Pregnancy, Pregnancy, Pregnancy

A pregnant patient asks why she must take calcium during pregnancy. The nurse practitioner replies that:

it will strengthen the bones and teeth in your fetus Calcium supplementation during pregnancy is for the fetus, not the pregnant mother. Calcium supplementation will provide extra calcium that is needed during fetal development. It is hypothesized that adequate amounts of calcium will reduce the risk of pregnancy-induced hypertension. Generally, 1000 mg daily is recommended.

Serotonin syndrome:

results from taking SSRI and dextromethorphan, a triptan, an intentional OD, or high dose SSRI in a sensitive patient. This causes too much adrenergic activity in the CNS, s/s hyperreflexia, clonus, LE rigidity, tachycardia, hyperthermia, HTN.

During pregnancy, as the skin over the abdomen stretches to accommodate the fetus, this purplish mark may appear. This finding is:

striae gravidarum. Abdomen stretches to accommadate, stretch marks appear. Linea nigra vertical browninsh stripe along midline.

Naegele's rule is calculated by adding 7 days to the last menstrual period and:

subtracting 3 months Naegele's rule is an accepted means of predicting gestational age of the fetus. This is based on an average length of pregnancy of 280 days. If the maternal history is not reliable, ultrasound becomes the standard.

A pregnant teenager asks if sexual activity is safe during pregnancy. The nurse practitioner responds:

this can expose you to STDs. It may also precipitate pre term labor. In the absence of risk, it is not contraindicated

Classic symptoms of an ectopic pregnancy are?

amenorrhea, vaginal bleeding, abdominal pain. usually appear 6-8 weeks after LMP. Shoulder pain may be present after the tube has ruptured.

Routine screening for gestational diabetes takes place:

at about 24-28 weeks

Routine screening for gestational diabetes:

at about 24-28 weeks The routine time for screening is at 24-28 weeks. This has been identified as the ideal time because she is more likely to exhibit elevations in glucose at 24-28 weeks due to placental hormones that increase insulin insensitivity. This is also a good time to initiate interventions that will decrease complications in the fetus associated with glucose elevations. If the pregnant patient has risk factors or symptoms of diabetes, she can be screened earlier in pregnancy, routinely at 24-28 weeks, and later if warranted.

A pregnant patient in her second trimester will probably have a decrease in her:

blood pressure A decrease in blood pressure is commonly observed in pregnant women in their second trimester. This is part of the normal cardiovascular changes that take place during pregnancy. In fact, sometimes pregnant women can become symptomatic if their blood pressure drops below 80 or 90 mm Hg systolic.

A pregnant patient is found to have positive leukocytes and positive nitrites in her urine. What medication should be given?

Nitrofurantoin

n order to establish pregnancy, a pregnancy test of the urine or blood is routinely performed. How early can this be done with reliable results?

1-2 weeks after conception.

When do clinical manifestation of ectopic pregnancy appear?

6-8 weeks after LMP

D. This patient has a contaminated specimen

A 19yo pregnant female has the following UA report. Which statement is true? (+ bacteria, - WBCs, - nitrites, + epithelial cells) A. E. coli is the most likely pathogen B. This patient has chlamydia C. This patient has a UTI D. This patient has a contaminated specimen

You have been asked to manage thyroid disease in a pregnant patient. A pregnant patient took L-thyroxin prior to becoming pregnant. What should be done about the L-thyroxin now that she is pregnant?

Continue L thyroxin and have monthly TSH levels. During pregnancy the thyroid need increases. If level drops, fetus development can be severly affected.

A pregnant patient is in her first trimester in October. How should flu immunization be handled?

Give the immunization without regard to trimester.

The classic presentation of placenta previa is:

Painless vaginal bleeding after the 20th week.

Weight gain should be monitored during pregnancy. For a pregnant woman whose BMI is = 30, the total weight gain should be:

11-20 pounds. The pregnant woman who has a BMI of <18.5, should gain 28 - 40 pounds; BMI 18.5-24.9 should gain 25 - 35 pounds; BMI 25-29.9 should gain 15 - 25 pounds; and the obese pregnant woman should gain 11 - 20 pounds.

A patient has a positive pregnancy test that she performed from an over the counter kit. It has been 6 weeks since her last menstrual period. What are the chances that she is pregnant?

>90% The over the counter urine pregnancy kits have very high sensitivity and specificity. Consequently, their results can be trusted. A positive urine tests will correlate with the serum results. The tests identify hCG in the specimen.

A. 1 month They have advised to wait for 23 days, but there has been no documented injury to the offspring if accidentally received while pregnant. It is excreeted in breast milk, but is still safe while lactating.

A female who is being counseled preconceptually is found to have a negative rubella titer. If she is immunized today, for how long should she avoid pregnancy? A. 1 month B. 3 months C. 6 months D. 12 months

B. Yes, the immunization offers no risk to her infant

A mother has a negative rubella titer. She is not pregnant but is breastfeeding her 4-month-old infant. Is the mother able to safety receive the MMR immunization today? A. No, her infant is too young for her to receive the MMR B. Yes, the immunization offers no risk to her infant C. No, she will shed rubella virus in her breastmilk D. Yes, the immunization at this time will confer protection to her infant.

D. Almost none OTC kids have a high sensitivity and specificity.

A patient has a positive pregnancy test that she performed using an OTC kit. What are the chances that a serum pregnancy test will be negative? A. About 25% B. About 10% C. About 50% D. Almost none

A. Not take place

A patient has type 2 diabetes. Screening for gestational diabetes should: A. Not take place B. Take place 16-20 weeks C. Take place 24-28 weeks D. Anytime after the first trimester

A pregnant patient in her second trimester will probably have a decrease in her:

Blood pressure. A decrease in blood pressure is commonly observed in pregnant women in their second trimester. This is part of the normal cardiovascular changes that take place during pregnancy. In fact, sometimes pregnant women can become symptomatic if their blood pressure drops below 80 or 90 mm Hg systolic.

What is the Chadwick's sign?

Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick's sign. Hegar's sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix.

Rust colored sputum is associated with pna caused by _______________

Strep pneumonaie.

The need for thyroid replacement during pregnancy:

increases Thyroid hormone needs in pregnant patients with a history of hypothyroidism increase during pregnancy. This occurs in nearly 80% of pregnant hypothyroid women. Since low circulating thyroid hormone can drastically affect growth, TSH levels should be monitored frequently. Needs can increase by up to 50%.

A. She should be treated now and rescreened later in pregnancy. Treat with azithromycin 1 gm po x 1 and ceftriaxone 250 mg IM x 1. Since the percentage of patients who become reinfected with an STD later in pregnancy (even after being treated and educated) is great, this patient should be rescreened later in pregnancy regardless of whether symptoms emerge. Deleterious effects can occur if she is infected and left untreated.

A patient in her first trimester of pregnancy is found to be infected with chlamydia and gonorrhea. Which statement below is true? A. She should be treated now and rescreened later in pregnancy. B. She should be treated in the second trimester C. She should be screened for other STDs later in pregnancy D. She should be treated now and rescreened in symptoms reappear

D. This may increase the risk of preterm labor. This can occur b/c the lower uterine segment may be physically stimulated. Additionally, oxytocin is released, which may precipitate preterm labor. However, in the absence of complications associated with the pregnancy, sexual activity is not contraindicated. If vaginal discharge or bleeding occurs, or rupture of membranes occurs, sexual intercourse should be avoided until assessed by the patient's provider.

A pregnant patient asks if engaging in sexual activity will place her fetus at increased risk. The nurse practitioner responds: A. There is absolutely no increased risk to the fetus. B. There is a slight cardiovascular risk to the fetus C. This may stimulate labor and so should be avoided. D. This may increase the risk of preterm labor.

A. Order urine culture and begin antibiotics The positive findings with the patient complaints are consistent with a UTI. Empiric antibiotic therapy should be initiated and a urine culture should be ordered. Pregnant females are at high risk of developing pyelonephritis if a UTI is left untreated or undertreated.

A pregnant patient complains of urinary frequency and dysuria. A urinalysis was obtained. What course of action is most appropriate? (+ nitrites, + bacteria, + leukocyte esterase) A. Order urine culture and begin antibiotics B. Repeat the UA C. Prescribe an antibiotic only D. Order urine culture only

A. Treat with azithromycin Azithromycin 1 GM. This patient should be screened for other STIs now, and all before delivery.

A pregnant patient in her first trimester is found to have chlamydia. How should this be managed? A. Treat with azithromycin B. Treat with ceftriaxone by injection C. Treat with doxycycline D. Do not treat in the first trimester

A pregnant patient is likely to have:

S3 and venous hum murmor. Many changes occur in the cardiovascular system when patients are pregnant. Nearly all pregnant women have a venous hum murmur. A higher basal heart rate, louder heart sounds and a systolic ejection murmur. An S3 is commonly present probably related to increased fluid. An S4 is rarely heard. Mitral stenosis and aortic regurgitation are diastolic murmurs and these are abnormal in pregnant patients.

A 17 year-old female is found to be pregnant. What is the LEAST likely risk to her fetus?

Down Syndrome. Routine prenatal screening is important for all pregnant women. Based on her age and the likelihood of multiple partners, she should be screened for STDs to include HIV and hepatitis B and C and chlamydia. Down syndrome is more likely in older pregnant women. Toxoplasmosis is contracted after exposure to feces of cats and undercooked meats.

A pregnant patient with urinary frequency is found to have a UTI. What drug is safest to treat this?

Doxy, Amox, Cipro, or Nitrofurantoin. Nitrofurantoin. nitrofurantoin is the safest and most efficacious medication listed. Amoxicillin is as safe as nitrofurantoin but has a lower efficacy against typical urinary tract pathogens. Doxycycline is associated with fetal tooth discoloration and so it should be avoided. Ciprofloxacin is not recommended during pregnancy due to potential problems with bone and cartilage formation.

Hypertension that occurs after 20 weeks gestation in the absence of proteinuria is:

Gestational hypertension refers to elevated blood pressure detected after 20 weeks gestation in the absence of proteinuria. Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage.

A. Is recommended by many learned authorities The CDC and ACOG recommend an "opt-out" approach meaning that it is routinely performed unless the patient opts out.

HIV screening during pregnancy: A. Is recommended by many learned authorities B. Is an "opt-in" approach C. Is better performed in the third trimester D. Produces many false positives

During pregnancy, which hormone is produced by the placenta and supports progesterone synthesis in the corpus luteum?

Human chorionic gonadotropin (HCG) is produced by the placenta and supports progesterone synthesis in the corpus luteum, effectively preventing the early embryo from being lost to menstruation. Next

B. Persistent, intractable vomiting during pregnancy A common definition used to define HEG is persistent vomiting that produces a weight loss exceeding 5% of prepregnancy body weight. The etiology of HEG is unknown.

Hyperemesis gravidarum is: A. Morning sickness B. Persistent, intractable vomiting during pregnancy C. Always occurs with hydatiform mole D. Indicative of multiple gestation

C. FHT are audible at about 9-12 weeks Doppler can be used at 9-12 weeks. Transvaginal ultrasound can identify movement of the heart at 5-6 weeks.

In a viable pregnancy: A. FHT can be heard at 4-6 weeks B. Heart rates can exceed 240 bpm C. FHT are audible at about 9-12 weeks D. The fetus begins to respire at 6-8 weeks

Is TSH screening done routinely in pregnancy?

NO, only in hypothyroidism is present, or another disease is present like gestational diabetes that is associatied with hypothyroidism.

Classic presentation of placenta previa is?

Painless vaginal bleeding after the 20th week. Bleeding is likely at this time because the lower uterine segment develops and uterine contractions occur. At this time, the cervix dilates and effaces. The placenta can become detached and bleeding can occur. In women who are identified to have placenta previa, coitus and vaginal exam are contraindicated because both can cause separation and further bleeding.

A patient that you are caring for in your clinic has Medicare Part B. What does this mean?

Part B pays the examiner (NP, PA, MD, etc.). Part B of Medicare pays for outpatient care, ambulatory surgery services, x-rays, durable medical equipment, laboratory, and home health. Part B is an option that Medicare recipients can pay for with a monthly option. This charge is based on income. Since there is an initial co-pay, the federal government's insurance plan may NOT pay for his visit to your clinic today.

C. Takes place at about 24-28 weeks This is the ideal time b/c the patient is more likely to exhibit elevations in glucose at 24-28 weeks due to placental hormones that increase insulin sensitivity. This is also a good time to initiate interventions that will decrease complications in the fetus associated with glucose elevations. If the patient has risk factors, she can be screened early.

Routine screening for gestational diabetes: A. Takes place only if the mother is symptomatic B. Takes place at about 16-20 weeks C. Takes place at about 24-28 weeks D. Takes place routinely in each trimester

A 17 year-old female is found to be pregnant. What is the most important part of her initial screening?

STDs and HIV Routine prenatal screening is important for all pregnant women. As a sexually active adolescent, she is at high risk for STDs and should be screened. These screenings include the most common STDs as well as HIV, hepatitis B and C. Hepatitis A is not transmitted to the fetus. Iron deficiency anemia is very common but is easy to correct. Toxoplasmosis is contracted after exposure to feces of cats and undercooked meats.

A patient was diagnosed today with pregnancy. Her last pregnancy was 3 years ago. At that time she had a protective rubella titer. What should be done about evaluating a rubella titer today?

She does not need one because it was protective 3 years ago Standard practice across the United States is to insure that a protective rubella titer exists in women who are pregnant now. If a pregnant patient had a protective rubella titer in a previous pregnancy, re-evaluation is not necessary. A protective titer is usually 1:10 or greater. If she was found at any time during pregnancy to have a negative rubella titer, she should be vaccinated AFTER delivery.

A patient was diagnosed today with pregnancy. Her last pregnancy was 3 years ago. At that time she had a protective rubella titer. What should be done about evaluating a rubella titer today?

She does not need one, given 3 yrs. ago. Standard practice across the United States is to insure that a protective rubella titer exists in women who are pregnant now. If a pregnant patient had a protective rubella titer in a previous pregnancy, re-evaluation is not necessary. A protective titer is usually 1:10 or greater. If she was found at any time during pregnancy to have a negative rubella titer, she should be vaccinated AFTER delivery

B. Abuse can worsen during pregnancy The incidence of abuse during pregnancy ranges between 7-20% and is higher when pregnancies are unplanned. This percentage is higher than gestational diabetes or pre-eclampsia. Screening is routinely performed for these two conditions. Domestic violence often begins during pregnancy and can accelerate when it has existed prior to pregnancy. Therefore, it is important to screen. Unfortunately, this is not reportable in all 50 states.

The NP suggests that a pregnant patient may have been physically abused by a domestic partner. The NP knows that: A. Abuse often ends in homicide by the abuser B. Abuse can worsen during pregnancy C. This is reportable in all 50 states D. This will usually end when the pregnancy ends

Pt with environmental allergies presents. She takes an oral antihistamine q24h. What is the single most effective maintenance medication for allergic rhinitis?

These agents are particularly effective in the treatment of nasal congestion and would be a good choice for the patient in this scenario. Intranasal glucocorticoids are effective in relieving nasal congestion, discharge, itching, and sneezing. A trial of stopping the oral antihistamine could be tried in this patient. Symptoms would determine whether the antihistamine should be resumed. Next

Few pregnant patients actually deliver on their due dates. Why is a due date established?

To determine timing of maternal/fetal screenings Accurate dating is critical so that maternal and fetal screening tests may be done at the most appropriate time. If a screening test is supposed to take place at 20 weeks, and it is done too early, the opportunity to identify an abnormality may be missed. In the U.S., if a last menstrual period (LMP) cannot be established, or a woman becomes pregnant while taking contraceptives, an ultrasound should be performed.

A patient in her first trimester of pregnancy is found to be infected with chlamydia and gonorrhea.

Treat now and re screened later in pregnancy.

B. Inactive influenza Live and attenuated immunizations should not be given during pregnancy. The CDC recommends pneumococcal, hepatitis A, and hepatitis B vaccines during pregnancy only if a risk factor is present; otherwise, these should be delayed until after pregnancy.

Which of the following immunizations may be safely administered during the first trimester of pregnancy? A. MMR and hepatitis B B. Inactive influenza C. Pneumococcal and varicella D. Hepatitis A and varicella

A female who is being counseled preconceptually is found to have a negative rubella titer. If she is immunized today, for how long should she avoid pregnancy?

Women of childbearing age should be advised to avoid pregnancy for 28 days after immunization with MMR. The vaccine is safe for women who are breastfeeding even though the rubella virus is excreted in breast milk. It is safe for young children of pregnant mothers to be immunized with MMR because infection is not transmitted from immunized individuals.

B. She should continue it and have monthly TSH levels During pregnancy, thyroid hormone needs increase, so she will need frequent monitoring. If levels drop to a hypothyroid state, neurologic growth of the fetus can be severely affected.

You have been asked to manage thyroid disease in a pregnant patient. A pregnant patient took levothyroxine prior to becoming pregnant. What should be done about the levothyroxine now that she is pregnant? A. It should be discontinued during pregnancy B. She should continue it and have monthly TSH levels C. She should be switched to a supplement that is safe during pregnancy D. She can continue the same dose during pregnancy without concern

Persistent, intractable vomiting during pregnancy is:

hyperemesis gravidarum Hyperemesis gravidarum (HEG) is a severe form of nausea and vomiting which occurs during pregnancy. In contrast, morning sickness is significantly milder. A common definition used to define HEG is persistent vomiting which produces a weight loss exceeding 5% of pre-pregnancy body weight. The etiology of morning sickness and HEG is unknown.

Ultrasounds are commonly performed during the first trimester of pregnancy because they help estimate gestational age and:

identify fetal malformations Ultrasounds are excellent tools in the first trimester of pregnancy because they can help identify fetal malformations. They are helpful in detecting multiple fetuses, status of the placenta, and help assess gestational age. While it may be argued that ultrasound use improves outcomes in the fetus or mother, this is not why they are commonly performed during the first trimester. There is no evidence that performing an ultrasound early in pregnancy eliminates or reduces the need for ultrasounds later in pregnancy.

Descritpition of acute cholecystitis patient is:

ill appearing and febrile, RUQ or epigastric pain. +nausea. May lie still on exam table. Elderly folks more likely to NOT exhibit murphys sign.

What immunizations may be safely given during first trimester?

inactive. Tdap and inactive influenza. No live or attenuated immunizations should not be given during pregnancy.

The most effective way to decrease the incidence of neural tube defects in pregnant patients is to:

increase folic acid Folic acid has been found to drastically decrease the incidence of neural tube defects (NTD). Folate plays an essential role in synthesis of amino acids and DNA. Since these are critical in cell division and adequate amounts should be on board when cell division begins, folic acid should be taken pre-conceptually. Since this is the second most common congenital anomaly, folic acid should be initiated pre-conceptually.

The rubella vaccine is contraindicated in pregnant women because:

it can cause rubella in the infant The rubella vaccine is contraindicated in pregnant patients because it crosses the placenta. Pregnant women should be advised to avoid pregnancy for 28 days after immunization with MMR. It should not be given during pregnancy. However, CDC has collected data on women who have accidentally received the immunization while pregnant and there has been no documented injury to the offspring. The vaccine is safe for women who are breastfeeding even though the rubella virus is excreted in breast milk.

In order to establish pregnancy, a pregnancy test of the urine or blood is routinely performed. This test assesses for:

presence of beta hCG Whether performed on urine or blood, the presence of the beta subunit of human chorionic gonadotropin (hCG) indicates pregnancy. This can be found in detectable quantities in the first morning urine or at any time in a serum sample from a pregnant woman. Both tests are highly sensitive. However, if the pregnancy is very early and first morning urine is NOT used, the urine test could be negative in a pregnant patient. A serum specimen will indicate pregnancy at any time of day if it is present. Quantifying the beta hCG level is not necessarily used to diagnose pregnancy, but may be used to determine whether a pregnancy is progressing as expected since beta hCG levels are predictable during pregnancy.

A pregnant patient complains of lower extremity edema and asks for a "fluid pill". The NP explains that:

this is best treated with rest and elevation of the legs It is very common during pregnancy to have lower extremity edema. While this should be monitored to make certain that other more serious conditions are not occurring (pre-eclampsia, heart failure, etc.), this is best treated with rest and elevation of the legs. Lower extremity edema is no longer considered a criterion for pre-eclampsia.

A pregnant patient asks if engaging in sexual activity will place her fetus at increased risk. The nurse practitioner responds:

this may increase the risk of pre-term labor Sexual activity during pregnancy could precipitate pre-term labor because the lower uterine segment may be physically stimulated. Additionally, oxytocin is released which may precipitate pre-term labor. However, in the absence of complications associated with the pregnancy, sexual activity is not contraindicated. If vaginal discharge or bleeding occurs; or rupture of membranes occurs, sexual intercourse should be avoided until assessed by the patient's provider.

A pregnant patient is 30 weeks gestation. She wants to travel to a higher elevation in order to go on a hiking trip. She will fly in an airplane. The nurse practitioner knows:

traveling to a city of high altitude can precipitate pre-term labor There is no risk for the pregnant patient (prior to 35-36 weeks) who is traveling in an airplane with a pressurized cabin. Travel to a city of moderate or high altitude may impose the risk of pre-term labor and bleeding complications. She may be allowed to hike at higher elevations but she should be apprised of the potential risks to her and the fetus. These include dehydration, shortness of breath, tachycardia, pre-term labor, and increased risk of bleeding complications. Practically speaking, serious trauma could occur if she falls. Her balance may be compromised at 30 weeks and falling might be likely. In any event, she should have adequate time to acclimate at this higher elevation before engaging in physical activities like hiking.