N144 Week 2 Case Study - Susan Wilson (1)

Susan has noticed some darkening of her face in the shape of a "mask." You advise her that this is normal and record it as ________________.

chloasma

You instruct Susan about taking her daily iron supplement. Which of the following statements should be included in the teaching session? Select all that apply "Take the iron supplement first thing in the morning to avoid gastrointestinal discomfort." "Drink a glass of milk along with your iron supplement." "Increase your intake of citrus fruits and juices." "If tolerated, take the iron supplement on an empty stomach."

"Increase your intake of citrus fruits and juices." "If tolerated, take the iron supplement on an empty stomach." Iron supplements can cause gastrointestinal discomfort, especially when taken in the morning. Discomfort can be alleviated by taking iron supplements at bedtime instead of the morning. Milk decreases iron absorption from the gastrointestinal tract and should not be taken along with an iron supplement. Iron absorption is enhanced when intake of Vitamin C is increased. Citrus fruits and juices, tomatoes, melons, and strawberries are all high in Vitamin C and should be encouraged when iron supplements are prescribed. Absorption is optimal when an iron supplement is taken on an empty stomach. Pregnant women taking iron supplements should be encouraged to take supplements on an empty stomach, provided gastrointestinal distress is not a problem.

In counseling Susan about sexual activity during pregnancy, which of the following comments would be best? "You are very fortunate. Most women don't want anything to do with sex during pregnancy." "It is common for sexual desire to vary during pregnancy." "It's great that you enjoy sex now. You will need to abstain from sex after 36 weeks." "Be very careful about sexual relations during pregnancy. Orgasm can cause preterm labor."

"It is common for sexual desire to vary during pregnancy." This comment would be appropriate. Sexual desire during pregnancy is variable. However, during the first trimester, when the pregnant woman is fatigued and experiencing nausea, sexual desire may diminish. The second trimester may bring an increased libido, with an improved sense of well-being. In the third trimester, sexual desire may wane, as physical bulkiness and fatigue become major concerns. In general, however, sexual desire during pregnancy is highly individual. Telling her that women don't want anything to do with sex during pregnancy would not be accurate. While sexual desire and response varies among pregnant women, most women still find pleasure in sexual relations during pregnancy. This response would not give correct advice. As long as Susan experiences no complications, it is safe for her to continue to have intercourse until her membranes rupture. This response would not give correct advice. While orgasm is known to cause uterine contractions, it rarely results in preterm labor.

Susan is curious about when she should gain all this weight. Your response is based on the concept that: primigravidas should gain two pounds (0.9 kg) per week throughout pregnancy most women gain more than half their weight by the end of the first trimester amount of weight gain is more critical than the pattern of weight gain 2-5 pounds (0.9 - 2.3 kg) should be gained in the first trimester, then an average of one pound per week thereafter

2-5 pounds (0.9 - 2.3 kg) should be gained in the first trimester, then an average of one pound per week thereafter The recommended pattern of weight gain during pregnancy is 2-5 pounds (0.9 - 2.3 kg) during the first trimester, and an average of one pound (0.5 kg) per week during the second and third trimesters. The developing fetus increases in size more dramatically during the second and third trimesters. Poor weight gain during the first trimester is associated with an increased risk of a small-for-gestational age (SGA) infant. Poor weight gain in the last half of pregnancy is associated with increased risk for preterm delivery. Weight gain during pregnancy is based on pre-pregnancy weight for height (body mass index), not on gravidity. The majority of weight gain during pregnancy should occur AFTER the first trimester, not during the first trimester. The pattern of weight gain during pregnancy is equally as important as the amount of weight gain. Progressive weight gain is necessary for normal growth and development of the fetus and for buildup of maternal stores to prepare the body for lactation.

You advise Susan that an appropriate weight gain during pregnancy based on her weight and height would be: 15 pounds (7 kg) 15 - 25 pounds (7 - 11.5 kg) 25 - 35 pounds (11.5 - 16 kg) 28 - 40 pounds (12.5 - 18 kg)

25 - 35 pounds (11.5 - 16 kg) For a woman who is obese according to body mass index, an appropriate weight gain during pregnancy would at least 15 pounds (7 kg). Susan is normal weight for her height. For a woman determined to be overweight by body mass index, an appropriate weight gain during pregnancy would be 15-25 pounds (7 - 11.5 kg). Susan is normal weight for her height. An appropriate weight gain during pregnancy for Susan, who is normal weight for her height, would be 25-35 pounds (11.5 - 16 kg). For a woman who is underweight, an appropriate weight gain would be 28-40 pounds (12.5 - 18 kg). For a woman determined to be overweight, an appropriate weight gain would be 15-25 pounds (7 - 11.5 kg). For a woman who is obese, an appropriate weight gain during pregnancy would be at least 15 pounds (7 kg). For a woman who is underweight, based on body mass index, an appropriate weight gain during pregnancy would be 28-40 pounds (12.5 - 18 kg). Susan is normal weight for her height.

What measures could you suggest to Susan to help decrease or alleviate the annoying discomfort of heartburn? Select all that apply Lie down for 15-30 minutes immediately after eating Avoid fatty and gas-producing foods Maintain good posture Take any over-the-counter liquid antacid after meals Eat six small meals a day instead of three large meals

Avoid fatty and gas-producing foods Maintain good posture Eat six small meals a day instead of three large meals Lying down after eating would not be advisable, as it would increase the likelihood of gastroesophageal reflux and subsequent heartburn. Maintaining the upright position after eating would be helpful. Fatty and gas-producing foods are known to contribute to heartburn. It would be appropriate to recommend to Susan that they be avoided. Maintaining an erect, non-stooped posture would promote emptying of the stomach and prevent gastroesophageal reflux, which could contribute to heartburn. It would be unsafe to recommend any antacids to Susan. Antacids with a high sodium content (such as sodium bicarbonate) may cause fluid retention. Susan should discuss her options with her healthcare provider before choosing any over-the-counter medication. With advancing pregnancy, the stomach is displaced upward and compressed by the uterus. Stomach capacity is thus decreased. Eating six small meals a day instead of three large ones should help prevent heartburn associated with overfilling of the stomach and subsequent gastroesophageal reflux.

You explain that the contractions she describes are common during late pregnancy and function to increase blood flow to the uterus. They are referred to as ____________ contractions.

Braxton Hicks

During Susan's pelvic examination, a bluish discoloration of the cervix and vaginal mucosa is observed. This is a sign of pregnancy and is documented as ___________.

Chadwick's sign

Which of the following suggestions are appropriately made to Susan to help alleviate her symptoms? Select all that apply Eat a large breakfast Eat small frequent meals throughout the day Eat dry toast or crackers before getting out of bed Drink plenty of fluids when nausea occurs

Eat small frequent meals throughout the day Eat dry toast or crackers before getting out of bed Eating a large meal in the morning would distend Susan's stomach and increase the likelihood of nausea and vomiting. Eating a large meal in the morning should be avoided. Small, frequent meals are recommended for the pregnant woman who is experiencing nausea and vomiting. An empty stomach or one that is overloaded would increase the likelihood of nausea and vomiting. Eating a dry carbohydrate, such as toast or crackers, before getting out of bed in the morning, often helps to prevent the nausea associated with "morning sickness." If nausea is present before rising, it is advisable to remain in bed after eating a dry carbohydrate until the feeling of nausea subsides. Increasing fluids would not be useful in alleviating nausea. Fluids can distend the stomach, increasing nausea. Small amounts of fluid, alternated hourly with dry carbohydrates, may be helpful in alleviating nausea.

Which of the following is considered a positive sign of pregnancy that could be present at this point in Susan's pregnancy (eight weeks gestation)? Fetal cardiac activity or body movement noted on ultrasound Palpation of fetal movements by an examiner Ballottement noted on vaginal examination Uterine souffle auscultated with Doppler

Fetal cardiac activity or body movement noted on ultrasound Ultrasonography is a noninvasive technique that can detect the presence of fetal cardiac activity or body movement as early as 6-7 weeks gestation. Detection of fetal cardiac activity or movement by ultrasound would be a positive sign of pregnancy. At eight weeks gestation, fetal activity could be demonstrated on ultrasound. Palpation of fetal movements by an examiner is considered a positive sign of pregnancy. However, Susan is only eight weeks pregnant, making such an observation unlikely at this time. Fetal movements are generally palpable by an examiner beginning with the nineteenth week of gestation. Ballottement, passive movement of an unengaged fetus, can usually be identified between 16 and 18 weeks gestation. As ballottement may be attributed to other causes, it is considered a probable, not a positive, sign of pregnancy. Uterine souffle, the sound of maternal blood flowing through uterine arteries to the placenta, is synchronous with the maternal pulse. It is considered a probable, not a positive, sign of pregnancy.

In formulating a plan of care based on Susan's symptoms of nausea and vomiting, which of the following is determined to be an appropriate nursing diagnosis? Risk for Injury related to malnutrition Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting Imbalanced Nutrition: Less than Body Requirements related to inadequate knowledge of good nutrition Deficient Fluid Volume related to nausea and vomiting

Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting Susan's diet is lacking in caloric intake, protein, and calcium. However, there is no data to suggest that she is at Risk for Injury at this time as a result of any perceptual or physiological deficit associated with these dietary problems. Susan's diet is lacking in caloric intake, protein, and calcium, substances deemed especially necessary during pregnancy. Because Susan is experiencing nausea and vomiting, she is likely to be eating less, and may often be "losing" what she eats. Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting is an appropriate nursing diagnosis for Susan. There is no data to support that Susan has an inadequate knowledge of good nutrition. Susan could be at risk for Deficient Fluid Volume if nausea and vomiting persist. However, there is no data to support that she is fluid deprived at this time.

Which of the following information should be communicated to Susan regarding the benefits of smoking cessation at this point in her pregnancy? Select all that apply It will decrease the risk of intrauterine growth restriction (IUGR) and giving birth to a low-birth-weight infant It will increase the oxygen supply to the fetus It will reduce the risk of preterm labor and premature rupture of membranes It will reduce the risk of neural tube defects

It will decrease the risk of intrauterine growth restriction (IUGR) and giving birth to a low-birth-weight infant It will increase the oxygen supply to the fetus It will reduce the risk of preterm labor and premature rupture of membranes Maternal smoking interferes with diffusion of nutrients and oxygen to the developing fetus and is associated with low birth weight infants, secondary to the vasoconstrictive effect of smoking on placental vessels. Oxygen supply to the fetus is reduced with maternal smoking for a number of reasons. Smoking causes vasoconstriction of placental vessels, interfering with diffusion of nutrients and oxygen to the developing fetus. Also, maternal hemoglobin has a greater affinity for carbon monoxide (found in cigarette smoke) than for oxygen. Thus, oxygen levels are lower in women who smoke. In turn, less oxygen is available to the developing fetus. There is a recognized association between maternal smoking and the incidence of preterm labor and premature rupture of membranes. These may be related to the decreased placental perfusion associated with smoking. Neural tube defects (e.g., spina bifida, meningocele, etc.) have been linked to folic acid deficiencies, not to cigarette smoking. Although smoking is not generally considered to be teratogenic, a link between smoking and cleft lip/palate anomalies has been suggested.

You teach Susan to expect which of the following breast changes as her pregnancy progresses? Select all that apply Nipples will darken and become more erectile Blood vessels will become visible at the skin surface Striae gravidarum may appear Stretching may cause minor ulcerations to appear Liquid may be expressed from the nipples as pregnancy advances

Nipples will darken and become more erectile Blood vessels will become visible at the skin surface Striae gravidarum may appear Liquid may be expressed from the nipples as pregnancy advances Nipples darken during pregnancy due to the influence of the hormone, melanocyte stimulating hormone (MSH). Increased estrogen levels cause increased vascularity of the breasts, which may cause the nipples to be more erectile. Blood vessels in the breasts become more visible during pregnancy due to increased blood flow. Primigravidas may have more obvious venous congestion. Striae gravidarum, or stretch marks, may appear along the outer aspects of the breasts as enlargement occurs. Ulceration on the breasts would not be normal and is not expected to occur with pregnancy. During the first trimester, a precolostrum secretion may be present. Colostrum, the precursor to milk, is present in the breasts as early as the third month of gestation. Colostrum usually cannot be expressed until 16 weeks or later, but sometimes can be expressed sooner in women who have breastfed in the recent past. These breast secretions may be clear or creamy yellow-white in color.

Susan asks you, "How much is too much vomiting?" You advise Susan to call the clinic if she experiences which of the following? Select all that apply She urinates less frequently than usual, and her urine becomes darker in color Her palms become reddened and itch She vomits blood or her throat becomes sore from vomiting She vomits everything she eats or drinks in a 24-hour period

She urinates less frequently than usual, and her urine becomes darker in color She vomits blood or her throat becomes sore from vomiting She vomits everything she eats or drinks in a 24-hour period With excessive vomiting, Susan could become dehydrated. With dehydration, the body would retain fluid as a compensatory measure, and urine output would decrease. Urine would also become more concentrated, and darker in color. It is appropriate that Susan be advised to report signs of dehydration. Palmar erythema (redness and itching of the palms) is common in pregnancy, and is thought to be related to the increased estrogen level. It may be an annoyance, but is not a reportable cause for concern. Vomiting blood and a very sore throat are significant. They could be the result of a tear in the mucosa of the esophagus, secondary to retching (dry heaves). Susan should seek medical attention immediately if these occur. A client who is unable to keep food or drink down for 24 hours, or is unable to stop vomiting, should be seen by her healthcare provider as soon as possible. Antiemetic medication and rehydration might be needed.

Susan's current vital signs are BP 110/70, P 80. Comparing them to baseline vital signs (BP 118/74, P 68) recorded during Susan's first visit, which of the following do you determine? Susan's vital signs are considered normal Susan's vital signs are considered abnormal

Susan's vital signs are considered normal During pregnancy, increases in blood volume, cardiac output, and basal metabolic rate cause changes in vital signs. Normal increases in heart rate up to 10-15 beats per minute can be expected during the second trimester. Blood pressure usually remains at prepregnancy levels during the first trimester. During the second trimester, BP decreases by 5-10 mm Hg, probably due to peripheral vasodilation caused by hormones of pregnancy. In the third trimester, blood pressure should approximate readings from the first trimester. Slight cardiac hypertrophy and grade II systolic ejection murmurs are also common, due to increases in blood volume and cardiac output. Susan's vital signs are considered abnormal Susan's vital signs would not be considered abnormal.

Theorists have identified three developmental tasks to be accomplished as the mother-child relationship evolves throughout pregnancy. You know that during this first trimester, Susan's developmental task is to: accept the biologic fact of pregnancy accept the fetus as distinct and separate from herself prepare realistically for parenting acknowledge that she will be a good mother

accept the biologic fact of pregnancy Acceptance of the biologic fact of pregnancy characterizes the first trimester. The pregnant woman needs to acknowledge "I am pregnant" as she accepts the immediate reality of the pregnancy itself. Acceptance of the fetus as distinct and separate from herself is the developmental task of the second trimester of pregnancy. It is facilitated by quickening (the mother's perception of fetal movement). The pregnant woman moves psychologically from "I am pregnant" to "I am going to have a baby." Preparing for the birth and parenting of the yet unborn child is the developmental task of the third trimester of pregnancy. During this stage, the pregnant woman moves psychologically from " I am going to have a baby" to "I am going to be a mother." Acknowledging that she will be a good mother is not a specific developmental task of pregnancy, as defined by theorists.

Susan mentions, "I've heard that it is normal to be a little anemic during pregnancy." You understand that Susan is probably referring to the "physiologic anemia of pregnancy." This is related to: a decrease in red blood cell production an increase in plasma volume in excess of an increase in red blood cells hemolysis of maternal red blood cells by fetal antibodies that cross the placenta

an increase in plasma volume in excess of an increase in red blood cells During pregnancy, Susan's plasma volume will increase by 50%, but her red blood cells will increase only by 18-30%, depending on whether or not she takes iron supplements. This results in hemodilution, with a corresponding decrease in normal hemoglobin and hematocrit values. This is often referred to as the "physiologic anemia of pregnancy" or the "hemodilution of pregnancy." Red blood cell production increases, not decreases, during pregnancy, in accordance with available iron. If an iron supplement is taken, red blood cell mass may increase by 30%. If no supplement is taken, an increase of 18% can be expected. hemolysis of maternal red blood cells by fetal antibodies that cross the placenta Fetal antibodies do not cross the placenta and hemolyze maternal red blood cells. The reverse may be true with Rh incompatibility, in which case maternal antibodies cross the placenta and cause hemolysis of fetal red blood cells.

After analyzing Susan's responses, you explain that feelings of ambivalence about pregnancy: are normal for fathers, but not for mothers are common among expectant mothers and fathers suggest an increased risk for future child abuse

are common among expectant mothers and fathers Feelings of ambivalence toward pregnancy generally are normal for both parents. Ambivalence is a common response to pregnancy for both parents, even when the pregnancy is desired. Such feelings are usually resolved as the second trimester begins, but may persist throughout pregnancy. There is no indication that feelings of ambivalence during pregnancy are associated with later child abuse.

You discuss the signs of "true labor" with Susan. You recognize that your teaching has been effective when Susan describes "true labor" contractions as: Select all that apply contractions that begin in the abdomen and radiate to the back contractions that intensify with walking or position change contractions that become more regular as time goes by

contractions that intensify with walking or position change contractions that become more regular as time goes by Contractions that begin in the abdomen and radiate to the back characterize false labor, not true labor. Contractions that become more intense with walking or position change are typically associated with true labor. Contractions that become more regular with time and increase in intensify, frequency, and duration are typically associated with true labor.

You advise Susan to return to the clinic regularly for prenatal visits. Provided there are no complications, she can anticipate visits to occur: every month throughout pregnancy every four weeks until 28 weeks, every two weeks until 36 weeks, then weekly until delivery every six weeks until 36 weeks, then weekly until delivery every four weeks until 24 weeks, every two weeks until 32 weeks, then weekly until delivery

every four weeks until 28 weeks, every two weeks until 36 weeks, then weekly until delivery Traditionally, monthly prenatal visits (every four weeks) are recommended during the first 28 weeks of pregnancy. Visits increase to every two weeks from the 28th to the 36th week, and then every week from 37 weeks until delivery. Visits increase because the risk of complications associated with pregnancy increases as pregnancy advances. Monthly prenatal visits (every four weeks) are recommended during the first 28 weeks of pregnancy. However, the frequency of visits increases thereafter. Monthly prenatal visits (every four weeks, not every six weeks) are recommended during the first 28 weeks of pregnancy. The frequency of visits increases thereafter. Traditionally, prenatal visits occur at different intervals.

During Susan's last trimester, she and John attend childbirth preparation classes. These classes are intended to teach expectant parents that: Select all that apply analgesics will not be needed during labor and delivery if breathing and relaxation techniques are used fear, tension, and pain during labor and delivery can be reduced and dealt with effectively understanding of the labor and delivery process can enhance participation and control during labor and delivery perception of painful uterine contractions during labor and delivery can be altered through relaxation and breathing

fear, tension, and pain during labor and delivery can be reduced and dealt with effectively understanding of the labor and delivery process can enhance participation and control during labor and delivery perception of painful uterine contractions during labor and delivery can be altered through relaxation and breathing Analgesics may not be needed during labor if relaxation and breathing techniques are used effectively. However, they often are used in combination with such techniques to promote comfort and control during labor and delivery. Fear, tension, and pain during labor and delivery can usually be reduced or controlled with effective use of relaxation and breathing techniques and analgesics, if needed. Understanding the labor and delivery process enables mothers (and coaches) to participate more effectively in measures designed to facilitate the natural course of labor and delivery. Informed mothers (and coaches) also tend to participate more cooperatively with staff members assisting with labor and delivery. Perception of painful uterine contractions can be altered with effective use of relaxation and breathing techniques. Distraction is also an important component of this process.

You also review Susan's lab work, recalling that pregnancy tests on urine or blood are determined to be positive based on the presence of a particular hormone. This biologic marker of pregnancy is: human chorionic gonadotropin estrogen progesterone follicle-stimulating hormone

human chorionic gonadotropin Human chorionic gonadotropin (HCG), produced by the trophoblast cells of the placenta soon after implantation of a fertilized ovum, is a biologic marker of pregnancy. It can be detected in maternal serum and urine as early as six days after conception, depending on the test performed. It reaches its maximum level in 50-70 days. The presence of HCG in Susan's blood is considered a probable sign of pregnancy. Positive pregnancy tests can also occur if the client has certain tumors which produce HCG. Progesterone is not a biological marker of pregnancy, but increases in progesterone levels are critical for the maintenance of a pregnancy. Estrogen is produced by the ovaries during each menstrual cycle. During pregnancy, estrogen is produced by the corpus luteum from the time of ovulation to the seventh week of pregnancy, and by the placenta after the seventh week of pregnancy. Its presence is not diagnostic of pregnancy. Progesterone is produced by the ovaries during each menstrual cycle. During pregnancy, progesterone is produced by the corpus luteum from the time of ovulation to about the tenth week of pregnancy, and after that time by the placenta. Its presence is not diagnostic of pregnancy, although increases in progesterone levels are critical for the maintenance of a pregnancy. Secretion of follicle-stimulating hormone (FSH) by the anterior pituitary is suppressed during pregnancy by elevated levels of estrogen and progesterone. Its presence is not diagnostic of pregnancy. Submit

You question Susan about whether or not she has had any abnormal vaginal discharge or itching. During pregnancy, women are more prone to develop vaginal yeast infections due to a/an ____________ in vaginal pH.

increase

Susan knows to notify her care provider immediately if she suspects her membranes have ruptured. This is important due to the increased risk of ____________ with ruptured membranes.

infection

Susan inquires, "Is this what my mother calls "the baby dropping?" You acknowledge her mother's information, and tell Susan that this event is called _________.

lightening

You know that this practice of consuming non-food substances, common to some cultures, is called __________.

pica

These assessments are done to detect the onset of the complication of pregnancy called ___________.

preeclampsia

You tell Susan that this "fluttering" is probably fetal movement. This first recognition of fetal movements by the mother is called ___________.

quickening