvaginal ultrasound ◯◯ Preparation of client ■■ Assist the client into a lithotomy position. The vaginal probe is covered with a protective device, lubricated with a water-soluble gel, and the client or examiner inserts the probe. ◯◯ Ongoing care ■■ During the procedure, the position of the probe or tilt of the table may be changed to facilitate the complete view of the pelvis. ■■ Inform the client that pressure may be felt as the probe is moved. ●● Client education ◯◯ Fetal and maternal structures may be pointed out to the client as the ultrasound procedure is performed.

nursing care hiv/aids

◯◯ Provide counseling prior to and after testing. ◯◯ Refer the client for a mental health consultation, legal assistance, and financial resources. ◯◯ Use standard precautions. ◯◯ Administer antiviral prophylaxis, triple-drug antiviral, or highly active antiretroviral therapy (HAART) as prescribed. ◯◯ Obtain prescribed laboratory testing. ◯◯ Encourage vaccination against hepatitis B, pneumococcal infection, Haemophilus influenzae type B and viral influenza. ◯◯ Encourage use of condoms to minimize exposure if partner is the source of infection. ◯◯ Review plan for scheduled cesarean birth at 38 weeks for maternal viral load of more than 1,000 copies/mL. ◯◯ Infant should be bathed after birth before remaining with the mother.

danger signs during pregnancy

◯◯ The following indicate potential dangerous situations that should be reported to the provider immediately. ■■ Gush of fluid from the vagina (rupture of amniotic fluid) prior to 37 weeks of gestation ■■ Vaginal bleeding (placental problems such as abruption or previa) ■■ Abdominal pain (premature labor, abruptio placentae, or ectopic pregnancy) ■■ Changes in fetal activity (decreased fetal movement may indicate fetal distress) ■■ Persistent vomiting (hyperemesis gravidarum) ■■ Severe headaches (gestational hypertension) ■■ Elevated temperature (infection) ■■ Dysuria (urinary tract infection) ■■ Blurred vision (gestational hypertension) ■■ Edema of face and hands (gestational hypertension) ■■ Epigastric pain (gestational hypertension) ■■ Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, and headache (hyperglycemia) ■■ Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and lightheadedness (hypoglycemia)

second trimester

☐☐ Benefits of breastfeeding ☐☐ Common discomforts and relief measures ☐☐ Lifestyle: sex and pregnancy, rest and relaxation, posture, body mechanics, clothing, and seat belt safety and travel ☐☐ Fetal movement ☐☐ Complications (preterm labor, gestational hypertension, gestational diabetes mellitus, premature rupture of membranes) ☐☐ Preparation for childbirth and childbirth education classes ☐☐ Review of birthing methods ☐☐ Development of a birth plan (verbal or written agreement about what client wishes during labor and delivery)

third trimester

☐☐ Childbirth preparation XX Childbirth classes or birth plan. XX Breathing and relaxation techniques XX Use of effleurage and counterpressure XX Application of heat/cold, touch and massage, and water therapy XX Use of transcutaneous electrical nerve stimulation (TENS) XX Acupressure and acupuncture XX Music and aromatherapy XX Discussion regarding pain management during labor and birth (natural childbirth, epidural) XX Signs and symptoms of preterm labor and labor XX Labor process XX Infant care XX Postpartum care ☐☐ Fetal movement/kick counts to ascertain fetal well-being. A client should be instructed to count and record fetal movements or kicks daily. XX Mothers should count fetal activity two or three times a day for 60 min each time. Fetal movements of less than 3 per hr or movements that cease entirely for 12 hr indicate a need for further evaluation. ☐☐ Diagnostic testing for fetal well-being (nonstress test, biophysical profile, ultrasound, and contraction stress test).

first trimester

☐☐ Physical and psychosocial changes ☐☐ Common discomforts of pregnancy and measures to provide relief ☐☐ Lifestyle: exercise, stress, nutrition, sexual health, dental care, over-the-counter and prescription medications, tobacco, alcohol, substance use, and STIs (encourage safe sexual practices) ☐☐ Possible complications and signs to report (preterm labor) ☐☐ Fetal growth and development ☐☐ Prenatal exercise ☐☐ Expected laboratory testing