BSMCON OB Test 1

5. Outline health screening recommendations for women across the lifespan. (2 questions)

Actions for reducing risks and promoting health Follow guidelines for routine screenings and immunizations HPV vaccine Breast cancer screening Cervical cancer screening Colonoscopy Blood glucose testing Cholesterol HPV is the most common sexually transmitted virus is the U.S. and the main cause of cervical cancer Two vaccine options: 1. Gardasil Protects against HPV types 6, 11, 16, and 18 Recommended for females and males age 9 through 26 years Typically girls and boys start the series at 11 or 12 years of age 2. Cervarix Protects against HPV types 16 and 18 Recommended for females age 9 through 25 years Update as of October 2016: For those younger than 15 years of age only two doses of HPV are recommended. Teens (15 years and older) and young adults will still need the three doses for protection. This change was a result of research that showed young adolescents who received two doses produced an immune response similar or higher than the response of young adults who received three doses. Cervical cancer screening should begin at age 21 Age 21-29 years = Pap every 3 years Age 30-65 years = Pap with combined HPV every 5 years (or Pap every 3 years if no HPV obtained) Age > 65 years can stop cervical screening if no serious pre-cancers found in past 20 years Breast Cancer: high risk in forties, 50s up should be getting screenings When to start? Newest Guidelines American Cancer Society: Women ages 40-44 should have the choice to start annual breast cancer screening Women age 45 -54 should get mammograms every year Women age 55 and older should switch to mammograms every 2 years or continue annual screening Screening continues as long as the woman is healthy and expected to live for 10 more years American Congress of Obstetricians and Gynecologists: Screening mammography every year starting at the age of 40 "Evidence and experience have shown that early detection can lead to improved outcomes in women diagnosed with breast cancer." US Preventive Services Task Force Women age 50 - 74 should have screening mammograms every two years High risk (BRCA1 or BRCA2 gene mutation, or history of chest radiation as a child) begin screening at age 40 Women should not wear any deodorants, perfume, lotion, or powder under their arms or on their breasts on the day of the appointment. These substances can make shadows on the x-ray. Abnormalities identified on a screening mammogram require further testing and may include a diagnostic mammogram, ultrasound, MRI, or biopsy. Clinical breast exam (CBE): ACOG guidelines include having a clinical breast exam every one to three years for those women under the age of 40 and then yearly. The American Cancer Society does not recommend CBE because there is no clear benefit of a physical exam by a professional. Self-breast exam (SBE): ACOG recommend "breast self-awareness" because it has the potential to detect palpable breast cancer. The American Cancer Society does not recommend SBE because there is no clear benefit of a physical exam by an individual. However, they state that " All women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away." So... there is controversy regarding the value of SBE and its role in reducing mortality rates from breast cancer in women. However, it remains a useful technique to help women become self-aware of how their breasts normally look and feel. It can result in earlier detection and treatment.

8. Compare common alterations in women's health to include risk factors, causes, signs and symptoms, nursing actions, and medical management. (3 questions)

Anovulation is the most common cause for missing menses once pregnancy has been ruled out. Primary amenorrhea: No menses by 14 years and no secondary sex characteristics or no menses by age 16 years with secondary sex characteristics: Causes: Body build (minimal levels of body fat), heredity (family history of delayed menses), Pituitary function (lack of secretions of FSH and LH), congenital absence of vagina, 90% of cases have no identifiable cause) Treatment: Identify and treat underlying condition, provide emotional support Secondary amenorrhea: No menses in 6 months in a woman who has had normal menstrual cycles: Causes: Lack of ovarian production, pregnancy, PCOS, nutritional disturbances, endocrine disturbances, uncontrolled diabetes, heavy athletic activity, emotional distress Treatment: Identify and treat underlying condition, explain cause Menorrhagia: Excessive bleeding characterized by increased duration (> than 7 days), increased amount (more than 80 mL), or both Causes: Anovulatory cycles with continued estrogen production, fibroids most common anatomic cause, inflammatory or infectious causes (ex. metritis, salpingitis), endometrial cause (ex. Hyperplasia, polyps, cancer), intrauterine device (IUD). Most common cause of menorrhagia is anovulatory uterine bleeding. Anovulation unopposed estrogen endometrium builds up until heavy bleeding occurs. Young women with excessive bleeding clotting disorders must be ruled out. Women in their 30's and 40's uterine fibroids (also called leiomyomas) and endometrial polyps are common causes. Treatment/Management: Endometrial biopsy to assist in diagnosis, identify and treat underlying cause, if no identifiable cause may try short course of contraceptives, D&C (dilation & curettage) Nursing education: avoid exercise, NSAIDS 1 week before menses, avoid hot tubs (heat increases blood flow), increase iron in diet. Metrorrhagia (aka "spotting" or "breakthrough bleeding"): Bleeding between periods or after menopause This is the most significant form of menstrual disorder and warrants immediate investigation! Causes: start of oral contraceptives (OC) or with ectopic pregnancy or spontaneous abortions; also caused by cervical or endometrial polyps, infections, carcinoma **Most common reason = first 3 months on birth control. If spotting continues after the first 3 months a different pill formation can be prescribed. Spotting also common with long acting progestin therapy (Mirena IUD) or progestin only products (Depo Provera) Women of reproductive age you must also consider pregnancy complications - spontaneous abortion or ectopic pregnancy vs postmenopausal women you must consider endometrial cancer. However, exogenous estrogen administration during hormone replacement therapy can cause metrorrhagia Treatment: treat underlying cause, endometrial biopsy to rule out endometrial cancer, antibiotics for infection, surgery (D&C, ablation), teach proper use of oral contraceptives Menometrorrhagia: Excessive bleeding that occurs at irregular intervals Causes: endometrial cancer or uterine fibroids Primary Dysmenorrhea Cramping usually begins 12 -24 hours before onset of flow and last 12 -24 hours May experience chills, nausea, vomiting, headaches, irritability, and diarrhea Causes: excessive endometrial production of prostaglandin. Increased prostaglandin production by endometrium (thanks to progesterone) tissue ischemia, increased sensitivity of pain receptors, lower abdominal pain, bloating, fluid retention, HA, migraine (called menstrual HA), nausea, vomiting, diarrhea, lightheadedness Management: explain cause, NSAIDS (prostaglandin inhibitors), heat to lower back/abdomen, warm bath, exercise, oral contraceptives, diet low in fat and meat products may decrease duration and intensity of pain, biofeedback, acupuncture Secondary dysmenorrhea Occurs most often in 30's through 40's with known anatomic factors or pelvic pathology - pain can be present at any point of the menstrual cycle Causes: endometriosis, pelvic adhesions, inflammatory disease, cervical stenosis, uterine fibroids, adenomyoma Management: identify and treat underlying cause, same symptomatic measure as primary dysmenorrhea Possible causes: endometriosis, chronic PID, adenomyosis, IUDs PCOS: Definition and etiology: chronic insulin resistance → chronic anovulation and hyperandrogenism ; endocrine disorder that affects 5 - 10 % of women of reproductive age; etiology is not fully understood - ? Genetic component since it occurs in families Signs and Symptoms: See Critical Component Durham & Chapman pg. 511 - Primary Characteristics of PCOS Infertility - PCOS is the most common cause of female fertility - most women with PCOS do not ovulate Menstrual disorders - irregular, infrequent, and/or absent menstrual periods Hirsutism - increased hair growth on face, chest, stomach, and back Ovarian cysts Obesity Oily skin and acne Pelvic pain Male-pattern baldness Abnormal labs: elevated estrogen, testosterone, and LH; decreased secretion of FSH; ultrasound = multiple follicular cysts on one or both ovaries producing excess estrogen Risk factors: Women with PCOS are at higher risk for: Type 2 diabetes - insulin resistance, obesity Cardiovascular disease - dyslipidemia due to endocrine changes (increased LDH and decreased HDH), hypertension Caner - endometrial, ovarian, breast due to high levels of continuous estrogen Infertility - anovulation sleep apnea Metabolic syndrome Review prn Metabolic Syndrome - group of conditions that increases risk for heart disease, stroke, and diabetes (1 in 3 women with PCOS will have): Abdominal obesity; high triglyceride levels; low HDL; increased blood pressure; elevated fasting blood glucose -- Must have three of the above to be diagnosed PICTURE NOTE Not every woman with PCOS will actually have polycystic ovaries Polycystic ovaries are two to five times larger than normal ovaries, and they have a white, thick, tough outer covering. Treatment: Lifestyle modifications - diet and exercise to assist in weight loss = reduce risk of type 2 diabetes, decrease levels of androgens, improve frequency of ovulation and menstruation, reduce risk of cardiovascular disease Hormone Therapy - low dose oral contraceptives - regulate cycles and controls acne & hirsutism Fertility Therapy - medication to induce ovulation (Clomid), assisted reproductive technology such as IVF Insulin-sensitizing medications- to help ovulation/hyperandrogenism and reduce DM2, CV risks * Metformin- increases tissue sensitivity to insulin, increases change of ovulation, increases success of ovulation medications GnRH agonist - controls hyperandrogenism TAH with BSO- may be elected if no desire for fertility & symptoms are bothersome Endometriosis: Definition: Endometriosis is the condition in which the tissue that normally lines in the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding. Risk Factors: Early menarche, > 30 day cycles; family history (10x risk); autoimmune diseases (Lupus, RA, MS); reproductive age women Signs and symptoms: Pelvic pain Dysmenorrhea - depends on location and depth of implants, NOT extent of disease - pain often associated with "normal" periods Low back pain Pelvic pressure Dyspareunia (painful intercourse) Infertility Premenstrual spotting and menorrhagia Diarrhea, pain with defecation (dyschezia), constipation - with lesions of the bowel Fixed retroverted uterus Enlarged and tender ovaries Urinary symptoms Diagnostics Laparoscopy: direct visualization of implants is ONLY DEFINITIVE DIAGNOSIS (although some MD will dx just based on really, really painful menses). Laparoscopy is the only way to diagnose endometriosis... and sometimes it helps control the symptoms!! Ultrasound (U/S), CT, MRI: to identify individual lesions, not to identify extent of disease Pelvic exam- especially early in menses when implants are largest & tender Mangament of endometriosis: GOAL create anovulatory state or pseudomenopause; note that symptoms may return when medications are stopped Treatment options: manage according to severity of signs and symptoms, desire for fertility, and degree of disease MEDICATIONS 1. Analgesic therapy - NSAIDs = to decrease pain 2. Hormonal therapy = suppress menstruation and further growth of tissue Oral contraceptive - progesterone only pills to decrease cyclic hormone changes Danazol (Danocrine) - antagonizes LH & FSH for mild- moderate endometriosis, only if no desire for fertility at the moment (teratogenic side effects) * Contraindications: liver disease, HTN, hyperlipidemia, CHF, decreased renal function, pregnancy * Caution: may decrease bone density GnRH agonists [leuprolide (Lupron), goserelin acetate (Zoladex), and nafarelin (Synarel) ] - create pseudomenopausal state; * Contraindications: breastfeeding, pregnancy, abnormal vaginal bleeding SURGERY: less recurrence occurs than with medical treatments Conservative- laparoscopic laser surgery or laparotomy to remove or destroy endometrial implants and lysing or excision of adhesions- for adnexal masses or if unresponsive to medical treatment; severe case but desires fertility Definitive- Total abdominal hysterectomy (TAH) with or without bilateral salpingectomy (BSO) for severe disease and no desire for fertility

Differentiate the risk factors for the different types of gynecological cancers.

Cervical Cancer: Human papillomavirus (HPV) primary cause; women with abnormal cervical cytology screenings need further evaluation; slow growing - begins with dysplasia (a precancerous condition) Risk factors: HPV infection (most important risk factor), early onset of sexually activity (before 16 years), cigarette smoking, STI, inadequate cervical screening, multiple sex partners, in utero exposure to DES, use of birth control pills for 5 or more years, and given birth to 3 or more children. Signs and symptoms: Early: may not produce symptoms; vaginal discharge that is watery/pink/brown/bloody/or foul smelling; abnormal vaginal bleeding between periods/after intercourse/or menopause; and menstrual periods that become heavier and lasts longer; Late: loss of appetite/weight; fatigue; pelvic/back/and/or leg pain; and leaking of urine/feces from vagina Management: cervical cone biopsy to establish diagnosis, additional testing to determine if cancer has spread to other organs, staging of cervical cancer, see Table 19-7 (Chapman pg. 530) for treatment options. Endometrial cancer: forms in the tissue lining of the uterus; 4th leading cause of cancer-related death in women Risk factors: menopausal hormone therapy (unopposed estrogen therapy in women with a uterus = endometrial hyperplasia); menopause after age 52, obesity, Tamoxifen, nulliparity, diabetes, PCOS Signs and symptoms: postmenopausal bleeding, abnormal premenopausal bleeding, abnormal vaginal discharge, difficulty/or painful urination, pain during intercourse, and pelvic pain/or pressure Management: Treatment based on size of tumor, stage of tumor, tumor grade, and whether tumor is effected by estrogen. Abdominal hysterectomy/radical hysterectomy, radiation therapy, chemotherapy, hormone therapy (progesterone) Ovarian cancer: 3rd leading cause of cancer related deaths in women; symptoms often vague = difficult to diagnose Risk factors: family history (1st degree relative), personal history of cancer, age > 55, Eastern European Jewish background, never gave birth, history of endometriosis, tested positive for BRCA1 or BRCA2 Signs and symptoms: early stages asymptomatic or vague abdominal, genitourinary, or reproductive symptoms; pressure or pain in abdomen, pelvis, back or leg; swollen or bloated abdomen; urinary urgency and frequency; difficulty eating or feeling full quickly Critical Component Ovarian Cancer Symptom Diary: Early warning signs = bloating , pelvic/abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms

Explore cultural competence as it relates to maternal newborn nursing and women's health care.

Culturally based behavioral practices: decision maker, concept of time (U.S. future oriented), communication, religion, worldview, and modesty and gender Common themes - childbearing families Prescriptive behavior - expected behavior Restrictive behavior - activities limited for the pregnant woman Taboo - cultural restrictions = serious supernatural consequences Cultural health disparities are created when nurses and other healthcare providers fail to understand the importance of client beliefs about health and illness. Barriers to culturally competent care Ethnocentrism = belief that customs and values of the dominant culture are preferred or superior in some way - judging ones values based on own values Stereotyping = assumption that everyone in a group is the same as everyone else in the group Lack of diversity of healthcare providers Quality of healthcare varies depending on race, ethnicity, and language Mainstream models of obstetric care in North American = formal prenatal care, technology, hospital deliveries, and a bureaucratic health care system When there is a practices, beliefs, or culture conflict nurses must consider the following questions: Is the practice safe? Is it feasible? Is it important to the woman? Promote = cultural practices that are helpful Tolerate = practices that are neutral Avoid = practices that are potentially harmful. If it's not safe....next step to educate

13. Explain the major components and appropriate anticipatory guidance of preconception health care.

Definition of preconception health care: interventions aiming to identify medical, behavioral, and social risks to a woman's health Preconception care consists of health promotion, risk screening, and implementation of interventions before a pregnancy. Goal is to modify risk factors that could negatively impact a pregnancy. Components: Routine physical exam: to include height, weight, vital signs, and a complete physical exam (to include breast and pelvic exam) Health screening: pap smear (if indicated), blood type and Rh, CBC, urine analysis, STI (HBsAg, HIV, chlamydia/gonorrhea, syphilis), and glucose (if at risk) anticipatory guidance: Nutrition - maintain healthy weight (calculate BMI and advise accordingly). Obesity increases a woman's risk for infertility, antepartum complications (HTN, preeclampsia, gestational diabetes, thromboembolism, and UTI), complications during childbirth (LGA baby), prolonged labor and difficult delivery, cesarean delivery, postpartum hemorrhage, and poor wound healing after cesarean. Medication - review medication history - are any current medications contraindicated with pregnancy? Prenatal vitamins include: Folic acid - helps with prevention of neural tube defects Calcium, magnesium, vitamin D - for bone health Iron supplement - anemia (greater risk if pregnancies are close together) Self-care - avoid ETOH, tobacco, second hand smoke, excessive caffeine Contraception - before pregnancy, have x2-3 normal cycles Timing of conception - includes education on normal ovulation schedule This is the time to modify behaviors to reduce risks!

12. Discuss common diagnostic tests for infertility and the psychosocial impact of infertility. (2 questions)

Diagnostic Tests: How do you know if ovulation takes place? Cervical mucous= spinnbarkeit... occurs near ovulation; abundant, watery, stretchy/gummy discharge... "fertile mucous" facilitates passage of sperm into uterus (Note: orgasm increases movement of sperm - will affect mucous) Ovulation tests: BBT, ovarian reserve testing, and detecting LH surge BBT - discussed on next slide Ovarian reserve testing - day 3 of menstrual cycle a serum FSH and estradiol test is performed Detecting LH surge - rapid increase in LH 36 hours before ovulation - can be tested with urine or serum. Urine test can be done at home to help identify ideal time for intercourse Tubal patency studies: Hysterosalpingogram - discussed two slides away Postcoital studies: - "have sex and then come in, so we can look at the sperm in your vagina" Endometrial biopsy: assess response of the uterus to hormonal signals that occur during the cycle - performed at the end of the menstrual cycle Laparoscopy: direct visualization and inspection of ovaries, fallopian tubes, and uterus - looking for abnormalities like endometriosis and scarring KNOW THIS CHART!! Basal Body Tempature = temperature upon awakening (right away - while in bed)... as ovulation approaches, estrogen increases which drops oral temperature... when ovulation occurs, progesterone is produced, causing an increase in temp Ovulation indicated by drop, then rise in temperature (progesterone rises - progesterone is thermogenic) Female partner takes temperature each morning before rising using an basal thermometer and records her daily temperature Ovulation has occurred if there is a rise in temperature by 0.4 F for 3 consecutive days Fuzzy - but have a blockage on her right (our left) Hysterosalpingogram: radiological examination that provided information about the endocervical canal, uterine cavity, and the fallopian tubes. Under fluoroscopic observation, dye is slowly injected through the cervical canal into the uterus. Able to detect tubal problems (adhesions or occlusions) and uterine abnormalities (fibroids, bicornate uterus, and uterine fistulas) Bifurcated uterus - heart-shaped - can conceivably carry twins Psychological Response: A developmental change usually accompanied by stress/anxiety Career goals/mobility may be altered Can be maturational crisis because of family disequilibrium, can have anger Cultural values and pregnancy: The rituals, customs, and practices of a group are a reflection of the group's values. Identification of cultural values are a must in planning and providing culturally sensitive nursing care

Explain standards of practice and legal and ethical issues in perinatal nursing.

Ethical Principles (you learned these in 2101): autonomy, respect, beneficence, nonmaleficence, justice, fidelity, and veracity Ethical Approaches Rights approach: focus on right to choose, to privacy, to know truth and free from injury Utilitarian approach: action that provide the greatest good for the greatest number of people Standards of Practice: Ethical standards are set by ANA - ANA Code of Ethics The Association of Women's Health, Obstetrics, and Neonatal Nurses (AWHONN) believes standards of practice are the nursing profession's best judgment and optimal practice based on current research and clinical practice. Ethical dilemma- a choice that has the potential to violate ethical principles (often advocacy)—often our responsibility is to the mother but indirectly the fetus. This is a unique aspect of maternity nursing because the nurse is an advocate for two patients - the woman and the fetus. Clinical examples of perinatal ethical dilemmas - Chapman Box 2-1 pg. 15 Invitro fertilization - how do we dispose of the remaining fertilized ova Genetic questions Sperm donations Surrogacy Borderline viability - do we resuscitate or do we not Preconception gender selection Court ordered treatment

9. Differentiate signs and symptoms, diagnosis, and management of women with sexual transmitted viral and bacterial infections. (2 questions)

HIV (viral): sore throat, rhinitis, rash, leukopenia, thrombocytopenia, fever, night sweats weight loss dry cough, unresolved infections; no cure only highly active antiretroviral therapy (HAART) to maintain health Genital warts/condyloma (viral): painless warts in vagina, anal area, perineum; treat with topical podofilox or trichloroacetic acid, cryotherapy, laser surgery, or surgical removal Genital herpes (viral): may be asymptomatic or burning, pressure, lesions/sores; no cure but may be treated with antiviral acyclovir to reduce outbreaks. Use of condoms to prevent spread, cant deliver baby vaginally Hepatitis B (viral): asymptomatic or fever, fatigue, n/v, abdominal pain, jaundice; treat to manage symptoms and antiviral immunizations Chlamydia (bacterial): may be asymptomatic or infertility, spotting, lower abdominal pain, fever, pain; treat with antibiotics -doxycycline, azithromycin; partner must also be treated Gonorrhea (bacterial): may be asymptomatic or vaginal discharge, menorrhagia, back ache, dysuria; treat with IM ceftriaxone & azithromycin or doxycycline; partner must also be treated Syphilis (bacterial): single painless ulcer, fever, sore throat, lymphadenopathy, weight loss, fatigue, may spread throughout the body and damage internal organs; treat with PCN G; partner must also be treated Trichomoniasis (protozoan): may be asymptomatic or gray discharge, fishy smell, ulceration, pain with sex; treat with metronidazole (Flagyl); partner must be treated

Evaluate contemporary issues and trends in maternal newborn nursing.

Infant morbidity: Preterm birth terms (term is considered anything over 38 0/7 gestational weeks) Very premature- neonates born at less than 32 weeks Moderately premature- neonates born between 32 and 33 weeks Late premature- neonates born between 34 and 37 6/7 weeks Infant morbidity: preterm birth weight categories Low birth weight (LBW): 1500-2500 grams (3.4-5.8 lbs.) Very low birth weight (VLBW): less than 1500 grams (less than 3.4 lbs.) Infant mortality - death before the first birthday. See Chapman Table 1-6 pg. 5 for leading causes of deaths and mortality rates. Top 3 leading caused of infant mortality: Congenital malformations and chromosomal abnormalities, disorders related to short gestation / low birth weight, and SIDS (sudden infant death syndrome) Maternal mortality- death of a woman during pregnancy or within 42 days of termination of pregnancy. Causes (worldwide) of maternal mortality: severe hemorrhage, infections, pre/eclampsia, obstructed labor, complications of abortions, and other medical problems/causes (cardiac, HIV) Teen births: teen birth rates have been decreasing but a teen birth may have long term affects. Issues: poverty, health issues for mother (STIs and hypertension), health issues for infant (preterm births and low birth weight), education issues, and teen fathers (lack of presence and support) Tobacco use in pregnancy: tobacco use has decreased - often it's the motivating factor to make a woman quit. Issues: less likely to breastfeed. Alcohol/Substance use in pregnancy: Issues: fetal death, low birth weight, IUGR, mental retardation, fetal ETOH syndrome, preterm birth, placenta abruption, and congenital defects. Opiod exposure Health disparities: addresses the differences in access, use of health care services, and health outcomes for various factors such as age, race, ethnicity, socioeconomic status, and geographic groups and health status of these populations. Critical component: Low-income women are less likely to seek early and continuous prenatal care. These health care behaviors place both the woman and her unborn child at higher risk for complications during pregnancy, labor and birth, and postpartum. Examples of barriers to access include limited finances, lack of transportation, difficulty with dominant language, and attitudes of the health care team. Based on race, Hispanics experience the worst health care. Based on income, the poor experienced the worst health care Obesity: defined as a body mass index (BMI) of >30. In the U.S. 35.7% of adults are obese and 16.9% of children are obese. Issues: fetal abnormalities such as spina bifida, heart defects, anorectal atresia, and hypospadias.

11. Discuss the nursing role as it relates to women with intimate partner violence.

Intimate partner violence or aka domestic violence: Approximately 1. 3 million women are physically assaulted each year - 50% of children living in homes of IPV are also abused IPV occurs in all socioeconomic, religious , and ethnic groups Review critical component Chapman p. 533 Signs of Intimate Partner Violence Per ANA how can nurses be advocates? Universal screening of all patients for IPV - follow up with a detailed assessment if a woman is a risk for abuse Documentation of the abuse Reporting of IPV - be aware of the laws regarding mandatory reporting Provide information regarding IPV and safe shelters Common questions that can be asked in an IPV screening tool: Has your partner ever hit you? Do arguments with your partner result in you feeling bad about yourself? Do you ever feel frightened by what your partner says or does? Do you feel safe in your current relationship

4. Analyze women's health promotion concepts to include the primary maternal and infant goals stated in Healthy People 2020 and levels of prevention.

Leading causes of death in women: heart disease, cancer (breast, lung, and colon/rectal), and stroke are the top 3 Refer to critical component Durham & Chapman pg. 488 Heart Attack & Stroke Warning Signs Actions for reducing risks and promoting health: Eat a healthy diet to include adequate amount of calcium (3 cups of low-fat or fat free milk, yogurt, or cheese). Be physically active to include weight bearing exercises. Physical activity decreases a woman's risk for multiple diseases: heart, colon cancer, falls, type II diabetes, breast cancer, depression. Maintain a healthy weight: obesity places a person at increased risk for multiple diseases. Avoid cigarette smoking and second-hand smoke Limit alcohol consumption Prevent injury from accidents: motor vehicle collisions is the leading cause of death for younger women and injury related to falls is the leading cause of death and injury in women > 65 years. Prevent sexually transmitted illnesses The health of a nation is reflected in the health of expectant women and their infants. Improving the health of women before and during pregnancy and the health of infants will have lifelong effects on the health of a nation. Healthy People 2020 is a national program, developed by the CDC and the Health Resources and Services, designed to improve the health of our nation. Primary = aimed toward prevention of disease Secondary = aimed at early detection/screening for disease Tertiary = aimed at rehabilitation and minimizing sequelae Example with breast cancer. Primary = Diet, maintaining adequate weight, breastfeeding Secondary = Mammogram, biopsy/surgery, breast self-exams, radiation or chemo (secondary or tertiary depending on timing) Tertiary = breast reconstruction, support group for survivors, annual screening afterwards (monitoring for recurrence- tertiary because prevent worsening) Heathy People 2020 Goals: Reduction in fetal/infant deaths Reduction in maternal complications/deaths Reduce cesarean births Reduce PTB and LBW/VLBW Increase number who begin early prenatal care Increase abstinence from ETOH/ Drugs/ Tobacco Increase infants "put on their back to sleep" Increase number of pregnancies with optimum folic acid level Increase mothers who breastfeed (postpartum period, 6months, and12 months)

6. Discuss the physical and emotional changes related to perimenopause and menopause.

Perimenopause: Begins with first signs of change in menstrual cycles Still ovulating can still get pregnant Menopause: Physiologic cessation of menses - 1 year after last period Post-menopause: Time in a woman's life after menopause The age of which menopause occurs ranges from 44 to 55 years, with an average of 51 years Menopause may occur earlier due to illness, surgical removal of uterus or both ovaries, side effects of radiation/chemotherapy, or drugs. Genetic factors, autoimmune conditions, cigarette smoking, and racial/ethnic factors have been linked to an earlier age of menopause. Age of menarche, physical characteristics, number of pregnancies, date of last pregnancy, or oral contraceptive use does not affect the age of menopause. Changes within the ovary start the cascade of events. As a woman ages, fewer ovarian follicles are responsive to the follicle-stimulating hormone (FSH). This results in a decrease in production of estrogen and progesterone and a gradual increase in FSH. The decrease in estrogen levels result in the signs and symptoms of menopause. Perimenopause can still get pregnant until menopause has occurred. Signs and symptoms of menopause: Typical: irregular vaginal bleeding leading to amenorrhea, hot flashes (vasomotor symptoms), increased sweating at night, hot flashes, loss of sleep, and depression Dermal: decreased skin elasticity, pigmentation, and thickness Endocrine: increased risk of hyper or hypothyroidism Musculoskeletal: decreased bone density and breast tone Genitourinary: vaginal thinning, pelvic relaxation syndrome, decreased bladder capacity, increased stress & urge incontinence, atrophy of external genitalia and decreased vaginal lubrication Hallmark signs of perimenopause include vasomotor instability - hot flashes and irregular menses. Hot flash or flush = sensation of warmth in upper chest, neck and face... followed by profuse sweating... lasts from seconds to minutes. Occur most often at night which disturbs sleep. The lowered estrogen levels correlates with dilation of cutaneous blood vessels resulting in hot flashes and increased sweating. May be triggered by= spicy meal, hot weather, stress, warm clothing, alcohol NOTE: Insomnia and depression is usually not DUE TO menopause, but rather is the "snowball effect" from the vasomotor symptoms... if sweat all night, you don't sleep... if you don't sleep, you aren't happy! Vaginal thinning Increased vaginal pH atrophic vaginitis (atrophy of vagina) increased risk of infections and dyspareunia (painful intercourse) significant emotional/relationship impact that is often not discussed with the healthcare provider Other signs of menopause include mood changes, loss of hair (head and pubic), cardiovascular (decrease in HDL and increase in LDL), and change in breast tissue. Long term issues of Menopause: 0steoporosis Increased incidence of heart disease (CAD) Possible relationship to Alzheimer's Weight gain Sexuality issues Osteoporosis: Big impact on bone activity with a rapid increase in bone absorption following menopause. And because women start with less "bone in the bank," they lose the bone more rapidly for a period of several years following menopause, and they therefore have a much higher fracture rate than men. Therefore, even if a women is on HRT encourage adequate calcium intake and supplement. Increase incidence of heart disease (CAD) Possible relationship to Alzheimer's: Alzheimer's is not a single diagnosis; there are lots of different causes of cognitive dysfunction. But there is certainly some relationship between hormonal and estrogen activity and cognitive function. Progesterone - really impacts cognitive function ("placenta brain") Weight gain: change in hormonal profile does lead to a change in body mass, largely conversion of muscle mass to fat mass. There is an increase in body weight associated with menopause. Sexuality d/t dyspareunia, may "want but can't b/c it hurts"... or d/t sleeplessness and mood issues "don't want but used to want" HT: always ask if pt still has a uterus In the recent years, there has been a paradigm shift in thinking about menopause management since the WHI study results came out (2002). See Position Statement: Hormone Therapy on pg. 495 of Durham & Chapman. No uterus and no risk of breast cancer = estrogen alone. Uterus = Estrogen and progesterone because unopposed estrogen builds up the endometrial lining and increases the risk of endometrial cancer. Prempro= combined estrogen and progestin; Premarin = estrogen only. The risks and benefits of therapy (minimizes bone loss, hot flashes, vaginal atrophic changes) should be considered carefully. The decision should be discussed between the woman and her health care provider. pearls of HT: HT should not be used to prevent MI HT should be used < 5 years Use lowest possible doses Annual CBE (clinical breast exam) and mammograms necessary if > 50 years Try lifestyle modifications and alternative therapies if appropriate Use local therapies for vaginal atrophy and dyspareunia NOTE: HRT estrogens are 1% as potent as oral contraceptives The risks and benefits of therapy (minimizes bone loss, hot flashes, vaginal atrophic changes) should be considered carefully. The decision should be discussed between the woman and her health care provider.

16. Explain the composition and functions of amniotic fluid and the development, structure and function of the placenta.

Placenta Development and Function: Purpose of placenta: metabolic and nutrient exchange between the embryonic and maternal circulation. Fully functional between 8-10 weeks Parts: Maternal and fetal Maternal consists of the decidual basalis and its circulation (red, fleshy) = dirty duncan fetal consists of chorionic villi and its circulation (covered by amnion=shiny/ gray) shiny schultz Placental circulation: Umbilical vein carries oxygenated blood in and umbilical arteries carry de-oxygenated blood away. Placental Function: Metabolic activities: produces glycogen, cholesterol and fatty acids for fetal use and hormone production, makes enzymes, stores glycogen and iron. Transport functions: transports nutrients, oxygen and CO2 Endocrine functions: produces hormones for fetus-hCG (able to determine at day 8 and used for pregnancy testing), hPL (human placental lactogen), estrogen and progesterone(maintains the endometrium in the uterus). Amniotic Fluid: Two membranes the amnion(inner layer) and chorion(outer layer) form the amniotic sac The chorion will develop on the implanted side with chorionic villi to provide fetal circulatory exchange. Amniotic fluid is the fluid contained within the amniotic sac. Primary functions: Cushion for mechanical injury Control temperature Permit symmetric growth Prevent adherence of embryo-fetus to amnion Allow for movement/musculoskeletal development Prevent cord compression Act as wedge during labor Fluid for analysis of fetal health. How secreted: Embryo & trophoblast early in pregnancy, By 23-25 weeks fetal kidneys become major source for amniotic fluid. Production and the fetus: Fetus swallows and inhales the amniotic fluid= matures lung /GI /Renal **Oligohydraminios (<500 mL) - decreased amount of amniotic fluid could be from congenital renal problems **Polyhydraminios (1,500-2,000 mL) - increased amount of amniotic fluid = increased risk for chromosomal disorders, G/I, cardiac, or neural tube disorders umbilical cord: Umbilical cord: connects the fetus to the placenta Vessels: One large vein (to the fetus), 2 smaller arteries (away from fetus)= (AVA) Arteries carry deoxygenated blood Vein carries oxygenated blood 2 vessels can mean that there may be cardiac or vascular defects Wharton's Jelly: specialized connective tissue that surrounds the blood vessels in the umbilical cord that helps prevent compression. Protects vessels from compression.

7. Develop a nursing plan of care for a post-menopausal woman. (2 questions)

Risk Factors for Osteoporosis: Risk factors: smoking Genetics: female; small thin body structure; family history; Caucasian/Asian Nutrition: low calcium, vitamin D; excessive alcohol use; history of eating disorders (anorexia/bulimia) Lifestyle: inactive (lack of weight bearing exercise), smoking (smoking 1 ppd throughout adult life= decreased bone mass by 5-10% = stimulates earlier menopause) Other: long-term use of steroids, thyroid replacements, chemotherapy, anticonvulsant medications; post-menopausal hypoestrogenic state; weight loss surgery Post-menopausal: 50% loss of bone pass in 5 years after menopause! ** loss of estrogen= osteoclast activity no longer held in check by estrogen and increase parathyroid hormone (which causes bone resorption by osteoclasts) Nutrition: Calcium intake: Good sources of Calcium see Table 64-14 Lewis pg. 1636); high spinach, milk, yogurt, hard cheeses, sardines, almonds; low eggs, poultry, fruit, cream cheese Note: daily calcium guidelines= reproductive age women= 1000 mg; teens= 1200 mg; postmenopausal = 1500 mg; pregnant/nursing= 1500 mg Vitamin D: most women get enough vitamin D in diet or skin exposure to sunlight; 800 -1000 IU daily for those who have limited exposure to sunlight

15. Discuss critical components of conception, embryonic development, fetal development, and fetal circulation.

Spermatogenesis - formation of mature spermatozoa regulated by FSH, LH & testosterone Oogenesis - formation of mature ovum regulated by FSH estrogen Ovum and sperm will fertilize and become the zygote and will be diploid (46 chromosomes) Primary Spermatocyte - 46 Chromosomes (diploid number) Secondary spermatocyte 23 chromosomes (haploid) 4 spermatids mature to spermatozoa (ready to fertilize) Oogenium - primary oocyte and polar body (waste) conceptions: Fertilization occurs in the outer 1/3 of the fallopian tubes Cell division zygote - cleavage - morula - (cellular multiplication and replication) is 16 cell stage (day 3) Blastocyst (embryoblast/embryo & trophoblast/placenta/Chorion) Multiple gestation—more than one embryo - monozygotic- identical twins formed when zygote splits or dizygotic- fraternal twins two separate ovum are fertilized Implantation - blastocyst begins to implant into the endometrium of the uterus (day 6-10) progesterone stimulated endometrium to become thicker and more vascular prior to implantation embedding of blastocyst into endometrium of uterus embryonic membranes begin to form at implantation=outermost is chorion chorionic villi implantation usually occurs in upper part of the posterior wall of the uterus embryonic development: Embryonic stage: Day 15-week 8 Week 8 is now the fetus Organogenesis: formation and development of body organs = most critical in development of the fetus 3 Primary Germ layers are formed Ectoderm - epidermis - epidermis, ant pituitary, nails, hair, central nervous system, eyes, tooth enamel and floor of amniotic cavity Mesoderm - bones, teeth, muscles, dermis, connective tissue and cardiovascular system, urogenital system Endoderm - epithelium lining, respiratory & digestive tracts, glandular cells liver, pancreas, urethra, bladder etc. First organ to form is the heart Week 3 tubular organ beats and connects the connection stalk, chorion and yolk sac. During the 4th & 5th week heart develops into a 4chamber heart and is completely developed by the end of the embryonic stage Embryonic disc= develops from blastocyst and is a double layer of cells from which embryo and amnion will develop. Chorionic villi= finger-like projections that form the fetal portion of placenta Fetus: Embryo (time of implantation through 8 weeks) Fetus (9 weeks until end of pregnancy) See Table 3-4 for growth/development Pregnancy duration: average of 10 LUNAR months, 40 weeks or 280 days from LMP - is calculated from the beginning of the last normal menstrual period to the time of birth From conception to maturity 266 days fetal circulation: Maternal The portion directly under the blastocyst where the chorionic villi tap into the maternal blood vessels is the decidua basalis of the endometrium (the maternal side of the placenta) Structures unique to fetal circulation: Blood flows in from umbilical vein Ductus venosus- most blood flows through the ductus venosus directly into the inferior vena cava, by-passing the liver, HOWEVER a small part enters the liver then the inferior vena cava via the hepatic veins. Foramen Ovale- allows blood to move from right to left atrium, then blood pours into left ventricle which pumps into the aorta. Ductus Arteriosus- allows lots of blood to pass from the pulmonary artery through to the descending aorta. Blood returns to placenta through the two umbilical arteries. the flow of fetal circulation: 1. Blood from the placenta flows in through the umbilical vein. Most of the blood flows through the ductus venosus directly in the inferior vena cava, bypassing the liver. Blood in the vena cava enters the right atrium. Goes through the foramen ovale into the left atrium., think of it as a shunt Pours into the left ventrical which pumps into the aorta. Some blood returns from the head and upper extremities via the superior vena cava and is emptied into the right atrium, passes through the tricuspid valve to the right ventricle and is then pumped in to the pulmonary artery (provides nourishment) and the greater amount passes from the pulmonary artery through the ductus arteriousus, into the descending aorta. Blood returns to placenta through the umbilical arteries.

14. Identify the potential effects of teratogens during vulnerable periods of embryonic and fetal development.

teratogens: Definition of teratogens (te-RAT O gens): Any drug, virus, or infection, or other exposure that can cause embryonic/fetal developmental abnormality. Teratogenic agents: Drugs Alcohol Infections/viruses: Rubella, varicella, parvovirus, syphilis, toxoplasmosis, cytomegalovirus (CMV), listeria Refer to Teratogenic Agents Table 3-2 Chapman pg. 27-28 The degree or types of malformation vary based on length of exposure, amount of exposure, and when it occurs during human development. Exposure most critical during the organogenesis (week 4-8weeks) = gross structural defects. Exposure to teratogens after 13 weeks of gestation = fetal growth restriction or reduction of organ size. Critical Component Toxoplasmosis (pg. 28) - found in cat feces - cause serious birth defects - women should avoid cleaning cat litter during pregnancy Most critical is from 4-8 weeks when the organs systems are being formed. After 13 weeks effect of teratogens may result in growth restriction or reduction of organ size. Old FDA system: A: Human studies show no risk. Ex. Vitamins B: Animal or human studies demonstrate no significant risk. Ex. PCN, Erythomycin, Tylenol C: No adequate human studies or animal studies show adverse effect. Ex. Steroid, Theodur, ASA D: Known increase in defects - Benefits outweigh risk. Ex. Dilantin - malformations, including heart defects, small head circumference and cleft lip and palate (low percentage) X: Risks too great AVOID. Ex. Accutane - intellectual disability, various brain malformations, heart defects, and facial abnormalities (higher incidence) New Pregnancy and Lactation Labeling Rule (PLLR): went into effect 6/30/15. All new drugs must comply and older drugs have a minimum of 3 years to comply with new labeling requirements Pregnancy exposure registry (if applicable) Risk summary (required) Clinical considerations (when relevant information is available) - to include dose adjustments during pregnancy and the postpartum period Data (when relevant information is available