test 2 maternity

PSYCHOLOGICAL ADAPTATION TO PREGNANCY

First-Trimester Task: Accept the Pregnancy Pregnancy is a development stage, and as such, psychological tasks of pregnancy have been identified. The first task of pregnancy is to accept the pregnancy. This task is usually met during the first trimester, although some women have difficulty fully accepting the pregnancy until they can feel the baby move. Second-Trimester Task: Accept the Baby Generally, during the first trimester, the woman is focused on the pregnancy and on accepting this new reality as being part of her identity. Gradually, as the pregnancy progresses, she comes to have a sense of the child as his or her own separate entity. This acceptance may be enhanced when she first hears the fetal heartbeat, when she feels the baby move inside her, or when she sees the fetal image during a sonogram. As she comes to accept the uniqueness of her baby, she may begin to shop for baby clothes or prepare the nursery. When an ultrasound is done in the second trimester, it is generally possible to detect the sex of the child. The couple may name the baby once they know if it is a boy or a girl.During the second trimester, the woman may become more extroverted. She often feels much better once the nausea and fatigue of the first trimester have passed. The fetus has begun to grow large enough that the pregnancy becomes apparent to those around her. Frequently, the second trimester is a happy time. The woman may enjoy the extra attention and deference society gives to pregnant women. It is important to remember that the partner is experiencing the pregnancy along with the woman. Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partners. This phenomenon is called couvade syndrome. It may be easier for the man to accept his partner now that she is feeling better and is less introverted. In any event, it is important to encourage the couple to communicate their needs effectively to each other. Each needs the support of the other. Third-Trimester Task: Prepare for Parenthood Nesting instincts often begin in the third trimester. The couple may prepare the nursery and shop for baby furniture and clothes. A name may be chosen. The woman usually has a heightened interest in safe passage for herself and the baby during labor. Toward the end of pregnancy, most women begin to feel tired of being pregnant. Many discomforts of pregnancy arise during the third trimester. It may be difficult to get comfortable at night, and so it may be hard to get a good night's sleep. Backache and round ligament pain may be bothersome. Urinary frequency often returns as the gravid uterus presses down against the bladder. Braxton Hicks contractions may become uncomfortable and more frequent. It is important to be supportive of the woman and listen to her concerns. It is helpful for the couple to attend childbirth preparation classes, which are often offered in the third trimester. Not only does the couple learn techniques to help them prepare for labor, but they are also able to interact with other couples who are facing issues similar to their own. The social aspect of childbirth preparation can be a powerful source of support to the woman and her partner.

HEALTH SCREENING FOR WOMEN

Health promotion is a broad concept that involves educating and assisting individuals to make behavior and lifestyle modifications for the prevention or early detection and treatment of disease. Because nurses are trusted health care professionals, individuals and families often turn to them for information and advice on health-related matters. As a result, health promotion for women is an area in which nurses can have great influence. Health screening is a component of health promotion. Screening tests do not diagnose disease. Instead, a positive result indicates the need for more thorough testing.

MENOPAUSE

Menopause, the cessation of menses, signals the end of the woman's reproductive capability. The climacteric refers to the gradual changes associated with declining ovarian function. Perimenopause refers to the time before menopause when vasomotor symptoms (hot flashes, night sweats) and irregular menses begin. Menopause is a normal part of the life cycle and is not a disease, although associated symptoms may be distressing to the woman and require interventions. Menopause occurs when the ovaries no longer respond to stimulation from the pituitary. During the perimenopausal period, the woman begins to experience variable menstrual cycles and irregular bleeding. Although these changes occur normally in response to hormonal changes, the woman should report all irregular bleeding to her health care provider for evaluation. Your perimenopausal clients will appreciate this tip! Although fertility declines with age, pregnancy can still occur. The woman in perimenopause should continue to use a reliable form of birth control. Clinical Manifestations The perimenopausal woman typically experiences a set of symptoms known as climacteric syndrome. These symptoms include hot flashes, insomnia, weight gain, bloating, emotional lability, irregular menses, and headache. A hot flash is a sudden feeling of warmth or intense heat sometimes accompanied by reddening of the skin on the upper body. The average length of symptoms in the perimenopausal woman is 2 years; however, some women experience hot flashes for five or more years. A hot flash corresponds to low estrogen levels and periodic surges of LH. Physical changes associated with hormone depletion include changes to the reproductive organs. The vaginal mucosa thins and becomes pale and dry. Vaginal rugae disappear, and the vaginal walls become smooth. The uterus and ovaries decrease in size. Pelvic support muscles can lose tone. Decreased bone mineral density is one of the changes that can have life-threatening effects on the menopausal woman. The overall effect of decreased bone mineral density is loss of bone mass with resulting reduction of bone strength and increased risk for fracture. This systemic condition is osteoporosis. Hormone replacement therapy (HRT) was the traditional approach for the prevention and treatment of perimenopausal symptoms as a whole. However, recent research is showing HRT may not be the best option for many women. HRT was associated with an increased risk for coronary heart disease, stroke, venous thromboembolism, and pulmonary embolism without a decrease in cardiovascular disease. Current recommendations for the use of HRT include control (not prevention) of perimenopausal symptoms. The health care provider should prescribe the lowest dose to control symptoms for the shortest time possible. Benefits of HRT include a decreased risk for colorectal cancer and osteoporotic fractures. Risk Factors for Osteoporosis • Female gender • Caucasian or Asian ethnicity • Slender build • Advanced age • Estrogen deficiency because of menopause (especially if early or surgically induced) • Low bone mass density • Family history of osteoporosis • Personal history of fracture as an adult • Smoking • Excessive alcohol intake • Low dietary intake of calcium • Vitamin D deficiency • Inactive lifestyle • Use of glucocorticoids • Use of anticonvulsants Treatment for Hot Flashes and Sweats Hot flashes and sweats are the most common reasons that the perimenopausal woman seeks medical treatment. To date, the most effective therapy for hot flashes continues to be HRT. Hormonal alternatives to HRT include progestins alone, which is beneficial in treating hot flashes. Nonhormonal options include the anticonvulsant gabapentin and SSRI antidepressants, such as paroxetine. Treatment for Osteoporosis HRT continues to be beneficial for reducing the risk of osteoporosis and fractures in the peri- and postmenopausal woman. However, other treatment options also lower the risk for fractures. These options include parathyroid hormone, raloxifene, calcitonin, and bisphosphonates. Calcium and vitamin D supplementation and regular weight-bearing exercise are preventive measures. Treatment for Vaginal Atrophy and Dryness HRT continues to be an effective treatment, although the use of local applications of estrogen-containing vaginal creams, tablets, or suppositories brings relief of symptoms with minimal systemic absorption. If estrogen use is contraindicated, the woman may benefit from nonestrogenic vaginal lubricants. Nursing Care Nurses have a large role to play in health promotion for the peri- and postmenopausal woman. It is important to develop a rapport with the woman and to let her know that you are available to talk about her concerns. Reassure the woman of the normality of menopause. Give the woman facts on HRT and other therapies. It may be helpful to give her a list of resources that she can read at home. It is important that the woman understand the risks and benefits of any therapy so that she can make an informed decision. Suggest lifestyle modifications to decrease the discomfort of hot flashes. These include dressing in lightweight clothing and dressing in layers. Regular exercise and setting the thermostat to a lower temperature may also be helpful. Suggest that she avoid spicy foods, caffeine, and alcohol. Give the woman information on strategies to prevent osteoporosis. Encourage regular weight-bearing activity, such as walking and stair climbing, at least three to four times per week. The postmenopausal woman should continue to take calcium and vitamin D supplements. She should take her calcium supplements with orange juice (or another vitamin C source) and avoid caffeine, which tends to interfere with the absorption of calcium. Safety instructions can help prevent fractures from falls inside the house. Encourage the postmenopausal woman to have her bed lowered, if possible; to eliminate throw rugs and clutter from the floors; and to use night-lights throughout the house. In the bathroom, it is helpful to install safety tread and safety rails. All of her slippers and shoes should have tread and should provide traction and stability. To reduce falls outside the home, instruct the woman to take extra precautions after dark. Advise her to use railings whenever possible. She should clear walkways of debris and avoid walking on ice. Review medications with the woman. She should understand how to take her medications and what side effects to report. She should also understand how often she should see her health care provider and have required routine screening examinations, such as yearly mammograms and bone density measurements. Family Teaching Tips: Reducing the Discomfort of Menopause lists helpful tips to share with the woman and her family. Reducing the Discomfort of Menopause • Wear cotton clothes in layers. • Avoid caffeine intake (e.g., colas, black tea, coffee). • Explore relaxation activities because stress exacerbates vasomotor symptoms. • Discuss HRT with your health care provider. • Consider nutritional supplements as recommended by your health care provider to help reduce vasomotor symptoms. • Use a water-soluble lubricant before intercourse. • Nonprescription products, such as Replens and Lubrin, are effective for the relief of vaginal dryness. • If using an estrogen vaginal cream, apply it at bedtime. • Perform Kegel exercises to improve pelvic muscle tone. • Drink at least five glasses of water per day. Do not count caffeine-containing drinks as part of this water intake. • Urinate regularly; do not allow the bladder to become overdistended. • Practice good hygiene, such as wiping from front to back after toileting.

Premenstrual Syndrome

Most women experience some discomfort just before the menstrual period, most commonly breast tenderness, food cravings, and pelvic heaviness or bloating. PMS is defined as physiologic and emotional symptoms that occur during the second half of the menstrual cycle that occur over repeated menstrual cycles and impact the woman's daily activities. These symptoms include headaches, weight gain, changes in activity and appetite, anxiety, and sadness. Symptoms of PMS usually resolve with the onset of the woman's menses. It is unclear why some women experience PMS while others do not. It is also unclear the exact percentage of women who experience PMS. Some studies inquire about symptoms but do not investigate the severity of the symptoms or the impact it has upon the woman's daily activities. Worldwide, women report similar symptoms that occur with PMS but in some countries the women do not report having PMS as that term does not exist in their language (Yonkers & Casper, 2017). Although the exact causes of PMS remain unknown, research shows that PMS symptoms are very complex and do not arise from one single causal factor. In fact, PMS results from the interplay between the central nervous system, the endocrine system, and other factors, such as genetics. Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS and is seen in a small percentage of women. PMDD includes all of the physical symptoms of PMS with additional and more debilitating emotional symptoms. Clinical Manifestations PMS presents with a wide variety of symptoms, which may be physical, behavioral, or both. The symptoms can be highly distressing for the woman and her family. In making a diagnosis of PMS, the crucial component is the cyclical nature of the symptoms. Typically, the severity of symptoms progresses over time. In the early stages of PMS, women describe symptoms beginning a few days before their period that stop when bleeding begins. With time, symptoms begin to appear 1 to 2 weeks before the onset of menses. Some women describe a cluster of symptoms occurring at the time of ovulation, followed by a symptom-free week, then a recurrence of symptoms a week before menses. PMS does not necessarily indicate dysmenorrhea will occur. Many women with symptoms of PMS do not have pain with menses. Common Symptoms Seen in Premenstrual Syndrome (PMS) Physical Symptoms • Breast tenderness • Abdominal bloating • Headache, migraine • Edema of the extremities Behavioral Symptoms • Angry outbursts • Confusion • Depression • Withdrawal from others • Anxiety • Irritable mood • Feelings of "edginess" Criteria the health care provider uses to make a diagnosis of PMS include the following: • The woman has at least one physical and one behavioral symptom occurring during the last half of the menstrual cycle. • The woman is asymptomatic before ovulation and has at least seven symptom-free days in each cycle. • Symptoms reported must be severe enough to affect relationships, work, and daily lifestyle. Treatment Pregnancy and menopause are the only true cures for PMS. Treatment aims to alleviate specific signs and symptoms. Some studies show that supplementation with vitamin B6, calcium, and magnesium are beneficial. Medications may be used to help relieve the symptoms of PMS. These include diuretics to reduce bloating, NSAIDs to reduce pain and cramping, and antianxiety drugs or antidepressants. Stress reduction, relaxation therapy, and exercise may also provide the woman with some relief. Some women report relief of PMS after starting oral contraceptives. PMDD responds to treatments similar to those used for PMS. In addition, the use of selective serotonin reuptake inhibitors (SSRIs) during the last half of the cycle has been effective in treating the severe mood swings and other emotional symptoms that are seen in PMDD. Nursing Care Assist the woman in finding ways to decrease stress. A healthy lifestyle contributes to a general sense of well-being. Encourage regular exercise, even when she is experiencing symptoms. Encourage reduction or elimination of caffeine and alcohol. Explain that limiting salt intake may decrease symptoms of bloating. Family Teaching Tips: Relief Measures for PMS describes additional relief measures.

Pica

Pica is the persistent ingestion of nonfood substances such as clay, laundry starch, freezer frost, or dirt. It results from a craving for these substances that some women develop during pregnancy. These cravings disappear when the woman is no longer pregnant. Pica may be accompanied by iron deficiency anemia (Schrier, 2017). If you suspect or discover that a pregnant woman is practicing pica, tell the registered nurse or the practitioner immediately. Special counseling is indicated in this situation.

SIGNS OF PREGNANCY

Presumptive signs of pregnancy are subjective data that the woman reports. The most common presumptive sign of pregnancy is a missed menstrual period or amenorrhea. There are many causes of amenorrhea. Some women have irregular periods. Emotional distress can cause a woman to skip a menstrual period. Some disorders, such as anorexia nervosa, can lead to amenorrhea. Women who perform intense exercise, such as marathon running, may experience amenorrhea. Because so many factors, other than pregnancy, can cause a woman to miss a menstrual period, amenorrhea is classified as a presumptive or subjective sign of pregnancy. Other presumptive signs include nausea; fatigue; swollen, tender breasts; and frequent urination. Nausea can be caused by emotional distress, a viral infection, gastritis, or many other problems. Anemia, lack of sleep, overexertion, or infection can lead to fatigue. Breast tissue can become swollen and tender just before a woman starts her menstrual period in response to hormonal changes. Frequent urination can result from a urinary tract infection, nervousness, or from taking in substances, such as caffeine or alcohol, that have diuretic properties. Probable Signs Probable signs of pregnancy are those detected by a trained examiner. These include objective data, such as Chadwick sign, the bluish-purplish color of the cervix, vagina, and perineum. The examiner identifies Hegar sign, softening of the uterine isthmus, and Goodell sign, softening of the cervix, during the speculum and digital pelvic examinations. Other objective signs include a change in the shape of the uterus, an enlarging uterus, and Braxton Hicks contractions. Ballottement occurs when the examiner pushes up on the uterine wall during a pelvic examination, then feels the fetus bounce back against the examiner's fingers. The reason these signs are considered probable, rather than positive, is that pelvic tumors and some types of cancers can cause similar signs. Another probable sign is the pregnancy test. Although pregnancy tests performed in a laboratory are highly reliable (from 97% to 99%), there is still the small possibility for error. Pregnancy tests measure the presence of human chorionic gonadotropin (hCG) in the urine or the blood. These levels can be elevated in conditions other than pregnancy, such as hydatidiform mole and choriocarcinoma. Many women use home pregnancy tests to determine whether they are pregnant. These home pregnancy tests are approximately 95% reliable when they are performed correctly and done within the time frame specified by the test. Some tests can detect the presence of hCG within 1 day of the woman's missed period. It is important for the woman to know that the home pregnancy test is more likely to be correct when it reveals a positive result than when a negative result is obtained. In other words, if the home pregnancy test is negative, she should still monitor for signs of pregnancy and repeat the test or schedule an appointment with her health care provider. Testing for hCG can be done in approximately 10 minutes, is reliable within 7 or 8 days after ovulation, and can be done on urine or the woman's serum. If urine is used, it is best to have the first voided specimen of the morning because this urine is highly concentrated, making detection of hCG easier. Positive Signs Positive signs are diagnostic of pregnancy because no other condition can cause the sign. The positive sign that can be elicited earliest in the pregnancy is visualization of the gestational sac or fetus. With transvaginal ultrasound, the gestational sac can be seen as early as 10 days after implantation. The fetal outline and cardiac activity are visible by abdominal ultrasound at 7 to 8 weeks of gestation. The fetal heartbeat, heard at 9 to 10 weeks of gestation with Doppler technology and by 18 to 20 weeks with a fetoscope, is a positive sign of pregnancy. Palpation of fetal movements by a trained examiner is a positive sign of pregnancy

ASSESSMENT OF FETAL WELL-BEING DURING PREGNANCY

Throughout the pregnancy, the health care provider may order tests to observe the well-being of the fetus. Some are screening tests, which means they are not diagnostic. If an abnormal result occurs with a screening test, additional diagnostic testing is recommended. The discussion that follows describes some of the most common tests and procedures. Not every woman will receive every test, although some screening tests are recommended for all pregnant women at certain points during the pregnancy. Fetal Kick Counts A healthy fetus moves and kicks regularly, although the pregnant woman usually cannot perceive the movements until approximately 16 to 20 gestational weeks. The fetus undergoes regular rest/activity cycles that last around 40 to 60 minutes. The woman is instructed to monitor her baby's movements on a daily basis. Instruct the woman to choose a time each day in which she can relax and count the baby's movements. Each kick or position change counts as one movement. Using a special form provided by the health care provider or a blank sheet of paper, instruct the woman to note the time she starts counting fetal kicks and then keep counting until she counts 10 movements. A healthy fetus will move at least 10 times in 2 hours. If the woman eats or drinks something high in sugar, such as orange juice, this may increase the fetal activity during kick counts. If it takes longer than 2 hours for the fetus to move 10 times, or if the woman cannot get her baby to move at all, she should immediately call her health care provider who will order tests to determine the well-being of the fetus. Don't forget! "Routine" for you as a nurse is not routine for the woman. She will need careful explanation of all prenatal tests. This includes routine testing that occurs as part of prenatal care and tests performed for other reasons. Ultrasonography Ultrasound is the gold standard in the United States to determine gestational age, observe the fetus, and diagnose complications of pregnancy Because it appears to be a safe and effective way to monitor fetal well-being, the procedure is performed frequently. One plus for parents is that with ultrasound, parents can know the gender of the child before he or she is born if they desire. Many sonographers take a still picture of the fetus and provide this to the parents, also if desired. As stated earlier in the chapter, ultrasound uses high-frequency sound waves to visualize fetal and maternal structures. The developing embryo can first be visualized at about 6 weeks' gestation. An ultrasound performed at this stage positively diagnoses the pregnancy. Ultrasound captures the fetus's cardiac activity and body movements in real time. lists ways ultrasound technology is used to monitor the pregnancy and fetal well-being. Concept Mastery Alert Ultrasonography is a powerful tool in determining not only maternal dimensions, but also informs the health care provider about the size of the infant. Uses for Ultrasound Technology During Pregnancy • Diagnose pregnancy: intrauterine and ectopic (outside the uterine cavity). • Diagnose multifetal pregnancies (twins, triplets). • Monitor fetal heartbeat and breathing movements. The fetus makes "practice" breathing movements in utero as early as 11 weeks' gestation. • Take measurements of the fetal head, femur, and other structures to determine gestational age or diagnose fetal growth restriction. • Detect fetal anomalies. • Estimate the amount of amniotic fluid that is present. Either too much (polyhydramnios) or too little (oligohydramnios) can indicate problems with the pregnancy. • Identify fetal and placental structures during amniocentesis or umbilical cord sampling. • Detect placental problems, such as abnormal placement of the placenta in placenta previa or grade the placenta (determine the age and functioning). • Diagnose fetal demise (death). Absence of cardiac activity is used to diagnose fetal death. • Verify fetal presentation and position. • Estimate the birth weight, particularly if the fetus is thought to be abnormally large (macrosomic). Ultrasound can best detect most abnormalities of the fetus, placenta, and surrounding structures between 16 and 20 weeks' gestation. Detailed sonograms can diagnose severe congenital heart, spine, brain, and kidney defects. However, ultrasound cannot pick up all abnormalities. Some anomalies, such as Down syndrome, have subtle characteristics that can be observed on ultrasound, for example, increased nuchal translucency (fetal neck thickness) and shortened long bones (femur or humerus). There are two main ways to perform an ultrasound during pregnancy—the transabdominal or the transvaginal approach. Transabdominal Ultrasound For the transabdominal method, the sonographer places a transducer on the abdomen to visualize the pregnancy. In the past, it was recommended that the woman have a full bladder for transabdominal ultrasound. Current recommendations are that the woman does not need to have a full bladder (Shipp, 2017). In fact, a full bladder may actually distort anatomy. If the sonographer cannot see sufficient detail with the transabdominal approach, a transvaginal approach can be used. If you are assisting during the procedure, place a small wedge (a pillow or folded towel) under one hip to prevent supine hypotension. Explain to the woman that the sonographer will place ultrasonic transducer gel on her abdomen and that the gel will probably be cold. She should not feel any discomfort during the procedure. A darkened room optimizes visualization of fetal structures during the procedure. Although the technician performing the sonogram can see fetal structures and obvious defects during the sonogram, it will take several hours to get the official results because the radiologist, not the sonographer, must review the films and give the diagnosis. After the procedure, clean the excess gel off the woman's abdomen and assist her to the bathroom if necessary. Here's a tip! The woman may be anxious or excited during the ultrasound. Use open ended questions to determine how she is feeling about the procedure. Don't assume every woman or partner is excited about the ultrasound. Also, some women do not wish to know the gender of the fetus so inquire about this prior to the procedure. Transvaginal Ultrasound For the transvaginal (also referred to as endovaginal) method, the sonographer uses a specialized probe that is placed in the woman's vagina. There are several advantages to this method. The transvaginal approach allows for a clearer image because the probe is very close to fetal and uterine structures. This method allows for earlier confirmation of the pregnancy than does the transabdominal method. The transvaginal method is superior for predicting or diagnosing preterm labor because the sonographer can measure and analyze the cervix for changes. Assist the woman into lithotomy position (as for a pelvic examination) and drape her for privacy. A female attendant must be present in the room at all times during the procedure if the sonographer is male. The examiner covers the probe (which is smaller than a speculum) with a specialized sheath, applies the transducer gel to the covered probe, and inserts the probe into the vagina. Explain to the woman that she will feel the probe moving about in different directions during the test. The probe may cause mild discomfort, but it is generally not painful. Doppler Flow Studies Another test that uses ultrasound technology is a Doppler flow study or Doppler velocimetry. A specialized ultrasound machine measures the flow of blood through fetal vessels. The ultrasound transducer on the woman's abdomen allows the sonographer to monitor blood flow through the umbilical vessels and in the fetal aorta, brain, and heart. If the test shows that blood flow through fetal vessels is less than normal, the fetus may not be receiving enough oxygen and nutrients from the placenta, and additional studies will be ordered. Preparation and nursing care for a Doppler flow study are the same as for a transabdominal ultrasound.

1. The client states she is 2 weeks late for her menstrual period. She has been feeling tired and has had bouts of nausea in the evenings. What is the classification of the pregnancy symptoms Amanda is experiencing? a. Positive b. Presumptive c. Probable d. No classification

b. Presumptive

3. A woman is having severe symptoms of PMS. She asks the nurse what she can do to obtain relief from these symptoms. What reply by the nurse is most likely to be helpful? a. "Antibiotics are necessary to treat the underlying infection." b. "Diuretics tend to be the most helpful medications for PMS treatment." c. "Don't worry. The medication the doctor has prescribed will take care of your symptoms." d. "In addition to taking medications, stress reduction and regular exercise are beneficial."

d. "In addition to taking medications, stress reduction and regular exercise are beneficial."

2. A woman presents to the clinic in the first trimester of pregnancy. She has three children living at home. One of them was born prematurely at 34 weeks. The other two were full term at birth. She has a history of one miscarriage. How do you record her obstetric history on the chart using GTPAL format? a. G3 T2 P1 A1 L3 b. G4 T3 P0 A1 L3 c. G4 T2 P1 A1 L3 d. G5 T2 P1 A1 L3

d. G5 T2 P1 A1 L3

2. During the obstetric pelvic examination, the health care provider notes that the uterine isthmus is soft. What is the name of this sign, and how is it classified? a. Chadwick sign; presumptive b. Goodell sign; presumptive c. Goodell sign; probable d. Hegar sign; probable

d. Hegar sign; probable

3 shunt in fetal circulation

ductus venosus, foramen ovale, and the ductus arteriosus.

Internal Reproductive Organs

internal reproductive organs include the vagina, uterus, fallopian tubes, and ovaries.

survival time of sperm

sperm are viable for 24 to 72 hours after ejaculation into the female reproductive system.

Uterus

uterus: or womb, is a hollow, pear-shaped, muscular structure located within the pelvic cavity between the bladder and the rectum. In the nonpregnant woman, the uterus is approximately 7.5 cm long by 5 cm wide (at the widest portion) and weighs approximately 40 g. The uterus normally tips forward and rests just above the urinary bladder. The functions of the uterus are to prepare for pregnancy each month, protect and nourish the growing fetus when pregnancy occurs, and aid in childbirth. divided into four sections: • cervix • uterine isthmus • corpus • fundus

1. During which time frame does the embryonic stage last? a. Ovulation to conception b. 1 to 14 days after conception c. 3 through 8 weeks after conception d. 9 through 38 weeks after conception

c. 3 through 8 weeks after conception

age of viability

20 weeks' gestation

4. The nurse is teaching the pregnant client about a proper diet during pregnancy. Which statement shows the client understands approximately how many calories per day she needs over her normal prepregnant needs? a. "I will need about 300 more calories." b. "I will need approximately 500 more calories." c. "I need to double my calories because I'm eating for two." d. "I should not increase my calories while I'm pregnant."

a. "I will need about 300 more calories."

The vagina is a hostile environment for sperm. What characteristic of semen protects sperm from the vaginal environment? a. Acidic fluid b. Alkaline fluid c. Presence of testosterone d. Secretions from seminiferous tubules

b. Alkaline fluid

3. Which is a fetal shunt that aids in fetal circulation? a. Foramen primum b. Foramen ovale c. Ductus deferens d. Septum secundum

b. Foramen ovale

3. The client is 16 weeks pregnant. If the pregnancy is progressing as expected, where would the health care provider be able to palpate the uterine fundus? a. Just above the pubic bone. b. Halfway between the pubic bone and the umbilicus. c. At the umbilicus. d. The uterine fundus would not be palpable at 16 weeks.

b. Halfway between the pubic bone and the umbilicus.

Selected Nursing Diagnoses

• Risk for injury related to complications of pregnancy • Anxiety related to unfamiliar procedures • Impaired comfort related to physiological changes of pregnancy • Deficient knowledge related to self-care activities during pregnancy • Fear related to lack of knowledge regarding labor and delivery

age at hearing heartbeat by Doppler

end of week 12 😊Length: 8 cm (3 in.). Weight: 25 g. Placenta is complete. Divisions of the brain begin to develop. The face is well formed. The eyes are widely spaced and fused. Heartbeat is audible by Doppler. Kidney secretion has begun. Spontaneous movements occur (may not yet be discernible by the woman). Gender is discernible by outward appearance.

THE NURSE'S ROLE IN PRENATAL CARE

.Nurses are in a unique position to influence behaviors of the pregnant woman and to increase the chance she and her baby will stay healthy. Through consistent use of the nursing process, you can detect problems early in order to intervene or assist the health care provider in intervening, and support the woman through her pregnancy. Providing the pregnant woman with information remains the primary nursing intervention throughout pregnancy. Assessment (Data Collection) Selected Nursing Diagnoses Outcome Identification and Planning Implementation Evaluation: Goals and Expected Outcomes

Maternal Serum Alpha-Fetoprotein Screening

Alpha-fetoprotein is a protein manufactured by the fetus. The woman's blood contains small amounts of this protein during pregnancy. Measuring MSAFP can be done between 15 and 20 weeks' gestation and the optimal time frame is between 16 and 18 weeks' gestation. Abnormal levels (high or low) may indicate a problem and the need for additional testing. MSAFP levels are elevated in several conditions. Higher than expected levels of MSAFP are seen when the woman is carrying multiple fetuses, when the fetus has died, or in the presence of neural tube defects. The main reason MSAFP is measured is to check for neural tube defects, such as anencephaly (failure of the brain to develop normally) or spina bifida (failure of the spine to close completely during development). MSAFP levels are usually elevated if the fetus has either of these anomalies. Omphalocele and gastroschisis (both are caused by a failure of the abdominal wall to close) are two other conditions that cause elevated MSAFP levels. Low MSAFP levels may indicate Down syndrome. Several factors can influence MSAFP results. These include an incorrect gestational age, increased maternal weight, maternal diabetes mellitus, and maternal race. It is important that these factors are reported to the laboratory with the MSAFP specimen. It is important for the parents-to-be to understand the reasons for and implications of MSAFP testing. Even when the levels are abnormal, the woman will often deliver a healthy baby. However, abnormal results increase the likelihood that the fetus has an abnormality, and additional diagnostic testing with ultrasound and/or amniocentesis will be recommended. An elevated MSAFP in the presence of a normal ultrasound increases the risk that the woman will develop a complication of pregnancy, such as preeclampsia or intrauterine growth restriction. Some women want to have the test done so that they can decide whether to end the pregnancy before the age of viability. Other women feel strongly that abortion is not an option, but they may want to know if an anomaly is present so that they can deliver in a hospital with high-level care and have specialists immediately available to care for the baby. Other women may decide against testing because a false-positive test might be needlessly worrisome and lead to more invasive, riskier tests, such as amniocentesis, even though the baby might be healthy. Each woman must consider these issues in consult with her partner and the health care provider. No matter what decision the woman makes regarding testing, it is critical to support her decision.

History

The history is one of the most important elements of the first prenatal visit. The woman may fill out a written questionnaire or the history may be obtained exclusively during a face-to-face interview. Whatever method is chosen, review the history thoroughly, and report any abnormal or unusual details. There are several parts to the history, including chief complaint, reproductive history, medical-surgical history, family history, and social history. Chief Complaint The chief complaint is the reason a client seeks care from the health care provider. For the woman seeking prenatal care, the chief complaint is usually a missed menstrual period. Ask the woman about any presumptive and probable signs of pregnancy she is experiencing. Reproductive History Note the age of menarche, as well as a summary of the characteristics of the woman's normal menstrual cycles. Common questions include, "Are your periods regular?" and "How frequently do your periods occur?" Note the first day of the last menstrual period (LMP). The obstetric history is a part of the reproductive history. Review details of each pregnancy, including history of miscarriages or abortions and the outcome of each pregnancy (i.e., how many weeks the pregnancy lasted and whether or not the pregnancy ended with a living child). There are specific medical terms that relate to the obstetrical history. The word "gravid" means pregnant. Gravida refers to the number of pregnancies the woman has had, including the present pregnancy, regardless of the outcome. For example, a woman who has had one pregnancy is a gravida 1, whereas a woman who has had five pregnancies is a gravida 5. A woman who has never been pregnant is a nulligravida (gravida 0), a woman who is pregnant for the first time is a primigravida, and a woman who has had more than one pregnancy is a multigravida. Parity, or para, refers to the number of pregnancies (not fetuses) carried past the age of viability (20 or more weeks). Each pregnancy is counted as one, even if the woman delivers twins or triplets. The current pregnancy is not counted in parity. Nonviable fetuses that deliver before the end of 20 weeks' gestation are termed spontaneous abortions. Abortions, either spontaneous or therapeutic, are not counted in the parity total. The term primipara is used for the woman delivering for the first time and multipara denotes a woman who has delivered more than once. It is important to obtain information regarding complications that may have occurred with other pregnancies. A problem the woman had in a previous pregnancy may manifest itself again in the current pregnancy or increase the chance that she will develop another type of complication. For example, if a woman hemorrhaged after a previous delivery, she has a higher risk of hemorrhaging after subsequent deliveries. This is also true for a previous history of gestational diabetes and preterm deliveries. Any finding that presented in a previous pregnancy is an important part of the obstetric history. Medical-Surgical History After eliciting a thorough reproductive history, the health care provider must obtain a detailed medical-surgical history. If the woman has any major medical problems, such as heart disease or diabetes, she will require closer surveillance throughout the pregnancy. The prenatal record should list all medications the woman is taking, including vitamins, over-the-counter medications, and herbal remedies. Part of the medical history involves determining if there are risk factors for infectious diseases. If the woman has been exposed to anyone with tuberculosis, she needs additional screening to rule out the disease. Determine the woman's immunization status. The woman who is nonimmune for a particular infection is at risk to contract that infection. Although most immunizations are contraindicated during pregnancy, the woman who is nonimmune can take precautions to decrease the chance she will contract infection during pregnancy. Determine risk factors for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted infections (Box 7-2). Risk Factors for Sexually Transmitted Infections • Sex with multiple partners • Sex with a partner who has risk factors • Intravenous drug use (needle sharing) • Anal intercourse • Vaginal intercourse with a partner who also engages in anal intercourse • Unprotected (no condom) intercourse Family History A family history is important because it may highlight the need for genetic testing or counseling. Verify the health status of the father of the baby and any close relatives of the couple. If there is a family history for cystic fibrosis or other genetically linked disorders, the health care provider may recommend genetic screening. The ethnic background of the woman and relatives of the unborn child are important factors to consider. For instance, many people of African-American descent are carriers for sickle cell anemia. Social History The social history focuses on environmental factors that may influence the pregnancy. A woman who has strong social support, adequate housing and nutrition, and greater than a high school education is less likely to develop complications of pregnancy than is a woman who lives with inadequate resources. The type of employment may influence the health of the pregnancy. A job that requires exposure to harmful chemicals is less safe for the woman and fetus than is a job that does not involve this type of exposure. Employment that requires the woman to stand for long periods of time, such as sales clerks, waitresses, and nurses, can increase her risk for preterm labor. Intimate partner violence can also threaten the pregnancy; therefore, it is important to screen every woman for intimate partner violence. Intimate partner violence affects women and men of all socioeconomic, religious, and cultural backgrounds Smoking, alcohol, and drug use (including illicit drugs, prescription, or over-the-counter medications), can all potentially harm a growing fetus. Therefore it is important to determine the woman's use of these substances, particularly since conception. If the woman owns a cat or likes to garden, she is at increased risk for contracting toxoplasmosis. Toxoplasmosis is caused by a protozoan that is passed from animals to humans, usually in contaminated soil or by animal feces. If the woman contracts toxoplasmosis while she is pregnant, it can cause the woman to miscarry or can result in severe abnormalities in the fetus. It can also cause visual or hearing problems in the infant later on after birth.

monozygotic/dizygotic

Twins can be either identical or fraternal. Identical twins derive from one zygote (one egg and one sperm which divides into two zygotes shortly after fertilization), so identical twins are monozygotic twins. They share the same genetic material and are always the same gender. Fraternal twins develop from separate egg and sperm fertilizations and are dizygotic twins. Fraternal twins may or may not be the same gender, and their genetic material is not identical (Fig. 5-10). In pregnancies that have more than two fetuses, they may have all developed from a single fertilized egg, also referred to as monozygotic; or they may have developed from separate eggs; or they may be a combination of both types.

Subsequent Prenatal Visits

Traditionally, the health care provider sees the woman once monthly from weeks 1 through 32. Between weeks 32 and 36, prenatal visits are every other week. From week 36 until delivery, the woman is seen weekly. Encourage the woman to keep her appointments and maintain regular prenatal care throughout the pregnancy. During subsequent visits, weight, blood pressure urine protein and glucose, and fetal heart rate (FHR) are all data that are routinely collected. At every visit, inquire regarding the danger signals of pregnancy Ask the woman about fetal movement, contractions, bleeding, and membrane rupture. Normally the pelvic examination is not repeated until late in the pregnancy closer to the expected time of delivery. At each office visit, the fundal height is measured. To do this, a tape measure is placed at the base of the uterus, at the symphysis pubis, and then laid against the abdomen. The fundal height is measured in centimeters with the reading at the top of the fundus. Between weeks 18 and 32 the fundal height in centimeters should match the gestational age of the pregnancy. For example, if the woman is 18 weeks pregnant, the fundal height should measure 18 cm. If there is a discrepancy between the size and dates, the health care provider needs to determine the cause of the discrepancy, usually this is done by sonogram. A fundal height that is larger than expected could indicate that the original dates were miscalculated, that the woman is carrying twins, polyhydramnios (excessive amniotic fluid, usually more than 2 L), or that there is a molar pregnancy . A fundal height that is smaller than expected could indicate that the original dates were miscalculated, oligohydramnios (too little amniotic fluid, usually less than 500 mL), or that the fetus is smaller than expected . After 32 weeks, the fundal height does not correlate with gestational age because of variances in fetal growth. Recommended screenings occur at particular times during the pregnancy. Sometime between 15 and 20 weeks' gestation, a maternal serum alpha-fetoprotein (MSAFP) should be drawn (see the discussion in the section on fetal assessment). Between 24 and 28 weeks, all women should be screened for gestational diabetes. At 28 weeks, a woman who is Rho(D)-negative should be screened for antibodies and given anti-D immune globulin (RhoGAM), if indicated The woman should undergo screening for group B streptococcus. Positive group B streptococcus cultures indicate the need for antibiotics for the woman during labor and close observation of the newborn for 48 hours after birth. To screen for Down syndrome in mothers with a high risk, the health care provider may recommend the woman have a cell-free DNA (cfDNA) blood test.

1. An adolescent girl asks the nurse when she should have her first "Pap test." How should the nurse reply? a. "I don't know. Ask the doctor." b. "When you first start having sex." c. "As soon as possible and every year thereafter." d. "It is recommended you have your first Pap smear when you turn 21."

d. "It is recommended you have your first Pap smear when you turn 21."

Outcome Identification and Planning

Maintaining the health of mother and fetus is the primary goal of nursing care during the prenatal period. Other important goals during this time frame are to relieve anxiety and also to ensure that the woman has the information she needs to adequately care for herself during pregnancy and the information needed to prepare for delivery.

luteinizing hormone (LH)

When the pituitary gland detects high levels of estrogen from the mature follicle, it releases a surge of LH. This sudden increase in LH causes the follicle to burst open, releasing the mature ovum into the abdominal cavity, a process called ovulation Luteal Phase After ovulation, LH levels remain elevated and cause the remnants of the follicle to develop into a yellow body called the corpus luteum. In addition to producing estrogen, the corpus luteum secretes a hormone called progesterone. If fertilization does not take place, the corpus luteum begins to degenerate, and estrogen and progesterone levels fall. This process leads back to day 1 of the cycle, and the follicular phase begins anew.

3. A woman who is 28 weeks' pregnant presents to the clinic for her scheduled prenatal visit. The nurse-midwife measures her fundal height at 32 cm. What action does the nurse expect the midwife to take regarding this finding? a. The midwife will order a multiple-marker screening test. b. The midwife will order a sonogram to confirm dates. c. The midwife will schedule more frequent prenatal visits to monitor the pregnancy closely. d. The midwife will take no action. This is a normal finding for a pregnancy at 28 weeks' gestation.

b. The midwife will order a sonogram to confirm dates.

Ovaries

ovaries are glands located on either side of the uterus. They are similar to almonds in size and shape. The broad and ovarian ligaments provide support to the ovaries. The functions of the ovaries are to store ova and help them mature and also to produce the female hormones estrogen and progesterone. Estrogen and progesterone are responsible for female secondary sex characteristics and also in the regulation of the menstrual cycle in response to anterior pituitary hormones . Every female is born with all the ova (eggs) that she will ever have. Typically, females are born with approximately 2 million eggs, many of which will deteriorate during childhood. The ovaries normally release the remaining ova at a rate of one per month until the woman's reproductive years are over.

Vagina

vagina: birth canal, muscular tube leads from the vulva to the uterus. posterior vaginal wall is longer than the anterior wall (approximately 9 and 7 cm long, respectively vagina important functions: The inner folds, or rugae, allow the vagina to stretch during birth to accommodate a full-term infant. In addition, the vagina normally maintains an acidic pH of 4 to 5, which protects the vagina from infection. The vagina receives the penis during sexual intercourse and serves as the exit point for menstrual flow.

Amniocentesis

An amniocentesis is a diagnostic procedure where a needle is inserted into the amniotic sac and a small amount of amniotic fluid is obtained A variety of biochemical, chromosomal, and genetic studies are possible using the amniotic fluid sample. The procedure is usually performed between 15 and 20 weeks' gestation, although early amniocentesis (at 12 to 14 weeks' gestation) may be preferable in some cases. Amniocentesis can determine the genetic makeup and gender of the fetus because amniotic fluid contains fetal cells. lists indications for first- and second-trimester amniocentesis. Third-trimester amniocentesis is usually done to determine fetal lung maturity, which allows for the earliest possible delivery in certain at-risk pregnancies. Selected Indications for Chromosomal Studies by Amniocentesis or Chorionic Villus Sampling • Advanced maternal age (generally accepted as older than 35) • Previous offspring with chromosomal anomalies • History of recurrent pregnancy loss • Ultrasound diagnosis of fetal anomalies • Abnormal MSAFP, triple-marker screen, or multiple-marker screen • Previous offspring with a neural tube defect • Both parents known carriers of a recessive genetic trait (such as cystic fibrosis, sickle cell anemia, or Tay-Sachs disease) Because amniocentesis is an invasive procedure that carries a small risk of spontaneous abortion, injury to the fetus, and chorioamnionitis (infection of the fetal membranes), the woman must give informed consent. The health care provider explains the procedure and risks and answers her questions. If you witness the consent, be certain that the woman has had all her questions answered and that she has not taken any antianxiety medications before she signs. Many women are worried that the procedure will be painful. Although pain is a subjective feeling that varies between individuals, most women find that the procedure is much less painful than they anticipated. Usually women report feeling a slight pinching sensation or vague cramping. Nursing responsibilities during an amniocentesis include observation of the woman and fetus, providing support to the woman, and assisting the health care provider as needed. Silence can be golden! The woman may not be very talkative during the procedure, especially if she is anxious. Do not try to fill the silence with excessive conversation or talking with the health care provider as if the woman is not there. Instead, offer a therapeutic statement such as, "I am here if you want to talk," and use therapeutic touch, such as holding her hand or touching her shoulder, if appropriate. Just before the procedure, ultrasound is used to locate a pocket of amniotic fluid. Without ultrasound to guide the needle, there is a high risk that the needle could puncture the placenta or the fetus. After the pocket of fluid is identified (usually on the upper portion of the uterus), the site is prepared with an antiseptic solution and sterile drapes are placed on the abdomen around the site. Sterile drapes also cover the ultrasound transducer. A 20- or 22-gauge spinal needle is inserted into the chosen site and guided into the pocket of fluid. The first 0.5 mL of fluid is discarded to avoid contamination of the specimen with maternal cells. Then, 20 mL (less for early amniocentesis) of fluid is withdrawn and the needle removed. The FHR is monitored by ultrasound to ensure fetal well-being. The fluid sample, which is normally straw colored, is placed into sterile tubes, labeled, and sent to the laboratory for analysis. Results are usually available within 2 to 3 weeks and are highly accurate (approximately 99%). Continuous electronic fetal monitoring (EFM) is done to observe the FHR and also for any contractions. Women who are Rho(D)-negative should receive RhoGAM after the procedure as there is risk for leaking of fetal blood into the maternal circulatory system from this invasive procedure. Immediately report to the registered nurse (RN) or the attending health care provider any maternal temperature elevation, leaking of amniotic fluid from the puncture site or from the vagina, vaginal bleeding, cramps, or contractions. After several hours of monitoring, the woman may go home. Instruct her to remain on bed rest for the rest of the day. The following day she may do light housework chores, and the third day she may resume regular activities. Warning signs she should immediately report to the health care provider include fever, amniotic fluid leakage, decreased fetal movement, vaginal bleeding, and/or cramping. As with any medical procedure that carries risk, amniocentesis has advantages and disadvantages that each woman must consider carefully. The most common reason for undergoing amniocentesis is to determine if there is a fetal abnormality so that the pregnancy might be terminated (elective abortion) before the age of viability if the woman desires. Many women will not consider an abortion under any circumstances. In these cases, there are still benefits to amniocentesis. If the fetus does have a chromosomal abnormality, knowing in advance allows the medical team and the parents to prepare for the birth. It also allows the health care provider to make better decisions about managing the pregnancy. Every woman who is contemplating amniocentesis should have genetic counseling. At that point, no matter what decision the woman makes, it is critical that the health care team supports her decision.

Ovarian Cycle

Cyclical changes in the ovaries occur in response to two anterior pituitary hormones: follicle-stimulating hormone (FSH) and luteinizing hormone (LH). There are two phases of the ovarian cycle, each named for the hormone that has the most control over that particular phase. The follicular phase, controlled by FSH, encompasses days 1 to 14 of a 28-day cycle. LH controls the luteal phase, which includes days 15 to 28

contraception

Natural Methods A natural contraceptive method refers to any method that does not use hormones, pharmaceutical compounds, or physical barriers that block sperm from entering the uterus. Natural methods of birth control include abstinence, coitus interruptus, and natural family planning or fertility awareness methods (FAMs). Abstinence Abstinence as related to birth control means refraining from vaginal sexual intercourse. Abstinence can include other means of sexual stimulation, such as oral sex. Complete, or strict, abstinence refers to the avoidance of all sexual contact. Abstinence is a normal and acceptable alternative to sexual intercourse, especially for teens and singles in noncommittal relationships. The use of complete abstinence as a method of birth control has no cost, is readily available, and is the only 100% effective method for preventing pregnancy and STIs. A major drawback is that it can be difficult to maintain abstinence. A couple may make a rash decision during the heat of passion, which may leave them without a means of preventing pregnancy. Coitus Interruptus Coitus interruptus, also called withdrawal, requires the man to pull the penis out of the vagina before ejaculation to avoid depositing sperm in or near the vagina. However, the pre-ejaculate fluid may contain sperm, so pregnancy can still occur. Effectiveness is dependent on the male partner's ability to withdraw his penis before ejaculation. One advantage of coitus interruptus is that it provides some level of protection when no other method is available. However, the disadvantages are many. This is an unreliable method of birth control, and it offers little, if any, protection from STIs. This method requires a great deal of self-control on the part of the male partner and is not effective if the man ejaculates prematurely. Lactational Amenorrhea Breast-feeding offers some level of contraceptive protection because elevated prolactin levels help suppress ovulation. The method works best during the first 6 months after childbirth. The woman must breast-feed frequently, every 2 to 3 hours without fail. Advantages of breast-feeding include promotion of weight loss, suppression of menses, and a more rapid return of the uterus to its pre-pregnant state. A major disadvantage is that the woman will not know for sure when fertility returns and pregnancy can occur even prior to the onset of her first menstrual cycle after childbirth. Fertility Awareness Methods FAMs, also known as the rhythm method, refer to all methods that use the identification of fertile and infertile phases of a woman's menstrual cycle to plan or prevent pregnancy. Such methods involve observing and charting the signs and symptoms of the menstrual cycle (e.g., menstrual bleeding, cervical mucus changes, and variations in basal body temperature [BBT]) to determine the woman's fertile period. The woman then uses abstinence or a barrier contraceptive method during days identified as fertile to reduce the risk of pregnancy. FAM is also effective in planning pregnancy. FAM requires the cooperation of both partners. Advantages of these methods are that they are inexpensive, do not require the use of artificial devices or drugs, and have no harmful side effects. Disadvantages include that the method requires discipline to use and can seem cumbersome for a woman or couple with a busy lifestyle. It also has a high failure rate during the first year with typical use. A foundational component for practicing FAM is knowledge about the menstrual cycle. Guidelines derive from the assumption that ovulation occurs exactly 14 days before the onset of the next menstrual cycle and that the fertile window extends 3 to 4 days before and after ovulation, or in other words, between days 10 and 17 of the menstrual cycle. Five methods used to anticipate the fertile window are as follows: 1. Calendar method 2. BBT method 3. Cervical mucus method 4. Symptothermal method 5. Standard days method (SDM) Calendar Method. With the calendar method, fertile days are determined by an accurate charting of the length of the menstrual cycle over a period of 6 months. The woman counts the number of days per cycle, beginning on the first day of menses. The beginning of the fertile period is determined by subtracting 18 days from the length of the shortest cycle. The end of the fertile days is determined by subtracting 11 days from the length of the longest cycle. Box 4-3 gives an example of how to calculate the fertile period using this method. To avoid pregnancy, the couple abstains from sexual intercourse or uses a barrier method during the identified fertile period. The major drawbacks of this method are that the couple is using data about past cycles to predict what will happen in the future, and they are counting on the regularity of what can be an unpredictable event. In reality, the timing of the fertile period can be highly variable, even for women who think that they have regular cycles. The method is contraindicated for women who do not have regular cycles, such as women who are anovulatory (absence of ovulation), adolescents, women approaching menopause, and women who have recently given birth. Calculation of Fertile Window Using the Calendar Method A woman keeps track of the length of her menstrual cycles for at least 6 months. Then she calculates her fertile window by subtracting 18 days from her shortest cycle and 11 days from her longest cycle. For example, for a woman whose shortest cycle is 24 days and longest cycle is 28 days, the calculation would be as follows. Therefore, the woman's fertile window would be days 6 to 17 of her menstrual cycle. She and her partner would then use abstinence or a barrier method to prevent pregnancy during the fertile window. Basal Body Temperature Method. The BBT is the lowest normal temperature of a healthy person, taken immediately after waking and before getting out of bed. The BBT method relies on identifying the shift in body temperature that occurs normally around the time of ovulation. The BBT ranges from 36.2°C to 36.3°C during menses and for about 5 to 7 days after. At about the time of ovulation, a slight drop in temperature may occur, followed by a slight rise (approximately 0.2°C to 0.4°C) after ovulation, in response to increasing progesterone levels. This temperature elevation persists until 2 to 4 days before menstruation. The BBT then drops to the lower levels recorded during the previous cycle, unless pregnancy occurs. To prevent conception, the couple avoids unprotected intercourse from the day the BBT drops through the fourth day of temperature elevation. The woman must chart the BBT daily on a graph for an entire month to accurately determine a pattern. Confounding factors such as fatigue, infection, anxiety, awakening late, getting fewer than 3 hours sleep, jet lag, alcohol consumption, and sleeping in a heated waterbed or using an electric heating blanket may all cause temperature fluctuation, altering the expected pattern. Because so many factors can interfere, BBT alone is not a reliable method for predicting ovulation. Using BBT along with the calendar or cervical mucus methods increases the effectiveness. Cervical Mucus Method. The cervical mucus method requires recognition and interpretation of characteristic changes in the amount and consistency of cervical mucus through the menstrual cycle. Accurate assessment of cervical mucus requires that the mucus be free of contraceptive gel or foam, semen, blood, or abnormal vaginal discharge for at least one full cycle. Before ovulation, cervical mucus is thick and does not stretch easily. This quality inhibits sperm from entering the cervix. Just before ovulation, changes occur that facilitate the viability and motility of sperm, allowing the sperm to survive in the female reproductive tract until ovulation. Cervical mucus becomes more abundant and thinner with an elastic quality. It feels somewhat slippery and stretches 5 cm or more between the thumb and forefinger, a quality referred to as spinnbarkeit (Fig. 4-3). These cervical mucus changes indicate the period of maximum fertility. Observation begins on the last day of menses and repeats several times a day for several cycles. The woman obtains mucus samples at the vaginal introitus, so there is no need to attempt to reach into the vagina to the cervix. Factors that can affect the cervical mucus appearance include the presence of sperm, contraceptive gels or foam, vaginal discharge, use of douches or vaginal deodorants, sexual arousal, and medications, such as antihistamines. Although self-evaluation of cervical mucus can help the woman predict ovulation, this method is more effective when used in combination with the calendar and/or BBT methods. This method may be unacceptable for the woman who is uncomfortable touching her genitals. Symptothermal Method. The symptothermal method is a combination of the calendar, BBT, and cervical mucus methods, along with an awareness of other signs of fertility. The woman acquires fertility awareness as she begins to understand the secondary physiologic and psychological symptoms marking the phases of her cycle. These secondary symptoms include increased libido, mid-cycle spotting, mittelschmerz (unilateral lower abdominal pain in the ovary region associated with ovulation), pelvic fullness or tenderness, and vulvar fullness. The woman may palpate the cervix to assess for changes that normally occur with ovulation. The cervical os dilates slightly, the cervix softens and rises in the vagina, and cervical mucus becomes abundant with a slippery consistency. Calendar calculations and cervical mucus changes are useful to approximate the beginning of the fertile period. Changes in cervical mucus and BBT may predict the end of the fertile period. Some studies have demonstrated a lower failure rate when the woman uses multiple indicators to predict the fertile window. Hormonal Methods Hormonal methods of contraception include oral contraceptives, implants, injections, vaginal ring, and transdermal patches. Depending on their hormonal composition, hormonal methods may prevent or suppress ovulation and may thicken cervical mucus, making it resistant to sperm penetration. Advantages of hormonal contraceptives are that they are highly effective in preventing pregnancy when used consistently and correctly. In addition, hormonal methods may provide noncontraceptive health benefits, such as menstrual cycle improvements, management of dysmenorrhea, and protection against certain cancers, ovarian cysts, and acne. Although efficacious in preventing pregnancy, there are disadvantages to the use of hormonal methods of contraception. Many new users discontinue hormonal methods during the first year of use because of experienced or perceived side effects. In addition, hormonal contraceptives do not offer protection from STIs, including HIV, for either partner. Therefore, the couple must use condoms if they desire STI protection. Combination Oral Contraceptives Combination oral contraceptives (COCs), also known as "the pill," are the most commonly used reversible method of contraception (Alan Guttmacher Institute, 2015). COCs can be monophasic or phasic. Monophasic pills provide fixed doses of estrogen and progestin, whereas phasic pills (biphasic, triphasic, and multiphasic) are formulated to alter the amount of progestin, and in some cases, estrogen, within each cycle. Phasic preparations reduce the total dosage of hormones in a cycle without sacrificing effectiveness. Typically, a pill is taken daily throughout the cycle The last 7 pills of the 28-pill pack are inert but help maintain the habit of taking the daily pill. Menstruation occurs during the time the woman takes the inert pills. Some health care providers prescribe longer regimens of COCs to suppress menstruation while also providing birth control. The woman must take the pill at the same time each day for it to be effective. If taken daily as prescribed, COCs provide a high contraception effectiveness rate. In addition, COC therapy offers many noncontraceptive benefits, in particular menstrual cycle improvements, including a decrease in menstrual blood loss, reduction in the occurrence of iron-deficiency anemia, regulation of irregular cycles, lessening of the symptoms of dysmenorrhea (painful menstrual periods), and lower incidence of PMS. COCs offer protection against endometrial and ovarian cancer. They are associated with a reduced incidence of benign breast disease, protection against the development of functional ovarian cysts and some types of PID, and a decreased risk for ectopic pregnancy (Kaunitz, 2017). Disadvantages of COCs include no protection from HIV and other STIs. In addition, the woman must remember to take the pill at the same time every day. A large percentage of women stop using COCs because of side effects. Common side effects include nausea, headache, breast tenderness, weight gain, breakthrough spotting or bleeding, and amenorrhea. These side effects usually decrease over time and are less common with lower dose preparations. COCs may promote growth of estrogen-dependent breast cancer, although they probably do not cause breast cancer. Another disadvantage is the expense. COCs require a visit to the health care provider and are available by prescription only. Some women should not use COCs, or use them only with great caution. Box 4-4 outlines contraindications for their use. Instruct the woman to report any preexisting health problems, any change in health that may affect her use of COCs, and the occurrence of any warning signs, including severe abdominal or chest pain, dyspnea, headache, weakness, numbness, blurred or double vision, speech disturbances, or severe leg Progestin-Only Pills Progestin-only pills (POPs), also referred to as the "mini-pill," contain only one hormone, progestin. Its major effect is to thicken the cervical mucus and make the endometrium inhospitable to implantation. POPs are slightly less effective than COCs in preventing ovulation. Advantages include no estrogen side effects, so the woman is less likely to quit using the contraceptive. In addition, women for whom COCs are contraindicated (e.g., those older than 35 years who also smoke and those who have a history of thrombophlebitis) may take POPs. There are no "hormone-free" days or inert pills to take, so the woman can maintain a daily routine of taking the same pill every day. The woman who is lactating can take POPs after the newborn is 6 weeks old. POPs decrease dysmenorrhea and the pain sometimes associated with ovulation. Menstrual irregularities are one disadvantage of POPs, although periods are usually very short and scanty, which some women find desirable. The woman must take POPs every day at the same time of day without fail because their main action (thickening cervical mucus) lasts only 22 to 24 hours. As with COCs, POPs do not provide STI protection and require a health care provider visit and a prescription. Contraindications for Using Combination Oral Contraceptives (COCs) Contraindications to the use of COCs include any of the following conditions or lifestyle patterns. • Thromboembolic disorders • History of heart disease or cerebral vascular accident • Estrogen-dependent cancer or breast cancer • Impaired liver function • Undiagnosed vaginal bleeding • A confirmed pregnancy or a strong suspicion of pregnancy • A smoking pattern of more than 15 cigarettes per day in women older than 35 years Signs of Complications with Oral Contraceptives The mnemonic "ACHES" can help you recall warning signs related to using oral contraceptives. A Abdominal pain C Chest pain, dyspnea, bloody sputum H Severe headache, weakness, or numbness in extremities E Eye problems such as blurred vision, double vision, or vision loss S Speech disturbance, severe leg pain, or edema Hormonal Injections One type of injectable hormonal contraceptive is available in the United States. Depot medroxyprogesterone acetate (DMPA, Depo-Provera) is a progestin-only agent. It provides a level of contraceptive protection similar to that of POPs. As with other hormonal contraceptive methods, DMPA does not provide protection against STIs. DMPA consists of a slow-release form of progestin that prevents ovulation. Intramuscular injections provide 3 months of protection. The health care provider administers the first injection within 7 days of the onset of menses. After that, the woman must schedule appointments every 13 weeks for an injection. A lower dose subcutaneous form of DMPA is available. Take it easy! When administering an injection of DMPA, do not massage the site. This could hasten absorption of the hormone and cause a shorter period of effective contraception. Advantages are that the woman does not have to remember to take a pill on a daily basis, and she does not have to use a product at the time of sexual intercourse. DMPA provides the woman with a high level of privacy. No one has to know she is using this method of birth control, unless she chooses to share this information. Lactating mothers and women who cannot take estrogen products can use DMPA. Other advantages include decreased risk of endometrial cancer and improvement of PMS and the pain associated with endometriosis. Disadvantages include prolonged amenorrhea. Many women stop menstruating after the third DMPA injection. This effect is not harmful, and some women may even consider it an advantage. In addition to menstrual irregularities, the most common side effects are weight gain, headache, and nervousness. Sometimes depression and premenstrual symptoms worsen. Another potential disadvantage is the length of time it takes (an average of 10 months) before fertility returns after discontinuing the method. DMPA may lower the woman's estrogen levels, leading to loss of bone mineral density and increased risk of fractures. Contraindications for using DMPA include pregnancy, history of breast cancer, stroke, or liver disease. Hormonal Implant The hormonal implant currently available in the United States is the Etonogestrel implant (Nexplanon, Implanon). The implant is a progestin-only, flexible plastic rod about the size of a matchstick. The health care provider inserts the rod using local anesthesia just under the skin on the inside of the upper arm. Insertion takes approximately 1 minute. Removal requires a small incision and takes about 3 minutes. Contraceptive protection is evident for 3 years. The implant is an extremely effective method of birth control. Advantages include having no daily pills to remember and no interference with sexual activity to use the method. Fertility returns quickly (within a month) after the implant is removed. The implant frequently improves symptoms of dysmenorrhea, does not have an effect on bone density like DMPA does, and appears to be safe for lactating women. Disadvantages include unscheduled bleeding, which is the most common reason women stop using this method of birth control; headache; weight gain; and acne. The implant does not provide protection from STIs. Transdermal Patch The transdermal patch (Ortho Evra) supplies continuous levels of estrogen and progestin (see Fig. 4-7). It is available only as a prescription. The woman places the patch on the lower abdomen, upper outer arm, buttock, or upper torso (excluding the breasts) on the first day of her menstrual period. She then applies a new patch every week for 3 weeks and then removes it for 1 week to allow menses to occur. The woman should apply each new patch on the same day of the week and should not wear more than one patch at a time. Individuals who use the patch are more likely to be compliant with the method than with COCs or POPs because there is no daily requirement. It is a highly effective form of birth control. Disadvantages include decreased effectiveness in women who weigh more than 198 lb. The most common side effects include breast symptoms, application site reactions, and headache. Women are at increased risk for venous thromboembolism and cardiovascular risks. Women who smoke and women who are breastfeeding should not use the transdermal patch. The transdermal patch does not protect the woman from STIs. Vaginal Ring The vaginal ring contraceptive (NuvaRing) is a soft, flexible ring, approximately 5 cm in diameter, that contains estrogen and progestin (see Fig. 4-7). The woman places the ring into the vagina once a month, during which time it releases low levels of hormones. Lower dosing is possible because it works in the vagina. After 21 days (3 weeks), the woman removes the ring to allow menstruation. Advantages include low estrogen exposure with high effectiveness. There is a low incidence of hormone-related side effects such as headaches, nausea, and breast tenderness. It is easy to insert and generally discreet to use. Disadvantages include that a woman must feel comfortable touching her genitals, some women or their partners may be able to sense the ring during intercourse, the ring may slip out during intercourse, and the device may cause increased vaginal discharge. The vaginal ring does not protect the woman from STIs. Intrauterine Device The intrauterine device (IUD) is a small T-shaped device that the health care practitioner inserts into the uterine cavity (Fig. 4-8). Four different IUDs are approved for use in the United States. ParaGard is a nonhormonal copper device and the other three, Mirena, Skyla, and Liletta, contain the hormone progestin that is slowly released over a long period of time (Henry J. Kaiser Family Foundation, 2016). The copper-bearing device is effective for up to 10 years and the progestin-releasing devices for 5 years. As a safety measure, IUDs are radiopaque (can be seen on x-ray). Each month, the woman must check for presence of the string in the vagina to confirm continued placement of the device. The device must be removed by the health care provider and not by the woman. The copper-bearing IUD acts by damaging sperm in transit through the uterus. Few viable sperm are able to reach the ovum, thus preventing fertilization. The progestin-bearing device makes the cervical mucus inhospitable to sperm and also prevents development of the endometrial lining. The IUD typically causes no disruption of ovulation. The absence of estrogen makes the copper IUD a more appropriate contraceptive for women older than 35 years; for heavy smokers; and for women with hypertension, vascular disease, or familial diabetes. You can help inform the woman The copper in the IUD decreases the effectiveness of sperm. The progestin in the hormonal IUD makes it hard for the sperm to penetrate the cervical mucus and also prevents the endometrial lining from developing each month. The IUD offers continuous protection from unwanted pregnancy without the need to remember a daily pill or to interrupt sex for contraception use. Placement of the IUD can occur at any time during the menstrual cycle after obtaining a negative pregnancy test. It is effective for use immediately after childbirth or after an abortion. When the woman wants to become pregnant, the health care provider removes the device, and fertility returns. The progestin-bearing device offers the added benefits of decreasing dysmenorrhea and is useful for decreasing bleeding in women with menorrhagia (abnormally long or heavy menstrual periods). Side effects include cramping and bleeding upon insertion of the device. Common reasons for removal of the copper device include dysmenorrhea and increased menstrual flow. Headache, breast tenderness, and acne are common side effects of the progestin-releasing device. Risks include uterine perforation and accidental device expulsion. The IUD offers no protection against STIs. Box 4-6 outlines signs of complications with IUD use. Sterilization Sterilization is a permanent method of birth control performed via a surgical procedure. Although in some instances reversal may be accomplished, the procedure to do so is expensive and often not successful. Therefore, those who choose surgical sterilization procedures should consider them permanent methods of birth control. Female Sterilization Female sterilization is accomplished by tubal ligation or tubal occlusion. Tubal ligation involves tying the fallopian tubes and then cutting the tubes into 2 parts. Tubal occlusion involves application of bands or clips via laparoscopy (Fig. 4-9A). The surgeon makes a small vertical incision in the abdominal wall near the umbilicus, brings each tube through the incision, and then ligation, clip application, or cauterization of the tube occurs. Regional or general anesthesia is required. Oral analgesics are usually sufficient to relieve postoperative discomfort. Female sterilization is a minor surgical procedure and the postoperative recovery period is about 1 to 2 days. The woman should report bleeding or signs of infection. The procedure may be done immediately after giving birth (within 24 to 48 hours), at the time of an abortion, or during any phase of the menstrual cycle. Signs of Complications with IUDs The mnemonic "PAINS" can help you remember the signs of potential complications related to IUDs. P Period late, abnormal spotting, or bleeding A Abdominal pain, pain with intercourse I Infection exposure, abnormal vaginal discharge N Not feeling well, fever, chills S String missing, shorter, or longer Male sterilization, or vasectomy, can be performed using local anesthesia in an outpatient setting. The procedure takes about 20 minutes to perform. The health care provider makes a small incision on each side of the scrotum over the spermatic cord. The next step is ligation and cutting of each vas deferens (Fig. 4-9B). The cut ends of the vas deferens may be cauterized and then buried in the scrotal fascia to reduce the chance of spontaneous re-anastomosis. Closure of the skin incisions completes the procedure, and a dressing may be applied. The man should expect some pain, bruising, and swelling of the scrotum after the procedure. Rest, the application of an ice pack, scrotal support, and a mild oral analgesic are effective comfort measures. The health care provider usually recommends moderate inactivity for 1 to 2 days because of scrotal tenderness. The man should report any signs of bleeding or infection. The man may resume sexual intercourse as desired; however, with vasectomy, sterilization is not immediate because sperm remain in the system distal to the ligation. It takes approximately 1 month to completely purge the remaining sperm from the man's system. Therefore, it is necessary for the couple to use another method of birth control until a negative sperm count verifies sterility. Vasectomy has no effect on the man's ability to achieve or maintain erection or on the volume of ejaculate. In addition, there is no interference with the production of testosterone, so secondary sexual characteristics are not affected. Emergency Contraception Emergency contraception (EC) refers to methods used to reduce the risk of pregnancy in the event of unprotected sexual intercourse or if the birth control being used failed (i.e., the condom breaks, the man did not pull out in time). The sooner the woman uses EC after the unprotected intercourse, the more effective it is at preventing pregnancy. EC should not be the only method of birth control a woman uses. It is much more effective to use a consistent form of birth control. EC does not protect against STIs. There are several oral medications approved for EC. Levonorgestrel is a one-dose over-the-counter treatment that the woman takes within the first 72 hours after the unprotected intercourse. The other medications are available with a prescription from a health care provider and are either a one- or two-dose treatment and must be started between 72 and 120 hours after the unprotected intercourse. EC medications work to prevent pregnancy by either delaying or inhibiting ovulation or by preventing implantation in the endometrium. Regardless of the EC medication used, the woman should also restart her initial birth control right away or use another form of birth control as her fertility can return rapidly and she can get pregnant with subsequent unprotected acts of intercourse. Another form of EC is the insertion of a copper IUD which can be inserted up to 7 days after unprotected intercourse. One advantage of this method is that it is very effective at preventing pregnancy and it provides long-term protection. A woman who has an active STI or who is at high risk for STIs should not use this form of EC.

5. A woman with epilepsy was on phenytoin (Dilantin) when she became pregnant. She is worried that her baby will have a birth defect. Which reply by the nurse is most therapeutic? a. "All substances and medications increase the risk of birth defects when you are pregnant. It is important for you to discontinue any medications or over-the-counter medications immediately. This is the best way you can protect your baby." b. "Please don't worry. Dilantin is a very safe medication and unlikely to cause a birth defect." c. "Yes, Dilantin increases the risk of certain defects in the fetus; however, overall the risk is low that your baby will be affected. Your doctor weighs the risk of untreated epilepsy on the fetus with the risk of the medication when making decisions about your treatment plan." d. "Yes, there is a very high risk that your fetus will have major birth defects. Your doctor will most likely switch you to a safer medication. Are you on any other medications?"

c. "Yes, Dilantin increases the risk of certain defects in the fetus; however, overall the risk is low that your baby will be affected. Your doctor weighs the risk of untreated epilepsy on the fetus with the risk of the medication when making decisions about your treatment plan."

Which ovarian hormone regulates the proliferative phase of the uterine cycle? a. FSH b. LH c. Estrogen d. Progesterone

c. Estrogen

2. A 35-year-old woman reports very heavy menstrual periods. How does the nurse chart this in the medical record? a. "Chief complaint: dysmenorrhea." b. "Complains of metrorrhagia." c. "Reports amenorrhea." d. "Reports menorrhagia."

d. "Reports menorrhagia."

cervix

tubular structure that connects the vagina and uterus. The cervix normally has a tiny slit that allows sperm to enter and the menstrual flow to exit. During childbirth, the cervix must be thin and open fully so that the baby can be born. The ciliated epithelium that lines the inner walls of the cervix produces mucus that lubricates the vaginal canal and protects the uterus from ascending infectious agents. The uterine isthmus is a narrow corridor that connects the cervix to the main body of the uterus. During pregnancy and childbirth, the uterine isthmus is referred to as the lower uterine segment. This is the thinnest portion of the uterus and does not participate in the muscular contractions of labor. Because the tissue is so thin, the lower uterine segment is the area that is most likely to rupture during childbirth. The corpus is the main body of the uterus, and the fundus is the top-most section resembling a dome. The walls of the corpus and fundus have three layers. The perimetrium is the tough outer layer of connective tissue that supports the uterus. The middle layer is the myometrium, a muscular layer that is responsible for the contractions of labor. The muscle fibers of the myometrium wrap around the uterus in three directions: obliquely, laterally, and longitudinally. This muscle configuration allows for tremendous expulsive force during labor and birth. The endometrium is the vascular mucosal inner layer. This tissue changes under hormonal influence every month in preparation for possible conception and pregnancy. Four paired ligaments provide support and hold the uterus in position. These ligaments anchor the uterus at the base (cervical region), leaving the upper portion (corpus) free in the pelvic cavity.

Physical Examination

The health care provider performs a complete physical examination. As the nurse, you may be asked to provide assistance as needed. The head-to-toe physical is done first. The examiner looks for signs of disease that may need treatment and for any evidence of previously undetected maternal disease or other signs of ill health. A breast examination is part of the physical. Although it is rare, breast cancer in a young pregnant woman is a possibility. A vaginal speculum examination and a bimanual examination of the uterus follow the head-to-toe physical. During the speculum examination, a Papanicolaou test or Pap smear is performed, and signs of pregnancy are noted, such as Chadwick sign. The bimanual examination allows the provider to feel the size of the uterus and to elicit Hegar sign.

Evaluation: Goals and Expected Outcomes

Goal: The woman's symptoms and discomforts of pregnancy are manageable. Expected Outcomes: The woman • identifies common discomforts of pregnancy. • describes measures to deal with the common discomforts of pregnancy. Goal: The woman feels confident in her ability to care for herself throughout pregnancy. Expected Outcomes: The woman • verbalizes an understanding of how to modify lifestyle to accommodate the changing needs of pregnancy. • describes self-care measures to perform during pregnancy. Goal: The woman expresses confidence in her ability to go through the labor and birth experience. Expected Outcomes: The woman • expresses realistic expectations regarding plans for labor and birth. • schedules and attends childbirth education and/or parenting classes. • prepares the home for arrival of the baby.

Breast Cancer Screening

In the United States, breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer (American Cancer Society, 2016). In the United States from 2008 to 2012, 125 out of every 100,000 women were diagnosed with breast cancer and for the same time period, 22 out of every 100,000 women died from breast cancer (National Cancer Institute, 2016). Detection of breast cancer before axillary node involvement increases the woman's chance for survival. For early identification of breast cancer, the American Cancer Society (ACS) recommends breast self-awareness by the woman, a clinical breast examination, and mammography. For women with average risk for breast cancer yearly mammograms should start at age 45 and can change to having mammograms every 2 years beginning at age 55. Women who are at a higher risk for breast cancer due to family history or another reason may need to begin screening earlier and/or more often (ACS, 2016). Educate the woman regarding the importance of each screening test and how to perform a breast self-examination (BSE).

Danger Signs of Pregnancy

Inquire regarding these warning signals at every visit. Instruct the woman to report any of these signs if she experiences them to her health care provider right away. • Fever or severe vomiting • Headache, unrelieved by Tylenol or other relief measures • Blurred vision or spots before the eyes • Pain in the epigastric region • Sudden weight gain or sudden onset of edema in the hands and face • Vaginal bleeding • Painful urination • Sudden gush or constant, uncontrollable leaking of fluid from the vagina • Decreased fetal movement • Signs of preterm labor Uterine contractions (four or more per hour) Lower, dull backache Pelvic pressure Menstrual-like cramps Increase in vaginal discharge A feeling that something is not right

follicle-stimulating hormone (FSH)

The ovary has follicles on it which are depressions that contain an ovum that has started, but not completed maturation. At the beginning of each menstrual cycle, a follicle on one of the ovaries begins to develop in response to rising levels of FSH. The follicle produces estrogen, which causes the ovum contained within the follicle to mature. As the follicle grows, it fills with estrogen-rich fluid and begins to resemble a tiny blister on the surface of the ovary. . Ovulation occurs on day 14 of a 28-day cycle. As the ovum floats along the surface of the ovary, the gentle beating of the fimbriae draws it toward the fallopian tube.

4. A G1 at 20 weeks' gestation is at the clinic for a prenatal visit. She tells the nurse that she has been reading about "group B strep disease" on the internet. She asks when she can expect to be checked for the bacteria. How does the nurse best reply? a. "I'm glad that you asked. You will be getting the culture done today." b. "The obstetrician normally cultures for group B strep after 35 weeks and before delivery." c. "You are only checked for group B strep if you have risk factors for the infection." d. "You were checked during your first prenatal visit. Let me get those results for you."

a. "I'm glad that you asked. You will be getting the culture done today."

4. Which statement by a woman with a pelvic support disorder should alert the nurse to instruct the woman to come in immediately for examination by a physician? a. "My urine is cloudy." b. "I forgot to do my Kegel exercises today." c. "Every time I cough, a little bit of urine comes out." d. "I took my pessary out to wash it and forgot to put it back in."

a. "My urine is cloudy."

4. What is the classification of twins who share the same chromosomal material? a. Monozygotic b. Dizygotic c. Fraternal d. Trizygotic

a. Monozygotic

1. A woman reports that her LMP occurred on January 10, 2018. Using Naegele rule, what is her due date? a. October 17, 2018 b. October 17, 2019 c. September 7, 2018 d. September 7, 2019

a. October 17, 2018

Nonstress Test

The nonstress test (NST) is a noninvasive way to monitor fetal well-being. After 28 weeks, the fetal nervous system is developed enough so that the autonomic nervous system works to periodically accelerate the heart rate. Therefore, FHR can be observed for accelerations using EFM. The woman requires no special preparation for the NST EFM is used to monitor the FHR and the woman may or may not have an event marker to hold. If she uses an event marker, she pushes a button every time she feels the fetus move. In the past, FHR was always monitored in conjunction with fetal movement. Now, it is generally felt that spontaneous accelerations with or without fetal movement are indicative of fetal well-being, so it is not necessary to have the woman track fetal movements, although some health care providers prefer this. The fetal monitor tracing is evaluated after 20 minutes. Generally, if there are at least two accelerations of the FHR, at least 15 beats above the baseline for at least 15 seconds, the NST is said to be "reactive" provided that the baseline and variability are normal and that there are no decelerations of the FHR. In the presence of a reactive NST, fetal well-being is assumed for at least the next week. If, however, there are no accelerations or less than two occur within 20 minutes, the strip is said to be "nonreactive." In this case, the monitoring would continue for another 20 minutes in the hopes of obtaining a reactive NST. This is because fetal sleep cycles last for approximately 20 minutes. During fetal sleep, accelerations do not usually occur, so it is prudent to observe for an additional 20 minutes. Sometimes attempts are made to stimulate the fetus. The provider may clap loudly close to the woman's abdomen or may manipulate the fetus through the abdomen, or the woman may be given something cold to drink. Any of these activities might stimulate a sleeping fetus to wake up and result in a reactive tracing. If the tracing remains nonreactive or equivocal (meaning the results cannot be interpreted), additional testing is warranted. In these instances, the health care provider frequently recommends vibroacoustic stimulation or a contraction stress test (CST).

5. Results of an early CVS test show that a woman's baby has severe chromosomal abnormalities. When the obstetrician explains the findings to her, she becomes tearful. She shares with the nurse that it is against her religious beliefs to have an abortion. How would the nurse best respond to her? a. "Abortion is really the best thing for the baby. He has no chance of a normal life." b. "I agree with you. It is against my religious beliefs, too." c. "It is dangerous to carry a fetus with chromosomal abnormalities to term. You really should consider an abortion to protect your health." d. "You don't have to decide what to do today. Take some time to talk this over with your family. I will support whatever decision you make."

d. "You don't have to decide what to do today. Take some time to talk this over with your family. I will support whatever decision you make."

You are caring for a woman in labor. The doctor is concerned that the uterus might rupture. Which part of the uterus requires the closest assessment because it is the thinnest part of the uterus? a. Corpus b. Fundus c. Inner cervical os d. Lower uterine segment

d. Lower uterine segment

1. You are informing a male client about the male reproductive system. You ask him which gland provides the sugar that gives the sperm energy to move. Which answer indicates that he correctly understands the information? a. Bartholin gland b. Bulbourethral gland c. Prostate gland d. Seminal vesicles

d. Seminal vesicles

2. What is the main purpose of the chorionic villi? a. To adhere the blastocyst to the endometrial lining b. To form the tissues that will become the placenta c. To produce amniotic fluid d. To provide an exchange site for the exchange of nutrients and wastes

d. To provide an exchange site for the exchange of nutrients and wastes

You are preparing to perform a urinary catheterization on a female client. In which location will you expect to find the urinary meatus? a. Above the clitoris b. Below the vaginal opening c. On the true perineum d. Within the vestibule

d. Within the vestibule

3 shunt sin fetal circulation

ductus venosus, foramen ovale, and the ductus arteriosus.

fallopian tubes

(also known as oviducts) are tiny, muscular corridors that arise from the superior surface of the uterus near the fundus and extend laterally on either side toward the ovaries. They are 8 to 14 cm in length. Each fallopian tube has three sections. The isthmus, which means a neck or narrow section, is the medial third of the tube that connects to the uterus. The ampulla is the middle portion of the tube. The infundibulum is the outer portion that opens into the lower abdominal cavity. At the outer edges of the infundibulum are fimbriae, finger-like projections that make gentle wave-like motions over the ovaries. The fallopian tubes have a critical role in conception. When the ovary releases an egg, the fimbriae make wave-like movements that attract the egg toward the fallopian tube. Once the egg is within the tube, muscular contractions and beating of tiny cilia within the tube propel the egg toward the uterus. If sperm are present, fertilization of the egg is possible. Fertilization most frequently occurs in the ampulla section of the tube. The tubes secrete lipids and glycogen to provide nourishment to the fertilized egg as it makes its way to the uterus. The functions of the fallopian tubes are to provide a site for fertilization, a passageway, and a nourishing, warm environment for the fertilized egg to travel to the uterus.

GTPAL

Gravida: Total number of pregnancies Term deliveries: Number of pregnancies that ended at term (at or beyond 38 weeks' gestation). Preterm deliveries: the number of pregnancies that ended after 20 weeks and before the end of 37 weeks' gestation Abortions: the number of pregnancies that ended before 20 weeks' gestation. Living children: the number of children delivered who are alive at the time of history collection. Susie is 38 weeks pregnant. This is her second pregnancy. She delivered a healthy baby boy at 39 weeks with her first pregnancy. What is this woman's GTPAL? • Right now, her GTPAL is G2, T1, P0, A0, L1 because she has not yet delivered her second baby. Once she does, she will be at G2, T2, P0, A0, L2.

End of 16 Weeks

Length: 10-17 cm. Weight: 55-120 g. Lungs are fully shaped. Fetus swallows amniotic fluid. Skeletal structure is identifiable. Downy lanugo hair present on body. Liver and pancreas are functioning. Gender can be determined by ultrasound.

Implementation

Maintaining Safety of the Woman and Fetus Monitor the pregnant woman at every visit for warning signs that might indicate problems with the pregnancy If she reports experiencing any of the warning signs, notify the RN or health care provider immediately. If at any time during the pregnancy an elevated blood pressure is noted, report this finding immediately to the RN or health care provider, particularly if it is accompanied by a headache, epigastric pain, or blurred vision. Relieving Anxiety Escort the woman to the examination room. Explain normal procedure and describe what she can expect during the visit. When the woman knows what to expect, she will be much less anxious. Maintain a calm, confident demeanor while giving care. Protect the woman's privacy during all procedures especially invasive examinations. Be mindful of the woman's perspective. Note if her anxiety level increases. Anticipate concern when fetal testing is required. Solicit questions and correct misconceptions the woman may have. Provide information concerning the treatment plan. Use active listening and encourage positive coping behaviors. Relieving the Common Discomforts of Pregnancy Pregnant women tend to experience similar discomforts because of the significant bodily changes they undergo. Some discomforts tend to occur in early pregnancy, some toward the end, and others continue throughout.

Puberty

Puberty is the time of life in which the individual becomes capable of sexual reproduction. Puberty occurs on average between the ages of 10 and 14 years. This phase is marked by maturation of the reproductive organs and development of secondary sex characteristics. Secondary sex characteristics are external physical evidence of sexual maturity but are not essential to reproduction. Secondary sex characteristics include growth of pubic and axillary hair, growth of external genitals (labia and penis), female breast development, and in the male, appearance of facial hair and deepening of the voice. The changes associated with puberty happen in response to hypothalamic and pituitary hormones. Secondary sex characteristics develop in an orderly sequence, although the timing varies between individuals. Breast budding in the female is usually the first physical sign noted and occurs between the ages of 10 and 12 years on average. Appearance of pubic hair usually occurs just before menarche, the first menstrual period. Menarche occurs most frequently between the ages of 12 and 14 years.

Vulvar Self-Examination

Some health care providers recommend that women older than 18 years (and those younger who are sexually active) should perform a monthly self-examination of the external genitalia. As with a BSE, the major value of the monthly vulvar self-examination is that the woman will become familiar with her own normal anatomy. Using a hand mirror and an adequate light source, the woman should inspect her vulva for any lesions, growths, reddened areas, unusual discharge, or changes in skin color. She should also take note of any changes in sensation, such as itching or pain. Caution the woman that although most changes are not cancerous, she should report all changes to her health care provider for evaluation.

Toxic Shock Syndrome

TSS is a rare illness typically caused by an exotoxin produced by the bacteria Staphylococcus aureus, although TSS can be caused by Group A streptococcus. TSS was first recognized in 1978; authorities quickly noticed that the majority of cases occurred in women who were using certain types of high-absorbency tampons. Shortly thereafter, manufacturers made changes to the composition and absorbency of tampons, and TSS cases declined dramatically. However, women who use tampons, diaphragms, or contraceptive sponges are still at risk for the illness. TSS starts suddenly with a high fever (higher than 102°F), nausea, vomiting, abdominal pain, a rapid drop in blood pressure, watery diarrhea, headache, sore throat, and muscle aches. Within 24 hours, a sunburn-like rash develops. The skin, particularly on the palms and soles, may peel approximately 1 to 2 weeks later. Treatment requires hospitalization, often in an intensive care setting, intravenous fluids, and antibiotics. Nurses can be helpful in the prevention of TSS. Teach the woman who uses tampons to wash her hands thoroughly before and after inserting or removing a tampon. She should use the lowest absorbency that will handle her menstrual flow, change tampons frequently (at least every 2 to 3 hours), or alternate tampons with sanitary napkins and never use more than one tampon at once. Between periods, tampons should be stored away from heat and moisture to help prevent bacterial growth. The woman should frequently remove and clean any vaginal device (e.g., a diaphragm) that she is using.

Food Safety During Pregnancy

Food Preparation Guidelines Follow the FDA guidelines to clean, separate, cook, and chill food. • Clean ■ Wash hands thoroughly with warm water and soap before and after handling food and after using the bathroom, changing diapers, or handling pets. ■ Wash cutting boards, dishes, utensils, and countertops with hot water and soap. ■ Rinse raw fruits and vegetables thoroughly under running water. • Separate ■ Separate raw meat, poultry, and seafood from ready-to-eat foods. ■ If possible, use one cutting board for raw meat, poultry, and seafood and another one for fresh fruits and vegetables. ■ Place cooked food on a clean plate. If cooked food is placed on an unwashed plate that held raw meat, poultry, or seafood, bacteria from the raw food could contaminate the cooked food. • Cook ■ Cook foods thoroughly. Use a food thermometer to check the temperature. ■ Keep foods out of the danger zone; the range of temperatures at which bacteria can grow, usually between 40°F and 140°F (4°C and 60°C). ■ 2-hour rule: Discard foods left out at room temperature for more than 2 hours. • Chill ■ Place an appliance thermometer in the refrigerator and check the temperature periodically. The refrigerator should register at or below 40°F (4°C) and the freezer at or below 0°F (−18°C). ■ Refrigerate or freeze perishables (foods that can spoil or become contaminated by bacteria if left unrefrigerated). Listeria Precautions Take precautions to avoid listeria, a harmful bacterium that can grow at refrigerated temperatures. • Do not eat hot dogs and luncheon meats, unless they are reheated until steaming hot. • Do not eat soft cheese, such as feta, brie, camembert, "blue-veined cheeses," "queso blanco," "queso fresco," and panela, unless it is labeled as made with pasteurized milk. Check the label. • Do not eat refrigerated pâtés or meat spreads. • Do not eat refrigerated smoked seafood unless it is in a cooked dish, such as a casserole. (Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna, or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky.") • Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk. Seafood Recommendations Follow the FDA recommendations about appropriate fish consumption to avoid mercury poisoning. • Do not eat any shark, swordfish, king mackerel, or tilefish during pregnancy. • Limit intake of other fish to no more than 12 oz (about two to three servings) per week. • Limit consumption of fish caught in local waters to 6 oz (one serving) per week. • Do not eat more than one 6-oz can of white tuna or two 6-oz cans of light tuna. • It is probably best to avoid tuna steaks because they often have high mercury levels. If you decide to eat tuna steak, do not eat more than 6 oz per week.

Menstrual Cycle

The menstrual cycle, or the female reproductive cycle, refers to the recurring changes that take place in a woman's reproductive tract associated with menstruation and the events that surround menstruation. Menstruation, the casting away of blood, tissue, and debris from the uterus as the endometrium sheds, is variable in amount and duration. On average, menstrual flow lasts 4 to 6 days, with a total blood loss of 25 to 60 mL. Although this loss is seemingly negligible, with time it can contribute to low iron stores and anemia. The menstrual cycle encompasses the events that transpire in the woman's reproductive organs between the beginnings of two menstrual periods Hormones from the ovaries and the pituitary gland regulate these cyclical changes. The average cycle lasts 28 days, approximately 1 month; however, there are great variations between women, and also an individual woman's cycle may vary in duration from cycle to cycle.

Energy Requirements and Weight Gain

Energy requirements increase during pregnancy because of fetal tissue development and increased maternal stores. During the first trimester, the recommended weight gain is 3 to 4 lb total. Subsequently, for the remainder of pregnancy, the recommendation is roughly 1 lb/wk, for a total weight gain of 25 to 35 lb for a woman who begins pregnancy with a normal body mass index (BMI).1 Total weight gain recommendations vary depending upon the woman's prepregnancy BMI. A woman who is underweight when she enters pregnancy (low BMI) should gain 28 to 40 lb, whereas a woman who has a high BMI (overweight) is recommended to gain 15 to 25 lb during the pregnancy (Garner, 2017). Failure to gain enough weight, and in particular gaining less than 16 lb during pregnancy, has been associated with an increased risk of delivering a low-birth-weight baby (less than 2,500 g or 5.5 lb). Low birth weight has consistently been associated with poor neonatal outcomes. Conversely, a woman who gains too much weight is at increased risk for delivering a macrosomic (4,000 g or 8.5 lb or more) baby. High-birth-weight babies experience complications and poor outcomes more frequently than do babies with normal birth weights. A woman who gains too much weight is also at greater risk of requiring cesarean section. Many women falsely assume that eating for two requires a significantly increased caloric intake. In fact, the required caloric increase during the first trimester is negligible. During the second and third trimesters, approximately 300 kcal/day is required above the woman's prepregnancy needs. It is important that the diet supply enough calories to meet energy needs; otherwise, protein will be broken down to supply energy, rather than to build fetal and maternal tissues.

Pelvic Examination and Pap Smear

Every woman should have a yearly physical examination. A pelvic examination should be part of the total physical examination. A pelvic examination detects changes associated with certain gynecologic conditions such as infection, inflammation, pelvic pain, and cancer. The Papanicolaou test (Pap smear) is one part of the pelvic examination but is not necessarily done with every examination. The pelvic examination begins with the woman in the lithotomy position. The health care provider palpates and examines the appearances of the structures of the vulva then inserts a speculum to examine the walls of the vagina and the cervix. When the cervix is clearly visible, the health care provider swabs the cervix to obtain cell samples for the Pap smear and secretions to culture for pelvic infection. Following the speculum examination a bimanual examination is done by inserting two lubricated fingers into the vagina with one hand and using the other hand to palpate uterine and ovarian structures through the abdominal wall. Frequently, a rectal examination to test for fecal occult blood and/or to palpate the rectovaginal wall completes the examination. See Nursing Procedure 4-1 for guidance in assisting the health care provider with collecting a Pap smear. The Pap smear is an important screening tool for cervical cancer. The overall rates of cervical cancer have decreased by 60% over the last 50 years due to the routine performance of Pap smears (leading to early detection and prompt treatment of precancerous cervical changes) and also because of the human papillomavirus (HPV) vaccine. Most cases of cervical cancer are caused by HPV. The health care provider may also screen for HPV during a pelvic examination or may combine the screen with a Pap smear. A woman who has a negative screen for HPV has a very low risk for developing cervical cancer (National Cancer Institute, 2014). In parts of the world where Pap smears are not done routinely, cervical cancer is a leading cause of death for women. Current guidelines recommend that the woman obtain the initial Pap smear at 21 years of age, regardless of when she first has sexual intercourse, then every 3 years thereafter from age 21 to 29, and then every 5 years after age 30 (National Cancer Institute, 2014). The woman's health care provider may advise more frequent examinations for the woman who has abnormal pap smears, has human immunodeficiency virus (HIV), has HPV, or is immunocompromised. Women should still have an annual examination even if a Pap smear is not done each time.

Laboratory Assessment

Many laboratory tests are done during the course of the pregnancy. A complete blood count gives information about the overall health status of the woman. Anemia is evaluated by checking for a low hemoglobin and hematocrit. Anemia can be caused by the pregnancy, or it can be an indicator of decreased nutritional status in the woman. A woman who is at risk for sickle cell anemia or thalassemia is given a hemoglobin electrophoresis test. Other laboratory tests routinely ordered include a blood type and antibody screen. This test helps identify women who are at risk of developing antigen incompatibility with fetal blood cells. Blood type incompatibilities (A, B, and O) can develop as well as Rho(D) incompatibilities. If the woman develops an antigen incompatibility, the fetus in a subsequent pregnancy may suffer from hemolytic anemia, as the mother's antibodies cross the placenta and attack the fetus's red blood cells

Due Date Estimation

One important aspect of the first visit is to calculate the due date or the estimated date of delivery (EDD). An older term that is sometimes used is estimated date of confinement (EDC). Both terms refer to the estimated date that the baby will be born. This is critical information for the health care provider because problems that may arise during the pregnancy are managed differently, depending on the gestational age of the fetus. Therefore, it is essential to have an accurate due date. There are several ways to date a pregnancy. The most common way to calculate the EDD is to use Naegele rule. To determine the due date using Naegele rule, add seven days to the date of the first day of the LMP, then subtract three months. This is a simple way to estimate the due date, but it is dependent upon the woman knowing when the first day of her LMP was and is also based upon the woman having a 28-day menstrual cycle. Sometimes the EDD is impossible to determine based upon Naegele rule, particularly if the woman experiences irregular menstrual cycles, or if she cannot remember the date. During the pelvic examination, the health care provider feels the size of the uterus to get an idea of how far along the pregnancy is. For instance, a uterus that is the size of a small pear is approximately 7 weeks. If the uterus feels to be the size of an orange, the pregnancy is approximately 10 weeks along, and at 12 weeks the uterus is the size of a grapefruit. Other ways to validate the gestational age are to note landmarks during the pregnancy. Initial detection of the fetal heartbeat by Doppler ultrasound takes place between 10 and 12 weeks. Quickening typically occurs around 16 weeks for multigravidas and 20 weeks for primigravidas. At 20 weeks, the uterus reaches the level of the umbilicus. One of the most common and reliable ways to date the pregnancy is through an obstetric sonogram, a picture obtained with ultrasound. High-frequency sound waves reflect off fetal and maternal pelvic structures, allowing the sonographer to visualize the structures in real time. The sonographer measures fetal structures, such as the head and the femur. These measurements allow the health care provider to estimate the gestational age of the fetus and thereby determine a due date. A sonogram obtained early in the pregnancy yields the most accurate due date. If there is a discrepancy between the EDD calculated using Naegele rule and the EDD determined by sonogram, the results of the sonogram (if it is done in the first half of the pregnancy) are used to base treatment decisions. The sonogram done at 20 weeks is the standard prenatal ultrasound. If the health care provider needs further evaluation of the fetus, such as to look for spina bifida or cardiac anomalies, a 3-D or 4-D ultrasound can be performed. A 3-D ultrasound reveals a three-dimensional image, not a flat picture like the standard ultrasound, whereas a 4-D ultrasound looks more like a film and can show images such as the fetus yawning or sucking. 3-D and 4-D ultrasounds are not routinely done, only if indicated.

STAGES OF FETAL DEVELOPMENT

three stages of human development during pregnancy are the pre-embryonic, embryonic, and fetal stages The pre-embryonic stage begins at fertilization and lasts through the end of the second week after fertilization. The embryonic stage begins approximately 2 weeks after fertilization and ends at the conclusion of the eighth week after fertilization. By the end of the embryonic stage, all of the organ systems have begun development, and the conceptus is distinctly human in form. The fetal stage begins at 9 weeks after fertilization and ends at birth. However, birth is not the end of human development. Human development is an ongoing process of transformation that begins with fertilization and continues through the teenage years and beyond. In this chapter, fertilization age (number of weeks after fertilization) will be used rather than gestational age (number of weeks after the last menstrual period) when discussing development during pregnancy. Once a single sperm has penetrated the thick membrane that surrounds the ovum, called the zona pellucida, a chemical reaction occurs that causes the ovum to become impenetrable to other sperm. A zygote, or conceptus, results when an ovum and a spermatozoon unite. Because the chromosomes of the sperm merge with those of the ovum, the zygote has the full complement of 46 chromosomes (also called the diploid number), arranged in 23 pairs.

Assessment (Data Collection)

Ongoing data collection is an essential component of prenatal visits. During the first prenatal visit, pay close attention to cues the woman may give regarding her feelings toward the pregnancy. Ambivalence is normal. The woman may express feelings of doubt about the pregnancy or her ability to be a good parent. These are normal reactions when a woman first finds out she is pregnant. Reassure her that her responses are normal. Withdrawal or consistently negative remarks are warning signs. Report these observations to the RN or health care provider. If you administer the initial questionnaire, show the woman all the pages and assist her in completing it if necessary. Review the document carefully when she is done to ensure completeness. Look for answers that indicate the need for further evaluation. Alert the RN or the health care provider of possible risk factors identified in the history. Observe for signs of nervousness and anxiety. The woman may express her nervousness by being restless or tense or by being quiet and withdrawn. Be attuned to signals she is giving regarding her comfort level. At every visit, inquire carefully regarding current medications, food supplements, and over-the-counter remedies she is using. Note if the woman has been experiencing nausea and vomiting. Pay close attention to signs that might indicate poor nutritional status. Weight is an obvious clue. If the woman is overweight or underweight, she will need special assistance with nutritional concerns throughout the pregnancy. Other warning signs of poor nutritional status include dull, brittle hair; poor skin turgor; poor condition of skin and nails; obesity; emaciation; or a low hemoglobin level. Ask the woman to write down a typical day's food consumption pattern, and then compare her normal intake to MyPlate (see Fig. 6-6) to determine if her diet is adequate for her nutritional needs. Determine her education level and knowledge of pregnancy and prenatal care. If she is highly knowledgeable, she may ask high-level questions that indicate an understanding of basic issues. Conversely, she may ask basic questions, or no questions at all, which could indicate a knowledge deficit.