Reproductive & Sexual Health/Nursing Care for the Family in Need of Reproductive Life Learning

Assessing and Meeting Reproductive Concerns An assessment in the area of reproductive health begins with interviewing to determine a patient's knowledge level of the reproductive process, STIs, concerns about his or her reproductive functioning, or safer sex practices (Box 5.2) This area of health interviewing takes practice, and the conviction that exploring sexual health is as important as exploring less emotionally involved areas of health, such as dietary intake or activity level. The 14-year-old girl, who is not yet menstruating, for instance, may be anxious about that fact but may be reluctant to say so unless asked directly. A statement such as the following invites discussion:

"Although many of your friends at school may be menstruating, it's not at all uncommon for some girls not to begin their periods until age 15 or 16 years. How do you feel about not yet having your period?" This combination of providing information and while interviewing may encourage an adolescent to discuss not only her possible concern about delayed menarche (the beginning of menstruation) but also other areas that will reveal her knowledge or lack of knowledge about reproductive health

The round ligaments are two fibrous, muscular cords that pass from the body of the uterus through the broad ligaments and down into the inguinal canal, inserting into the fascia of the vulva. The round ligaments act as additional

"stays" to further steady the uterus. If a pregnant woman moves quickly, she may pull one of these ligaments, causing a quick, sharp pain of frightening intensity in one of her lower abdominal quadrants. Pain of this type calls for conscientious assessment or it can be mistaken for labor or appendicitis pain.

Assessment for Contraception Options and Possible Contraindications As many as 93% of women of childbearing age in the United States use some form of contraception . Major benefits of this increase in contraception include

- decreases in unintended adolescent pregnancies, the need for "morning after" or postcoital medications, and elective terminations of pregnancy

Four types are commonly approved for use in the United States, but that number is increasing as companies expand their product line and other companies create generic versions:

-Copper T380 (ParaGard) -Levonorgestrel-releasing intrauterine system (Mirena or Liletta) -Levonorgestrel-releasing intrauterine system 13.5 mg (Skyla) -Levonorgestrel-releasing intrauterine system 19.5 mg (Kyleena)

Important things to consider when helping a couple choose a method -contraceptive that will be right for them include:

-Personal values -Ability to use a method correctly -If the method will affect sexual enjoyment -Financial factors -If a couple's relationship is short term or long term -Prior experiences with contraception -Future plans

To prevent TSS )while using a diaphragm or cervical cap (discussed in the following), advise women to:

1. Wash their hands thoroughly with soap and water before insertion or removal. 2. Do not use a diaphragm during a menstrual period. 3. Do not leave a diaphragm in place longer than 24 hours. 4. Be aware of the symptoms of TSS, such as elevated temperature, diarrhea, vomiting, muscle aches, and a sunburn-like rash. 5. If symptoms of TSS should occur, immediately remove the diaphragm and telephone a healthcare provider.

Reproductive development begins at the moment of conception and continues through life. What are the two types ?

1.INTRAUTERINE DEVELOPMENT 2.PUBERTAL DEVELOPMENT

THE SEXUAL RESPONSE CYCLE four discrete stages:

1.excitement, 2.plateau, 3.orgasm, 4.resolution. Whether stages are felt as separate steps this way or blended into one smooth process of desire, arousal, and orgasm is individualized.

The average age at which menarche (the first menstrual period) occurs is

12.4 years of age . It may occur as early as age 9 years or as late as age 17 years, however, and still be within a normal age range. Irregular menstrual periods are the rule rather than the exception for the first year or two. Menstrual periods do not become regular until ovulation occurs consistently, and this does not tend to happen until 1 to 2 years after menarche -The production of ova stops at menopause

The length of menstrual cycles differs from woman to woman, but the average length is

28 days (from the beginning of one menstrual flow to the beginning of the next). It is not unusual for cycles to be as short as 23 days or as long as 35 days.

The length of the average menstrual flow (termed menses) is

4 to 6 days -Because there is such variation in length, frequency, and amount of menstrual flow and also in the onset of menarche, many women have questions about what is considered normal. -Contact with healthcare personnel during a routine health examination or prenatal visit may be their first opportunity to ask questions they have had for some time.

Diaphragms should remain in place for at least

6 hours after coitus because spermatozoa remain viable in the vagina for that length of time; they may be left in place for as long as 24 hours. Leaving them in place longer than this can cause cervical inflammation (erosion) or urethral irritation from the pressure against the vaginal walls.

OUTCOME IDENTIFICATION AND PLANNING

A major part of nursing care in this area is to empower patients to feel control over their bodies. Plan health teaching to provide patients with knowledge about their reproductive system and specific information about ways to alleviate discomfort or prevent reproductive disease. It is also essential to design care that demonstrates acceptance of all sexual orientations and gender identities equally.

MENSTRUATION What is the menstrual cycle and its purpose or function ?

A menstrual cycle (the female reproductive cycle) is episodic uterine bleeding in response to cyclic hormonal change Purpose: -is to bring an ovum to maturity and renew a uterine tissue bed that will be necessary for the ova's growth should it be fertilized.

VAGINAL ESTROGEN/PROGESTIN RINGS (NuvaRing) -An etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) is a flexible silicone vaginal ring that, when placed in the vagina, continually releases a combination of estrogen and progesterone

Advantage: -left in place for 3 weeks and then removed for 1 week with menstrual bleeding occurring during the ring-free week -The hormones released are absorbed directly by the mucous membrane of the vagina, thereby avoiding a "first pass" through the liver, as happens with COCs; this is an advantage for women with liver disease. Rings do not need to be removed for intercourse. The effectiveness is equal to COCs. Disadvantage: vaginal discomfort or infection, both of which would make the ring an undesirable method of contraception. Side Effect:vaginal discomfort or infection

The Second Phase of the Menstrual Cycle (Secretory)

After ovulation, the formation of progesterone in the corpus luteum (under the direction of LH) causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen (an elementary sugar) and mucin (a protein). It takes on the appearance of rich, spongy velvet. This second phase of the menstrual cycle is termed the progestational, luteal, premenstrual, or secretory phase.

INTRAUTERINE DEVICES AND THE POSTPARTAL WOMAN

Although postpartum insertion of an IUD is usually done at a 6-week postpartal checkup, it can be done immediately after childbirth (also immediately after a spontaneous or induced abortion or at the time of a cesarean birth . An IUD inserted immediately this way does not affect uterine involution or the uterus's return to its prepregnant uterine size, but it is associated with a higher rate of expulsion. Yet another time for the copper IUD insertion is after unprotected sex as postcoital protection

A patient asks you if it will be all right to continue sexual relations during her pregnancy. Which of the following would be the best advice? A) Sexual relations can be continued safely during a normal pregnancy. B) Sexual relations are dangerous during pregnancy after 3 months. C) Sexual relations are dangerous for the first 2 months. D) Sexual relations can continue, but she must use a diaphragm.

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 97 Feedback: Continuing sexual relations is not detrimental to a pregnancy that has no complications.

When teaching an adolescent about ovulation, the nurse would include that ovulation is initiated by a surge in which hormone? A) luteinizing hormone B) progesterone C) follicle-stimulating hormone D) estrogen

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 81 Feedback: Luteinizing hormone is released from the pituitary gland to stimulate ovulation on approximately the 14th day of a typical cycle.

The term gender role refers to: A) a person's chromosomal inheritance. B) the gender a woman sees herself as being. C) a woman's sexual identity. D) demonstrated sexual behaviors.

Ans: D Client Needs: Psychosocial Integrity Cognitive Level: Understand Page: 78 Feedback: Gender role refers to the actions people take, not necessarily how they feel about themselves.

The Spinnbarkeit Test

At the height of estrogen secretion, yet another property of cervical mucus is the ability to stretch into long strands, a contrast to its thick, viscous state when progesterone is the dominant hormone. That means performing this test, known as spinnbarkeit, at the midpoint of a menstrual cycle is another way to demonstrate high levels of estrogen are being produced and, by implication, ovulation is about to occur. A woman can do this herself by stretching a mucus sample between thumb and finger, or it can be tested in an examining room by smearing a cervical mucus specimen on a slide and stretching the mucus between the slide and cover slip

Beginning (menarche)

Average age at onset, 12.4 years; average range, 9-17 years

Duration of menstrual flow

Average flow, 4-6 days; ranges of 2-9 days not abnormal

Interval between cycles

Average, 28 days; cycles of 23-35 days not unusual

Which of the following statements best defines sexual identity? A.The chosen activities a person uses to express masculinity or femininity B.The male or female characteristics determined by genetic factors C.The feeling of being male or female D.The male or female characteristics encouraged by the culture

C.The feeling of being male or female

Nursing Care Planning Based on Responsibility for Pharmacology DEPOT MEDROXYPROGESTERONE ACETATE

Classification: Contraceptive Action: Depot medroxyprogesterone acetate (DMPA) is a progesterone derivative that inhibits the secretion of pituitary gonadotropins, thereby altering the endometrium and preventing follicular maturation and ovulation . Pregnancy Category: X Dosage: 150 mg intramuscular injection every 3 months Possible Adverse Effects: Spotting, breakthrough bleeding, amenorrhea, irregular menstrual flow, headaches, weight fluctuations, fluid retention, edema, rash or acne, abdominal discomfort, glucose intolerance, pain at injection site, or osteoporosis (loss of bone density). Nursing Implications • Advise patient to have a routine physical examination that includes breast examination, pelvic examination, and Pap smear. • Caution the patient that potential side effects such as weight gain may occur. • Advise patient to maintain a high calcium intake to reduce development osteoporosis. • Advise the patient to report pain or swelling of the legs, acute chest pain, or shortness of breath; tingling or numbness in the extremities; loss of vision; sudden

Another medical regimen is methotrexate (Trexall) and misoprostol (Cytotec). Methotrexate (also used to end ectopic pregnancies or trophoblastic disease interferes with the : A mifepristone/misoprostol regimen is about 96% effective; methotrexate/misoprostol is slightly lower

DNA synthesis of dividing cells and so prevents growth of the zygote. Advantage: prevents growth of the zygote.

Color of menstrual flow

Dark red; a combination of blood, mucus, and endometrial cells

Amount of menstrual flow

Difficult to estimate; average 30-80 ml per menstrual period; saturating a pad or tampon in less than 1 hr is heavy bleeding

THE INFLUENCE OF THE MENSTRUAL CYCLE ON SEXUAL RESPONSE

During the second half of the menstrual cycle—the luteal phase—there is increased fluid retention and vasocongestion in the woman's lower pelvis. Because some vasocongestion is already present at the beginning of the excitement stage of the sexual response, women appear to reach the plateau stage more quickly and achieve orgasm more readily during this time. Women also may be more interested in initiating sexual relations during this time

The school nurse conducts a sports physical examination on a 14-year-old gymnast, who voices a concern that she has not begun menstruation, even though most of her friends have. Which is the best nursing action? Advise her to share her concerns with her family doctor because this certainly is an abnormal occurrence. Explain that because of her low body fat, it is not unusual for menstruation not to have begun yet. Report these findings immediately to her physician for further evaluation. Encourage the use of hormone supplements to promote puberty.

Explain that because of her low body fat, it is not unusual for menstruation not to have begun yet.

Oral Contraceptives and Effect on Sexual Enjoyment

For the most part, not having to worry about becoming pregnant because of the reliability of the contraceptive can make sexual relations more enjoyable for a couple. Some women appear to lose interest in coitus after taking COCs for about 18 months, possibly because of the long-term effect of altered hormones in their body. Some women experience nausea from COCs and find this interferes with sexual enjoyment as well as with other activities. If they are having side effects with one brand, they might be able to take another brand that has a different strength of estrogen without problems.

Levonorgestrel-releasing intrauterine system 13.5 mg (Skyla)

IUD, which is manufactured by the same company as Mirena, has a lower dose of progesterone in the stem. It works similarly to Mirena and is effective for 3 years. Women are more likely to have unscheduled bleeding with Skyla than with Mirena.

The First Phase of the Menstrual Cycle (Proliferative)

Immediately after a menstrual flow (which occurs during the first 4 or 5 days of a cycle), the endometrium, or lining of the uterus, is very thin, approximately one cell layer in depth. As the ovary begins to produce estrogen (in the follicular fluid, under the direction of the pituitary FSH), the endometrium begins to proliferate so rapidly the thickness of the endometrium increases as much as eightfold from day 5 to day 14. This first half of a menstrual cycle is interchangeably termed the proliferative, estrogenic, follicular, or postmenstrual phase

During a sports physical, a 17-year-old male adolescent asks the nurse when to begin testicular self-exams. Which is the most appropriate patient teaching? In adolescence In his early 20s In his early 30s In middle age

In adolescence

HORMONAL CONTRACEPTION AND THE POSTPARTAL WOMAN

It has been recommended that women who are lactating should not take estrogen-based contraceptives as a small amount of the hormone will not only be excreted in breast milk but will also reduce the amount of breast milk formed. Due to conflict in recent evidence about whether estrogen-based contraceptives affect milk supply, women who want hormonal contraception are, therefore, usually prescribed progestin-only pills, progesterone-activated vaginal rings, etonogestrel implant (Nexplanon), or IUDs until they are no longer breastfeeding

Many exercises suggested for pregnancy such as

Kegel exercises, squatting, and tailor sitting are aimed at making the perineal muscle as flexible as it can be to allow for optimal expansion during birth and to prevent tearing of this tissue.

Side Effects and Contraindications for Natural Family Planning

Natural family planning methods do not have side effects. If there is a contraindication to their use, it would be for couples who must prevent conception (perhaps because the woman is taking a drug that would be harmful to a fetus or the couple absolutely does not want the responsibility of children) because the failure rate of all forms is about 25%.

Locating the point at which this tissue changes from epithelium to mucous membrane (squamocolumnar junction) is important when obtaining a

Papanicolaou smear (a test for cervical cancer) because this tissue interface is most dynamic in cellular growth and is often the origin of cervical cancer

THE INFLUENCE OF PREGNANCY ON SEXUAL RESPONSE

Pregnancy is another time in life when there is vasocongestion of the lower pelvis because of the blood supply needed by a rapidly growing fetus. This causes some women to experience their first orgasm during their first pregnancy. Following a pregnancy, many women continue to experience increased sexual interest because the new growth of blood vessels during pregnancy lasts for some time and continues to facilitate pelvic vasocongestion. These differences in response are why discussing sexual relationships is an important part of health teaching during pregnancy

Why is the discussion of Reproductive and Sexual Health important?

Provide information about how to educate patients and their family about anatomy, physiology, and sexual health to better prepare them for childbearing and childrearing.

NURSING DIAGNOSIS Because reproductive life planning touches so many facets of life, nursing diagnoses can differ greatly depending on the circumstances and individual preferences. Examples might include:

Readiness for enhanced knowledge regarding contraception options related to a desire to prevent pregnancy Deficient knowledge related to use of a diaphragm Spiritual distress related to partner's preferences for contraception Decisional conflict regarding choice of birth control because of health concerns Decisional conflict related to unintended pregnancy Powerlessness related to failure of chosen contraceptive Altered sexuality pattern related to fear of pregnancy Risk for ineffective health maintenance related to lack of knowledge about natural family planning methods

Nursing Diagnosis: REPRODUCTIVE AND SEXUAL HEALTH Diagnoses relevant to sexual health may include:

Sexual dysfunction related to as yet unknown cause Altered sexuality patterns related to chronic illness Self-esteem disturbance related to recent reproductive tract surgery Altered sexuality patterns related to fear of harming a fetus Anxiety related to fear of contracting an STI Health-seeking behavior related to learning responsible sexual practices

Odor

Similar to marigolds

Uterine Nerve Supply Structure: Function:

Structure:The uterus is supplied by both efferent (motor) and afferent (sensory) nerves. The efferent nerves arise from the T5 through T10 spinal ganglia. The afferent nerves join the hypogastric plexus and enter the spinal column at T11 and T12. The fact that sensory innervation from the uterus registers lower in the spinal column than does motor control has implications for controlling pain in labor Function:has implications for controlling pain in labor. An anesthetic solution can be injected to stop the pain of uterine contractions at the T11 and T12 levels without stopping motor control or contractions (which are registered higher, at the T5 to T10 level). This is the principle of both epidural and spinal anesthesia

The Urethra Structure: Function:

Structure:a hollow tube leading from the base of the bladder, which, after passing through the prostate gland, continues to the outside through the shaft and glans of the penis. It is about 8 in. (18 to 20 cm) long. it is lined with mucous membrane. Function: tube that carries urine from the bladder to the outside of the body

Cervical Changes

The mucus of the uterine cervix also changes in structure and consistency each month during a menstrual cycle.

Male condoms Pt. teaching

To be effective, a condom must be applied before any penile-vulvar contact as even pre-ejaculation fluid may contain some sperm. The condom should be positioned so it is loose enough at the penis tip to collect the ejaculate without placing undue pressure on the condom. The penis (with the condom held carefully in place) must be withdrawn before it begins to become flaccid after ejaculation to prevent sperm from leaking from the now loosely fitting sheath into the vagina.

Goal of reproduction planning

To understand methods of contraception, family planning and health education of families

Barrier Methods and the Postpartal Woman

Vaginal spermicides are appealing to postpartal women as they can be purchased over the counter and have no effect on breastfeeding and so can be used in the short time period before a postpartal checkup when a more permanent form of contraception can be discussed and prescribed. As the cervix changes considerably with childbirth, women must be refitted for diaphragms and cervical caps after childbirth. This is usually done at a 4- or 6-week checkup.

Barrier Methods and the Perimenopausal Woman

Women older than 35 years have a higher incidence of cystocele or rectocele than younger women so diaphragms or cervical caps may not be the ideal contraceptive for them. Spermicide foam can help lubricate the vagina to increase sexual enjoyment in women nearing menopause. The use of vaginal film or suppository is not recommended as lessened vaginal secretions might prevent the film or suppository from dissolving completely.

Copper T380 (ParaGard)

a T-shaped plastic device wound with copper. It is effective for 10 years, after which time it should be removed and replaced with a new IUD.

INFORMATICS Dana, 17 years old, e-mails the nurse to ask how a tubal ligation prevents pregnancy. To be certain she's fully informed, which would be the nurse's best answer? a. Sperm can no longer reach the ova because fallopian tubes are blocked. b. Sperm cannot enter the uterus because the cervical entrance is blocked. c. Prostaglandins released from the cut fallopian tubes effectively kill sperm. d. The ovary no longer releases ova because there is nowhere for them to go.

a. Sperm can no longer reach the ova because fallopian tubes are blocked.

in females, androgenic hormones are produced by the

adrenal cortex and the ovaries. The level of the primary androgenic hormone, testosterone, In girls, testosterone influences enlargement of the -labia majora and clitoris and the -formation of axillary and pubic hair.

gonad is a body organ that produces the

cells necessary for reproduction (the ovary in females, the testis in males)

In nations which allow it, young girls approaching puberty may be circumcised or have their

clitoris removed with the labia minora excised as well. Aside from being a very painful procedure, female circumcision can lead to contractions and scarring of the vulva that make vaginal childbirth difficult because the vagina is unable to expand with birth

Use of an IUD may be contraindicated for a woman whose uterus is

distorted in shape (the device might perforate the uterine wall). The copper IUD use also is not advised for a woman with severe dysmenorrhea (painful menstruation) or menorrhagia (heavy bleeding) because use may increase the incidence of these conditions. Because use of a copper IUD can cause heavier than usual menstrual flow, a woman with anemia also may not be considered a good candidate for a copper IUD.

MALE INTERNAL STRUCTURES The male internal reproductive organs are the

epididymis, the vas deferens, seminal vesicles, the ejaculatory ducts, the prostate gland, the urethra, and the bulbourethral glands

Boys, especially those who are obese, may notice a temporary increase in breast size at puberty, termed

gynecomastia -If boys are not prepared that this is a normal change of puberty, they may be concerned that they are developing abnormally.

Hormonal Contraception

hormones that when taken orally, transdermally, intravaginally, or intramuscularly, cause such fluctuations in a normal menstrual cycle that ovulation or sperm transport does not occur.

The Male Reproductive System Andrology is the study of the

male reproductive organs. The male reproductive system consists of both external and internal divisions

If a pregnant woman should be prescribed a form of testosterone or, because of a metabolic abnormality, she produces a high level of testosterone, a chromosomal female could be born with

male-appearing genitalia

Women can analyze cervical mucus changes to help plan coitus so it coincides with ovulation if they want to increase their chance of becoming

pregnant or plan to avoid coitus at the time of ovulation to prevent pregnancy -During ovulation, the body of the cervix is softer and the os is slightly open compared with the rest of the cycle when it is firm and the os is closed as another indication of ovulation.

The myometrium also holds the internal cervical os closed during pregnancy to prevent a

preterm birth. After childbirth, the interlacing network of fibers is able to constrict the blood vessels coursing through the layers, thereby limiting the amount of blood loss. Myomas, or benign fibroid (leiomyoma) tumors that can interfere with conception or birth, arise from the myometrium

The broad ligaments are

two folds of peritoneum that cover the uterus in the front and back and extend to the pelvic sides to help steady the uterus.

Advise all women taking COCs to notify their healthcare provider if symptoms of myocardial or thromboembolic complications occur, such as:

• Chest pain (pulmonary embolus or myocardial infarction) • Shortness of breath (pulmonary embolus) • Severe headache (cerebrovascular accident) • Severe leg pain (thrombophlebitis) • Eye problems, such as blurred vision (hypertension, cerebrovascular accident)

Oral contraceptives have benefits in addition to preventing pregnancy, such as decreasing incidences of:

• Dysmenorrhea, because of lack of ovulation • Premenstrual dysphoric syndrome and acne because of the increased progesterone levels • Iron deficiency anemia because of the reduced amount of menstrual flow • Acute pelvic inflammatory disease (PID) and resulting tubal scarring • Endometrial and ovarian cancer, ovarian cysts, and ectopic pregnancies • Fibrocystic breast disease • Possibly osteoporosis, endometriosis, uterine myomata (fibroid uterine tumors), and possibly rheumatoid arthritis • Colon cancer

emergency contraception and how to use it within 120 hours of unprotected coitus. Reasons that elective terminations are most often requested are for a pregnancy that:

• Threatens a woman's life, such as pregnancy in a woman with class IV heart disease • Involves a fetus found on amniocentesis to have a chromosomal defect • Is unwanted because it is the result of rape or incest • Is unwanted because a woman chooses not to have a child at this time in her life for such reasons as being too young, not wanting to be a single parent, wanting no more children, having financial difficulties, or from failed contraception The majority of pregnancy terminations are done for this last reason.

Before a patient begins using a new method of contraception, information that should be obtained includes:

• Vital signs, possibly a Pap smear, pregnancy test, gonococcal and chlamydial screening, and perhaps hemoglobin for detection of anemia • Obstetric history, including STIs, past pregnancies, previous elective abortions, failure of previously used methods, and compliance history with previously used methods • Subjective assessment of the patient's desires, needs, feelings, and understanding of conception (a teen may believe she is too young to get pregnant; a woman in the immediate postpartum period may believe she cannot conceive immediately, especially if she is breastfeeding) • Sexual practices, such as frequency, number of partners, feelings about sex, and body image

Levonorgestrel 1.5 mg (Plan B One-Step and Next Choice) are available over the counter without a prescription by males or females. .

Advantage: are taken anytime within 72 hours (3 days) of unprotected coitus to interrupt a pregnancy.

Periodic abstinence

Advantage: avoid pregnancy by avoiding sex on the days a woman may conceive Disadvantage:Methods for determining the days when a woman could conceive are under "Fertility Awareness Methods." not always accurate Rx factors: pregnancy

A cervical cap is made of soft rubber shaped like a thimble, which fits snugly over the uterine cervix

Advantage: caps can be kept in place longer (up to 48 hours) because they do not put pressure on the vaginal walls or urethra. Disadvantage: The failure rate is estimated to be as high as 23% (ideal) to 35% (typical use) because caps tend to dislodge more readily than diaphragms during coitus -They may not be as effective in parous women as they are for those who have never had children because the cervix does not conform as well to a thimble shape after childbirth. Side Effect: UTI, TSS

An adolescent describes her menstrual pattern to you. Which of the following observations is typical of a usual menstrual pattern? A) Flow usually lasts 4 to 6 days. B) The usual cycle is 36 days. C) The average amount of flow is 500 mL. D) Menstruation typically begins at 18 years.

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 92 Feedback: The average menstrual flow is 4 to 6 days in length; the cycle is 28 days; the average flow is 25 to 60 mL. Average age of onset is 12 to 14 years.

You help take vaginal cultures on a woman at a prenatal visit. When inserting a culture applicator for this procedure, it would be important to slant the applicator: A) parallel with the bed surface. B) sharply downward. C) downward and backward. D) upward for 2 cm, then downward.

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 89 Feedback: The slant of the vagina in a supine body position is downward and backward.

The Maturation of Oocytes

Between 5 and 7 million ova form in utero. Most never develop beyond a primitive state and then atrophy, so by birth, only about 2 million are still present. By age 7 years, only about 500,000 are present in each ovary; by 22 years of age, the count is down to 300,000; and by menopause, or the end of the fertile period in females, none are left (all have either matured or atrophied)

Milk glands Structure: Function:

Structure: of the breasts are divided by connective tissue partitions into approximately 20 lobes Function: All of the glands in each lobe produce milk by acinar cells and deliver it to the nipple via a lactiferous duct.

the American Academy of Pediatrics (AAP) advises that the health benefits of male circumcision outweigh its medical risks; however, the benefits are not strong enough to recommend every male newborn be circumcised. The AAP advises that circumcision decisions should be made in ?

consultation with parents with consideration of their cultural or religious beliefs. Its advantages allow for lower rates of urinary tract infections, HIV, STIs, and penile cancer. Its disadvantages include surgical complications, such as bleeding and pain, and reduction of sensation with sexual stimulation

girls are beginning puberty at earlier ages than ever before (8 to 11 years of age) due to ?

obesity and nutrition.

The beginning of breast development is termed

thelarche, which usually starts 1 to 2 years before menstruation

Secondary sex characteristics of boys usually occur in the order of:

• Increase in weight • Growth of testes • Growth of face, axillary, and pubic hair • Voice changes • Penile growth • Increase in height • Spermatogenesis (production of sperm)

Barrier Methods and the Adolescent-Females

- Because of the nontraditional settings in which adolescents may engage in coitus (cars or couches), some young women find inserting the product awkward and consequently may not use it, even though they have purchased it and intended to be more cautious. -Adolescents may need to be reminded that pelvic examinations will be necessary to ensure the diaphragm or cap continues to fit properly. Some adolescents may not know where their cervix is or how to feel for it when checking the placement of a diaphragm. -Use an anatomic diagram or model to show them or give them a mirror to use to view their own cervix during a pelvic examination. Caution them not to accidentally tear the diaphragm with long or sharp fingernails.

To help patients better understand reproductive functioning and sexual health, specific teaching might include:

-Explaining to a school-age boy that nocturnal emissions are normal - Teaching an early adolescent about normal anatomy and physiology and the process of reproduction -Teaching a young adolescent safer sex practices -Explaining reproductive physiology to a couple who wish to become pregnant

Nursing Diagnosis: REPRODUCTIVE AND SEXUAL HEALTH -Common nursing diagnoses used with regard to reproductive health include:

-Health-seeking behaviors related to reproductive functioning -Anxiety related to inability to conceive after 6 months without contraception -Pain related to uterine cramping from menstruation -Disturbance in body image related to early development of secondary sex characteristics -Risk for infection related to high-risk sexual behaviors

Diaphragms should not be used in the presence of acute cervicitis, herpes virus infection, or a papillomavirus infection because the close contact of the rubber and the use of a spermicide can cause additional irritation. Other contraindications include:

-History of toxic shock syndrome (TSS; a staphylococcal infection introduced through the vagina) -Allergy to rubber or spermicides History of recurrent -UTIs

Reproductive Life Planning Includes all decisions an individual or a couple make about having children, including

-If and when to have children -How many children to have -The length of time between having children Counseling may include the topics of avoiding conception, increasing fertility, and/or what to do if contraception has failed.

Caution women with young children that tleaving pills in plain sight or on bathroom or kitchen counters is a potentially dangerous practice, why ?

-Poisoning with increased blood clotting from the high estrogen content could result if a small child ingested the pills accidentally (urge the woman to use her calendar or some other method to remind her)

Intentional pregnancies are important for the health of children because when a pregnancy is unintended or mistimed, both short-term and long-term consequences can result. The woman may be less likely or less careful to:

-Seek prenatal care -Breastfeed -Protect her fetus from harmful substance -A disproportionate share of women who bear children whose conception was unintended are adolescents; such women are less apt to complete high school or college and more likely to require public assistance and/or live in poverty than their peers who are not mothers. The child of such a pregnancy is at greater risk for low birth weight, dying in the first year of life, being maltreated, and not receiving sufficient resources for healthy development

Intrauterine Development

-Sex assigned at birth is generally determined at the moment of conception by chromosome information, which is supplied by the sperm that joins with the ovum to create the new life.

MALE EXTERNAL STRUCTURES External genital organs of the male include the

-Testes (which are encased in the scrotal sac) and the penis -Scrotum -Penis

LACTATION AMENORRHEA METHOD When a woman is breastfeeding, there is a natural suppression of both ovulation and menses (Pratts & Lawson, 2015). Lactation amenorrhea method (LAM) is a safe birth control method (a failure rate of about 1% to 5%) if: An infant is:

-Under 6 months of age -Being totally breastfed at least every 4 hours during the day and every 6 hours at night -Receives no supplementary feedings, and Menses has not returned Advantage: Effective while infant is totally breastfed; approved by all religions and cultures Disadvantage:Temporary measure Not reliable if infant takes supplemental feedings Rx factors:

Patient teaching: Medically induced abortion A woman can expect to have mild vaginal spotting and perhaps cramping for 2 weeks postprocedure. Caution her to use

-sanitary pads rather than tampons and not to douche to help avoid infection. -She should not take aspirin for discomfort as this can increase bleeding (advise acetaminophen [Tylenol] instead). -She can resume regular activities but avoid heavy lifting or strenuous exercise for about 3 days. -period will return in 2 to 4 weeks. -It's best if she doesn't have sexual relations until a scheduled checkup to avoid infection, but if she does, she should advise her partner to use a condom to avoid a second pregnancy. It's important that she notify her healthcare provider if she has heavy vaginal bleeding (more than two pads saturated in 1 hour), passing of clots, abdominal pain or tenderness, oral temperature over 102.4°F, or if she notices severe depression or sadness. As a last measure, she should be certain to keep her follow-up appointment in about 2 weeks for postprocedure ultrasonography or a pregnancy test to ensure the pregnancy has ended and obtain contraceptive counseling so she can avoid a repeat procedure.

Side Effects and Contraindications- tubal ligation, If tubal ligation surgery is done by laparoscopy, an what can occur ?

-umbilical hernia or ureter or bowel perforation are possible complications. -vaginal spotting, intermittent vaginal bleeding, and even severe lower abdominal cramping after tubal ligation—symptoms termed posttubal ligation syndrome. Removal of the fallopian tubes appears to relieve these symptoms. -Not only is it difficult to reconstruct fallopian tubes after tubal ligation but there is also a possibility that, afterward, the anastomosis site could cause an ectopic (tubal) pregnancy because of its irregular surface. If a silicone gel has been instilled into the tubes as a blocking agent, this can be removed at a later date to reverse the procedure much more easily.

The Role of Estrogen When triggered at puberty by FSH, ovarian follicles in females begin to excrete a high level of the hormone estrogen. This increase influences the development of the

-uterus, -fallopian tubes, -and vagina; -typical female fat distribution; hair patterns; and breast development. -It also closes the epiphyses of long bones in girls the same way testosterone closes the growth plate in boys.

Uterine Deviations What does the shape or position tell you ?

A number of uterine deviations (i.e., shape and position) can interfere with fertility or pregnancy and so are helpful to recognize. When a uterus first forms in intrauterine life, it is split by a longitudinal septum into two portions. As the fetus matures, this septum dissolves, so, typically at birth, no remnant of the division remains. In some women, half of the septum or even the entire septum never atrophies, so the uterus remains as two separate compartments. Still, other women have oddly shaped "horns" at the junction of the fallopian tubes—a bicornuate uterus.

ORAL CONTRACEPTIVES Oral contraceptives, commonly known as the pill, OCs (for oral contraceptive), or COCs (for combination oral contraceptives), are composed of varying amounts of natural estrogen (17β-estradiol, estradiol valerate) or synthetic estrogen (ethinyl estradiol) combined with a small amount of synthetic progesterone (progestin).

Advantage/action: -estrogen acts to suppress follicle-stimulating hormone (FSH) and LH to suppress ovulation. -Prevents pregnacy -reduce incidence of cervial or uterine caner Action: progesterone action causes a decrease in the permeability of cervical mucus and so limits sperm motility and access to ova. Progesterone also interferes with tubal transport and endometrial proliferation to such an extent the possibility of implantation is significantly decreased. Disadvantage: nausea, break-through bleeding, failaire due to missed pill. Side Effect:Nausea ,Weight gain ,Headache ,Breast tenderness ,Breakthrough bleeding (spotting outside the menstrual period), Monilial vaginal infections ,Mild hypertension, Depression

An intrauterine device (IUD) is a small plastic device that is inserted into the uterus through the vagina. IUDs can be either hormonal or nonhormonal.

Advantage: 100% effective and need no memory aide -to prevent fertilization as well as to create a local sterile inflammatory reaction that prevents implantation. -When copper is added to the device, the possibility sperm will not be able to successfully cross the uterine space and reach the ovum increases as well. -used as an emergency birth control (The copper IUD )within 5 days of unprotected sex as a form of emergency contraception. Disadvantage: -breakthrough bleeding, dislodgment risks, eptopic pregnancy Side Effect: -spotting or uterine cramping the first 2 or 3 weeks after IUD insertion. -Rarely, a woman continues to have cramping and spotting after insertion; in such instances, she may expel the device spontaneously -Nulliparous women may have a higher percentage of spontaneous expulsion than others

A newer form of pill, ulipristal acetate (known as ella) and may be taken as late as 120 hours (5 days) after unprotected intercourse The dose is the same (one pill).

Advantage: 120 hours (5 days) after unprotected intercourse Disadvantage: requires a prescription -Most women expect the pills will begin a menstrual flow; caution them this will not happen, although they may notice some spotting from the change of hormones in their body. Their next menstrual flow may begin either earlier or later than usual Side Effect: bleeding

Coitus interruptus (withdrawal) Unfortunately, ejaculation may occur before withdrawal is complete and, despite the caution used, some spermatozoa may be deposited in the vagina. Furthermore, because there may be a few spermatozoa present in pre-ejaculation fluid, fertilization may occur even if withdrawal seems controlled

Advantage: A male-controlled method -the man withdraws and spermatozoa are emitted outside the vagina. Disadvantage:Sperm may be present in pre-ejaculatory fluid Rx factors: method should be used with caution as it also can lead to STIs

A diaphragm is a circular rubber disk that is placed over the cervix before intercourse to mechanically halt the passage of sperm

Advantage: Although use of a spermicide to coat a diaphragm is not required, using a spermicidal gel with one combines a barrier and a chemical method of contraception so one is usually added. Disadvantage: is prescribed and fitted initially by a healthcare provider to ensure a correct fit. Side Effect: cervical inflammation (erosion) or urethral irritation from the pressure against the vaginal walls, UTI

VASECTOMY In a vasectomy, a small puncture wound (referred to as "no-scalpel technique") is made on the scrotum. -Men who want their sperm to be available for the future can have it sperm banked before vasectomy.

Advantage: The vas deferens on each side are then pulled forward, cut and tied, cauterized, or plugged, blocking the passage of spermatozoa. - the sperm simply do not pass beyond the plugged vas deferens and are absorbed at that point. The man will still have full erection capacity and continue to produce testosterone. -Because he also continues to form seminal fluid, he will ejaculate seminal fluid; it will just not contain sperm. Disadvantage: -Some men resist the concept of vasectomy because they are not sufficiently aware of their anatomy to know exactly what the procedure will involve. - can be reversed, but the procedure is complicated, expensive, and success rates are low -develop autoimmunity or form antibodies against sperm following a vasectomy, so even if reconstruction is successful, sperm may not have good mobility or be incapable of fertilization. Side Effect: A hematoma at the surgical site may occur, although this is seen less frequently with "no scalpel" or puncture incisions. The procedure may also be associated with the development of urolithiasis (kidney stones). A few men develop chronic pain after vasectomy (postvasectomy pain syndrome); having the procedure reversed relieves this pain

Progestin-Only Pills (Mini-Pills) Oral contraceptives containing only progestins are popularly called mini-pills .

Advantage: Without estrogen content, ovulation may occur, but because the progestins have not allowed the endometrium to develop fully or sperm to freely access the cervix, fertilization and implantation will not take place. Disadvantage: must be taken conscientiously every day -more breakthrough bleeding than combination pills, but they are just as effective and do not pose a danger of thromboembolism Side Effect:Nausea ,Weight gain ,Headache ,Breast tenderness ,Breakthrough bleeding (spotting outside the menstrual period), Monilial vaginal infections ,Mild hypertension, Depression

The symptothermal method of birth control combines the cervical mucus and BBT methods. The woman takes her temperature daily, watching for the rise in temperature that marks ovulation. She also analyzes her cervical mucus every day and observes for other signs of ovulation such as mittelschmerz (midcycle abdominal pain) or if her cervix feels softer than usual. The couple then abstains from intercourse until 3 days after the rise in temperature or the fourth day after the peak of mucus change.

Advantage: assesses more clues to ovulation, is more effective than either the BBT or the cervical mucus method alone Disadvantage :Requires motivation and cooperation from male partner -requires conscientious daily assessment Rx factors:

Marquette Model

Advantage: combines the use of ovulation detection with other signs of ovulation (cervical mucus, BBT, cervix position and softness) to avoid pregnancy during a woman's fertile period Disadvantage:cooperation from partner, Rx factors:

Advantages of medically induced over surgical termination include the: The complications of medically induced termination include:

Advantage: decreased risk of damage to the uterus through instrument insertion and decreased use of anesthesia necessary for surgically performed procedures. Disadvantage: nausea and vomiting, diarrhea, severe uterine cramping, incomplete abortion, and the possibility of prolonged bleeding.

ESTROGEN/PROGESTERONE TRANSDERMAL PATCH

Advantage: does not need to remember to take a daily pill. -Patches can be worn in the shower, while bathing, or while swimming -No additional contraception is needed if the woman is sure the patch has been loose for less than 24 hours. Disadvantage: Although mild breast discomfort as well as irritation at the application site may occur -can slip off Side Effect:breast discomfort , skin irritation

INTRAMUSCULAR INJECTIONS A single intramuscular injection of depot medroxyprogesterone acetate or DMPA (Depo-Provera), a progesterone given every 12 weeks, inhibits ovulation, alters the endometrium, and thickens the cervical mucus so sperm progress is difficult -The injection is made deep into a major muscle (buttocks, deltoid, or thigh) before the fifth day after the beginning of a menstrual flow. Be sure the woman does not massage the injection site after administration so the drug can absorb slowly from the muscle

Advantage: effectiveness rate of this method is almost 100% -long-term reliability without many of the side effects and contraindications associated with COC -reductions in ectopic pregnancy, endometrial cancer, endometriosis, and, for unknown reasons, the frequency of sickle cell crises Disadvantage: The woman must return to a healthcare provider for a new injection every 12 weeks for the method to remain reliable. rx for osteporosis and weight gain Side Effect: weight gain may, osteporosis, breakthrough bleeding.

Sterilization of women could include removal of the uterus or ovaries (hysterectomy), but it usually refers to a minor surgical procedure, such as tubal ligation,

Advantage: fallopian tubes are occluded by cautery, crushed, clamped, or blocked, thereby preventing passage of both sperm and ova. -has a 99.5% effectiveness rate . It also is associated with a decreased incidence of ovarian cancer. Disadvantage: abdominal discomfort caused by local necrosis if clips were used, and she may notice abdominal bloating for the first 24 hours, until the carbon dioxide infused at the beginning of the procedure is absorbed. -The presence of carbon dioxide can also cause sharp diaphragmatic or shoulder pain if some of the carbon dioxide escapes under the diaphragm and presses on ascending nerves -turn to in vitro fertilization (IVF) as a method to have future children Side Effect: bowel perforation, hemorrhage, and the risks of general anesthesia if this was used.

Ovulation Detection

Advantage: kits detect the midcycle surge of luteinizing hormone (LH) that can be detected in urine 12 to 24 hours before ovulation. Such kits are 98% to 100% accurate in predicting ovulation can be used in the future to help conception when the couple is ready Disadvantage: expensive, cooperation from partner, not a form of protection or contraceptive. Rx factors:

Cervical Mucus Method (Billing's Method) A woman using this method must be conscientious about assessing her vaginal secretions every day, or she will miss the change in texture and amount. .

Advantage: knowledge of ovulation and cervical mucus Disadvantage:The feel of vaginal secretions after sexual relations is unreliable because seminal fluid (the fluid containing sperm from the male) has a watery, postovulatory consistency and can be confused with ovulatory mucus. -This method has a potentially high failure rate because of difficulty in interpreting mucus status (Blackwell, Vigil, . Because sperm have a life span from 3 to more than 5 days, a woman needs to abstain for at least 4 days prior to the appearance of estrogen-influenced mucus; therefore, this method should be combined with a calendar method for best results. Rx factors: pregnancy

Fertility awareness methods rely on detecting when a woman will be capable of impregnation (fertile) so she can use periods of abstinence during that time. There are a variety of ways to determine a fertile period, such as using a calendar to calculate the period of time based on a set formula, using a visual tool such as "CycleBeads," measuring the woman's body temperature, observing the consistency of cervical mucus, or employing a combination of these methods The methods consider the typical length of sperm survival (anywhere from 3 to more than 5 days) and the length of time an ova is ripe for fertilization (about 1 day). Based on this, a fertile period exists from about 5 days before ovulation to 1 day after.

Advantage: no cost, Visual aid can improve compliance Available as iPhone app Disadvantage:Initial cost May need to mark on a calendar they have moved a bead rather than rely on memory -requires motivation, cooperati rx factors: pregnancy, stds if unprotected sex

POSTCOITAL DOUCHING

Advantage: none Disadvantage: no matter what solution is used, is ineffective as a contraceptive measure as sperm may be present in cervical mucus as quickly as 90 seconds after ejaculation, long before douching could be accomplished Rx factors: pregnancy, yeast infection,

Abstinence

Advantage: refraining from sexual relations, has a theoretical 0% failure rate and is also the most effective way to prevent STIs. -Acceptable to all religious groups Disadvantage: Due to the natural human sexual drive, patients may find it difficult to adhere to abstinence because they may deny the possibility of sexual activity and fail to plan for pregnancy and STI prevention. Because it is difficult for many couples to adhere to abstinence, the method has a high failure rate rx factors: If teen or adult break their pledge (about 50% do), that could leave them more vulnerable to STIs and pregnancy than others

Female condoms are sheaths made of latex or polyurethane, prelubricated with a spermicide so, similarly to male condoms The inner ring (closed end) covers the cervix, and the outer ring (open end) rests against the vaginal opening. The sheath may be inserted any time before sexual activity begins and then removed after ejaculation occurs.

Advantage: they offer protection against conception as well as STIs, including HIV. -Because they prevent skin-to-skin contact STIs, they are the only woman-controlled safer sex method available Disadvantage: are more expensive than male condoms -should not be used w/male condoms or there is an increased chance of tearing one or the other Side Effect:There are no contraindications to the use of either male or female condoms except for sensitivity or allergy to latex. If either the male or his partner has a sensitivity or allergy to latex, polyurethane or natural membrane types can be used. Couples should be cautioned that these types of condoms do not offer the same level of protection against STIs

male condom is a latex rubber or synthetic sheath that is placed over the erect penis before coitus to trap sperm .

Advantage: trap sperm - are one of the few "male-responsibility" birth control measures available. In addition, no healthcare visit or prescription is needed. -prevent the spread of STIs such as gonorrhea and chlamydia; their use has become a major part of the fight to prevent infection from HIV. Disadvantage: true failure rate of about 15% because breakage or spillage occurs in up to 15% of uses -do not necessarily offer protection against diseases spread by skin-to-skin contact such as human papillomavirus (HPV), syphilis, or genital herpes Side Effect:There are no contraindications to the use of either male or female condoms except for sensitivity or allergy to latex. If either the male or his partner has a sensitivity or allergy to latex, polyurethane or natural membrane types can be used. Couples should be cautioned that these types of condoms do not offer the same level of protection against STIs

Two-Day Method

Advantage: woman assesses for vaginal secretions daily. If she feels secretions for 2 days in a row, she avoids coitus that day and the day following as the presence of secretions suggests fertility Disadvantage:Requires motivation and cooperation from male partner -requires conscientious daily assessment and results in about 12 days per month in which she should avoid coitus Rx factors:

Spermicides

Advantage:causes the death of spermatozoa before they can enter the cervix. It is a chemical barrier method and is often used in combination with other physical barrier methods. Spermicides not only actively kill sperm but also change the vaginal pH to a strong acid level, a condition not conducive to sperm survival. -They may be purchased without a prescription or an appointment with a healthcare provider, so they allow for greater independence and lower costs. - When used in conjunction with another contraceptive, they increase the other method's effectiveness. -Various preparations are available, including gels, creams, sponges, films, foams, and vaginal suppositories. Disadvantage: They do not protect against STIs Side Effect: contraindicated in women with acute cervicitis because they might further irritate the cervix. Some women find the vaginal leakage after use of these products bothersome. Vaginal suppositories, because of the cocoa butter or glycerin base, are the most bothersome in this regard

Barrier Methods and Effect on Sexual Enjoyment

Although barrier methods must be inserted fairly close to the time of coitus, most couples find the inconvenience of insertion only a minor problem. If a couple is concerned the method does not offer enough protection, worrying about becoming pregnant may interfere with sexual enjoyment. Some couples find the foam or moisture irritating to vaginal and penile tissue during coitus and, therefore, are unable to use them. Some men report that condoms dull their enjoyment of coitus; some couples do not like the fact the man must withdraw promptly after ejaculation (not true for female condoms). For some couples, concern that a condom may break or slip may inhibit sexual pleasure.

The Fern Test

An interesting property of cervical mucus just before ovulation when estrogen levels are high is the ability to form fernlike patterns on a microscope slide when allowed to dry. This pattern is known as arborization or ferning When progesterone is the dominant hormone, as it is just after ovulation, this fern pattern is no longer discernible. Cervical mucus, therefore, can be examined at midcycle for ferning to detect whether a high estrogen surge is present. Women who do not ovulate usually show a ferning pattern throughout their menstrual cycle (progesterone levels never become dominant), or they never demonstrate it because their estrogen levels never rise.

The nurse is preparing instruction about the menstrual cycle for adolescent patients. What will the nurse include about changes in the uterine endometrium during the second half of the cycle? A) It is corkscrew-like because of progesterone stimulation. B) It is thick and purple-hued because of estrogen stimulation. C) It is thin and transparent because of progesterone stimulation. D) It is twisted and ragged because of follicle-stimulating hormone.

Ans: A Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 95 Feedback: During the second half of the menstrual cycle, the formation of progesterone in the corpus luteum causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated. The uterine endometrium is thin and transparent immediately after the end of the menstrual cycle. The uterine endometrium does not become thick and purple in color because of estrogen stimulation. The uterine endometrium does not become twisted and ragged because of follicle-stimulating hormone.

. After reviewing the various types of contraception available and discussing the pros and cons about each with the nurse, a young woman decides to use a spermicidal cream. When teaching the woman about this type of contraception, the nurse would instruct the woman to insert the cream at which time frame before intercourse? A) 1 hour B) 1.5 hours C) 2 hours D) 3 hours

Ans: A Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 110 Feedback: Spermicidal gels or creams are easily inserted into the vagina before coitus with the provided applicator. The woman should do this no more than 1 hour before coitus.

Following reproductive tract surgery, assessment of urinary status is important because the: A) ureters pass just behind the uterine arteries. B) ureters pass in front of the uterus. C) bladder is supplied by the uterine arteries. D) bladder and the cervix surfaces touch.

Ans: A Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 89 Feedback: The proximity of the ureters to the fallopian tubes can cause them to be injured during uterine or fallopian tube surgery.

A patient recovering from a surgical pregnancy termination returns for a postprocedure examination. The patient tells the nurse that she is relieved that the procedure is over but that she is feeling sad. What should the nurse do to assist the patient at this time? A) Suggest the patient talk with a counselor. B) Ask the patient to identify the source of the sadness. C) Recommend the patient attend contraceptive counseling sessions. D) Discuss the need for an antidepressant with the health care provider.

Ans: A Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 127 Feedback: After a surgical pregnancy termination, most women report to be relieved with the decision; however, those who express sadness and guilt may need to be referred for professional counseling so they can integrate and accept this event in their lives. Asking the patient to identify the source of the sadness will not help the patient work through feelings caused by the procedure. Recommending the patient attend contraceptive counseling sessions does not focus on the source of the patient's sadness. Discussing antidepressant use may be premature for this patient.

The nurse instructs a patient on the use of a vaginal estrogen/progestin rings for contraception. Which patient statement indicates that additional instruction is needed? A) "I am to take the ring out overnight." B) "I will leave the ring in place for 3 weeks." C) "I leave the ring in place during intercourse." D) "I am to use other birth control if I take the ring out for 4 hours."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 117 Feedback: If the ring is removed for 4 hours for any purpose, it should be replaced with a new ring and a form of barrier protection is to be used for the next 7 days. The ring is not removed overnight. The ring is left in place for 3 weeks and then removed for menstruation during the ring-free week. The ring does not need to be removed for intercourse.

For which patient assessment finding would an intrauterine device (IUD) be contraindicated? A) Misshapen uterus B) Multiple sexual partners C) Diagnosis of hypertension D) History of thromboembolic disease

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 120 Feedback: Use of an IUD may be contraindicated for a woman whose uterus is distorted in shape because the device might perforate the uterine wall. The device is not contraindicated for multiple sexual partners, hypertension, or history of thromboembolic disease. Infection is no longer a concern because the vaginal string no longer conducts fluid. The device does not impact hormone levels and will not influence blood pressure or blood flow.

A postpartum patient asks the nurse when the subdermal hormone implant for contraception can be inserted. What should the nurse respond to this patient? A) In 6 weeks B) In 1 month C) 1 week after your next menstrual cycle D) Before being discharged after this delivery

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 113 Feedback: The subdermal hormone implant can be placed 6 weeks after the birth of a baby. One month is too soon for the implant to be placed after the birth of a baby. Typically, the rod is inserted during menses or no later than day 7 of a menstrual cycle to be certain that the patient is not pregnant at the time of insertion. The implant will not be placed immediately after the delivery of a baby.

The nurse is planning instruction for a patient desiring to have a tubal ligation. Which information should the nurse emphasize when teaching the patient? A) She must think of the procedure as irreversible. B) The procedure will reduce her menstrual flow in amount. C) She should schedule it to be done just before a menstrual flow. D) She will have lessened dysmenorrhea following the procedure.

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 121 Feedback: People considering tubal ligation should think of this procedure as permanent before having it done. Although reversal of the procedure can be done, the success rate is between 70% and 80%. Tubal ligation does not alter the menstrual flow or affect dysmenorrhea. Ectopic pregnancy could result if it is done following ovulation.

A patient received a scheduled dose of depot medroxyprogesterone acetate (DMPA) 6 weeks ago. Today, the patient reports that a regular menstrual cycle is 2 weeks late. What is the first thing that should be done for this patient? A) Perform a pregnancy test. B) Provide prenatal counseling. C) Discuss pregnancy termination options. D) Explain side effects of the contraceptive.

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 127 Feedback: Because the patient is receiving a contraceptive that could cause amenorrhea, and the patient's menstrual cycle is 2 weeks late, the first thing that should be done is a pregnancy test to determine if the patient is pregnant. The results of this test will determine the next course of action. Depot medroxyprogesterone acetate (DMPA) is a pregnancy category X medication, which means it should not be administered to someone who is pregnant. It is unclear if the patient was already pregnant when the last dose was provided 6 weeks prior to the current situation. It is premature to provide prenatal counseling. Depending on the results of the pregnancy test, the nurse may need to explain side effects of the contraceptive which include amenorrhea.

A patient sustains a vaginal tear during the labor and delivery process and is experiencing profuse vaginal bleeding. What should the nurse instruct the patient about this injury? A) This injury will heal rapidly. B) Surgery is needed to repair the tear. C) Future vaginal deliveries will be compromised. D) Bleeding will continue for several weeks to months.

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 91 Feedback: The blood supply to the vagina is furnished by the vaginal artery, a branch of the internal iliac artery. Vaginal tears at childbirth tend to bleed profusely because of this rich blood supply. The same rich blood supply is the reason any vaginal trauma at birth heals rapidly. Surgery is not needed to repair the tear. Future vaginal deliveries will not be compromised. Bleeding will not continue for several weeks to months.

An Rh-negative woman at 6 weeks' gestation is scheduled for a medically induced termination. Which outcomes should the nurse identify as appropriate for this patient? Select all that apply. A) Attended contraceptive counseling B) Received Rho (D) immune globulin C) Scheduled postprocedure sonogram D) Avoided strenuous activity for 3 weeks E) Experienced menstrual cycle in 2 months

Ans: A, B, C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 127 Feedback: A medically induced termination should be performed within 63 days of gestation. Once the termination medication has been provided, the patient should receive Rho (D) immune globulin, schedule a postprocedure sonogram, and attend contraceptive counseling. The patient should avoid strenuous activity for 3 days and have a return of a menstrual cycle within 2 to 4 weeks.

The nurse is planning an education seminar on safer sexual practices for a group of young adults. Which information should the nurse include in this teaching? Select all that apply. A) Use a latex condom for intercourse. B) Void immediately after having sex. C) Avoid sex with intravenous drug users. D) Hand-to-genital sex is the safest sexual practice. E) Inspect your sexual partner for lesions in the genital area.

Ans: A, B, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 79 Feedback: Safer sexual practices include using a latex condom for intercourse, voiding immediately after having sex, avoiding sex with intravenous drug users, and inspecting the sexual partner for genital lesions. Hand-to-genital sex is not the safest sexual practice. Abstinence is the only 100% guarantee against not contracting a sexually transmitted infection.

A male patient is considering a vasectomy. Which information should the nurse instruct the patient about this procedure? Select all that apply. A) Sexual intercourse can resume in a week. B) The procedure can be done as an outpatient. C) An opioid analgesic will be prescribed for pain control. D) Use a birth control method until a negative sperm reports occur. E) Spermatozoa present in the vas deferens will be viable for 2 weeks.

Ans: A, B, D Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 121 Feedback: After a vasectomy, sexual intercourse can resume after 1 week. The procedure can be completed as an outpatient. The patient may experience a small amount of local pain afterward, which can be managed by taking a mild analgesic and applying ice to the site. An additional birth control method should be used until two negative sperm reports at about 6 and 10 weeks have been obtained. Spermatozoa, which were present in the vas deferens at the time of surgery, can remain viable for as long as 6 months.

The nurse is determining the topics to include in an educational program to meet the 2020 National Health Goals for sexuality and reproductive health. What should the nurse include when planning this program? Select all that apply. A) Outline safer sex practices. B) Discuss the disadvantages of annual mammography. C) Review skills to use to negate unwanted sexual advances. D) Stress the importance of abstinence when teaching adolescent patients. E) Explain the advantages of obtaining the human papillomavirus vaccination.

Ans: A, C, D, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 78 Feedback: The nurse can help the nation achieve the 2020 National Health Goals for sexuality and reproductive health by outlining safer sex practices, reviewing refusal skills, teaching about abstinence, and explaining the advantages of obtaining the human papillomavirus vaccination. Annual mammography is not a disadvantage for women of a specific age range.

After an examination, a pregnant patient is diagnosed with a cystocele. How should the nurse explain this finding to the patient? A) A fold of peritoneum behind the uterus B) Pouching of the bladder into the vaginal wall C) A part of the rectum is pushing into the vaginal wall. D) Folds of peritoneum that cover the uterus front and back

Ans: B Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 89 Feedback: Pouching of the bladder into the vaginal wall is a cystocele. A fold of peritoneum behind the uterus is posterior ligament. A part of the rectum pushing into the vaginal wall is a rectocele. Folds of peritoneum that cover the uterus front and back are the broad ligaments.

An adolescent female patient asks the nurse questions about menstruation. What should the nurse include when instructing the patient? A) Keeping active increases discomfort. B) A prostaglandin inhibitor best relieves pain. C) Eating sour foods contributes to discomfort. D) Hair permanents do not take during a menstrual flow.

Ans: B Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 93 Feedback: Prostaglandin inhibitors such as ibuprofen are most effective for menstrual pain because they reduce inflammation as well as relieve pain. Activity reduces the discomfort of menstrual pain. Eating sour foods does not influence menstruation. Menstruation does not affect hair care needs.

A nurse is working with a woman who is using the calendar method to determine her safe days. The nurse would instruct the woman to subtract: A) 14 from 28. B) 18 from her shortest period and 11 from her longest. C) The length of her average period from the ideal of 28. D) 18 from the longest period and 11 from her shortest.

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 107 Feedback: The days surrounding ovulation (3 days before and 3 days after) are the most fertile days. To plan, the woman keeps a diary of about six menstrual cycles. To calculate "safe" days, she subtracts 18 from the shortest cycle she documented. This number predicts her first fertile day. She then subtracts 11 from her longest cycle. This represents her last fertile day. If she had six menstrual cycles ranging from 25 to 29 days, her fertile period would be from the 7th day (25 [the shortest cycle] - 18) to the 18th day (29 [the longest cycle] - 11). To avoid pregnancy, she would avoid coitus during those days

A woman tells the nurse she has difficulty achieving orgasm. Orgasm in females results mainly from which stimulus? A) penile penetration B) clitoral stimulation C) uterine stimulation D) sensory arousal

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 84 Feedback: The clitoris is thought to be the main stimulus for initiating orgasm in women.

The nurse needs to assess a patient for biologic gender. Which of the following factors would be most important to assess? A) Temperament B) Hair distribution C) Occupation D) Ability to love

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 86 Feedback: Hair distribution is a biologic factor. Temperament, occupation, and ability to love are not gender specific.

A woman calls the clinic to report that she has had some cramping and spotting since the insertion of her IUD three days ago. Which instruction would be most appropriate? A) "Come to the clinic as soon as possible." B) "Consider this normal, because your IUD is newly inserted." C) "Take your blood pressure daily for the rest of the month." D) "You'll have to change your method of birth control."

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 120 Feedback: A woman may notice some spotting or uterine cramping the first 2 or 3 weeks after IUD insertion.. Ibuprofen, a prostaglandin inhibitor, is helpful in relieving the pain.

A woman uses a diaphragm for contraception. The nurse would instruct her to return to the clinic to have her diaphragm fit checked after which occurrence? A) cervical infection B) a weight gain of 10 lb (4.5 kg) C) a vaginal infection D) six months of nonuse

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 111 Feedback: A substantial weight gain or weight loss of 10 pounds (4.5 kilograms) or more may shift the relationship of pelvic organs enough that the diaphragm no longer fits correctly.

The nurse completes an assessment of an adolescent patient's menstrual pattern. Which finding should the nurse identify as being within normal limits? A) The usual cycle is 19 days. B) Flow usually lasts 4 to 6 days. C) Menstruation started at age 10 years. D) The average amount of flow is 500 ml.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 92-93 Feedback: The duration of menstrual flow averages between 4 and 6 days. The average menstrual cycle is 28 days. The average age at onset of menstruation is 12.4 years. The average amount of flow is 30 to 80 ml per menstrual period.

A patient wants to calculate fertile days using the calendar method. What will the nurse instruct the patient to subtract when making this calculation? A) 14 from 28 B) 18 from the shortest period and 11 from the longest C) 18 from the longest period and 11 from the shortest D) The length of the average period from the ideal of 28

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 107 Feedback: To calculate "safe" days, the patient should subtract 18 from the shortest cycle. This number predicts the first fertile day. Then subtract 11 from the longest cycle. This represents the last fertile day. The other calculations are incorrect to determine fertile days.

A patient asks the nurse if a cervical cap is better than a diaphragm for contraception. What should the nurse explain is the advantage of a cervical cap? A) No initial fitting is required. B) It can be left in place longer. C) It needs no spermicidal jelly. D) It does not need to be refitted after pregnancy.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 112 Feedback: Caps can be kept in place longer—up to 48 hours—because they do not put pressure on the vaginal walls or urethra. A fitting is needed for a cervical cap. They are used with spermicidal jelly, and they do need to be refitted after pregnancy.

A 40-year-old woman who smokes desires a reliable contraceptive method. Which should the nurse recommend to this patient? A) An ovulation suppressant B) A condom and spermicide C) A spermicidal suppository D) The rhythm (calendar) method

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 115 Feedback: Women who are 40 years of age and smoke should not take ovulation suppressants. Irregular menstrual cycles make natural methods difficult. Women older than the age of 40 may have vaginal dryness, so a spermicidal suppository would not be effective. The best option is for the patient to use a condom and spermicide.

What is an advantage of a cervical cap over a diaphragm? A) No initial fitting is required. B) It can be left in place longer. C) It needs no spermicidal jelly. D) It does not need to be refitted after pregnancy.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 112 Feedback: Because a cervical cap does not press against the sides of the vagina, possibly interfering with blood supply, it can be left in place longer.

Which information is important for a woman to understand before undergoing a scheduled tubal ligation? A) She will have lessened dysmenorrhea following the procedure. B) She must think of the procedure as irreversible. C) The procedure will reduce her menstrual flow in amount. D) She should schedule it to be done just before a menstrual flow.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 121 Feedback: Sterilization by fallopian tube obstruction does not alter menstrual symptoms or flow. Ectopic pregnancy could result if it is done following ovulation; reversing the process is difficult.

The nurse is preparing an educational session about menstruation for a group of adolescents. Which hormone should the nurse instruct as initiating ovulation? A) Estrogen B) Progesterone C) Luteinizing hormone D) Follicle-stimulating hormone

Ans: C Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 93 Feedback: Luteinizing hormone is responsible for ovulation or release of the mature egg cell from the ovary. Estrogen, progesterone, and follicle-stimulating hormone are not hormones responsible for initiating ovulation.

A nurse is teaching a woman how to use the basal body temperature method of contraception. The nurse determines that the teaching was successful when the woman identifies that she should refrain from having sexual intercourse at which time? A) 4 days after she notices her temperature rise. B) 7 days after noting a slight increase followed by a dip in her temperature. C) 3 days after she records a slight drop in her temperature followed by an increase. D) 14 days after the last day of her menstrual period.

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Analyze Page: 108 Feedback: Ovulation occurs after a slight drop in temperature followed by an increase. The ovum has a life span of 3 days. As soon as a woman notices a slight dip in temperature followed by an increase, she knows she has ovulated. She refrains from having coitus (sexual relations) for the next 3 days (the possible life of the discharged ovum).

. A client decides to use the cervical mucus method as her contraceptive method. When describing this method, the nurse explains that the client can determine ovulation based on which characteristic of the mucus? A) thick consistency with clumping B) acidic odor and slightly yellow color C) thin and slippery D) transparent with the odor of eggs

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 108 Feedback: Before ovulation each month, the cervical mucus is thick and does not stretch when pulled between the thumb and finger. Just before ovulation, mucus secretion increases. On the day of ovulation (the peak day), it becomes copious, thin, watery, and transparent. It feels slippery (like egg white) and stretches at least 1 inch before the strand breaks, a property known as spinnbarkeit.

A woman telephones the nurse after taking an ovulation suppressant for 3 months to state that she has forgotten to take her pill two mornings in a row. What would be the best advice to give her regarding this? A) Start a new cycle of 21 pills immediately plus additional estrogen for the next 3 days. B) Take three pills immediately and avoid coitus for the remainder of the month.term-313 C) Take two pills now and use a second method of contraception for the remainder of the month. D) Take two pills a day for the rest of the month.

Ans: C Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 115 Feedback: Failure to take two pills could have resulted in ovulation, so additional protection should be used for the remainder of the cycle.

You care for a patient who has a retroverted uterus. You would explain that this means her: A) uterus is bent sharply backward at the cervix. B) cervix is located behind the Douglas cul-de-sac. C) entire uterus is tipped backward. D) uterus is anterior to the bladder.

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Understand Page: 90 Feedback: Retroverted means to tip backward; retroversion means to bend backward.

After assessing a client, a nurse determines that an IUD as a method of contraceptive would be contraindicated based on a history of which finding? A) Smoking B) Hypertension C) Abnormal uterine shape D) Thromboembolic disease

Ans: C Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 120 Feedback: Use of an IUD may be contraindicated for a woman whose uterus is distorted in shape (the device might perforate the uterine wall). The copper IUD use also is not advised for a woman with severe dysmenorrhea (painful menstruation) or menorrhagia (heavy bleeding)

A patient who has unprotected intercourse has obtained the morning after pill but has not yet taken the prescribed dosage. What nursing diagnosis should the nurse identify as appropriate for the patient at this time? A) Powerlessness B) Spiritual distress C) Decisional conflict D) Readiness for enhanced knowledge

Ans: C Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 102 Feedback: The patient has the morning after pill but has not yet taken the prescribed dosage. This indicates that the patient has not yet made a decision. Powerlessness would be applicable if the patient's planned contraceptive was ineffective. Spiritual distress would be appropriate if there were a conflict regarding contraceptive methods. Readiness for enhanced knowledge would be applicable if the patient was asking about different contraceptive types.

After an assessment, a pregnant patient asks the nurse questions about her changing uterus and body. Which nursing diagnosis would be appropriate for the patient at this time? A) Anxiety related to being pregnant B) Ineffective coping related to being pregnant C) Health-seeking behaviors related to reproductive functioning D) Disturbance in body image related to body changes with pregnancy

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 78 Feedback: The patient is asking questions related to reproductive functioning which indicates health-seeking behaviors. The patient's questions do not indicate that the patient is experiencing anxiety, ineffective coping, or a disturbance in body image.

The nurse completes instructing a patient on the use of the contraceptive patch. Which patient response indicates that teaching has been effective? A) The patch is immediately effective after application. B) The patch should be applied to the breasts, hips, or back. C) The patch should be applied to the abdomen, buttocks, or back. D) The patch should be covered when swimming because of chlorine's effect on the adhesive.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 117 Feedback: The patch should be applied only to the buttocks, back, abdomen, or torso and never on the breasts. The patch is safe for wearing during swimming and bathing. The patch requires application for 1 week before becoming effective.

A patient is diagnosed with a uterus that is slightly retroverted. When discussing the implications of this finding, what should the nurse include? A) This finding indicates the need for surgery. B) This finding will render the patient infertile. C) This finding should not cause fertility issues. D) This finding could interfere with conception.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 90 Feedback: A retroverted uterus means the uterus tips back. Minor variations of these positions do not tend to cause reproductive problems. A retroverted uterus does not mean that the patient needs surgery. A retroverted uterus does not interfere with fertility. The only way that a retroverted uterus will interfere with conception is if the abnormal position is extreme because the sharp bend can block the deposition or migration of sperm.

A pregnant woman asks you how the uterine arteries will be able to supply blood to the uterus after the uterus increases to four times its prepregnant size. You would explain that this will happen easily because of which of the following? A) More arteries form during pregnancy. B) The muscle of the uterus decreases during pregnancy. C) Venous congestion causes stasis of arterial blood. D) The normally twisted and coiled uterine vessels uncoil and elongate.

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Understand Page: 89 Feedback: No new arteries form during pregnancy; those already present uncoil and elongate.

A woman tells you that both she and her husband like to continue sexual relations during her menstrual period. They have a monogamous relationship. She asks you if this will harm her. Which of the following would be the best response? A) "Avoid sexual relations because orgasm may be painful for during your menses." B) "The risk of infection is too great for sexual relations during this time." C) "You will not be able to achieve orgasm during your menses." D) "If this is satisfying for you and your partner, then there is no harm in it."

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 97 Feedback: Sexual relations may be continued through a menstrual flow if this is satisfying for both partners.

When reviewing normal menstruation with an early adolescent, the nurse would teach that during the second half of a typical menstrual cycle, the endometrium of the uterus becomes: A) thin and transparent because of progesterone stimulation. B) twisted and ragged because of follicle-stimulating hormone. C) thick and purple-hued because of estrogen stimulation. D) corkscrew-like because of progesterone stimulation.

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 95 Feedback: Progesterone is released following ovulation and thus is the dominating hormone of the second half of the menstrual cycle; its effect is to increase endometrium growth.

The nurse is teaching a client about sildenafil citrate prescribed for erectile dysfunction. Which client statement indicates that teaching has been effective? A) "A change in vision is to be expected." B) "This medication is birth control for men." C) "I can take this medication several times a day." D) "I should report to my health care provider an erection that lasts longer than 4 hours."

Ans: D Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analyze Page: 78 Feedback: An erection lasting more than 4 hours can occur when taking sildenafil citrate. This condition can lead to penile tissue damage and should be reported to a health care provider. A change in vision should be reported to the health care provider. Sildenafil citrate is not birth control. This medication should be taken up to one dose per day.

The estrogen content in the contraceptive pill performs which action? A) decreases the permeability of cervical mucus B) increases the level of luteinizing hormone (LH) C) interferes with endometrial proliferation D) suppresses follicle-stimulating hormone (FSH)

Ans: D Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 113 Feedback: Estrogen has a direct effect on the pituitary gland suppressing FSH; progesterone increases permeability of cervical mucus and endometrial proliferation.

When using the contraceptive patch, a client should understand that it: A) should be applied to the breasts, hips, or back. B) should be covered when swimming in a pool because of chlorine's effect on the adhesive. C) is immediately effective after application. D) should be applied to the abdomen, buttocks, or back.

Ans: D Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Remember Page: 117 Feedback: The patch should be applied only to the buttocks, back, abdomen, or torso (never the breasts). The patch is safe for wearing during swimming and bathing. The patch requires application for 1 week before becoming effective.

A woman visits the family planning clinic to request a prescription for birth control pills. Which factor would indicate that an ovulation suppressant would not be the best contraceptive method for her? A) She is 30 years old. B) She has irregular menstrual cycles. C) She has a history of allergy to foreign protein. D) She has a family history of thromboembolism.

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 109 Feedback: The estrogen content of birth control pills may lead to increased blood clotting, leading to an increased incidence of thromboembolism. Women who already are prone to this should not increase their risk further.

A woman is 40 years old and a heavy smoker. She has a single sexual partner but has very irregular menstrual cycles. She wants a highly reliable contraceptive. Which method would be the best recommendation? A) an ovulation suppressant B) a spermicidal suppository C) the rhythm (calendar) method D) a diaphragm and spermicide

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 111 Feedback: Women over 40 who smoke should not take ovulation suppressants; irregular menstrual cycles make natural methods difficult; women over 40 may have vaginal dryness, so a spermicidal suppository would not be activated.

A patient comes into the family planning clinic and requests a prescription for birth control pills. Which assessment finding indicates that an ovulation suppressant would not be the best contraceptive method for the patient? A) Age 30 years B) Allergy to foreign protein C) Irregular menstrual cycles D) History of thromboembolism

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 129 Feedback: Combination oral contraceptives are not routinely prescribed for patient with a history of thromboembolic disease. The patients' age would not be a contraindication for this type of contraceptive. An allergy to foreign protein would impact the patient's ability to use condoms. Irregular menstrual cycles would be an indication for combination oral contraceptives.

The nurse is determining a patient's gender role. What is the nurse doing to make this determination? A) Assessing the patient's sexual preferences B) Asking what gender the patient identifies with C) Analyzing the patient's chromosomal inheritance D) Analyzing the patient's demonstrated sexual behaviors

Ans: D Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 79 Feedback: Gender role is the male or female behavior a person exhibits, which may or may not be the same as biologic gender or gender identity. Assessing the patient's sexual preferences, asking what gender the patient identifies, and analyzing the patient's chromosomal inheritance will not determine the patient's gender role.

A patient with vaginismus has attended counseling to treat the disorder. Which patient statement indicates that treatment has been effective? A) "Lacking an interest in sex is a normal part of aging." B) "I can learn to tolerate sex if I want to have a family." C) "I can use lubricants to help with the pain of having sex." D) "Sex is not a bad thing but can be enjoyed with my husband."

Ans: D Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 79 Feedback: Vaginismus is involuntary contraction of the muscles at the outlet of the vagina when coitus is attempted that prohibits penile penetration and may occur in women who have been raped. Other causes are unknown, but it could also be the result of early learning patterns in which sexual relations were viewed as bad or sinful. As with other sexual problems, sexual or psychological counseling to reduce this response may be necessary. A lack of interest in sex is not a normal part of aging. Learning to tolerate sex and using lubricants does not help with the problem of vaginismus.

The nurse instructs a patient on cervical mucus changes that occur during ovulation. Which statement indicates that teaching has been effective? A) "During ovulation, the mucus is thick." B) "Ovulation makes the mucus more acidic." C) "The mucus is white because of more white blood cells." D) "When the mucus is thin and watery, then ovulation is occurring."

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 108 Feedback: On the day of ovulation, the cervical mucus becomes copious, thin, watery, and transparent. During ovulation, the mucus is not thick, not acidic, and not white.

The nurse is teaching a patient on the use of a diaphragm for contraception. Which patient statement indicates that instruction has been not been effective? A) "I need to use my finger to remove the diaphragm." B) "I should remove the diaphragm 6 hours after intercourse." C) "I should stop using a diaphragm if I get an infection of my cervix." D) "I need to have the diaphragm checked if my weight changes by 30 lb."

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 111 Feedback: The patient should be instructed to have the size of the diaphragm checked if weight changes by 15 lb. The patient does need to use the finger to remove the diaphragm. The diaphragm should be removed 6 hours after intercourse. The diaphragm should not be used if the patient is experiencing a cervical infection.

The nurse is planning expected outcomes for a female patient who will be celebrating her 40th birthday in a few months. Which outcome would be appropriate for this patient? A) Patient will follow safer sex practices. B) Patient will explain the process of reproduction. C) Patient will perform breast self-examination every 2 months. D) Patient will schedule a mammogram shortly after 40th birthday.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 78 Feedback: To help patients better understand reproductive functioning and sexual health throughout their life, an expected outcome might include encouraging women over 40 to have mammograms. The process of reproduction would be appropriate for younger patients. Teaching on safer sex practices would be appropriate for an adolescent. Breast self-examinations should be conducted every month.

The nurse is planning an educational session on contraceptives for a group of adolescent high school students. What does the nurse need to do when planning this session? A) Argue that encouraging abstinence is unrealistic during the teenage years. B) Discuss that the application of a condom should occur after penile-vulvar contact. C) Explain that the combination oral contraceptive approach is the best for adolescents. D) Teaching about contraceptive options while avoiding indirect encouragement of sexual activity.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 102 Feedback: The nurse can help the nation achieve the 2020 National Health Goals by teaching adolescents about contraceptive options while being cautious to avoid indirectly encouraging sexual activity among teens. A 2020 National Health Goal is to increase the number of adolescents being instructed on abstinence. A condom should be applied before penile-vulvar contact. Oral contraceptives are not the contraceptive of choice for adolescents.

An adolescent female who has recently started menstruating asks for a highly reliable birth control method. Which method should the nurse discuss with the patient? A) Postcoital douching B) An intrauterine device C) An ovulation suppressant D) Vaginal foam for her and a condom for her partner

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 113 Feedback: For many adolescent couples, use of a dual method, such as a vaginally inserted spermicide by the girl and a condom by her partner, is a preferred method of birth control. Postcoital douching is not a method of birth control. Intrauterine devices are rarely used for early adolescents because the uterus may still be small. Ovulation suppressants are not recommended until a female has been menstruating for at least 2 years.

A female patient has forgotten to take an ovulation suppressant for two mornings in a row. What should the nurse advise the patient to do? A) Take two pills a day for the rest of the month. B) Take three pills immediately and avoid coitus for the remainder of the month. C) Start a new cycle of 21 pills immediately plus additional estrogen for the next 3 days. D) Take two pills now and use a second method of contraception for the remainder of the month.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 115 Feedback: If two consecutive active pills are missed, the patient should be advised to take two pills immediately. Then the patient should continue the following day with the usual schedule. Missing two pills may allow ovulation to occur, so an added contraceptive such as a spermicide should be used for the remainder of the month. The patient does not need to take two pills every day for the rest of the month, take three pills and abstain from coitus, or start a new cycle of 21 pills.

Specific Questions to Include in a Sexual History

Are you sexually active? Is your sexual partner of the same or a different gender? How many sexual partners have you had in the past 6 months? Are you satisfied with your sex life? If not, why not? Do you have any concerns about your sex life? If so, what are they? What would you like to change? What measures do you take to practice safer sex? For those at high risk of contracting HIV: Are you using pre-exposure prophylaxis (PrEP) to reduce your chances of HIV infection? Have you ever contracted a sexually transmitted infection or are you worried you have one now? Have you ever experienced a problem such as maintaining an erection, erectile dysfunction, failure to achieve orgasm, or pain during intercourse? If you're sexually active, are you using a method to prevent pregnancy? Are you satisfied with your current reproductive planning method? Do you have any questions about it? For adolescents and women under the age of 27 years: Are you vaccinated against human papillomavirus (HPV)?

ASSESSMENT

As a result of changing social values and lifestyles, many people today are able to talk easily about reproductive life planning. Other people, however, may be uncomfortable with this topic and may not voice their interest in the subject independently. For this reason, at health assessments, ask patients if they want more information or need any help with reproductive life planning as part of obtaining a basic health history

Patient Teaching for menstruation

Because menarche may occur as early as 9 years of age, it is good to include health teaching information on menstruation to both school-age children and their parents as early as fourth grade as part of routine care. It is a poor introduction to sexuality and womanhood for a girl to begin menstruation unwarned and unprepared for the important internal function it represents

A diaphragm pt. teaching

Because the shape of a woman's cervix changes with pregnancy, miscarriage, cervical surgery (dilatation and curettage [D&C]), or elective termination of pregnancy, teach women to return for a second fitting if any of these circumstances occur. A woman should also have the fit of the diaphragm checked if she gains or loses more than 15 lb because this could also change her pelvic and vaginal contours. -Before expected coitus, after first coating the inside rim and center portion of the diaphragm with a spermicide gel, the diaphragm is inserted into the vagina, sliding it along the posterior wall and pressing it up against the cervix so it is gripped by the vaginal fornices. -A woman should check a diaphragm with a finger after insertion to be certain it is fitted well up over the cervix; she should be able to palpate the cervical os through the center of the diaphragm. Do not leave in any longer than 24 hrs -A diaphragm is removed by inserting a finger into the vagina and loosening the diaphragm by pressing against the anterior rim and then withdrawing it vaginally. After use, a diaphragm should be washed in mild soap and water, dried gently, and stored in its protective case. With this care, a diaphragm will last for 2 years, after which it should be replaced

Ordinarily, the body of the uterus tips slightly forward. Positional deviations of the uterus that are commonly seen include

Common positions: • Anteversion: The entire uterus tips far forward. • Retroversion: The entire uterus tips far back. • Anteflexion: The body of the uterus is bent sharply forward at the junction with the cervix. • Retroflexion: The body of the uterus is bent sharply back just above the cervix.

pt. teaching on spermacide

Gels or creams are easily inserted into the vagina before coitus with the provided applicator . The woman should do this no more than 1 hour before coitus. If she chooses to douche to remove the spermicide afterward (no need to do this), she should wait 6 hours after coitus to ensure the agent has completed its spermicidal action. Still, other vaginal products are cocoa butter and glycerin-based vaginal suppositories containing a spermicide. Because it takes about 15 minutes for a suppository to dissolve, it must be inserted 15 minutes before coitus. Foam-impregnated synthetic sponges are moistened to activate the impregnated spermicide and then inserted vaginally to block sperm access. Caution women preparations labeled "feminine hygiene" products are for vaginal cleanliness and are not spermicidal; therefore, they are not effective contraceptives.

Levonorgestrel-releasing intrauterine system 52 mg (Mirena or Liletta)

IUD, which features a drug reservoir of progesterone in the stem The progesterone (levonorgestrel) in the drug reservoir gradually diffuses into the uterus through the plastic; it both prevents endometrium proliferation and thickens cervical mucus. Because it reduces endometrium proliferation, it also has the potential to reduce endometrial cancer It is effective for 5 years (possibly as long as 7 years). Many women using the Mirena will have a cessation of menses or periodic light spotting instead of a normal menses.

Levonorgestrel-releasing intrauterine system 19.5 mg (Kyleena)

IUD, which is manufactured by the same company as Mirena, has a lower dose of progesterone in the stem as compared to Mirena but higher than that of Skyla. It is approved for 5 years and has a bleeding profile similar to Mirena. Women may choose this over Mirena due to the lower dose of progesterone but the benefits of Mirena in terms of duration of use and lower rates of breakthrough bleeding.

Chapter 6: Keypoints

IUDs are small plastic devices wound with copper or filled with slow-acting progesterone placed in the uterus to prevent fertilization and implantation and are highly effective forms of birth control. Barrier methods of contraception include the diaphragm, cervical cap, sponges, vaginal spermicides, and condoms (male and female). Such methods are low in cost but are not as effective as ovulation suppressant methods. Use of diaphragms may be associated with UTIs. Postcoital or "Plan B" protection involves administration of a high dose of progesterone that prevents FSH release, which then prevents ovulation. A copper-wound IUD may also be used for postcoital protection; its insertion creates changes in the endometrium and cervical mucus to slow or prevent sperm transport. Surgical methods of contraception are tubal ligation in women and vasectomy in men. -Counsel individuals who wish to undergo these procedures that they are largely irreversible and should not be considered lightly. An elective termination of pregnancy can be accomplished medically by administration of mifepristone and misoprostol or surgically by menstrual extraction, D&C, D&E, or prostaglandin or saline induction. Counsel women not to think of elective termination of pregnancy as a contraceptive method but as a recourse to be used if preventive measures fail. Women who are Rh negative need to receive Rho(D) immune globulin after these procedures. When counseling patients about reproductive life planning, nurses have the second responsibility to teach about safer sex practices. Such thoroughness not only helps in planning care that meets QSEN guidelines but also best meets the family's total needs.

PLANNING

If a woman has a history of poor compliance with medication, for instance, it might not be realistic for her to plan on taking an oral contraceptive every day. If she only desires temporary contraception, tubal ligation or vasectomy for her partner would certainly be inappropriate. Be certain when counseling to be sensitive to a couple's spiritual, cultural, and moral beliefs before suggesting possible methods. It is equally important to explore your own beliefs and values before counseling. This not only helps develop self-awareness of how these beliefs affect nursing care, but it also allows you to become more sensitive to the beliefs of others.

EFFECT ON PREGNANCY IUD

If a woman with an IUD in place suspects she is pregnant, she should alert her primary healthcare provider. The woman will receive an early sonogram to document placement of the IUD and rule out ectopic pregnancy. Following confirmation of the IUD's location, it may be left in place during the pregnancy, but it is usually removed vaginally to prevent the possibility of infection or spontaneous miscarriage during the pregnancy.

Barrier Methods and Effect on Pregnancy

If conception should occur while using a barrier method, there is no reason to think the fetus will be affected. Some women worry a sperm that survived a spermicide must have been weakened by migrating through it and, therefore, will produce a child with problems. They can be assured conception most likely occurred because the product did not completely cover the cervical os, so the sperm that reached the uterus was free of the product and unharmed.

The Third Phase of the Menstrual Cycle (Ischemic)

If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days, and therefore, the production of progesterone decreases. -With the withdrawal of progesterone, the endometrium of the uterus begins to degenerate (at about day 24 or day 25 of the cycle). The capillaries rupture, with minute hemorrhages, and the endometrium sloughs off.

HORMONAL CONTRACEPTION AND THE ADOLESCENT

It is usually recommended that adolescent girls have well-established menstrual cycles for at least 2 years before beginning COCs. -This reduces the chance the estrogen content will cause permanent suppression of pituitary-regulating activity. Estrogen has the side effect of causing the epiphyses of long bones to close and growth to halt; therefore, waiting at least 2 years also helps ensure the preadolescent growth spurt will not be halted. Because adolescents' compliance with most medications is low, adolescent girls may not take either combined or progestin-only pills reliably enough to make them effective. COCs have side benefits of improving facial acne in some girls because of the increased estrogen/androgen ratio created and also decreasing dysmenorrhea, both of which are appealing to most adolescents and may increase their compliance rate. -The pill may be prescribed to some adolescents specifically to decrease dysmenorrhea, especially if endometriosis is present

The Individual With a Hypoactive Sexual Desire

Lessened interest in sexual relations is normal in some circumstances, such as after the death of a family member, a divorce, or a stressful job change. The support of a caring sexual partner or relief of the tension causing the stress allows a return in sexual interest. Decreased sexual desire can also be a side effect of many medicines. Chronic diseases, such as peptic ulcers or chronic pulmonary disorders that cause frequent pain or discomfort, may interfere with a man's or a woman's overall well-being and interest in sexual activity. Obese men and women may not feel as much satisfaction from sexual relations as others because they have difficulty achieving deep penetration due to the bulk of their abdomens. An individual with an STI such as genital herpes may choose to forgo sexual relations rather than inform a partner of the disease. Some women experience a decrease in sexual desire during perimenopause. Administration of androgen (testosterone) to women may be helpful at that time because it can improve interest in sexual activity

Barrier Methods and the Adolescent-Males

Male adolescents are showing increased ability to use condoms responsibly. -They may need to be cautioned that condoms should never be reused due to concern for infection and wear on the condom itself that could cause STI transmission or pregnancy. Adolescent boys who have infrequent coitus may have condoms they have owned and stored for a long time. The effectiveness of these old condoms, especially if they are carried in a warm pocket, is questionable. For many adolescent couples, use of a dual method, such as a vaginally inserted spermicide by the girl and a condom by her partner, is a preferred method of birth control. These two methods used in conjunction increase effectiveness

The Individual With a Disability Individuals who are physically challenged have sexual desires and needs the same as all others

Males with upper spinal cord injury, for example, may have difficulty with erections and ejaculation because these actions are governed at the spinal level. Manual stimulation of the penis or psychological stimulation can, however, achieve erection in most men with spinal cord lesions, allowing the man a satisfying sexual relationship with his partner. Most women with spinal cord injuries cannot experience orgasm but are able to conceive and have children.

The Fourth Phase of the Menstrual Cycle (Menses)

Menses, or a menstrual flow, is composed of a mixture of blood from the ruptured capillaries; mucin; fragments of endometrial tissue; and the microscopic, atrophied, and unfertilized ovum. -Menses is actually the end of an arbitrarily defined menstrual cycle. Because it is the only external marker of the cycle, however, the first day of menstrual flow is used to mark the beginning day of a new menstrual cycle. -The iron loss in a typical menstrual flow is approximately 11 mg. This is enough loss that many adolescent women could benefit from a daily iron supplement to prevent iron depletion during their menstruating years

Natural Family Planning and the Adolescent

Natural methods of family planning (with the exception of abstinence) are usually not the contraceptive method of choice for adolescents as they require a great deal of thought and persistence. Adolescent boys may lack the control or experience to use coitus interruptus effectively. Girls tend to have occasional anovulatory menstrual cycles for several years after menarche and so may not experience definite cervical changes or an elevated body temperature each month. In addition, these methods require adolescents to say "no" to sexual intercourse on fertile days, a task that may be difficult to complete under peer pressure

Two types of sexual harassment exist.

One is quid pro quo (an equal exchange), in which an employer asks for something in return for sexual favors, such as a hiring or promotion preference. The second is a hostile work environment, in which an employer creates an environment in which an employee feels uncomfortable and exploited (such as being addressed as "honey" or "babe," asked to wear revealing clothing, or working where walls are decorated with sexist posters).

OUTCOME EVALUATION The evaluation must be ongoing in the area of reproductive health because health education needs to change with circumstances and increased maturity. For example, the needs of a woman at the beginning of a pregnancy may be different from her needs at the end. How people feel about themselves sexually also changes. Their concept of themselves may have a great deal to do with how quickly they recover from an illness, how quickly they are ready to begin self-care after childbirth, or even how motivated they are as an adolescent to accomplish activities in life phases that depend on being sure of their sexuality or gender. Examples of expected outcomes include:

Patient states he is taking precautions to prevent contracting an STI. Patient states she is better able to manage symptoms of premenstrual dysphoric syndrome. Couple state they have achieved a mutually satisfying sexual relationship.

OUTCOME EVALUATION Evaluation is important in reproductive life planning because anything that causes patients to discontinue or misuse a particular method will leave them at risk of pregnancy. Reassess early (within 1 to 3 weeks) after a couple begins a new method of contraception to prevent such an occurrence. Evaluate not only whether a chosen method is effective but also whether the woman and her partner are satisfied or have further questions. Examples of expected outcomes include:

Patient voices confidence in chosen contraceptive method by next visit. Patient expresses satisfaction with chosen method at follow-up visit. Patient consistently uses chosen method without pregnancy for 1 year.

IMPLEMENTATION

Patients are required to provide informed consent for surgical contraceptive methods or procedures such as vasectomy or tubal ligation. The risks, benefits, alternatives, and proper use of the method and the patient's understanding of his or her rights and responsibilities should be included in the consent form as this helps ensure patients have weighed their options and know the procedure may be irreversible. If you are helping to obtain a consent signature, always do so in the presence of a witness. It is also helpful to refer patients to online resources for further information

The Vas Deferens (Ductus Deferens) Structure: Function:

Structure: hollow tube surrounded by arteries and veins and protected by a thick fibrous coating. Altogether, these structures are referred to as the spermatic cord Function:carries sperm from the epididymis through the inguinal canal into the abdominal cavity, where it ends at the seminal vesicles and the ejaculatory ducts below the bladder. -Sperm complete maturation as they pass through the vas deferens. They are still not mobile at this point, however, probably because of the fairly acidic medium of semen

Two Skene glands and Bartholin glands

Structure: Two Skene glands (paraurethral glands) are located on each side of the urinary meatus; their ducts open into the urethra. Bartholin glands (vulvovaginal glands) are located on each side of the vaginal opening with ducts that open into the proximal vagina near the labia minora and hymen Function: Secretions from both of these glands help to lubricate the external genitalia during coitus. The alkaline pH of their secretions also helps to improve sperm survival in the vagina.

The Bulbourethral Glands Structure: Function:

Structure: Cowper's, glands lie beside the prostate gland and empty by short ducts into the urethra Function: supply one more source of alkaline fluid to help ensure the safe passage of spermatozoa. Semen, therefore, is derived from the prostate gland (60%), the seminal vesicles (30%), the epididymis (5%), and the bulbourethral glands (5%)

The Uterus

Structure: a hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and anterior to the rectum. Development: During childhood, it is about the size of an olive; the cervix is the largest portion and the uterine body is the smallest part. 8 years of age, an increase in the size of the organ begins. This growth is so slow, however, the young woman is closer to 17 years old before the uterus reaches its adult size and changes its proportions so that the body cavity, not the cervix, is its largest portion. Small uterine size may be a contributing factor to the number of low-birth-weight babies typically born to adolescents younger than this age Function: to receive the ovum from the fallopian tube; provide a place for implantation and nourishment; furnish protection to a growing fetus; and, at maturity of the fetus, expel it from a woman's body.

The Scrotum Structure: Function:

Structure: a rugated, skin-covered, muscular pouch suspended from the perineum. function: -to support the testes and help regulate the temperature of sperm. -In very cold weather, the scrotal muscle contracts to bring the testes closer to the body. - In very hot weather, or in the presence of fever, the muscle relaxes, allowing the testes to fall away from the body. In this way, the temperature of the testes can remain as even as possible to promote the production and viability of sperm.

The Fallopian Tubes Structure: Function:

Structure: arise from each upper corner of the uterine body and extend outward and backward until each opens at its distal end, next to an ovary. Fallopian tubes are approximately 10 cm long in a mature woman Function: is to convey the ovum from the ovaries to the uterus and to provide a place for fertilization of the ovum by sperm

The Prostate Gland Structure: Function:

Structure: chestnut-sized gland that lies just below the bladder and allows the urethra to pass through the center of it, like the hole in a doughnut Function: to secrete a thin, alkaline fluid, which, when added to the secretion from the seminal vesicles, further protects sperm by increasing the naturally low pH level of the urethra

The myometrium, or muscle layer of the uterus Structure: Function:

Structure: composed of three interwoven layers of smooth muscle, the fibers of which are arranged in longitudinal, transverse, and oblique directions Function: This intertwining network of fibers is what offers extreme strength to the organ so when the uterus contracts at the end of pregnancy to expel the fetus, equal pressure is exerted at all points throughout the cavity. Another function of the myometrium is to constrict the fallopian tubes at the point they enter the fundus, preventing regurgitation of menstrual blood into the tubes.

The endometrium layer of the uterus Structure: Function:

Structure: consists of two layers of cells and is the one important for menstrual function Function: It grows and becomes so thick and responsive each month under the influence of estrogen and progesterone that it becomes capable of supporting a pregnancy. If pregnancy does not occur, this is the layer that is shed as the menstrual flow. -During pregnancy, so much mucus is produced, the endocervix becomes plugged with mucus, forming a seal to keep out ascending infections (the operculum).

The Vagina Structure: Function:

Structure: hollow, musculomembranous canal located posterior to the bladder and anterior to the rectum. It extends from the cervix of the uterus to the external vulva. -lined with stratified squamous epithelium similar to that covering the cervix. Under this, it has a middle connective tissue layer and a strong muscular wall. Normally, the walls contain many folds or rugae that lie in close approximation to each other Function: Its function is to act as the organ of intercourse and to convey sperm to the cervix. With childbirth, it expands to serve as the birth canal -Even though the vagina opens to the outside, it is considered an internal reproductive organ.

The nipple Structure: Function:

Structure: is composed of smooth muscle capable of erection on manual or sucking stimulation -composed of smooth muscle capable of erection on manual or sucking stimulation -The skin surrounding the nipples is darkly pigmented out to about 4 cm and termed the areola. -approximately 20 small openings through which milk is secreted. An ampulla portion of the duct, located just posterior to the nipple, serves as a reservoir for milk before breastfeeding. Function: On stimulation, it transmits sensations to the posterior pituitary gland to release oxytocin, which then acts to constrict milk glands and push milk forward into the ducts that lead to the nipple (a let-down reflex).

The Mons Veneris Structure: Function:

Structure: pad of adipose tissue located over the symphysis pubis, the pubic bone joint. Covered by a triangle of coarse, curly hairs Function: protect the junction of the pubic bone from trauma

The fourchette and perineal muscle

Structure: ridge of tissue formed by the posterior joining of the labia minora and the labia majora. This is the structure that sometimes tears (laceration) or is cut (episiotomy) during childbirth to enlarge the vaginal opening Function: Posterior to the fourchette is the perineal muscle (often called the perineal body). Because this is a muscular area, it stretches during childbirth to allow enlargement of the vagina and passage of the fetal head.

The vaginal wall

Structure: thin at the fornices that an examiner can palpate the bladder through the anterior fornix, the ovaries through the lateral fornices, and the rectum through the posterior fornix. -the walls contain many folds or rugae that lie in close approximation to each othe Function: A circular muscle at the external opening of the vagina, called the bulbocavernosus muscle, acts as a voluntary sphincter. -Relaxing and tensing this external vaginal sphincter muscle a set number of times each day (Kegel exercises) makes it more supple for birth and helps maintain tone after birth.

The Epididymis Structure: Function:

Structure: tightly coiled tube, over 20 ft long. Some sperm are stored in the epididymis, and a part of the alkaline fluid (semen, or seminal fluid that contains a basic sugar and protein) that will surround sperm at maturity is produced by the cells lining the epididymis Function: responsible for conducting sperm from the tubule to the vas deferens, the next step in the passage to the outside -Sperm are immobile and incapable of fertilization as they pass through or are stored at the epididymis level. It takes at least 12 to 20 days for them to travel the length of the tube and a total of 65 to 75 days for them to reach full maturity. This is one reason that aspermia (absence of sperm) and oligospermia (fewer than 20 million sperm per milliliter) do not appear to respond immediately to therapy but do respond after 2 months of treatment

The blood supply

Structure: to the vagina is furnished by the vaginal artery, a branch of the internal iliac artery. Function: Vaginal tears at childbirth tend to bleed profusely because of this rich blood supply. The same rich blood supply, however, is also the reason any vaginal trauma at birth heals rapidly.

The Seminal Vesicles Structure: Function:

Structure: two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by ejaculatory ducts Function: These glands secrete a viscous alkaline liquid with a high sugar, protein, and prostaglandin content. Sperm become increasingly motile because this added fluid surrounds them with a more favorable pH environment

The Labia Majora Structure: Function:

Structure: two folds of tissue, fused anteriorly but separated posteriorly, which are positioned lateral to the labia minora and composed of loose connective tissue covered by epithelium and pubic hair Function: serve as protection for the external genitalia; they shield the outlets to the urethra and vagina. Trauma to the area, such as occurs from childbirth or rape, can lead to extensive edema formation because of the looseness of the connective tissue base.

The Labia Minora Structure: Function:

Structure: two hairless folds of connective tissue, pink in color; the internal surface is covered with mucous membrane, and the external surface is covered with skin Development: Before menarche, these folds are fairly thin; by childbearing age, they have become firm and full; and after menopause, they atrophy and again become much smaller. Function: protect The area is abundant with sebaceous glands, so localized sebaceous cysts may occur here. Women who perform monthly vulvar examinations are able to detect infection or other abnormalities of the vulva such as sebaceous cysts or herpes lesions.

Uterine Supports Structure: Function:

Structure: uterus is suspended in the pelvic cavity by a number of ligaments that also help support the bladder; it is further supported by a combination of fascia and muscle. Function:free to enlarge without discomfort during pregnancy. If its ligaments become overstretched during pregnancy, however, they may not support the bladder well afterward, and the bladder can then herniate into the anterior vagina (a cystocele), possibly causing frequent urinary infections from status of urine . -If the rectum pouches into the vaginal wall, a rectocele develops, possibly leading to constipation

Uterine Blood Supply Structure: Function:

Structure:The large descending abdominal aorta divides to form two iliac arteries; these then form the hypogastric arteries and the uterine arteries, which supply the uterus Function: Because the uterine blood supply is not far removed from the aorta this way, it is guaranteed to be copious and adequate to supply the growing needs of a fetus. As an additional guarantee that enough blood will be available, after supplying the ovaries with blood, the ovarian artery (a direct subdivision of the aorta) joins the uterine artery and adds more blood to the uterus. -As a uterus enlarges with pregnancy, the vessels "unwind" and stretch as another guarantee that the uterus will maintain an adequate blood supply as the organ grows larger. The uterine veins follow the same twisting course as the arteries; they empty into the internal iliac veins.

The Ovaries Structure: Function:

Structure:approximately 3 cm long by 2 cm in diameter and 1.5 cm thick, or the size and shape of almonds. They are grayish-white and appear pitted, with minute indentations on the surface. The ovaries are located close to and on both sides of the uterus in the lower abdomen. Normally, they lie so low they cannot be located by abdominal palpation. -Only if an abnormality exists, such as an enlarging ovarian cyst, can the resulting tenderness and enlargement be evident on lower left or lower right abdominal palpation. Function: produce, mature, and discharge ova (the egg cells). In the process of producing ova, the ovaries also produce estrogen and progesterone and initiate and regulate menstrual cycles.

vestibule

Structure:flattened, smooth surface inside the labia. The openings to the bladder (the urethra) and the uterus (the vagina) both arise from this space

The clitoris

Structure:is a small (approximately 1 to 2 cm), rounded organ of erectile tissue at the forward junction of the labia minora. It's covered by a fold of skin, the prepuce; Function:is sensitive to touch and temperature; and is the center of sexual arousal and orgasm in a woman. -Arterial blood supply for the clitoris is plentiful. When the ischiocavernosus muscle surrounding it contracts with sexual arousal, the venous outflow for the clitoris is blocked and this leads to clitoral erection.

The Breasts Structure: Development: Function:

Structure:located anterior to the pectoral muscle , and, in many women, breast tissue extends well into the axilla Development: -form early in intrauterine life -remain in a halted stage of development until a rise in estrogen at puberty causes them to increase in size -The glandular tissue of the breasts, necessary for successful breastfeeding, remains undeveloped until a first pregnancy begins. Function: to produce milk for nutrition for an infant or baby.

perimetrium Structure: Function:

Structure:the outermost layer of the uterus, Function:is to add further strength and support to the organ.

The Testes Structure: Function:

Structure:two ovoid glands, 2 to 3 cm wide, that rest in the scrotum. Each testis is encased by a protective white fibrous capsule and is composed of a number of lobules. Each lobule contains interstitial cells (Leydig cells) that produce testosterone and a seminiferous tubule that produces spermatozoa. Function: Produce and formation of sperm and testosterone -Normal testes feel firm and smooth and are egg shaped. Beginning in early adolescence, boys need to learn testicular self-examination so they can detect tenderness or any abnormal growth in testes

SURGICAL ELECTIVE TERMINATION PROCEDURES Dilatation and vacuum extraction (D&E) is used with terminations between

When: 12 and 16 weeks of gestation. Where: either an inpatient or ambulatory setting. In some centers, dilatation of the cervix is begun the day before the procedure by administration of buccal misoprostol or insertion of a laminaria tent (seaweed that has been dried and sterilized) into the cervix. In a moist body part such as the cervix, the seaweed absorbs fluid and swells in size. Over a 24-hour period, gradually, painlessly, and without trauma, it dilates the cervix enough for a vacuum extraction tip to be inserted. Advantage: Termination of fetus during 12th-16th week Disadvantage: concern that if a woman needs frequent surgical dilatation of the cervix, as would occur from frequent abortion procedures, it could lead to a cervix that dilates so easily it would not remain contracted during a subsequent pregnancy. What is given if : Antibiotic prophylaxis may be initiated at the time of the laminaria insertion, and the woman is cautioned not to have sexual relations until the process is complete to protect against infection.

Second - trimester abortion Prostaglandin or a saline induction is used if a pregnancy is between:

When: 16 and 24 weeks Where:is done on an inpatient or same-day surgery basis. Following oral misoprostol or vaginal laminaria to prepare the cervix for dilatation, prostaglandin F2 or E2 is administered followed by a 20% saline injection into the uterus. The saline, because it is hypertonic, causes fluid shifts and sloughing of the placenta and endometrium. -A dilute intravenous solution of oxytocin (Pitocin) to assist the start of contractions may also be used. Pain from the procedure is similar to natural birth but can be controlled by analgesics and breathing exercises. Advantage: drains placenta, terminates pregnancy Disadvantage: water intoxication (fluid accumulating in body tissue), such as severe headache and confusion. A serious potential complication of saline administration is hypernatremia from accidental injection of the hypertonic saline solution into a blood vessel within the uterine cavity. This could cause interstitial fluid to shift into the blood vessels in an attempt to equalize osmotic pressure and result in serious hypertension and dehydration of tissue. What to give: If an intravascular puncture should occur, the woman immediately experiences an increased pulse rate, a flushed face, and a severe headache. The injection must be stopped immediately and an intravenous solution such as 5% dextrose is begun to dilute the saline solution and restore fluid balance Side Effect: vaginal hemorrhage following the procedure, the same as after a term birth. If a procedure is prolonged, a woman may develop disseminated intravascular coagulation , making her very susceptible to hemorrhage because her blood clotting mechanism has become compromised.

Second - trimester abortion D&C is used when the gestational age of a pregnancy is:

When: less than 13 weeks Where:This is done in an ambulatory setting using a paracervical anesthetic block that does not eliminate all pain but limits what the woman experiences to cramping and a feeling of pressure. The cervix is dilated and the uterus is scraped clean with a curette, removing the zygote and trophoblast cells with the uterine lining Advantage: Removes and aborts zygote, ending pregnancy Disadvantage:potential risk of uterine perforation from the instruments used and carries an increased risk of uterine infection compared with menstrual extraction because of the greater cervical dilatation.

A vasectomy can be done.

Where: under local anesthesia in an ambulatory setting, such as in a primary healthcare provider's office or a reproductive life planning clinic. Pain relief:The man may experience a small amount of local pain afterward, which can be managed by taking a mild analgesic and applying ice to the site Checkup: Although the procedure is about 99.5% effective, spermatozoa, which were present in the vas deferens at the time of surgery, can remain viable for as long as 6 months. Therefore, although the man can resume sexual intercourse within 1 week, an additional birth control method should be used until two negative sperm reports at about 6 and 10 weeks have been obtained (proof all sperm in the vas deferens have been eliminated, usually requiring 10 to 20 ejaculations).

INTRAUTERINE DEVICES AND THE PERIMENOPAUSAL WOMAN

Women who are premenopausal are, overall, good candidates for IUDs.

Orgasm phase occurs when stimulation proceeds through the plateau stage to a point at which a vigorous contraction of muscles in the pelvic area expels or dissipates blood and fluid from the area of congestion. What happens in women and men during this stage ?

Women: The average number of contractions for the woman is 8 to 15 contractions at intervals of 1 every 0.8 seconds. Men: muscle contractions surrounding the seminal vessels and prostate project semen into the proximal urethra. These contractions are followed immediately by three to seven propulsive ejaculatory contractions, occurring at the same time interval as in the woman, which force semen from the penis -As the shortest stage in the sexual response cycle, orgasm is usually experienced as intense pleasure affecting the whole body, not just the pelvic area. It is also a highly personal experience: Descriptions of orgasms vary greatly from person to person.

Resolution Phase The resolution is a 30-minute period during which the external and internal genital organs return to an unaroused state. What happens in women and men during this stage ?

Women: do not go through this refractory period, so it is possible for women who are interested and properly stimulated to have additional orgasms immediately after the first. Men: a refractory period occurs during which further orgasm is impossible.

Plateau Phase The plateau stage is reached just before orgasm. What happens in women and men during this stage ?

Women: the clitoris is drawn forward and retracts under the clitoral prepuce, the lower part of the vagina becomes extremely congested (formation of the orgasmic platform), and there is increased breast nipple elevation. Men: vasocongestion leads to distention of the penis. Heart rate increases to 100 to 175 beats/min and respiratory rate to about 40 breaths/min

Excitement Phase Excitement occurs with physical and psychological stimulation (sight, sound, emotion, or thought) that causes parasympathetic nerve stimulation. This leads to arterial dilation and venous constriction in the genital area. The resulting increased blood supply leads to vasocongestion and increasing muscular tension. What happens in women and men during this stage ?

Women: vasocongestion causes the clitoris to increase in size and mucoid fluid to appear on vaginal walls for lubrication. The vagina widens in diameter and increases in length. Breast nipples become erect Men: penile erection occurs as well as scrotal thickening and elevation of the testes. In both sexes, there is an increase in heart and respiratory rate and blood pressure

COCs typically increase or strengthen the action of some drugs such as caffeine and corticosteroids. They may also interact with drugs such as

acetaminophen, anticoagulants, and some anticonvulsants by reducing their therapeutic effect, so women may be advised to temporarily change their method of birth control while prescribed these drugs. Several drugs, such as barbiturates, griseofulvin, isoniazid, penicillin, and tetracycline, decrease the effectiveness of COCs, so women might want to change their contraceptive method temporarily while taking these drugs

In males, androgenic hormones are produced by the

adrenal cortex and the testes -The level of the primary androgenic hormone, testosterone, is low in males until puberty (between ages 12 and 14 years) when it rises to influence pubertal changes in the -testes, -scrotum, -penis, -prostate, and seminal vesicles; -the appearance of male pubic, axillary, and facial hair; -laryngeal enlargement with its accompanying voice change; -maturation of spermatozoa; and closure of growth plates in long bones (termed adrenarche)

With maturity, a uterus is about 5 to 7 cm long, 5 cm wide, and, in its widest upper part, 2.5 cm deep. In a nonpregnant state, it weighs

approximately 60 g.

When palpating for breast health, always include the

axillary region in the examination, or this breast tissue can be missed. -Women should be aware of the usual appearance of their breasts (breast awareness) so they can report any change in contour or density to their healthcare provider.

TEAMWORK AND COLLABORATION Suppose Dana, 17 years old, chooses intramuscular injections of DMPA as her method of reproductive life planning. What instructions would the nurse want members of the care team to give her with regard to this method? a. "Encourage Dana to limit cigarette smoking to no more than one pack per day." b. "Encourage Dana to drink a glass of milk or take a calcium supplement daily." c. "Teach Dana not to swim for longer than an hour at any one time." d. "Teach Dana not to expose the injection site to direct sunlight."

b. "Encourage Dana to drink a glass of milk or take a calcium supplement daily." Intramuscular injections (DMPA) are associated with osteoporosis, so recommending a high calcium intake is important

QSEN Checkpoint Question 6.2 QUALITY IMPROVEMENT Dana, 17 years old, wants to try female condoms as her reproductive planning method. If the nurse was creating a relevant educational handout, it should include which of the following directives? a. The hormone that condom use stimulates may cause mild weight gain. b. Female condoms should be inserted before any penile penetration. c. Women should coat the condom with a spermicide before use. d. Female condoms, unlike male condoms, can be reused after being washed.

b. Female condoms should be inserted before any penile penetration.

PATIENT-CENTERED CARE Suppose Dana, 17 years old, tells the nurse she wants to use a fertility awareness method of contraception. How should the nurse best meet Dana's learning needs? a. The nurse should teach her to record if she feels hot and whether she is perspiring heavily. b. The nurse should teach her to assess whether her cervical mucus is thin and watery. c. The nurse should teach her to monitor her emotions for sudden anger or crying. d. The nurse should teach her to assess whether her breasts feel sensitive to cool air.

b. The nurse should teach her to assess whether her cervical mucus is thin and watery.

For counseling to be successful, it is necessary to understand how various methods of contraception work and how they compare in terms of

benefits and disadvantage -Although there are many contraceptive options for reliable pregnancy prevention, only condoms (both male and female) provide protection against sexually transmitted infections (STIs) or HIV—an important concern if a relationship is not a monogamous one.

PATIENT-CENTERED CARE Suzanne Matthews tells the nurse she's worried she might be subfertile because both breast development and her first menstrual period occurred later than most of her friends. To increase her self-esteem and meet her learning needs, the nurse could assure her of what fact? a. Adrenarche, the development of breasts, typically occurs before the first menstrual period. b. Breast development, termed mamarche, is not fully complete until about age 25 years. c. The time for development of breasts varies a great deal and is termed thelarche. d. Menarche, the term for breast development, typically occurs before 12 years

c. The time for development of breasts varies a great deal and is termed thelarche.

QUALITY IMPROVEMENT Suppose Kevin Matthews tells the nurse he is planning on having a vasectomy after the birth of his new child but is worried about having his testes removed this way. The nurse would want the clinic's educational material on vasectomy to clearly state that this procedure involves which of the following structures? a. The seminal vesicles b. The epididymis c. The vas deferens d. The ducts of the bulbourethral glands

c. The vas deferens

Because the fallopian tubes are open at their distal ends, a direct pathway exists from the external genital organs, through the vagina to the uterus and tubes, to the peritoneum. This open pathway is what makes

conception possible. It also, however, can lead to infection of the peritoneum (peritonitis) if germs spread from the perineum through the uterus and tubes to the pelvic cavity. -For this reason, clean technique must be used during pelvic examinations. -During labor and birth, vaginal examinations are done with sterile technique to ensure no organisms can enter by this route.

INFORMATICS The nurse documents the fact that Suzanne Matthews typically has a menstrual cycle of 34 days. If she had coitus on days 8, 10, 15, and 20 of her last cycle, which is the day on which she most likely conceived? a. The 8th day b. The 10th day c. Day 15 d. Day 20

d. Day 20

QSEN Checkpoint Question 6.3 SAFETY Suppose Dana, 17 years old, chooses to use a COC as her family planning method. What is a danger sign of COCs the nurse would ask her to report? a. A stuffy or runny nose b. Arthritis-like symptoms c. Weight gain over 5 lb d. Severe migraine headache

d. Severe migraine headache

TEAMWORK & COLLABORATION On physical examination, Suzanne Matthews is found to have a cystocele. The nurse should confirm that the vocational nurse who is contributing to Suzanne's care knows that a cystocele can cause which of the following? a. A fear of developing cancer from the sebaceous vulvar cyst that develops b. Nagging pain from protrusion of the lower intestine into the posterior vagina c. Bleeding from the prolapse of the uterine body and cervix into the distal vagina d. Urinary infection from the pocket caused by pressure against the anterior vaginal wall

d. Urinary infection from the pocket caused by pressure against the anterior vaginal wall

At about week 12 of intrauterine life, the external genitals begin to

develop. In males, penile tissue elongates and the ventral surface of the penis closes to form a urethra. In females, with no testosterone present, the uterus, labia minora, and labia majora form.

Assessment:REPRODUCTIVE AND SEXUAL HEALTH Problems of sexual or reproductive health may not be evident on first meeting with patients because it may be difficult for people to bring up the topic until they feel more secure with your relationship. This makes good follow-through and planning important because even if people find the courage to discuss a problem once, they may be unable to

do so again. If the problem is ignored or forgotten through a change in caregivers, the problem can go unsolved. Any change in physical appearance (such as occurs with puberty or with pregnancy) can intensify or create a sexual or reproductive concern. The person with a sexually transmitted infection (STI); excessive weight loss or gain; a disfiguring scar from surgery or an unintentional injury; hair loss such as occurs with chemotherapy; surgery, inflammation, or infection of reproductive organs; chronic fatigue or pain; spinal cord injury; or the presence of a retention catheter needs to be assessed for problems regarding sexual role as well as other important areas of reproductive functioning.

IMPLEMENTATION A primary nursing role concerning reproductive anatomy and physiology is

education because both female and male patients may feel more comfortable asking questions of nurses rather than other healthcare providers. For example, nurses may be asked about contraception or fertility needs, STI prevention, or concerns related to congenital health conditions. It is important to address potential concerns of patients of all sexual orientations and gender identities when providing reproductive and sexual health education. For example, include a discussion about anal or oral-genital sex practices when presenting information on safer sex.

It is also recognized that COCs can interfere with glucose metabolism. For this reason, women with diabetes mellitus or a history of liver disease, including hepatitis, are

evaluated individually before COCs are prescribed. The World Health Organization (WHO) recommends women who experience migraines with an aura or those who take certain drugs for seizures avoid the use of oral contraceptives as these women may be at an increased risk for cerebrovascular accident

If testosterone is not present by week 10, the paramesonephric duct becomes dominant and develops into

female reproductive organs. -When ovaries form, all of the oocytes (cells that will develop into eggs throughout the woman's mature years) are already present

If, for some reason, testosterone secretion is halted in utero, a chromosomal male could be born with

female-appearing genitalia (ambiguous genitalia)

In most girls, puberty changes are stimulated when the hypothalamus synthesizes and releases gonadotropin-releasing hormone (GnRH), which then triggers the anterior pituitary to release

follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH are termed gonadotropin (gonad = "ovary"; tropin = "growth") hormones not only because they begin the production of androgen and estrogen, which in turn initiate secondary sex characteristics, but also because they continue to cause the production of eggs and influence menstrual cycles throughout women's lives

The Female Reproductive System The female reproductive system, like the male, has both external and internal components. The study of the female reproductive organs is

gynecology

When a woman lies on her back, as she does for a pelvic examination, the course of the vagina is

inward and downward. Because of this downward slant and the angle of the uterine cervix, the length of the anterior wall of the vagina is about 6 to 7 cm and the length of the posterior wall is 8 to 9 cm. At the cervical end of the structure, there are recesses on all sides, termed the posterior, anterior, and lateral fornices.

Elective Termination of Pregnancy Unsupervised abortions are terminations of pregnancy performed by unskilled people, often under less than sterile conditions at any point in pregnancy. An elective termination of pregnancy is a procedure performed by a :

knowledgeable healthcare provider to end a pregnancy before fetal viability. Such procedures are also referred to as therapeutic, medical, or induced abortions. Pt. Education: -Women should be educated that elective termination is not ideal as a method of reproductive life planning but should be used as remediation for failed contraception. In addition, women should be counseled about other options such as adoption or single parenthood before the procedure

Studies of female athletes and girls with anorexia nervosa demonstrate that delays or halts in menstruation are related to the

lack of body fat or energy expenditure

Mucus produced by the vaginal lining has a rich glycogen content. When this glycogen is broken down by the lactose-fermenting bacteria that frequent the vagina

lactic acid is formed. This causes the usual pH of the vagina to be acidic, a condition detrimental to the growth of pathologic bacteria, so even though the vagina connects directly to the external surface, infection of the vagina does not readily occur. You can advise women not to use vaginal douches or sprays as a daily hygiene measure so they do not clear away this natural acidic medium because this would invite infection

The blood supply to the breasts is profuse because it is supplied by

large thoracic branches of the axillary, internal mammary, and intercostal arteries. This effective blood supply is necessary so milk glands can be supplied with nutrients and fluid to make possible a plentiful supply of milk for breastfeeding. Unfortunately, this rich blood connection also aids in the metastasis of breast cancer if cancer is not discovered early

Natural Family Planning and the Postpartal Woman

most women are interested in delaying their next pregnancy until their new baby is older This makes them good candidates for natural family planning as they can breastfeed with these methods without worrying about hormonal contamination or a decrease in breast milk. However, a postpartal woman often ovulates before her first menstrual cycle and should be warned that she could become pregnant even before her return to menses.

The lining of the fallopian tubes is composed of a mucous membrane, which contains both

mucus-secreting and ciliated (hair-covered) cells. Beneath this mucous lining are connective tissue and a circular muscle layer. The muscle layer is important because it is able to produce peristaltic motions that help conduct the ovum the length of the tube (probably also aided by the action of the ciliated lining and the mucus, which acts as a lubricant). The mucus produced may also serve as a source of nourishment for the fertilized egg because it contains protein, water, and salts.

The Role of Androgen Androgenic hormones are the hormones responsible for ?

muscular development, physical growth, and the increase in sebaceous gland secretions that cause typical acne in both boys and girls during adolescence.

Circumcision vs Un-circumcision At the distal end of the organ is a bulging, sensitive ridge of tissue called the glans. A retractable casing of skin, the prepuce, protects the

nerve-sensitive glans at birth. Based on religious or cultural beliefs, many male infants have the prepuce tissue removed surgically (circumcision) shortly after birth

After a pregnancy, the uterus

never returns to exactly its nonpregnant size but remains approximately 9 cm long, 6 cm wide, 3 cm thick, and 80 g in weight

Because the milk glands are the structures important for breastfeeding and the size of breasts is associated with fat deposits, the size of breasts has

no effect on whether a woman can successfully breastfeed.

During a physical examination, it's important to include observation for what in females and males ?

normal distribution of body hair such as triangle-shaped pubic hair in women and diamond-shaped pubic hair in men, normal genital and breast development, and signs and symptoms of STIs. Many STIs are asymptomatic, so it is important to assess whether the patient is at risk for contracting such an infection

Because no method of contraception, except abstinence, offers 100% protection against pregnancy, it is important to carefully answer a patient's questions regarding methods of contraception. It is necessary to be prepared to answer questions about postcoital protection if there were unprotected sexual relations as well as elective termination of pregnancy if contraception failed. Only when couples have sufficient information in all these areas and the freedom to discuss specific concerns can they be prepared to make a decision that will be right for them. An ideal contraceptive should be:

o Safe o Effective o Compatible with religious and cultural beliefs and personal preferences of user and partner o Free of bothersome side effects o Convenient to use and easy to obtain o Affordable and needing few instructions for use o Free of effects on future pregnancies after discontinuation

Nursing Care Planning Based on Family Teaching

offer empathy for a patient's concerns, such as a woman's worry that increased tension before menstruation is a symptom of premenstrual dysphoric syndrome, to help her validate her suspicions. Websites set up by health professionals can be an ideal method for adolescents to learn more about their bodies and safer sex practices because they can do this in a private, nonjudgmental setting Again, follow-up is important to be certain the content was understood and the adolescent didn't also visit websites with misleading information.

Sexual violence or violence in general occurs when

one partner does not respect these boundaries. This is a particular concern for maternal and child health nurses because intimate partner violence tends to occur at an increased frequency during pregnancy -Young children and adolescents are also persons targeted for sexual maltreatment

At approximately week 5 of intrauterine life, mesonephric (wolffian) and paramesonephric (müllerian) ducts, the tissue that will become

ovaries and testes, have already formed

Female internal reproductive organs include the

ovaries, the fallopian tubes, the uterus, and the vagina.

Any person who interprets a procedure such as a colostomy as disfiguring may be reluctant to participate in sexual activities, fearing the sight of an apparatus will diminish their

partner's satisfaction. People with chronic pain such as from arthritis may be too uncomfortable to enjoy sexual relations. Individuals with urinary catheters may be concerned about their ability to enjoy coitus with the catheter in place. For women, a retention catheter should not interfere with coitus. Men can be taught how to replace their own catheter, so they can remove it for sexual relations. -Encouraging these patients to ask questions and work on specific difficulties is a nursing role.

When discussing COCs, be certain to assess both a woman's ability to

pay for them and her ability to follow instructions faithfully

BARRIER METHODS OF CONTRACEPTION Barrier methods are forms of birth control that

place a chemical or latex barrier between the cervix and advancing sperm so sperm cannot reach and fertilize an ovum.

The posterior fornix serves as a place for the

pooling of semen after coitus; this allows for a large number of sperm to remain close to the cervix and encourages sperm migration into the cervix.

If the ovaries are removed before puberty (or are nonfunctional), the resulting absence of estrogen normally produced by the ovaries

prevents maturation and maintenance of secondary sex characteristics; in addition, pubic hair distribution will assume a more male than female pattern.

As with a vasectomy, however, woman should view tubal ligation as a permanent, irreversible

procedure as the length of their tube may be shortened afterward, interfering with fertilization -can turn to in vitro fertilization (IVF) as a method to have future children

Mifepristone (RU-486 or Mifeprex) is a progesterone antagonist that blocks the effect of:

progesterone, preventing implantation of the fertilized ovum and therefore causing the pregnancy to be lost. When used for a medical termination of pregnancy, the compound is taken as a single oral dose any time before 63 days gestational age followed by buccal or vaginal misoprostol (Cytotec) (a prostaglandin), which causes uterine contractions. Some women may also be prescribed an antibiotic as prophylactic protection against infection. Advantage: -prevents implantation of fertilized ovum -prescribed to women for regression of uterine leiomyomas or detoxification in cocaine overdose. Disadvantage: infections Side Effect: infections, bleeding

Sexual harassment may be so distressing that it can lead to short- or long-term

psychosocial consequences for victims and their families such as emotional distress (e.g., anxiety, depression, posttraumatic stress disorder, substance abuse), interpersonal conflict, and impaired intimacy and sexual functioning

A fold of peritoneum behind the uterus is the posterior ligament. This forms a pouch (Douglas cul-de-sac) between the

rectum and uterus. Because this is the lowest point of the pelvis, any fluid (such as blood) released from a condition, such as a ruptured tubal (ectopic) pregnancy, tends to collect in this space. The space can be examined for the presence of fluid or blood to help in diagnosis by inserting a culdoscope through the posterior vaginal wall (culdoscopy) or a laparoscope through the abdominal wall (laparoscopy)

Side Effects and Contraindications of depo shot

s/e headache, weight gain, depression, irregular or heavy menstrual cycles for 1 year, and no menstrual bleeding after the first year rx factors -DMPA may also impair glucose tolerance in women at risk for diabetes so it should be prescribed cautiously for this population. -increase in the risk for osteoporosis from a loss of bone mineral density, women need to include an adequate amount of calcium in their diet (up to 1,200 mg/day) and engage in weight-bearing exercise daily to minimize this risk.

PUBERTAL DEVELOPMENT Puberty is the stage of life at which

secondary sex changes begin

MASTURBATION

self-stimulation for erotic pleasure; it can also be a mutually enjoyable activity for sexual partners. It offers sexual release, which may be interpreted by the person as overall tension or anxiety relief. Masters et al. (1998) reported women may find masturbation to orgasm the most satisfying sexual expression and use it more commonly than men

The vagina has both sympathetic and parasympathetic nerve innervations originating at the S1-S3 levels. Despite this dual nerve supply, the vagina is not an extremely

sensitive organ. Sexual excitement, often attributed to a vaginal origin, is actually mainly a clitoral function.

The nipple on these auxiliary sites may look like a mole, so adolescents may report this as a "mole changing in color" or be concerned they have skin cancer. You can assure them

supernumerary breast tissue or nipples are not uncommon and are innocent findings.

If the Skene glands or the Bartholin glands (the most common site) become infected, they

swell, feel tender, and produce a serous discharge.

By week 7 or 8, in chromosomal males, this early gonadal tissue begins formation of ___________ Under the influence of testosterone, the mesonephric duct develops into male reproductive organs and the paramesonephric duct regresses.

testosterone.

Female condoms pt. teaching

the sheath may be inserted any time before sexual activity begins and then removed after ejaculation occurs

At the beginning of each cycle, when estrogen secretion from the ovary is low, cervical mucus is

thick and scant. Sperm survival in this type of mucus is poor.

At the time of ovulation, when the estrogen level has risen to a high point, cervical mucus becomes

thin, stretchy (spinnbarkeit), and copious. Sperm penetration and survival in this thin mucus are both excellent. Because progesterone becomes the major influencing hormone during the second half of the cycle, cervical mucus again thickens and sperm survival is again poor

The Penis The penis is composed of

three cylindrical masses of erectile tissue in the penis shaft. The urethra passes through these layers of tissue, allowing the penis to serve as both the outlet for the urinary and reproductive tracts in men. -With sexual excitement, nitric oxide is released from the endothelium of blood vessels. This causes dilation and an increase in blood flow to the arteries of the penis (engorgement). The ischiocavernosus muscle at the base of the penis, under stimulation of the parasympathetic nervous system, then contracts, trapping both venous and arterial blood in the three sections of erectile tissue. This leads to distention (and erection) of the penis.

Sexual harassment is

unwanted, repeated sexual advances, remarks, or behavior toward another that is offensive to the recipient or interferes with job or school performance. It can involve actions as obvious as a job superior demanding sexual favors from an employee, or it could be a man or woman sending sexist jokes by e-mail to another person in the department. In school, it can refer to bullying

An important organ relationship to be aware of is the close proximity of uterine blood vessels and

ureters. Ureters pass from the kidneys on their way to the bladder directly behind the ovarian vessels, near the fallopian tubes This close anatomic relationship has implications in procedures such as tubal ligation, cesarean birth, and hysterectomy (removal of the uterus) because a ureter this close to the fallopian tubes can be injured if bleeding during surgery is controlled by clamping of the uterine or ovarian vessels. This is a reason a first voiding after uterine or tubal surgery is measured and assessed carefully for color or the presence of blood.

The Uterus ( menstration cycle)

uterine changes that occur monthly as a result of stimulation from the estrogen and progesterone produced by the ovaries 1. Proliferative 2.Secretory 3.Ischemic 4.Menses

FEMALE EXTERNAL STRUCTURES The structures that form the female external genitalia are termed the

vulva (from the Latin word for "covering")

Menopause: Changes in Female Reproductive Cycle

´Signals the end of menstruation ´Ends the fertile period in females ´Stops the production of ova

Medically induced termination of pregnancy is contraindicated if a woman has:

• A confirmed or suspected ectopic pregnancy (only methotrexate is used and the woman needs additional follow-up) • An IUD in place • A serious medical condition such as chronic adrenal failure • A history of current long-term systemic corticosteroid therapy • A history of allergy to mifepristone, misoprostol, or other prostaglandins • A hemorrhagic disorder or is taking concurrent anticoagulant therapy

Many women cannot use cervical caps because their cervix is too short for the cap to fit properly. Like diaphragms, they must be fitted individually by a healthcare provider. They include a small strap, which can be grasped for easy removal. They are contraindicated in any woman who has:

• An abnormally short or long cervix • A current abnormal Pap smear • A history of TSS • An allergy to latex or spermicide • A history of cervicitis or cervical infection • A history of cervical cancer • Undiagnosed vaginal bleeding

HORMONAL CONTRACEPTION AND EFFECT ON PREGNANCY Different hormonal applications have different effects on pregnancy.

• Estrogen/progestin combination pills (COCs). If a woman taking an estrogen/progestin combination pill suspects she is pregnant, she should discontinue taking any more pills if she intends to continue the pregnancy as high levels of estrogen might be teratogenic to a growing fetus . -After women stop taking COCs, they may not be able to become pregnant for 1 or 2 months, and possibly 6 to 8 months, because the pituitary gland requires a recovery period to resume cyclicgonadotropin stimulation. If ovulation does not return spontaneously after this time, there is likely an underlying hormonal imbalance and ovulation can be stimulated by administration of FSH, LH, clomiphene citrate (Clomid), or letrozole (Femara) to restore fertility. • Progestin-impregnated rings or progestin patches. If a woman using a progestin ring or patch becomes pregnant, the progestin should have no effect on a developing fetus. After discontinuing both methods, women become fertile again immediately. • DMPA. DMPA, like other progestin products, should have no effect if a woman becomes pregnant. A worrisome post-use effect for some women, however, is that the return to fertility is often delayed by 6 to 12 months.

Secondary Sex Characteristics Adolescent sexual development has been categorized into stages. There is wide variation in the time required for adolescents to move through these developmental stages; however, the sequential order is fairly constant. In girls, pubertal changes typically occur as:

• Growth spurt • Increase in the transverse diameter of the pelvis • Breast development • Growth of pubic hair • Onset of menstruation • Growth of axillary hair • Vaginal secretions

EMERGENCY POSTCOITAL CONTRACEPTION

• High-dose progestin-based pills • Insertion of a copper IUD •Ulipristal acetate (known as ella) Advantage: potential to greatly reduce the number of unintended pregnancies and abortion, fear of side effects, reluctance to have a pelvic examination (not necessary), lack of knowledge about how to use the pills, and reluctance to ask a family pharmacist for the pills limit the number of these products being sold Disadvantage: It may be important to explain to women postcoital methods such as Plan B One-Step and Next Choice (the most frequently used forms) do not cause abortion; the pills work by inhibiting ovulation and interfering with fertilization by slowing the transport of sperm. An IUD creates changes in the endometrium and cervical mucus to also slow or prevent sperm transport Side Effect: bleeding

Nursing Care Planning Based on 2020 National Health Goals

• Increase the proportion of adolescents who receive formal instruction on abstinence before 18 years of age from a baseline of 87.2% to a target of 95.9%. • Increase the proportion of females less than 15 years of age who have never had sexual intercourse from a baseline of 82.9% to a target of 91.2%; of males, from 82.0% to 90.2%. • Reduce the proportion of females experiencing pregnancy despite use of a reversible contraceptive method from a baseline of 12.4% to a target of 9.9%. • Increase the proportion of intended pregnancies from a baseline of 51% to a target of 56%. • Decrease the proportion of births occurring within 18 months of a previous birth from a baseline of 35.3% to a target of 31.7% -Nurses can help the nation achieve these objectives by teaching people, especially adolescents, about contraceptive options while being cautious to avoid indirectly encouraging sexual activity among teens.

Nursing Care Planning Based on 2020 National Health Goals A number of 2020 National Health Goals speak directly to reproductive and sexual health:

• Increase the proportion of adolescents who, by age 15 years, have never engaged in sexual intercourse to 80.2% of girls and 79.2% of boys from baselines 72.9% and 72.0%. • Increase to at least 91.3% the proportion of sexually active 15- to 19-year-olds at risk for unintended pregnancy who used contraception at last sexual intercourse from a baseline of 83.0%. • Reduce deaths from cancer of the uterine cervix to no more than 2.2 per 100,000 women, from a baseline rate of 2.4 per 100,000. • Reduce breast cancer deaths to no more than 20.6 per 100,000 women, from a baseline rate of 22.9 per 100,000. • Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals (developmental goal)

PSYCHOLOGICAL ASPECTS OF ELECTIVE TERMINATION OF PREGNANCY Women of all ages request elective terminations. For such a procedure, the usual profile is a woman who:

• Is young; 18% of women obtaining abortions are teenagers, women in their 20s account for more than 50% of abortions. • Is unmarried, 45% of all women seeking abortions • Has had a previous live birth; 61% of abortions are obtained by women who have one or more child. • Undergoes the procedure to end an unintended pregnancy; 75% of women report economic issues limiting their ability to care for a child. • Has not taken any or adequate protection against becoming pregnant; however, 51% of women seeking abortion used contraception during the month they got pregnant, either condoms or a hormonal method. • Abortions are provided to women of all races, 1/3 white women, 1/3 black women, 1/4 Hispanic women, and 9% to women of other races. • Most women obtaining abortion are low income, 42% below the federal poverty line, and 27% just above the federal poverty line -Those few who express sadness and guilt may need to be referred for professional counseling so they can integrate and accept this event in their lives. -Only 1.9% of women seeking elective termination of pregnancy do so for reasons associated with rape. However, around 20% of women are raped at some point in their life

Popular COCs prescribed in the United States are:

• Monophasic pills, which contain fixed doses of both estrogen and progestin throughout a 21-day cycle • Biphasic, or preparations that deliver a constant amount of estrogen throughout the cycle but varying amounts of progestin • Triphasic and tetraphasic preparations, which vary in both estrogen and progestin content throughout the cycle -Typical pills are supplied in 28-pill dispensers (21 active pills and 7 placebo pills) labeled with the day of the cycle they should be taken. Newer forms designed to eliminate menses are supplied in 84-day dispensers (see the following). Caution women to always take pills in the order designated by the dispenser or the progesterone level could be inaccurate and ineffective for that day

Women can set a start date for a cycle of pills in one of four ways:

• Sunday start: Take the first pill on the first Sunday after the beginning of a menstrual flow. • Quick start: Begin pills as soon as they are prescribed. Beginning pills immediately after a prescription is filled may increase compliance, reducing unintended pregnancies. • First day start: Begin pills on the first day of menses. • After childbirth : a woman should start the contraceptive on a day (or Sunday) closest to 2 weeks after birth; after an elective termination of pregnancy, she could begin on a chosen day or the first Sunday after the procedure. -Because COCs are not effective for the first 7 days, advise women to use a second form of contraception during the initial 7 days that they take pills. A woman begins a second dispenser of pills the day after finishing the first dispenser. Menstrual flow will begin during the 7 days on which she is taking the placebo tablets.

Anatomically, the uterus consists of three divisions: the body or corpus, the isthmus, and the cervix.

• The body of the uterus is the uppermost part and forms the bulk of the organ. The portion of the uterus between the points of attachment of the fallopian tubes is termed the fundus. During pregnancy, the body of the uterus is the portion of the structure that expands to contain the growing fetus. The fundus is the portion that can be palpated abdominally to determine the amount of uterine growth during pregnancy, to measure the force of uterine contractions during labor, and to assess that the uterus is returning to its nonpregnant state after childbirth. • The isthmus is a short segment between the body and the cervix. In the nonpregnant uterus, it is only 1 to 2 mm in length. During pregnancy, this portion also enlarges greatly to aid in accommodating the growing fetus. It is the portion where the incision most commonly is made when a fetus is born by a cesarean birth. • The cervix is the lowest portion of the uterus. It represents about one third of the total uterine size and is approximately 2 to 5 cm long. About half of it lies above the vagina and half extends into the vagina. Its central cavity is termed the cervical canal. The opening of the canal at the junction of the cervix and isthmus is the internal cervical os; the distal opening to the vagina is the external cervical os. The level of the external os is at the level of the ischial spines (an important relationship in estimating the level of the fetus in the birth canal at the time of birth).

Uterine and Cervical Coats The uterine wall consists of three separate coats or layers of tissue:

• The endometrium, an inner layer of mucous membrane • The myometrium, a middle layer of muscle fibers • The perimetrium, an outer layer of connective tissue

Although a fallopian tube is a smooth, hollow tunnel, it is anatomically divided into four separate parts

• The most proximal division, the interstitial portion, is the part of the tube that lies within the uterine wall. This portion is only about 1 cm in length; its lumen is only 1 mm in diameter. • The next distal portion is the isthmus. This is about 2 cm in length and, like the interstitial tube, remains extremely narrow. This is the portion of the tube that is cut or sealed in a tubal ligation, or tubal sterilization procedure. • The ampulla is the third and also the longest portion of the tube. It is about 5 cm in length and is the portion of the tube where fertilization of an ovum usually occurs. • The infundibular portion is the most distal segment of the tube. It is about 2 cm long, funnel shaped, and covered by fimbria (small hairs) that help to guide the ovum into the fallopian tube.