Chapter 10,11, 12, -Normal Pregnancy

QUALITY IMPROVEMENT Lauren wasn't totally happy about learning that she was pregnant. What psychological task is important for the woman to complete during the first trimester of her pregnancy? a. Accepting morning sickness nausea b. Accepting the fact that she is pregnant c. Appreciating the responsibility of having a baby d. Choosing a name for her baby

b. Accepting the fact that she is pregnant

Iron

Prepregnancy: Pregnancy:Need 800 μg more daily Reason: Fetal growth, increase in maternal red blood cells†

Papanicolaou Smear

A Pap smear is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not present. In addition, a photograph of the cervix may be taken to document the appearance of a suspicious lesion on the cervix or confirm that a previous lesion from an infection has healed.

If a woman is 3 months pregnant, which finding related to breast changes would the nurse expect to assess? A) slack, soft breast tissue B) deeply fissured nipples C) enlarged lymph nodes D) darkened breast areolae

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Understand Feedback: As part of the pigment changes that occur with pregnancy, breast areolae become darker.

Two major changes do occur with pregnancy:

a more rapid than usual breathing rate (18 to 20 breaths/min) and a chronic feeling of shortness of breath

Vaccines (live)

Rubella (ProQuad) Provide immunity Possible infection in fetus

Anticoagulants

Warfarin (Coumadin) Anticoagulation Fetal bleeding or anomalies

Accepting the baby as a welcome addition to the family might not come, however, until labor has begun or a woman first hears her

baby's cry or feeds her newborn. If a woman has a complication of pregnancy, it could take several weeks after the baby is born for her to accept that the birth was real and to come to terms with motherhood. .

CULTURAL INFLUENCES A woman's cultural background may strongly influence how active a role she wants to take in her pregnancy because certain beliefs and taboos can place restrictions on her

behavior and activities

In a nulligravida (a woman who is not now or never has been pregnant), the cervical os appears

round and small

Advise women to eat a protein and a complex carbohydrate such as

peanut butter and whole wheat bread at least 15 minutes before exercise to keep blood sugar from falling during exercise and to drink water before and after to prevent dehydration.

Psychological Change: Second trimester task: Accepting the fetus

Description: The woman and her partner move through emotions such as narcissism and introversion as they concentrate on what it will feel like to be a parent. Role-playing and increased dreaming are common. -Physical evidence of pregnancy -Fetus as primary focus -Body image, change in sexuality

Antivirals

Ribavirin (Rebetol) Respiratory infection, chronic hepatitis C Multiple anomalies

Nicotine

Tobacco Relaxation Growth restriction

A platypelloid, or "flattened," pelvis has a smoothly curved oval inlet, but the anteroposterior diameter is shallow. A fetal head might not be able to

rotate to match the curves of the pelvic cavity.

A gonorrhea infection presents with a

thick, greenish-yellow discharge and extreme inflammation.

Psychological Change: First trimester task: Accepting the pregnancy

Description:T he woman and her partner both spend time recovering from the surprise of learning they are pregnant and concentrate on what it feels like to be pregnant. A common reaction is ambivalence, or feeling both pleased and not pleased about the pregnancy.

OUTCOME EVALUATION Evaluation during prenatal visits should concentrate on a woman's initial understanding of the goals for care during pregnancy and assessing outcomes established for specific concerns. Examples of expected outcomes include:

-Couple state they have reached a mutual decision to both stop smoking. -Patient states she feels well informed about the common body changes of pregnancy and actions to take to relieve any discomfort these cause. - Patient lists ways to avoid exposure to teratogens at her work site during pregnancy.

Grand multipara

A woman who has carried five or more pregnancies to viability

Primipara

A woman who has given birth to one child past age of viability

INTERVIEW CONCLUSION

End an interview by asking if there is anything you have not covered that the woman wants to discuss; this gives her one more chance to ask any questions she has about this new life experience. Explore any further concerns she mentions because these can be equally as important as her first concern mentioned

Nursing Diagnosis:

Health-seeking behaviors related to learning more about minor body changes of early pregnancy, such as morning nausea

Introversion Versus Extroversion

Introversion, or turning inward to concentrate on oneself and one's body, is a common finding during pregnancy. Some women, however, react in an entirely opposite fashion and become more extroverted. They are more active, appear healthier than ever before, and are more outgoing. This tends to occur in women who are finding unexpected fulfillment in pregnancy, perhaps who had seriously doubted they would be lucky enough or fertile enough to conceive. Such a woman regards her expanding abdomen as public proof of her ability to fulfill the maternal role. Although these changes may make a woman become more varied in her interests during pregnancy, she may be puzzling to those around her who liked her for her quiet and self-contained manner.

Antineoplastics

Methotrexate (Trexall) Cyclophosphamide (Cytoxan) Chemotherapy Multiple anomalies

Examples of other possible nursing diagnoses associated with the minor body changes of middle-to-late pregnancy are:

Pain related to almost constant backache Acute abdominal pain related to sudden postural change in pregnancy Anxiety related to shortness of breath, resulting from expanding uterine pressure on the diaphragm Deficient knowledge related to beginning signs of labor

Outcome Evaluation:

Patient states she is familiar with early body changes of pregnancy and will take measures to relieve them.

Anticonvulsants

Phenytoin (Dilantin) Valproic acid (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal) Seizures Fetal hydantoin syndrome Neural tube defects Neural tube defects Possibly fetal anomalies

Female genital cutting

Possible Symptoms: Surgical removal of the clitoris; possibly vagina is sewed closed Significance and Suggested Therapy: Illegal in United States; done as a cultural ritual in young girls from African and Middle Eastern countries. Vaginal stricture may need to be excised to allow for menstrual flow and childbirth.

7.An indirect Coombs test determination of whether

Rh antibodies are present in an Rh-negative woman. This test is generally repeated at 28 weeks of pregnancy. If an Rh-negative woman's titer is not elevated, she will be offered RhIG (RhoGAM) at 28 weeks of pregnancy, after any procedure that might cause placental bleeding (amniocentesis or external version), and within 72 hours after delivery.

Almost all recreational drugs put a fetus at risk in two ways:

The drug may have a direct teratogenic effect and, if taken intravenously, the drug increases the mother's risk of exposure to diseases such as HIV and hepatitis B and C

1. A complete blood count, including hemoglobin or hematocrit and red cell index to determine the presence of

anemia, a white blood cell count to determine infection, and a platelet count to estimate clotting ability.

If a cervical infection is present,

cervical lesions (herpes simplex 2 appear

Partner's Adaptation The more emotionally attached a partner is to a pregnant woman, the

closer the partner's attachment is apt to be to the child

In an android, or "male," pelvis, the pubic arch forms an acute angle, making the lower dimensions of the pelvis extremely narrow. A fetus may have

difficulty exiting from this type of pelvis.

PRESUMPTIVE (SUBJECTIVE) SYMPTOMS Presumptive symptoms are those which, when taken as single entities, could

easily indicate other conditions These findings, discussed in connection with the body system in which they occur, are experienced by the woman but cannot be documented by an examiner

If a woman rises suddenly from a lying or sitting position or stands for an extended time in a warm or crowded area, she may

faint from the same phenomenon (blood pooling in the pelvic area or lower extremities). Rising slowly and avoiding extended periods of standing prevents this problem. If a woman should feel faint, sitting with her head lowered—the same action as for any person who feels faint—alleviates the problem.

Perineal and Breast Self-Examination Perineal self-examination is inspecting the external genitalia monthly for signs of ?

infection or lesions Immigrants from other countries may have had female genital cutting (clitoris removed) in childhood; this needs to be documented because scarring and strictures may limit the size of the vaginal opening

Palmar Erythema

probably caused by increased estrogen levels. Constant redness or itching of the palms can make a woman believe she has developed an allergy. Explain that this type of itching in early pregnancy is normal to prevent a woman from spending time and effort trying different soaps or detergents or attempting to implicate certain foods she has eaten as the cause of her discomfort. She may find calamine lotion to be soothing.

Early diagnosis is important because the earlier a woman realizes she is pregnant or comes for a first prenatal visit, the sooner she can begin to

safeguard fetal health by measures such as discontinuing all drugs not specifically prescribed or approved by her primary healthcare provider

REVIEW OF SYSTEMS

A review of systems completes the subjective information of a health history. Use a systematic approach, such as head to toe, and explain what you will be doing by an explanation such as "I'm going to start at the top of your head and go through to your toes, asking about body parts or systems and any diseases you may have had." A review of systems helps women recall concerns they forgot to mention earlier, such as a urinary tract infection, a condition that can influence the outcome of pregnancy and thus would be important to your history taking.

IMPLEMENTATION

An important nursing intervention at prenatal visits is teaching women and their families about a safe pregnancy lifestyle. Women often discount prepared lists, believing their pregnancy is too personal to be a condition for which there are routine lists of advice. Advice, therefore, needs to be individualized for each woman. For visual learners, it can be helpful to offer a woman and her partner pamphlets that cover the same topics discussed verbally. Be certain all printed materials you give to families are consistent with what you say and with the views of the patient's obstetric healthcare provider. In addition, reinforce to the woman that she should feel free to call or e-mail the healthcare setting between visits with any problems or questions. Some women may feel reluctant to "bother" a healthcare provider outside of scheduled visits unless you give them this permission

MINOR BODY CHANGES OF PREGNANCY: SECOND AND THIRD TRIMESTERS

At about the midpoint of pregnancy (the 20th to 24th weeks), a woman is usually ready for further health teaching that relates to the new symptoms that occur in the latter half of pregnancy. As she starts to view the child within her as a separate person, she becomes interested in discussing and making plans for the signs and symptoms of beginning labor, birth, and the infant's care. The midpoint of a pregnancy is also a good time to review precautionary measures to prevent constipation, varicosities, and hemorrhoids, as these increase in intensity as the pregnancy progresses.

Nausea, Vomiting, Constipation, and Pyrosis

At least half of pregnant women experience gastrointestinal symptoms such as nausea, vomiting, constipation, and pyrosis.

SELF-CARE NEEDS

Because pregnancy is a state of wellness, few special care measures or advice other than common sense measures about self-care are needed. Many women, however, have heard different warnings about what they should or should not do during pregnancy, which may mean that they need some help separating fact from fiction. Doing so may enable the woman to enjoy her pregnancy unhampered by unnecessary restrictions. In no other area of nursing, except possibly infant feeding, does there seem to be as many misconceptions or inappropriate information available to women.

cardiovascular system

Blood flow: must be channeled to the placenta as well Obstruction of the inferior vena cava and iliac veins/ uterus obstructs the blood return from the veins of the legs , leads to venous distension Prolong engorgement can lead to varicose veins of the legs, vulva, and rectum (hemorrhoids).

Vaginal Changes An increase in the vascularity of the vagina parallels the vascular changes in the uterus. The resulting increase in circulation changes the color of the vaginal walls from their normal light pink to a deep violet known as

Chadwick's sign

Demographic Data

Demographic data usually obtained include name, age (additional testing such as genetic screening may be necessary if she is over age 35 years), address, telephone number, e-mail address, religion, ethnicity, type and place of employment, and health insurance information.

Psychological Change: Third trimester task: Preparing for the baby and end of pregnancy

Description: The woman and her partner prepare clothing and sleeping arrangements for the baby but also grow impatient as they ready themselves for birth. -Vulnerability, -Increasing dependence -High levels of stress in anticipation

Tranquilizers

Diazepam (Valium) Reduce anxiety Growth restriction; CNS dysfunction, hypotonia, respiratory depression

SECOND TRIMESTER: ACCEPTING THE BABY The Partner

Goal: Being more involved with the baby arriving soon - going to prenantal visits with partner for support - Educated on women's sexual hea;th What happens: -a partner increasingly may feel as if he or she is left standing in the wings, waiting to be asked to take part in the event. To compensate for this feeling, a partner may become overly absorbed in work, striving to produce something concrete on the job as if to show the woman is not the only one capable of creating something -Some men may have difficulty enjoying the pregnancy because they have been misinformed about sexuality, pregnancy, and women's health. A man might believe, for example, that breastfeeding will make his wife's breasts no longer attractive or that after birth, sexual relations will no longer be enjoyable. Such a man needs education to correct misinformation. Read the pamphlets supplied by your prenatal healthcare setting and ask: Do they contain mainly information about childbirth and pregnancy from a woman's perspective? Would they be relevant to a supportive partner?

Because each woman's experience is unique, nursing diagnoses and care must be developed according to each woman's individual needs. Additional nursing diagnoses that might be developed for women experiencing the minor body changes of early pregnancy include:

Health-seeking behaviors related to interest in using herbal remedies to relieve discomfort early in pregnancy Constipation related to reduced peristalsis in pregnancy Fatigue related to increased physiologic need for sleep and rest during pregnancy Acute pain related to frequent muscle cramps secondary to physiologic changes of pregnancy Disturbed sleep pattern related to frequent movement of fetus during night

History of Family Illnesses

Identifying any illnesses that occur frequently in a woman's relatives can help identify potential problems a woman or her infant could experience during pregnancy or after birth. Ask specifically about cardiovascular and renal disease, diabetes, cognitive impairment, blood disorders, and any known genetically inherited diseases or congenital anomalies.

GYNECOLOGIC HISTORY

In the past, most women had children early in their childbearing years, so they experienced few reproductive tract or women's health disorders, such as breast disease, before pregnancy. Today, with women delaying conception of their first child past 30 years of age, it is not unusual to discover a woman who has had a reproductive tract or breast disorder

Pancreas*

Increases insulin production but insulin is less effective due to estrogen, progesterone, and other hormones that are antagonists to insulin. This allows for more glucose to be circulating in the maternal blood stream to be available to the fetus.

Carcinoma

Possible Symptoms: Asymptomatic; intermenstrual bleeding Significance and Suggested Therapy: Ovarian cancer originates in epithelial tissue most often in women over 50 years of age. Tendency may be inherited; environmental contamination such as use of talcum powder may play a role in development. Therapy is hysterectomy and salpingo-oophorectomy.

Blood constitution

Pregnancy: Increased clotting factors, platelets, white blood cells, lipids. Decreased protein level Reason: Increased clotting factors and platelets help with bleeding during delivery, white blood cells increase to protect against infection and as a result of blood volume increases, blood lipids increase to provide energy to the fetus. Protein decreases as a result of the proteins being used by the fetus and can lead to edema.††

Blood pressure (BP)

Pregnancy:Decreases in second trimester, rises to prepregnancy level in third trimester Reason:Increased heart rate and cardiac output usually cause no change in BP.

Nursing Care Planning Based on Family Teaching

Q. Sandra asks you, "What can I do to make sure my boyfriend feels involved with my prenatal care?" A. Have you tried these ideas? • Ask for appointments to be scheduled at a time that is convenient for both of you. • A prenatal visit can be lengthy. Be certain your partner reserves enough time so the visit doesn't become more of an inconvenience than an enjoyable event. • Ask your partner to accompany you into the examining room at visits so you both can share your pregnancy progress or decisions • Be certain your partner listens to the fetal heart at visits as soon as it can be heard. • If a sonogram is scheduled, ask your partner to view it with you (it's an exciting moment for both of you to see your fetus moving).

History of Past Illnesses

Questions about a woman's past medical history are important because a past condition can become active during or immediately following pregnancy. Representative diseases that pose potential difficulty during pregnancy include kidney disease, heart disease (coarctation of the aorta and heart valve problems cause concern most often), hypertension, sexually transmitted infections (including hepatitis B and C, herpes, and HIV), diabetes, thyroid disease, recurrent seizures, gallbladder disease, urinary tract infections, varicosities, phenylketonuria, tuberculosis, and asthma.

Gonorrhea causes such a severe conjunctivitis that it can lead to ?

blindness

If a woman had a cervical tear during a previous birth, the cervical os may appear as a transverse

crease the width of the cervix or a typical star-like (stellate) formation

Labor may begin with rupture of the membranes, experienced either as a sudden

gush or as a scanty, slow seeping of clear fluid from the vagina. Some women may worry if their labor begins with a rupture of the membranes because they have heard labor will then be "dry," and this will cause it to be difficult and long. Actually, amniotic fluid continues to be produced until delivery of the membranes after the birth of their child, so no labor is ever "dry." Early rupture of the membranes can actually be advantageous as it can cause the fetal head to settle snugly into the pelvis, aiding cervical dilation and shortening labor.

She cannot be immunized with the oral Sabin poliomyelitis vaccine or with the vaccine against measles, mumps, or rubella because the vaccines for these contain live viruses that could be

harmful to the fetus if the virus crossed the placenta Because many women don't know if they have ever had rubella, almost all women have blood drawn for an antibody titer against rubella at a first prenatal visit. After birth, a woman who shows a high titer could then be immunized against the disease to provide fetal protection for a following pregnancy.

Muscular/Skeletal Discomfort As pregnancy advances, a lumbar lordosis develops and postural changes necessary to maintain balance lead to backache . Wearing shoes with

low-to-moderate heels reduces the amount of spinal curvature necessary to maintain an upright posture. Encouraging a woman to walk with her pelvis tilted forward (i.e., putting pelvic support under the weight of the fetus) is also helpful. In addition, applying local heat from a heating pad may aid in relieving backache Generally, acetaminophen (Tylenol) is considered to be safe and effective for relieving this type of pain during pregnancy. Acupuncture can also be effective .

Darkened or reddened areas may appear on the face as well, particularly on the cheeks and across the nose. This is known as

melasma (chloasma) or the "mask of pregnancy." With the decrease in the level of melanocyte-stimulating hormone after pregnancy, these areas lighten but do not always disappear.

The cervix color a nonpregnant cervix is ________ in pregnancy, it changes to almost ________) and any lesions, ulcerations, discharge, or otherwise abnormal appearance are documented.

non pregnant: light pink; pregnant: purple

Musculoskeletal System Calcium and phosphorus needs are increased during pregnancy because an entire fetal skeleton must be built. As pregnancy advances, a gradual softening of a woman's pelvic ligaments and joints occurs to create pliability and to facilitate passage of the baby through the

pelvis at birth. This softening is probably caused by the influence of both the ovarian hormone relaxin and placental progesterone. This excessive mobility of joints can cause discomfort late in pregnancy, especially if there is a separation of the symphysis pubis. Separation this way causes acute pain and makes walking difficult and painful.

Trichomoniasis, a protozoal infection, if present, causes

petechial spots on the vaginal walls, cervical redness, and a profuse, whitish, bubbly discharge. It is important that trichomoniasis and bacterial vaginosis be treated in pregnancy as there is a link between these infections and preterm birth

Genital herpes simplex virus (HSV) is a sexually transmitted infection spread by intimate contact. The first time a woman contracts an HSV infection, systemic involvement occurs. The virus spreads into the bloodstream (viremia) and, if a woman is pregnant, can cross the

placenta to a fetus, thus posing substantial fetal risk If the infection takes place in the first trimester, severe congenital anomalies or spontaneous miscarriage can occur. If the infection invades during the second or third trimester, there is a high incidence of premature birth, intrauterine growth restriction, neurologic disease, and continuing infection of the newborn at birth. Mortality may be as high as 60% -If genital lesions are present at the time of birth, however, a fetus may contract the virus from direct exposure during birth. For this reason, if a woman has existing genital lesions at the time of birth, cesarean birth is usually advised to reduce the risk of this route of infection.

Examination of Pelvic Organs Following the speculum examination, a bimanual (two-handed) examination is performed to assess the

position, contour, consistency, and tenderness of pelvic organs

Physiologic Changes of Pregnancy Physiologic changes that occur during pregnancy are the basis for the signs and symptoms used to confirm a

pregnancy. They can be categorized as local (i.e., confined to the reproductive organs) or systemic (i.e., affecting the entire body).

A good way to measure the level of a woman's acceptance of her coming baby is to measure how well she follows

prenatal instructions

Vitamins C, A, and B complex are all important for circulatory health. Vitamin C appears to be most important as it is necessary for the formation of blood vessel collagen and endothelium. Ask at prenatal visits if women are taking a daily

prenatal vitamin as well as including fresh fruit or juice in their diet every day as yet another measure to help prevent varicosities.

chancre (syphilis, a mucus discharge may be

present

A nonpregnant woman needs medication to relieve discomfort from these infections. A pregnant woman needs medication to not only relieve discomfort but also prevent

preterm birth or transmission of the infection to the newborn as the newborn passes through the birth canal at term

For this test, a small amount (0.1 ml) of tuberculin units are injected by a needle and syringe intradermally (just under the top layer of skin). In 48 to 72 hours, the area is inspected. If the woman has tuberculosis, has been exposed to tuberculosis, or has received the bacille Calmette-Guérin (BCG) vaccine for tuberculosis, a

reddened, raised, hardened area (called induration) will appear at the injection site. If the induration area is at least 10 cm in diameter, the test is considered positive (a person has been either exposed to tuberculosis or has tuberculosis); in a person with a lowered immune response, 5 cm can be considered a positive result.

Substances frequently used as inhalants include gasoline, butane lighter fluid, Freon, glue, and nitrous oxide \. Although the teratogenic properties of these inhalants are not well studied, they all carry the possibility of a

respiratory distress effect on the mother, which could limit the oxygen supply to a fetus.

Advise a woman who is taking a long trip by automobile to plan for frequent

rest or stretch periods. Preferably every hour, but at least every 2 hours, she should get out of the car and walk a short distance. This break relieves stiffness and muscle aches and improves lower extremity circulation, helping prevent varicosities, hemorrhoids, and thrombophlebitis.

RESTLESS LEG SYNDROME AND CARPAL TUNNEL SYNDROME Two other concerns that arise more frequently in pregnant women than others are

restless leg syndrome and carpal tunnel syndrome. Carpal tunnel syndrome is named for the Greek word karpos meaning "wrist" and the narrow space where the median nerve passes between the bones of the wrist. Repetitive movements, such as typing or swinging a tennis racket, can irritate the nerve resulting in sensations of pain, tingling, and numbness. Probably because of the effect of the hormone relaxin secreted by the placenta, pregnant women seem to be more susceptible to this condition than others

Outcome Evaluation: Patient states she feels confident in

self-managing the minor body changes of late pregnancy.

In a woman who has had a previous vaginal birth, the cervical os has much more of a

slitlike appearance

Internal Genitalia To view the cervix, the vagina must be opened and held open with a __________. When fully inserted and rotated to this horizontal position, the blades are opened and the cervix becomes visible. They are secured in the open position by a thumb screw (metal speculum) or sliding latch (plastic speculum) at the side

speculum

3. A serologic test for

syphilis (venereal disease research laboratory [VDRL] or rapid plasma reagin test). If syphilis is present, it must be treated early in pregnancy before fetal damage occurs.

Because HIV testing is controversial, be certain the information given about test results is relayed accurately and with

tact and compassion (a high blood antibody titer means the woman has been exposed to the virus, not that she is necessarily infected). The result of HIV testing, like all patient information, is confidential; be certain not to report this information to anyone other than the woman.

Early in pregnancy, the breasts begin readying themselves for the secretion of milk. By the 16th week, colostrum—the

thin, watery, high-protein fluid that is the precursor of breast milk—can be expelled from the nipples.

REPRODUCTIVE SYSTEM CHANGES Reproductive tract changes are

those involving the uterus, ovaries, vagina, and breasts.

EXERCISE As a rule, average, well-nourished women should exercise during pregnancy about

three times weekly for 30 consecutive minutes Their exercise program should consist of 5 minutes of warm-up exercises, an active "stimulus" phase of 20 minutes, and then 5 minutes of cool-down exercises. Movements that exercise large muscle groups rhythmically, such as walking, are best but the type of activity chosen should depend on their interests. Continue exercise (intensity depends on baseline fitness); continue sports participation unless it involves body contact

Uterine height is measured from the top of the symphysis pubis to over the

top of the uterine fundus

Varicosities Varicosities, or the development of

tortuous leg veins, commonly form in pregnancy because the weight of the distended uterus puts pressure on the veins returning blood from the lower extremities

Toxoplasmosis, a protozoan infection, is spread most commonly through contact with uncooked meat, although it may also be contracted through handling cat stool in soil or cat litter\. As many as 1 in 900 pregnancies may be affected by toxoplasmosis. Prepregnancy serum analysis can be done to identify women who have never had the disease and so are susceptible (about 50% of women). Removing a cat from the home during pregnancy as a means of prevention is not necessary as long as the cat is healthy. However, taking in a new cat, which could be infected, is unwise. Instruct pregnant women to avoid

undercooked meat and also not to change a cat litter box or garden in soil in an area where cats may defecate to avoid exposure to the disease. Also, reinforce proper hand washing after handling uncooked meat.

Potentially Teratogenic Vaccines Live virus vaccines, such as measles, human papillomavirus (HPV), mumps, rubella, and poliomyelitis (Sabin type), are contraindicated during pregnancy because they may transmit a

viral infection to a fetus . Women who work in biologic laboratories where vaccines are manufactured are well advised to use protective gear or not to work with live virus products during pregnancy.

SLEEP Pregnant women rarely have difficulty falling asleep at night because of this increased physiologic need for sleep. If a woman does have trouble falling asleep, drinking a glass of

warm milk may help. Relaxation exercises (e.g., lying quietly, systematically relaxing neck muscles, shoulder muscles, arm muscles) also may be effective. A good resting or sleeping position is a left-sided Sims position, with the top leg forward . This position puts the weight of the fetus on the bed, not on the woman, and allows good circulation in lower extremities

To help both male and female partners resolve these feelings of ambivalence during the acceptance of pregnancy, be certain to make partners feel

welcome at prenatal visits or during fetal testing, provide an outlet for them to discuss concerns, and offer parenting information as necessary.

By the end of the 12th week of pregnancy, the uterus is large enough that it can be palpated as a firm globe under the abdominal wall, just above the symphysis pubis. An important factor to assess regarding uterine growth at healthcare visits is its constant, steady, and predictable increase in size

• By the 20th or 22nd week of pregnancy, it typically reaches the level of the umbilicus. • By the 36th week, it usually touches the xiphoid process and can make breathing difficult. • About 2 weeks before term (the 38th week) for a primigravida, a woman in her first pregnancy, the fetal head settles into the pelvis and the uterus returns to the height it was at 36 weeks.

Tuberculosis screening may also be done by a blood serum test called an interferon-gamma release assay (IGRA). IGRA testing is the preferred method because:

• In a woman who has a history of tuberculosis or who has received the BCG vaccine, a PPD test can cause an extreme reaction. BCG vaccine is not administered to people in the United States, but women from other countries may have received it. • It can offer results for a woman who states it will be difficult for her to return for a follow-up appointment for a PPD test to be read and interpreted

Beginning an exercise program during pregnancy not only offers the advantage of being healthy during pregnancy but also provides long-term benefits such as:

• Lowering cholesterol levels • Reducing the risk of osteoporosis • Increasing energy levels • Maintaining a healthy body weight • Decreasing the risk of heart disease • Increasing self-esteem and well-being

The physiologic reasons for those changes include:

• Residual volume (the amount of air remaining in the lungs after expiration) is decreased up to 20% because of the pressure of the diaphragm. • Tidal volume (the volume of air inspired) is increased up to 40% as a woman draws in deeper breaths trying to increase the effectiveness of her air exchange. • Total oxygen consumption increases by as much as 20%.

Signs Indicating Possible Complications of Pregnancy A pregnant woman should report the following signs or symptoms immediately:

• Vaginal bleeding. A woman should report vaginal bleeding, no matter how slight, because some of the serious bleeding complications of pregnancy begin with only slight spotting. If a woman reports bleeding, ask her how she discovered the blood. If she found it on toilet paper following a bowel movement, she's probably reporting spotting from hemorrhoids. Until the bleeding is found to be innocent this way, however, all women with spotting need further evaluation. • Persistent vomiting. Once- or twice-daily vomiting is not uncommon during the first trimester of pregnancy. Persistent, frequent vomiting is not normal nor is vomiting that continues past the 12th week of pregnancy. Persistent or extended vomiting depletes the nutritional supply available to a fetus and thus is a danger to the pregnancy. (See Chapter 13 for an in-depth discussion of persistent vomiting [hyperemesis gravidarum].) • Chills and fever or pain on urination. Chills and fever may be symptoms of a relatively benign gastroenteritis, but they also may indicate an intrauterine infection, a potentially serious complication for both a woman and a fetus. Pain on urination is a symptom of a urinary infection, which is potentially serious because these infections are associated with preterm birth. Because a woman cannot make a definite determination about the cause of a fever herself, further evaluation by a healthcare provider is necessary. • Sudden escape of clear fluid from the vagina. When a gush of clear fluid is discharged suddenly from the vagina, it means the membranes have ruptured and mother and fetus are now both threatened because the uterine cavity is no longer sealed against infection. If a fetus is small so the head does not fit snugly into the cervix, the umbilical cord may prolapse. If the fetal head then presses on the misplaced cord, oxygenation can be compromised and the fetus will be in immediate and grave danger. Alerting a healthcare provider to any sudden escape of fluid is crucial so a safe and controlled birth can be planned.

Nursing diagnoses appropriate to prenatal care include:

-Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy - Deficient knowledge regarding exposure to teratogens during pregnancy -Health-seeking behaviors related to strong cultural desire to have a healthy child -Risk for injury to fetus related to lifestyle choices

NURSING DIAGNOSIS Although most women probably have used a home pregnancy kit to find out if they are pregnant, the first prenatal visit officially confirms this, so nursing diagnoses usually focus on the response of a woman and her family to that information. Examples include:

-Decisional conflict related to desire to be pregnant -Risk for ineffective coping related to confirmation of unintended pregnancy

FIRST TRIMESTER: ACCEPTING THE PREGNANCY The Woman

-Goal: Accepting Pregnancy What happens: - feeling of ambivalence. Ambivalence doesn't mean positive feelings counteract negative feelings and a woman is left feeling nothing. Instead, it refers to the interwoven feelings of wanting and not wanting, feelings which can be confusing to an ordinarily organized woman. -most women who were not happy about being pregnant at the beginning are able to change their attitude toward their pregnancy by the time they feel the child move inside them. Some healthcare plans provide for a routine sonogram at about this time in pregnancy, between 18 and 22 weeks, to date the pregnancy and to assess for growth anomalies. This can be a major step in promoting acceptance because women can see a beating heart or a fetal outline or can learn the sex of their fetus

FIRST TRIMESTER: ACCEPTING THE PREGNANCY The Partner

-Goal: Accepting partner is Pregnant - Being apart of the pregnancy -accepting the woman in her changed state. What happens: - may also experience a feeling of ambivalence. A partner may feel proud and happy at the beginning of pregnancy, for example. Soon, however, it's easy to begin to feel both overwhelmed with what the loss of a salary will mean to the family if the woman has to quit work, and a feeling close to jealousy of the growing baby who, although not yet physically apparent, seems to be taking up a great deal of the woman's time and thought -Remember, once partners feel an attachment to a coming child, they can then feel as deep a sense of loss as the woman if the pregnancy should end before term or the baby is born with a unique concern.

SOCIAL INFLUENCES Today, pregnancy is viewed as a

-healthy span of time best shared with a supportive partner and/or family. -Women bring their families for prenatal care visits as well as to watch the birth. -Women choose what level of pain management they want to use for labor and birth; many women choose to breastfeed their newborn. How well a pregnant woman and her partner feel during pregnancy and are prepared to meet the challenges this new responsibility brings is related to their cultural background, their personal beliefs, the experiences reported by friends and relatives, as well as by the current plethora of information available on the Internet. Nurses play an important role in teaching women about their healthcare options as well as continuing to work with other healthcare providers to "demedicalize" or humanize childbirth

Frequent Urination

-occurs in early pregnancy because the growing uterus presses on the anterior bladder. This sensation lasts about 3 months, beginning as early as the first or second missed menstrual period, disappears in midpregnancy as the uterus rises above the bladder, and then returns again in late pregnancy as the fetal head presses against the bladder

The pelvic cavity is the space between the inlet and the outlet. This space is not a straight but a curved passage; the purpose of its curve is to

-slow and control the speed of birth. The snugness of the cavity also serves to compress the chest of the fetus as he or she passes through. This helps to expel lung fluid and mucus and thereby better prepare lungs for good aeration at birth.

With the speculum in place, the cervix is inspected for position. Normally, the uterine cervix is centered in the vagina; the cervix of a retroverted uterus will be positioned ___________, and the cervix of an anteverted uterus is positioned __________.

1.anteriorly 2.posteriorly

Concept Mastery Alert Although probable signs of pregnancy (such as laboratory tests, ballottement, and softening of the cervix) are objective and can be verified by an examiner, they are not reliable enough to positively diagnosis a pregnancy. The only three positive signs of pregnancy are

1.demonstration of a fetal heartbeat separate from the mother's, 2.fetal movement felt by an examiner, 3.visualization of the fetus by ultrasound.

Cytomegalovirus (CMV), a member of the HSV family, is another teratogen that can cause extensive damage to a fetus while causing few symptoms in a woman. It is not sexually transmitted but spreads from person to person by droplet infection such as occurs with sneezing. If a woman acquires a primary CMV infection during pregnancy and the virus crosses the placenta, the infant may be born with ?

1.severe neurologic challenges (e.g., hydrocephalus, microcephaly, or spasticity) 2.with eye damage (e.g., optic atrophy or chorioretinitis), 3.hearing impairment, 4.chronic liver disease. 5.The newborn's skin may be covered with large petechiae (i.e., "blueberry-muffin" lesions). Diagnosis in the mother or infant can be established by the isolation of CMV antibodies in blood serum. -Advise women to wash hands thoroughly before eating and to avoid crowds of young children at daycare or nursery school settings to help prevent exposure

to learn about beliefs of a particular woman and her partner, ask at prenatal visits if

1.there is anything the couple believes should or should not be done to make the pregnancy successful and keep the fetus healthy. 2. Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health

MEASUREMENT OF FUNDAL HEIGHT AND FETAL HEART SOUNDS At about 12 to 14 weeks of pregnancy, the uterus becomes palpable as a firm globular sphere showing over the symphysis pubis. It grows to reach the umbilicus at

20 to 22 weeks and the xiphoid process of the sternum at 36 weeks. In primiparas, it then often returns to about 4 cm below the xiphoid process because of "lightening" for the rest of pregnancy.

Fetal Movements Felt by an Examiner Fetal movements may be felt by a woman as early as 16 to 20 weeks of pregnancy. An objective examiner can discern fetal movements at about the

20th to 24th week of pregnancy unless the woman is extremely obese. This outside evaluation is considered the more reliable assessment because a woman could mistake the movement of gas through her intestines for fetal movement.

Carcinoma of the cervix appears as an irregular, granular growth. Cervical polyps (red, soft, pedunculated benign protrusions) are also occasionally seen at the os to the cervix. Women should have a first Pap smear to detect cervical cancer when they reach

21 years of age and then every 3 years thereafter

Gastrointestinal System Known as morning sickness, nausea and vomiting begins to be noticed at the same time levels of hCG and progesterone begin to rise, so these may contribute to its cause. Another reason may be a systemic reaction to increased estrogen levels or decreased glucose levels because glucose is being used in such great quantities by the growing fetus. Nausea usually subsides after the first

3 months, after which time a woman may have a voracious appetite

Breast self-examination is no longer thought to yield enough reliable information to be continued as a monthly self-care routine, but women should be alerted to normal breast changes during pregnancy and about the responsibility to begin having mammograms when they reach

40 to 45 years of age depending on risk status Clinical breast examination in women of average risk has not been shown to be effective in average risk women at any age. However, it may be helpful in identifying any anatomical issues with breastfeeding that may occur

Demonstration of a Fetal Heart Separate From the Mother's Although a fetal heart beat cannot be heard through an ordinary stethoscope until 18 to 20 weeks of pregnancy, an echocardiography can demonstrate a heartbeat as early as

5 weeks An ultrasound can reveal a beating fetal heart as early as the sixth to seventh week of pregnancy. Doppler instrumentation that converts ultrasonic frequencies to audible frequencies is able to detect fetal heart sounds as early as the 10th to 12th week of gestation.

Multipara

A woman who has carried two or more pregnancies to viability

Nulligravida

A woman who has never been and is not currently pregnant

Nursing Care Planning to Empower a Family Q. You notice Lauren Maxwell rubbing her back at a prenatal visit. She asks how she can keep her backache from becoming worse.

A. Backache is a common symptom of pregnancy because of the strain the extra uterine weight puts on lower vertebrae. Common measures to relieve backache in pregnancy include: • Limit the use of high heels because they add to the natural lordosis of pregnancy. • Try to rest daily with feet elevated. • Walk with head high and pelvis straight. • Pelvic rocking (see Chapter 14) at the end of the day may relieve pain for the night. Backache should be reported if: • It is experienced as waves of pain (i.e., could be preterm labor). • There are accompanying urinary symptoms, such as frequency and pain on urination (i.e., could be a urinary tract infection). • The back is tender at the point of backache (i.e., could be pyelonephritis or a kidney infection or a ruptured vertebrae). • Rest doesn't relieve it (i.e., could be a muscle strain).

NURSING DIAGNOSIS Examples of nursing diagnoses involving the changes that occur with pregnancy include:

Altered breathing patterns related to respiratory system changes of pregnancy Disturbed body image related to weight gain from pregnancy Deficient knowledge related to normal changes of pregnancy Imbalanced nutrition, less than body requirements, related to early morning nausea Powerlessness related to unintended pregnancy Possible impaired health and prenatal care behaviors associated with cultural beliefs

A pregnant patient has a history of genital herpes lesions and has experienced outbreaks periodically throughout the pregnancy. What should the nurse instruct the patient regarding this virus if lesions are present at the time of delivery? A) A cesarean section will be advised at the time of birth. B) There are no precautions needed at the time of birth. C) The patient will need medication immediately after birth. D) The baby will be given a vaccination against the virus at birth.

Ans: A Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 272 Feedback: If genital lesions are present at the time of birth, a fetus may contract the virus from direct exposure. A woman who has existing genital lesions at the time of birth will be advised to have a cesarean birth to reduce the risk of infecting the baby. There are precautions that need to be undertaken if lesions are present at the time of birth. The use of medication will depend on the patient's and infant's exposure to the virus.

A pregnant patient is experiencing a vaginal discharge and wants to douche. What should the nurse instruct the patient about this health practice? A) Avoid routine douching. B) Use an alkaline solution. C) Use only a commercial solution. D) Use a solution that has been chilled.

Ans: A Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 260 Feedback: Douching while pregnant is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix and lead to uterine infection. In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth. The alkalinity, purchase type, or temperature of the solution does not matter. The pregnant patient should not douche.

When measuring the diagonal conjugate of a woman's pelvis, the distance between which anatomic landmarks would be used? A) anterior surface of the sacral prominence and the anterior surface of the symphysis pubis B) medial surface of the ischial tuberosities C) interior surface of the sacral prominence and the posterior surface of the symphysis pubis D) posterior surface of sacrum and the axis of the ischial tuberosities

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 247 Feedback: The diagonal conjugate measures the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis, or the anterior-posterior diameter of the pelvic inlet.

Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management? A) episodes of double vision B) increased lumbar curvature C) nasal congestion and swollen nasal membranes D) palpitations when lying on her back

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 257 Feedback: Difficulty with vision can occur from cerebral edema or is a symptom of hypertension of pregnancy.

A woman in early pregnancy asks you why she has palmar erythema. Your reply would be based on the principle that palmar erythema is most likely caused by which of the following? A) An increased estrogen level B) An allergy to fetal protein C) Reduced serum protein D) Chorionic gonadotropin hormone secretion

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 265 Feedback: The cause of palmar erythema during early pregnancy is unknown but is attributed to the increasing estrogen level.

What advice should the nurse provide to a pregnant patient who admits to continuing to drink alcohol one to two times a week? A) Avoid all alcohol while pregnant. B) Avoid alcohol in the first trimester. C) The effects of alcohol on the fetus are not fully understood. D) An occasional drink is permitted only after the first trimester.

Ans: A Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 274 Feedback: There is evidence to confirm that women who consume large quantities of alcohol during pregnancy can have babies with congenital craniofacial deformities. It is impossible to define a safe level of alcohol consumption. Women should be screened for alcohol use at a first prenatal visit and advised to abstain from alcohol completely for the remainder of their pregnancy. Refer pregnant women with alcohol addiction to an alcohol treatment program as early in pregnancy as possible to help them reduce their alcohol intake.

Early in pregnancy, frequent urination results mainly from which cause? A) pressure on the bladder from the uterus B) increased concentration of urine C) addition of fetal urine to maternal urine D) decreased glomerular selectivity

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Remember Page: 220 Feedback: Early in pregnancy, the expanding uterus presses on the bladder. Later, it rises above the bladder so pressure is relieved.

Gynecologic health is an important part of a woman's health history. Which statement best illustrates the way to begin a menstrual history? A) "Discussing menstrual periods can be embarrassing. . ." B) "I'd like to ask you some questions about your menstrual periods." C) "I know you're probably uncomfortable talking about your health. D) "I bet you have pain with menstrual periods."

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Analyze Page: 233 Feedback: Beginning any history with an open-ended question allows the woman the optimal opportunity to elaborate on her health concerns.

When discussing rest and sleep with a pregnant woman, the nurse would discuss which position to use for napping? A) on her stomach with a pillow under her breasts B) on her side with the weight of the uterus on the bed C) on her back with a pillow under her knees and hips D) on her back with a pillow under her head

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 261 Feedback: Resting on the side prevents pressure from the uterus against the vena cava and, therefore, allows blood to return to the uterus.

A client the nurse meets in a prenatal clinic states that she has a vaginal discharge and asks about douching. Which rule is safe regarding douching during pregnancy? A) Only commercial solutions should be used. B) Routine douching is not advised. C) The solution used never should be acid. D) A room-temperature solution should not be used.

Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Remember Page: 260 Feedback: Douching might force fluid into the cervix and infect the uterus and fetus, so it is contraindicated during pregnancy.

During her first prenatal visit, a woman 18 weeks pregnant reports she did not realize she was pregnant and continued to take her birth control pills. She is concerned about their effects on her baby. Which of the following would be the best response to her concerns? A) "There are no risks to the fetus related to the ingestion of birth control pills during pregnancy." B) "Because of concerns about the estrogen exposure to the baby, we will monitor the fetal development." C) "As long as you did not take them too far into the second trimester, there is no risk." D) "Birth defects are a realistic possibility and must be monitored."

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Feedback: Studies have demonstrated a correlation between fetal growth problems and increased estrogen exposure.

After a routine examination, a patient tells the nurse that she plans to use a home pregnancy test to determine if she is pregnant. What should the nurse's response be to this patient's plan? A) Use a diluted urine specimen. B) Arrange for prenatal care if the test is positive. C) Wait until after two missed menstrual periods. D) Refrain from eating for 4 hours before testing.

Ans: B Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 211-212 Feedback: After a positive pregnancy test, the first step should be to arrange for prenatal care. This is the response that the nurse should make to the patient. The urine is not usually diluted for a home pregnancy test. The patient should not wait for 2 months before determining if she is pregnant. Eating does not impact the results of the home pregnancy test.

During a routine prenatal examination, a pregnant patient's urine is found to have a trace amount of glucose. What does this finding indicate to the nurse? A) The patient has gestational diabetes. B) Lactose may be spilling into the urine. C) The patient is eating excessive calories. D) It is because of a decrease in glomerular filtration rate.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 217 Feedback: Because reabsorption of glucose by the tubule cells occurs at a fixed rate, this causes some accidental spilling of glucose into the urine during pregnancy. Lactose, which is being produced by the mammary glands but is not used during pregnancy, will also be spilled into the urine. If more than a trace amount of glucose is found in the pregnant patient's urine, this could indicate gestational diabetes. The increase of glucose in the urine is not because of eating excessive calories. The glomerular filtration rate increases in pregnancy.

Which of the following would you advise a woman about breast self-examination during pregnancy? A) There is no reason to continue this during pregnancy. B) Self-exams are nonproductive during pregnancy. C) She should choose a date each month to do this. D) She should do it weekly, because she no longer has menstrual periods.

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 234 Feedback: Nonpregnant women use their menstrual period as a reminder to do a self-exam. Without this reminder, pregnant women need to use another system, such as a certain day each month.

A woman is concerned that orgasm will be harmful during pregnancy. Which statement is factual? A) Most women do not experience orgasm during pregnancy. B) Orgasm during pregnancy is potentially harmful. C) Some women experience orgasm intensely during pregnancy. D) Venous congestion in the pelvis makes orgasm painful.

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 260 Feedback: Because of pelvic congestion, orgasm may be achieved more readily by pregnant women than nonpregnant women.

What advice would you give to a woman who is 4 months pregnant and owns a cat? A) Give it away until after delivery. B) Be careful that it doesn't scratch her. C) Ask someone else to change the cat litter. D) Refrain from cleaning the cat's dish.

Ans: C Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 271-272 Feedback: Toxoplasmosis, an infection detrimental to fetal growth, can be spread by cat feces. Women are advised not to change litter boxes during pregnancy.

The nurse instructs a pregnant patient on the need to increase foods containing folic acid. Which patient statement indicates that teaching has been effective? A) "Eating an extra orange a day is important." B) "I need to drink two glasses of milk each day." C) "I will add spinach to my salad every evening." D) "Cabbage and cauliflower are important for me to eat."

Ans: C Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 202 Feedback: The patient should be instructed to eat foods that are high in folic acid such as spinach, asparagus, and legumes. Adding spinach every day to the evening salad indicates that teaching about folic acid nutrition has been effective. Oranges, milk, cabbage, and cauliflower are not food items that will specifically influence the folic acid level.

During a prenatal examination, the nurse learns that a pregnant patient has a supernumerary nipple. What should the nurse teach the patient about this finding? A) Such growths fade with menopause. B) Bleeding from such growths is not uncommon. C) Such growths deepen in color during pregnancy. D) The tendency for supernumerary nipples is genetic.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 241 Feedback: Breast changes may be one of the first things women notice in pregnancy. Any supernumerary nipples may become darker and enlarge in size. There is no information to support that supernumerary nipples fade with menopause or bleed. There is also no information to support that supernumerary nipples are genetic in origin.

A pregnant patient is planning travel to a foreign country as part of a work assignment and needs immunizations. What should the nurse instruct the patient about immunizations while pregnant? A) Immunizations should be restricted to live viruses only. B) There are no restrictions on immunizations while pregnant. C) The only immunization that should be avoided is for the flu. D) Live virus immunizations are contraindicated while pregnant.

Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 264-265 Feedback: All live virus vaccines are contraindicated during pregnancy and should not be administered unless the risk of the disease outweighs the risk to the pregnancy because live virus vaccines can cross the placenta and infect the fetus. The influenza vaccine is recommended if it is flu season when visiting crowded locations.

A pregnant patient enjoys exercising at a local health spa once a week. Which patient comment indicates to the nurse that additional health teaching is needed? A) "I'm learning to play table tennis." B) "I limit exercising to low-impact aerobics." C) "The gym gets hot and stuffy by midmorning." D) "Nothing feels nicer than a hot tub soak after exercise."

Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 278 Feedback: Pregnant women should not soak for long periods in extremely hot water or hot tubs because heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. Playing table tennis, performing low-impact aerobics, and the environment of the gym are not comments that indicate the need for additional teaching.

What advice should the nurse provide to a patient who is 4 months pregnant and owns a cat? A) Give it away until after delivery. B) Refrain from cleaning the cat's dish. C) Be careful that it doesn't scratch the skin. D) Ask someone else to change the cat litter.

Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 271-272 Feedback: Toxoplasmosis, a protozoan infection, may be contracted through handling cat stool in soil or cat litter. Removing a cat from the home during pregnancy as a means of prevention is not necessary as long as the cat is healthy. The pregnant woman should be instructed not to change a cat litter box or garden in soil in an area where cats may defecate to avoid exposure to the disease. Cleaning the cat's dish is acceptable. Scratches do not cause the disease.

A pregnant woman experiences frequent leg cramps. Which measure would the nurse include in her teaching plan to provide her with relief? A) elevating her leg on two pillows B) bending her knee and dorsiflexing her foot C) plantar flexing her foot and wiggling her toes D) extending her knee and dorsiflexing her foot

Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 266 Feedback: Dorsiflexing the foot with the knee extended is an effective method for relieving cramps in the calf muscle, the most frequently affected muscle.

A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her? A) Impaired urinary elimination related to inability to excrete creatine from her muscles B) Risk for ineffective breathing pattern related to pressure of the growing uterus C) Pain related to severe complications of pregnancy D) Health-seeking behaviors related to ways to relieve discomforts of pregnancy

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 265-268 Feedback: Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.

Why is a Papanicolaou smear done at the first prenatal visit? A) It predicts whether cervical cancer will occur. B) It helps to date the pregnancy. C) It detects if uterine cancer is present. D) It identifies abnormal cervical cells.

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Understand Page: 244 Feedback: A Pap smear is a test for cervical cancer. Should abnormal cells be present, the woman may need to make a decision about her priorities of therapy for cervical disease or continuing the pregnancy.

The spouse of a pregnant patient is quiet during prenatal visits but is demonstrating emotional involvement in the pregnancy. What action did the spouse perform? A) States he definitely wants a girl B) Refuses to paint the baby's room blue C) States he is concerned about the loss of his free time D) Walks around furniture as if his abdomen is enlarged

Ans: D Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Feedback: Many men experience physical symptoms and may begin to gain weight along with their partner. As a woman's abdomen begins to grow, the partner may perceive himself as growing larger too, as if he were the one who was experiencing changing boundaries the same as his partner. This is known as couvade syndrome. This indicates emotional involvement in the pregnancy. Stating a specific sex for the baby, losing free time, and refusing to paint the baby's room blue are not indications that the spouse is emotionally involved in the pregnancy.

A patient makes an appointment at the prenatal clinic because she thinks she might be pregnant. Which assessment is a probable sign of pregnancy? A) Amenorrhea B) Enlargement and darkening of areola C) Nausea and vomiting D) A positive pregnancy test

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Feedback:A probable sign of pregnancy is one that is objective and can be measured by an observer. A positive pregnancy test is a probable sign of pregnancy. Amenorrhea, enlargement and darkening of areola, and nausea and vomiting are presumptive signs because they could

Reproductive Planning

Ask also about what reproductive planning method, if any, a woman has been using. Occasionally, a woman may become pregnant with an intrauterine device (IUD) in place. If this occurs, its location needs to be evaluated prior to making the decision to proceed with removal. Another woman, not certain she is pregnant, may be continuing to take an oral contraceptive. If a pregnancy is confirmed, you can assure her taking the pill while pregnant will not cause fetal harm but she should discontinue taking it for the remainder of pregnancy

Vaginal Inspection

Before the vaginal speculum is removed, a culture for trichomoniasis (microscope slide wet mount sample) or group B Streptococcus (done at 35 to 37 weeks gestation) may be taken. Some Pap test specimen can be analyzed for gonorrhea, chlamydia, and HPV, so a separate swab for these infections is not required. Treatment to eliminate all of these infections during early pregnancy helps guard maternal, fetal, and newborn health -In a nonpregnant woman, vaginal walls are light pink; pregnancy may turn them dark blue to purple. Any areas of inflammation, ulceration, lesions, or discharge should be noted.

The most commonly used classification system used to interpret Pap smears is the

Bethesda system -Be certain when discussing results of Pap exams with woman that they are not overinterpreting results -the first three levels describing squamous cells reveal some abnormal cells are present, but only the last category indicates that cancer is present

Body Image and Boundary

Body image (i.e., the way your body appears to yourself) and body boundary (i.e., a zone of separation you perceive between yourself and objects or other people) both change during pregnancy as a woman begins to envision herself as a mother or becoming "bigger" in many different ways. Changes in concept of body boundaries are so startling that a pregnant woman may walk far away from an object such as a table to avoid bumping against it. At the same time, she may perceive herself as needing body boundaries as if her body were delicate and easily harmed.

Nursing Diagnosis:2 Health-seeking behaviors related to learning more about the minor body changes of late pregnancy such as

Braxton Hicks contractions

Braxton Hicks Contractions Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again . Early in pregnancy, these sensations, termed

Braxton Hicks contractions, are not apt to be noticeable. By middle or late pregnancy, the contractions become so strong a woman who tenses at the sensation may experience pain, similar to a forceful menstrual cramp. Although these contractions are not a sign of beginning labor, women should telephone or e-mail their primary care provider to report them so they can be evaluated. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of preterm labor.

Uterine contractions begin early in pregnancy, at least by the 12th week, and are present throughout the rest of pregnancy, becoming stronger and harder as the pregnancy advances. A woman experiences them as waves of hardness or tightening across her abdomen. If a hand is placed on her abdomen, an examiner may be able to feel these contractions as well; an electronic monitor can easily measure both the frequency and length of such contractions. These "practice" contractions, termed

Braxton Hicks contractions, serve as warm-up exercises for labor and also play a role in ensuring the placenta receives adequate blood. They may become so strong in the last month of pregnancy that a woman mistakes them for labor contractions (i.e., false labor)

Narcotics

Cocaine Heroin Social pleasure Dysmorphic and central nervous system (CNS) anomalies Growth restriction; narcotic abstinence in newborn

Caffeine

Coffee, soft drinks, chocolate Social use Low birth weight

Auscultate for fetal heart sounds (a rate of 110 to 160 beats/min is normal) by

Doppler if the pregnancy is past 10 weeks (the lower limit at which they can usually be heard). Palpate for fetal outline and position after the 28th week as a further estimation of fetal size and growth.

The Psychological Tasks of Pregnancy

During the 9 months of pregnancy, a woman and her partner run a gamut of emotions, ranging from surprise at finding out about the pregnancy (or wishing she were not), to pleasure and acceptance as they begin to identify with the coming child at the middle of pregnancy, to worry for themselves and the child, to acute impatience near the end of pregnancy . Once the child is born, a woman and her partner may feel surprised again that the pregnancy is over and they really do have a child. From a physiologic standpoint, it is fortunate that a pregnancy is 9 months long because this gives the fetus time to mature and be prepared for life outside the protective uterine environment. From a psychological standpoint, the 9-month period is also fortunate because it gives a family time to prepare emotionally as well. These psychological changes are frequently termed "guaranteeing safe passage" for the fetus

THIRD TRIMESTER: PREPARING FOR PARENTHOOD

Goal: Preparing for the baby's arrival -nesting What happens: -couples usually begin "nest-building" activities, such as planning the infant's sleeping arrangements, choosing a name for the infant, and "ensuring safe passage" by learning about birth. These preparations are evidence the couple is completing the third trimester task of pregnancy or preparing for parenthood. -attending prenatal classes and/or classes on preparing for childbirth. It's helpful to ask a couple what specifically they are doing to get ready for birth to see if they are interested in taking such a class and to document how well prepared they will be for the baby's arrival. -

A woman experiences an irregular heart rate and a feeling of apprehension. Relieving the problem is simple:

If a woman turns or is turned onto her side, pressure is removed from the inferior vena cava, blood flow is restored, and the symptoms quickly fade. To prevent the syndrome, advise pregnant women to always rest or sleep on their side, not their back. If they can only fall asleep on their back, they should insert a small firm pillow under their right hip to cause the weight of their uterus to shift off their inferior vena cava.

Day History/Social Profile

Information about a woman's current nutrition, elimination, sleep, recreation, and interpersonal interactions can be elicited best by asking a woman to describe what her typical day is like. If any of this information is not reported spontaneously as she describes her day, ask for additional details

Women can relieve stress incontinence to some degree by strengthening perineal muscles with the use of

Kegel exercises (periodic tightening of the perineal muscles; ). Surgical correction to increase support to the bladder neck could be performed following the pregnancy.

OUTCOME EVALUATION Evaluation should determine whether a woman has really "heard" your teaching. Remember that people under stress do not always comprehend well, so it is not unusual for a woman who is worried about her pregnancy to pocket away information, thinking, "I'll concentrate on that when it happens to me, not now." Then, when a particular change does happen, she realizes she has forgotten what you said. Examples of outcome criteria you might strive for include:

Patient states she is able to continue her usual lifestyle throughout pregnancy. Family members describe ways they have adjusted their lifestyles to accommodate the mother's fatigue. Couple states they appreciate the physiologic changes of pregnancy and even though they are causing discomfort, they know these are healthy changes.

Uterine prolapse

Possible Symptoms: Vaginal pressure and low back pain Significance and Suggested Therapy: The uterus has descended into the vagina due to overstretching of uterine supports and trauma to the levator ani muscle. Occurs most often in women who had insufficient prenatal care, birth of a large infant, a prolonged second stage of labor, bearing-down efforts or extraction of a baby before full dilatation, instrument birth, and poor healing of perineal tissue postpartally. -Therapy is surgery to repair uterine supports or placement of a pessary, a plastic uterine support. Women with pessaries in place need to return for a pelvic examination every 3 months to have the pessary removed, cleaned, and replaced and the vagina inspected; otherwise, vaginal infection or erosion of the vaginal walls can result. Surgical replacement is also possible.

Leiomyomas (fibroids)

Possible Symptoms: Asymptomatic or with increased menstrual flow; uterus may be enlarged Significance and Suggested Therapy: Muscle and fibrous connective tissue form in response to estrogen stimulation. May increase in size during pregnancy; may cause interference with cervical dilatation and result in postpartal hemorrhage. Stress to the myometrium by uterine contractions may be the original cause of formation. Therapy is embolization (blocking the blood supply), oral contraceptives or gonadotropin-releasing hormone agonists to lower estrogen level, surgical resection (myomectomy), or hysterectomy if childbearing is complete.

Peripheral blood flow

Prepregnancy: Pregnancy:Impaired blood return from lower extremities through the pelvis (due to weight of the baby) Reason: Leads to edema and varicosities in vulva, rectum, and legs‡

Ask also about any previous miscarriages or therapeutic abortions and whether she had any complications during or following those. If a woman's blood type is Rh negative, ask if she received

Rh immune globulin (RhIG [RhoGAM]) after miscarriages, abortions, or previous births, so you will know whether Rh sensitization could have occurred. In conjunction, ask if she has ever had a blood transfusion to establish possible risk of hepatitis B or HIV exposure or Rh sensitization from a blood transfusion.

Narcissism

Self-centeredness (narcissism) may be an early reaction to pregnancy. A woman who previously perhaps was barely conscious of her body, who dressed in the morning with little thought about what to wear, suddenly begins to concentrate on these aspects of her life. She dresses so her pregnancy will or will not show. She may lose interest in her job or community events because the work seems alien to the more important event taking place inside her.

Antibiotics

Sulfonamides Tetracycline (Apo-Tetra) Infection Infection Hyperbilirubinemia in newborn Teeth and bone deformities

A more comprehensive system for classifying pregnancy status (GTPAL or GTPALM) provides greater detail on a woman's pregnancy history. By this system, the gravida classification remains the same, but para is broken down as follows:

T: the number of full-term infants born (infants born at 37 weeks or after) P: the number of preterm infants born (infants born before 37 weeks) A: the number of spontaneous miscarriages or therapeutic abortions L: the number of living children -Using this system, a woman in the first example who is pregnant and has two children at home would be gravida 3, para 2002 (GTPAL) or gravida 3, para 2002 (GTPAL). A multigestation pregnancy is considered as one para. For example, a woman who had term twins, then one preterm infant, and is now pregnant again would be a gravida 3, para 2103 (GTPAL)

TERATOGENIC MATERNAL INFECTIONS Teratogenic maternal infections involve viral, bacterial, or protozoan organisms, which cross the placenta from mother to fetus. Most infections that may detract from a healthy pregnancy outcome cause relatively mild, flu-like symptoms in the woman but can have much more serious effects on a fetus or newborn. Preventing and predicting fetal injury from an infection is complicated because when a disease is subclinical (without any symptoms in the mother), it is difficult to analyze any effect on the fetus. When newborns are tested to see if antibodies against the common infectious teratogenic diseases are present, the test is described collectively under the umbrella term

TORCH, an acronym for toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus

Rectovaginal Examination After a bimanual pelvic examination, the hand is withdrawn from the vagina.

The index finger is reinserted into the vagina and the middle finger into the rectum. By palpating the tissue between the examining fingers in this way, it is possible to assess the strength and irregularity of the posterior vaginal wall. -This maneuver may be slightly uncomfortable for a woman because of rectal pressure. -After completing the examination, any excess lubricant is wiped away from the vaginal and rectal openings. Be certain to wipe front to back to prevent bringing rectal contamination forward from the rectum to the vagina

Para

The number of pregnancies that have reached viability, regardless of whether the infants were born alive

Grief

The thought that grief can be associated with such a positive process as having a child seems at first incongruent. But before a woman can take on a mothering role, she has to give up or alter her present role as she will never be the woman she has been in exactly the same way again. She will never be able to be as irresponsible and carefree again, or perhaps sleep soundly for the next few years. All of this takes mental preparation, which may manifest as a form of grief, as she incorporates her new role as a mother into her other roles as daughter, wife, business professional, or friend. Partners must also incorporate a new role as a parent into their other roles in life.

Muscle Cramps Decreased serum calcium levels, increased serum phosphorus levels, and, possibly, interference with circulation commonly cause muscle cramps of the lower extremities during pregnancy.

This problem is best relieved if a woman lies on her back momentarily and extends the involved leg while keeping her knee straight and dorsiflexing the foot until the pain disappears -Taking a calcium supplement, which would lower the phosphorus level, may be helpful. If a woman is experiencing frequent leg cramps, she may be advised to take magnesium lactate or citrate once in the morning and again in the evening as these bind phosphorus in the intestinal tract and thereby lower its circulating level; however, there is a lack of strong evidence that this decreases the frequency or intensity of leg cramps -levating lower extremities frequently during the day to improve circulation and avoiding full leg extension, such as stretching with the toes pointed, may also be helpful

Presumptive Finding

Week 2: Breast changes Feelings of tenderness, fullness, tingling; enlargement and darkening of areola Week 2: Nausea, vomiting Nausea or vomiting on arising or when fatigued Week 2 :Amenorrhea Absence of menstruation Week 3: Frequent urination Sense of having to void more often than usual Week: 12 Fatigue General feeling of tiredness Week: 12 Uterine enlargement Uterus can be palpated over symphysis pubis Week 18: Quickening Fetal movement felt by woman Week 24:Linea nigra Line of dark pigment forms on the abdomen Week 24:Melasma Dark pigment forms on face Week 24:Striae gravidarum Stretch marks form on abdomen

POSITIVE SIGNS OF PREGNANCY

Week 8: Sonographic evidence of fetal outline Fetal outline can be seen and measured by sonogram Week 10-12: Fetal heart audible Doppler ultrasound reveals heartbeat Week 20: Fetal movement felt by examiner Fetal movement can be palpated through abdomen

Depression

a feeling of sadness marked by loss of interest in usual things, feelings of guilt or low self-worth, disturbed sleep, low energy, and poor concentration—is a common finding in late adolescents. Depression causes as many as 15% of women to enter pregnancy feeling depressed; others grow depressed during pregnancy, especially if they lack a meaningful support person Screening for women who have a history of depression is important at a preconception visit as common drugs prescribed for depression can be teratogenic to a fetus as well as cause hypertension in the woman It is also important to investigate if the woman has a meaningful support person or the stress and anxiety that can come with pregnancy can increase depression substantially and lead to postpartum depression

QUALITY IMPROVEMENT The nurse is reviewing an educational pamphlet that has been frequently provided to pregnant women. What statement from the pamphlet suggests that revision is necessary? a. "You may want to jog rather than walk to get an increased amount of exercise." b. "Be certain to rest or sleep on your side, not flat on your back." c. "Plan to pack a lunch every day so that you won't eat junk food." d. "Try to walk around your desk every hour to help leg circulation."

a. "You may want to jog rather than walk to get an increased amount of exercise."

Other problems that can occur with employment include interference with adequate rest and nutrition. Urge a woman who works outside her home to put her

feet up and rest when performing tasks that can be done in that position. Review what she eats at fast-food restaurants or packs for herself to be certain she plans ways to make lunch as nutritious as if she were eating at home.

FOR HEALTHY ADAPTATION TO PREGNANCY ASSESSMENT During a preconception assessment, evaluate a woman's overall

health status, nutritional intake (ask specifically about sufficient intake of folic acid and protein), and lifestyle (especially drinking, smoking, and recreational drug habits); identify any potential problems (such as a risk for ectopic pregnancy because of tubal scarring); and identify a woman's understanding and expectations of conception, pregnancy, and parenthood.

9.HIV screening. The CDC recommends that all women be tested in early pregnancy for HIV, and those at high risk should be retested in the third trimester. High-risk criteria include women who have used or are using

intravenous drugs; have engaged in sex with multiple partners; have had sexual partners who are infected or are at risk because they are bisexual, intravenous drug users, or hemophiliac; or received a blood transfusion between 1977 and 1985.

A chlamydia infection can cause

pneumonia or conjunctivitis in a newborn.

Uterine contractions before 37 weeks of pregnancy. Women do have faint and irregular Braxton Hicks contractions prior to this point, but regular rhythmic contractions before 37 weeks suggest

preterm birth is beginning. A woman needs to lie down, drink a glass of water to ensure she is well hydrated, and telephone her obstetric care provider. Such contractions may be innocent, but it is better to report them than to ignore them and allow a preterm birth to continue.

Women who engage in anal intercourse may have an anal swab taken as well as vaginal swabs to detect anal

squamous neoplasms. The technique for obtaining an anal Pap smear is the same as that for vaginal specimens (a cytobrush is used). Caution the patient that she may have slight rectal bleeding following this procedure so she isn't unnecessarily concerned

Pelvic examinations have the reputation of being painful and causing a loss of modesty. If this is a first pregnancy and the patient is under the age of 21 years, it may be the first time a woman has ever had this type of examination. Having heard stories about how painful these examinations can maybe cause a woman to ?

tense just thinking about it. -When pelvic muscles are tense, however, not only can the examination become painful but also an examiner has difficulty assessing the status of pelvic organs. This examination may be particularly difficult if a patient has a history of sexual abuse or assault.

Gestational hypertension. Gestational hypertension refers to a potentially severe and even fatal elevation of blood pressure that occurs during pregnancy usually after 20 weeks of pregnancy. A number of symptoms signal that gestational hypertension is developing:

• Rapid weight gain (over 2 lb/week in the second trimester, over 1 lb/week in the third trimester) • Swelling of the face or fingers • Flashes of light or dots before the eyes • Dimness or blurring of vision • Severe, continuous headache • Decreased urine output • Right upper quadrant pain unrelated to fetal position • Blood pressure increased above 140/90 mmHg

It is also important to ask whether a woman had childhood diseases such as

-chickenpox (varicella), -mumps (epidemic parotitis), -measles (rubeola), -German measles (rubella), and poliomyelitis or if she has had immunizations against these illnesses. Confirm whether a woman has had a human papillomavirus (HPV) vaccine; many women are not yet aware that the vaccine has the potential not only to prevent HPV infections but also to prevent cervical cancer. It is now routinely prescribed for both male and female adolescents

ASSESSMENT The first prenatal visit is a time to establish baseline data relevant to a woman's health and identify health-promotion strategies that will be important at every prenatal visit. This begins by obtaining a

-detailed health and sexual history including screening for the risk of teratogen (any factor that may adversely affect the fetus) exposure as well as any concerns a woman has about her pregnancy. Explaining why specific assessment data are important has the potential to lead to health teaching. -For instance, while you are weighing a woman, discuss the importance of a healthy body mass index (BMI) and how her expected weight gain over the coming months will be calculated based on her prepregnancy value.

TRAVEL Regardless of the month of her pregnancy, if a woman plans to spend time at a remote location, such as could happen to a migrant worker, or a woman taking a family vacation at a campsite, be certain she has investigated the location of a nearby

-healthcare facility should an unexpected complication occur . -Caution her not to eat unwashed fruits or vegetables or raw meats and not to drink unpurified water. -If she is going to be away from home for an extended time, she should make arrangements to visit a healthcare provider in that area so she can keep the schedule of her regular prenatal visits. -Encourage her to make these plans far enough in advance so her records can be copied and carried by her or, with her consent, an electronic record can be forwarded to the interim healthcare provider. Also, make certain she has enough of her prescribed vitamin supplement plus adequate prescriptions for refills as necessary.

Varicosities causes blood pooling and vessel distention. The veins become enlarged, inflamed, and painful. Although usually confined to the lower extremities, varicosities can extend up to and including the vulva. They occur most frequently in women with a family history of varicose veins, those who are obese, and those who have a large fetus or a multiple pregnancy. Urge such women to

-take active measures to prevent varicosities beginning in early pregnancy; if left until late in pregnancy, the best they will be able to accomplish is relief of pain from already formed varicosities. -Resting in a Sims position or on the back with the legs raised against the wall (with a small firm pillow under their right hip) or elevated on a footstool for 15 to 20 minutes twice a day is a good precaution . Caution women not to sit with their legs crossed or their knees bent and to avoid constrictive knee-high hose or garters.

POSITIVE SIGNS OF PREGNANCY There are only three documented or positive signs of pregnancy:

1. Demonstration of a fetal heart separate from the mother's 2. Fetal movements felt by an examiner 3. Visualization of the fetus by ultrasound

INDIVIDUAL DIFFERENCES A woman's ability to cope with or adapt to stress plays a major role in how she can resolve any conflict she feels at becoming a mother. This ability to adapt (e.g., to being a mother without needing mothering, to loving a child as well as a partner, to becoming a mother for each new child) depends, in part, on her basic temperament, on whether she adapts to:

1. new situations quickly or slowly, on whether she faces them with intensity or maintains a low-key approach, and on whether she has had experience coping with change and stress 2.The extent to which a woman feels secure in her relationship with the people around her, especially the father of her child or her chief support person, is usually also important to her acceptance of a pregnancy. -Anxiety as to whether her partner may soon disappear, leaving her alone to raise a child, may make her reexamine whether her pregnancy is a wise life step 3.A woman who thinks of brides as young but mothers as old may believe pregnancy will rob her of her youth. If she's concerned about her appearance, she may worry pregnancy will permanently stretch her abdomen and breasts. She may also worry pregnancy will rob her financially and ruin her chances of job promotion (referred to as a "mommy track")

Breast Care Women need to make few changes related to breast care during pregnancy. A general rule is: as her breast size increases, a woman should be certain to wear a

1.firm, supportive bra with wide straps to spread breast eight across the shoulders. Interestingly, evidence shows that a woman's breasts enlarge more if the fetus she carries is male than if the fetus is female Regardless of fetal sex, women may need to buy a larger bra size halfway through pregnancy to accommodate breast changes. Assuming a woman plans on breastfeeding, recommend she choose bras suitable for this (open in the front), so she can continue to use them after the baby's birth.

At day's end, assuming a knee-chest position for

10 to 15 minutes is an excellent way to reduce the pressure on rectal veins. A knee-chest position may initially make a woman feel light-headed. If this happens, advise her to remain in this position for only a few minutes at first and then gradually increase the time until she can maintain the position comfortably for about 15 minutes.

The fetal heart rate ranges between

120 and 160 beats/min. Sounds are more difficult to hear if a woman's abdomen has a great deal of subcutaneous fat or if there is a larger-than-normal amount of amniotic fluid present (polyhydramnios). They are heard best when the position of the fetus is determined by palpation and the stethoscope is placed over the area of the fetal back.

Cervicitis (erosion)

Possible Symptoms: Reddened cervical tissue with a whitish exudate Significance and Suggested Therapy: Douching with a vinegar solution aids healing. May be treated with cryosurgery if extensive.

Endometrial carcinoma

Possible Symptoms: Vaginal bleeding between menstrual periods Significance and Suggested Therapy: Diagnosis is by endometrial washing, not Pap test. Initial therapy is hysterectomy.

Uterine Contractions Advise a woman to telephone her primary care provider when contractions begin to alert healthcare personnel that she is in labor. Her healthcare provider will advise her as to what point in labor she should come to the healthcare facility she has chosen or when to begin preparations for home birth if that is her choice. The typical time for this is when contractions areUterine Contractions

5 minutes apart, but this will vary depending on a woman's past and present pregnancy history. In all instances, if a woman should become exceptionally anxious, be home alone, or have a long drive, she should be given options as to when it would be best for her to leave home.

If a woman has a history of previously unexplained fetal loss, has a family history of diabetes, has had babies who were large for gestational age (9 lb or more at term), has a BMI over 30, or has glycosuria, she will need to be scheduled for a

50-g oral 1-hour glucose loading or tolerance test (sometimes called a glucose challenge test) toward the end of the first trimester (12 weeks) to rule out gestational diabetes The addition of a serum (HgA1C) has the best predictive value for identifying diabetes

Uterine blood flow increases during pregnancy as the placenta requires more and more blood for perfusion. Doppler ultrasonography has shown that, before pregnancy, uterine blood flow is 15 to 20 ml/min. By the end of pregnancy, it expands to as much as

500 to 750 ml/min, with 75% of that volume going to the placenta. Measuring an increase in placenta blood volume and velocity is an important gauge of fetal health

ULTRASONOGRAPHY If the date of the last menstrual period is unknown, a woman will be scheduled for a sonogram to confirm the pregnancy length and document healthy fetal growth at

7 to 11 weeks of pregnancy. An ultrasound may also be done, ideally between 11 and 13 weeks of pregnancy, as a part of a first trimester screening to assess for increased risk of Down syndrome.

Infections That Cause Illness at Birth

A number of infections are not teratogenic to a fetus during pregnancy but are harmful if they are present at the time of birth. Gonorrhea, candidiasis, chlamydia, streptococcus B, and hepatitis B infections are examples of these.

Laboratory Assessment

A number of laboratory studies are included as part of assessment at a first prenatal visit to confirm general health and rule out sexually transmitted infection that could injure a growing fetus.

Gravida

A woman who is or has been pregnant

Primigravida

A woman who is pregnant for the first time

A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient? A) Transverse narrow B) Ideal for childbearing C) Similar in shape to a male D) Has weaker bones than normal

Ans: A Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 249 Feedback: In an anthropoid pelvis, the transverse diameter is narrow. A gynecoid pelvis has an inlet that is well rounded forward and backward and has a wide pubic arch. This pelvic type is ideal for childbirth. An android pelvis is similar in shape to that of a male. The shape of the pelvis does not determine the strength of the bones.

At midpoint during pregnancy, you review beginning signs of labor with a patient. One of the beginning signs of labor you would review is A) a sudden gush of clear fluid from the vagina. B) excessive fatigue and headache. C) sharp, right-sided abdominal pain. D) an increased pulse rate and upper abdominal pain.

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 279 Feedback: A sudden gush of fluid from the vagina may signal that membranes have ruptured. Labor pains usually begin in the back and are described as nagging or cramping.

A woman reports to the clinic to have her IUD checked. During the visit it is determined she is 6 weeks pregnant. How will the presence of the IUD be handled? A) It will be removed to allow the pregnancy to grow. B) It will remain in place to avoid disturbing the growing embryo. C) The patient will most likely have a miscarriage so there is no need for action. D) The patient should be asked for her preference in this matter.

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 234 Feedback: The IUD must be removed to allow room for safe growth and development for the embryo.

The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which patient statement indicates that the nurse's efforts have been successful? A) "It was so nice to not have to wait long in the waiting room." B) "I really hate having my weight and blood pressure measured around other people." C) "Why does everyone push breastfeeding and natural childbirth? What about what I want?" D) "I thought you would have more reading material on labor and delivery in the waiting room."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Feedback: Strategies to individualize prenatal care include trying to schedule appointments so there won't be a long wait time, providing privacy for weight and blood pressure assessments, educating on care options and encouraging participating in decisions about care, and providing materials on pregnancy in the waiting room.

The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed? A) "Pain with urination is expected during pregnancy." B) "I should call the doctor if I have any vaginal bleeding." C) "A sudden rush of fluid means that my membranes ruptured. D) "I should not worry if I vomit once a day for the first 12 weeks."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 251 Feedback: Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional patient teaching is needed. The patient should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy.

A pregnant woman needs to increase the amount of milk she drinks daily. Early in pregnancy, which statement would probably be most effective as a health teaching measure? A) "Milk will strengthen your fingernails as well as be good for the baby." B) "The fetus needs milk to build strong bones and teeth." C) "Milk is a rich source of calcium that is important for fetal growth." D) "Your future baby will benefit from a high milk intake."

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Feedback: Early in pregnancy, before the pregnancy seems real, women often respond best to health teaching that meets their needs rather than those of the coming infant.

A nurse is assessing a pregnant women in her second trimester and obtains a urine sample for analysis. When reviewing the results, which finding would cause the nurse to be concerned? A) serum creatinine: 1.2 mg/100 mL (106 mmol/L) B) BUN: 10 mg/100 mL (3.57 mmol/L) C) reduced glomerular filtration rate D) creatinine clearance: 100 mL/minute (1.67 mL/s/m2)

Ans: A Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 222 Feedback: During pregnancy, the urinary system undergoes many physiologic changes, including alterations in fluid retention and renal, ureter, and bladder function. Glomerular filtration rate increases by 50%, BUN decreases by 25%, and creatinine decreases. A serum creatinine greater than 1 mg/100 mL (88.40 mmol/L) is abnormal and would be a cause for concern. A BUN of 15 mg/100 mL (5.35 mmol/L) or higher is abnormal. A creatinine clearance should be 90 to 180 mL/min (1.50 to 3.01 mL/s/m2) in a 24-hour urine sample.

A pregnant patient is observed talking with another patient holding an infant in the clinic waiting room. What does this observation indicate to the nurse? A) The patient is role-playing. B) The patient is being narcissistic. C) The patient is reworking developmental tasks. D) The patient is ambivalent about being pregnant.

Ans: A Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 207 Feedback: A step in preparing for parenthood is role-playing or fantasizing about what it will be like to be a parent. This is done by a pregnant woman spending time with other pregnant women or mothers of young children to learn how to be a mother. The pregnant patient's behavior does not indicate narcissism. Spending time with a mother of a small child is not reworking developmental tasks. This behavior does not demonstrate ambivalence about being pregnant.

A nurse is assessing a pregnant woman who has come to the clinic for a follow up visit. During the visit the nurse assesses the woman for evidence that she is working through the developmental tasks and adjusting psychologically. Which statement would the nurse interpret as indicating that the woman is adjusting positively? A) "My mother and I are closer than ever before." B) "I don't care what sex baby I have as long as it's healthy." C) "I'm thinking about everything I eat these days." D) "There are a lot of allergies in my husband's family."

Ans: A Client Needs: Psychosocial Integrity Cognitive Level: Analyze Page: 207 Feedback: A developmental task for a woman during pregnancy is to review and restructure her relationship with her mother.

What advice should the nurse provide to a pregnant client who admits to continuing to drink alcohol 1 to 2 times a week? A) She should avoid alcohol in the first trimester. B) Alcohol should not be consumed during pregnancy. C) The effects of alcohol on the fetus are not fully understood. D) She may have an occasional drink after the first trimester.

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Understand Page: 274 Feedback: There is no safe amount of alcohol to consume during pregnancy. If the client refuses or has a problem, alert the health care provider for the appropriate referral.

The nurse determines that a pregnant patient is working through developmental tasks. Which statement did the patient make to the nurse? A) "My mother and I are closer than ever before." B) "I'm thinking about everything I eat these days." C) "There are a lot of allergies in my husband's family." D) "I don't care what sex baby I have as long as it's healthy."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 207 Feedback: For the first time in her life, a woman during pregnancy can begin to empathize with the way her mother used to worry. This can make her own mother become more important to her and a new, more equal relationship develops. Thinking about diet, allergies, and the baby's sex are not developmental tasks for the pregnant patient.

A pregnant patient who has frequent allergic responses to drugs is concerned about an allergic reaction to the fetus. What information will the nurse use when responding to this patient's concern? A) Immunologic activity is decreased during pregnancy. B) The level of aldosterone during pregnancy reduces production of IgG antibodies. C) The kidneys release a hormone during pregnancy to prevent this from happening. D) The decreased corticosteroid activity during pregnancy ensures this will not happen.

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 217 Feedback: Immunologic competency during pregnancy decreases, probably to prevent a woman's body from rejecting the fetus as if it were a transplanted organ. Aldosterone does not impact the production of IgG antibodies. The kidneys do not influence an allergic response. Adrenal gland activity increases during pregnancy.

A pregnant patient is experiencing leg cramps. What should the nurse include in the patient's teaching plan as a relief measure? (Select all that apply.) A) Avoid full leg extension. B) Elevate lower extremities. C) Elevate the legs on two pillows. D) Stand on each leg and perform a squat. E) Bend the knee and perform dorsiflexion.

Ans: A, B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 266 Feedback: If a pregnant woman is experiencing frequent leg cramps, she may be advised to elevate lower extremities frequently during the day to improve circulation and avoiding full leg extension. Elevating the legs on two pillows may or may not help the patient. The patient should not be instructed to perform squats or dorsiflexion to help with the leg cramps.

A patient who is 6 months pregnant is complaining of a lumbar backache. What actions should the nurse suggest to help this patient? Select all that apply. A) Do pelvic rocking. B) Walk with head high. C) Rest and elevate the feet. D) Wear higher heeled shoes. E) Twist the spine at the hips.

Ans: A, B, C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 223 Feedback: Interventions to reduce lower lumbar backache associated with pregnancy include pelvic rocking exercises, walking with the head high, and resting and elevating the feet. The patient should be instructed to limit the use of high heels. Twisting the spine is not recommended to help with a lumbar backache.

The nurse is planning a seminar that focuses on the 2020 National Health Goals during pregnancy for patients who are in the first trimester of pregnancy. Which information should the nurse include in this seminar? (Select all that apply.) A) Refusing alcohol B) Importance to stop smoking C) Maintaining health appointments D) Seeking alternative care approaches E) Abstaining from drugs and substances

Ans: A, B, C, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 257 Feedback: The 2020 National Health Goals for pregnancy include objectives to abstain from social and binge alcohol intake, avoid smoking, receive prenatal care, and abstain from illicit drugs. Seeking alternative care approaches is not a 2020 National Health Goal for pregnancy.

The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit. For what will the nurse test this patient's urine? Select all that apply. A) Protein B) Glucose C) Bacteria D) Drug levels E) White blood cells

Ans: A, B, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 250 Feedback: Urine is tested for proteinuria, glycosuria, nitrites, and pyuria. All of these can be done by means of test strips. The nurse will not test the patient's urine for drug levels as part of a routine prenatal visit.

The nurse in a community clinic is identifying ways to achieve the 2020 National Health Goals to support prenatal care. Which nursing actions would support the achievement of these goals? Select all that apply. A) Urge female patients to ingest an adequate intake of folic acid. B) Recommend pregnant patients attend developmental childbirth classes. C) Discuss strategies to avoid intimate partner violence with every pregnant patient. D) Provide a play area in the waiting room for the children of patients waiting to be seen. E) Support pregnant patients to achieve the recommended weight gain during pregnancy.

Ans: A, B, D, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 227 Feedback: A number of 2020 National Health Goals speak directly to the importance of prenatal care to include increasing the proportion of pregnant women who attend a series of prepared childbirth classes, increasing the proportion of women of childbearing potential who have an intake of at least 400 mcg of folic acid from fortified foods or dietary supplements before pregnancy, increasing the proportion of mothers who achieve a recommended weight gain during their pregnancies, and making sites for prenatal care "family friendly" or maximally receptive to women and families. Strategies to avoid intimate partner violence will not help the nurse achieve the 2020 National Health Goals for prenatal care.

A patient enjoys exercising and wants to know if it can continue to be done while pregnant. What should the nurse instruct the patient about exercising at this time? (Select all that apply.) A) Drink plenty of liquids to prevent dehydration. B) Limit strenuous exercise to no longer than 20 minutes. C) Eat a low-protein, simple carbohydrate snack before exercising. D) Warm up for 5 minutes by walking or cycling on low resistance. E) Avoid exercises that require jumping or rapid changes in direction.

Ans: A, B, D, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 260-261 Feedback: The nurse should instruct the patient to drink liquids to prevent dehydration, limit strenuous exercise to 20 minutes, warm up before beginning an exercise session, and avoid exercises that can jar the body. The patient should be instructed to eat a protein and complex carbohydrate snack before exercise to maintain the serum glucose level.

At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk during the pregnancy. Which data from the patient's past illness history does the nurse use to make this decision? Select all that apply. A) Seizure disorder B) Previous cesarean birth C) Hypertension for 10 years D) History of abnormal Pap smear E) Previous treatment for gonorrhea

Ans: A, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 252 Feedback: Past illness history criteria that place a patient at risk during pregnancy include a seizure disorder, a chronic disease such as hypertension, and sexually transmitted infections. A previous cesarean birth and a history of abnormal Pap smears are criteria for the obstetrical history that can place the patient at risk during pregnancy.

What should the nurse recommend to this patient to support the 2020 National Health Goals for pregnancy? Select all that apply. A) Stop smoking. B) Increase exercise. C) Eat a healthy diet. D) Reduce work hours. E) Limit alcohol intake.

Ans: A, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Feedback:Nurses can help the nation achieve the 2020 National Health Goals for pregnancy by being certain women receive counseling in nutrition and low uses of alcohol and tobacco before pregnancy so they can enter intended pregnancies in the best health possible. Increasing exercise

A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history? A) Ask her to complete a written questionnaire concerning her past and present status. B) Conduct an interview in a private room to obtain her health history. C) Wait until she is in the examining room and prepared for her physical examination. D) Ask her some basic questions in the waiting room before taking her to the examining room.

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 230 Feedback: Health interviewing is always conducted best in a quiet, private setting before examination procedures begin.

A primapara woman, 30 weeks' gestation, has no family support and frequently calls the health care provider's office with questions. Which report by the woman would alert the nurse that she may be having a complication related to the pregnancy and needs to come to the clinic today for further assessment? A) having a hard time having bowel movements and feeling like anal area is swollen B) feeling of achy, cramping in vaginal area accompanied by bleeding that has saturated 1 pad/hour C) experiencing some shortness of breath after walking up five flights of stairs D) having some discharge from nipples that has never happened before

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 251 Feedback: A woman should report vaginal bleeding, no matter how slight, because some of the serious bleeding complications of pregnancy begin with only slight spotting. Constipation followed by hemorrhoid development is common with pregnancy. Walking upstairs during the third trimester does produce some shortness of breath. It is normal to have some colostrum, or pre-milk, discharge during pregnancy.

A pregnant woman enjoys exercising at a local health spa once a week. Which comment would lead the nurse to believe she needs additional health teaching? A) "I limit exercising to low-impact aerobics." B) "Nothing feels nicer than a hot sauna after exercise." C) "I'm learning to play table tennis." D) "The gym gets hot and stuffy by midmorning."

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 261 Feedback: Hyperthermia may be associated with fetal anomalies and should be avoided during pregnancy. Exercise should be limited to low-impact activities.

Which statement would indicate a pregnant nurse needs additional health teaching about avoiding teratogens during pregnancy while at work? A) "I care for about five clients a day." B) "Latex gloves irritate my hands, so I don't use them." C) "I never accompany clients to the X-ray department." D) "I find giving emotional support taxing."

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 263 Feedback: Teratogens are agents or factors that cause harm to a fetus. To avoid exposure while working, nurses should always wear proper PPE to prevent contact with blood and body fluids. It is recommended to avoid x-ray exposure, except dental, during pregnancy as there is no safe dosage determined. Caring for multiple clients and giving emotional support do not increase exposure to teratogens.

A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms? A) Exercise helps reduce the frequency of them. B) If rhythmical, they could indicate preterm labor. C) Lying down for a few hours will help them stop. D) They are false labor and do not need to be reported.

Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 270 Feedback: Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. These sensations are Braxton Hicks contractions and can be similar to a forceful menstrual cramp. These contractions are not usually a sign of beginning labor but should be reported for evaluation. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of preterm labor. Exercise or rest does not reduce the frequency of Braxton Hicks contractions.

During the interview portion of her first prenatal visit, a woman reports she thinks she may have a vaginal infection. When questioned, she reports the discharge is thick, greenish-yellow, and she is very uncomfortable. She reports she thinks it is "yeast." How should the nurse reply? A) "You are describing gonorrhea." B) "Yeast is usually a thick, cheesy, white discharge so we will need to evaluate it during the pelvic exam." C) "You have a sexually transmitted disease." D) "You may have chlamydia so we will need to perform a pelvic exam."

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 244 Feedback: Yeast is normally a thick, cheesy discharge. Greenish-yellow discharge is associated with gonorrhea.

What is a positive sign of pregnancy? A) positive pregnancy test B) fetal movement felt by examiner C) Hegar's sign D) uterine contractions

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Remember Page: 212 Feedback: The positive signs of pregnancy are fetal image on sonogram, hearing a fetal heart rate, and examiner feeling fetal movement.

An important focus of all prenatal visits, is

education about pregnancy and helping a woman achieve a healthy pregnancy lifestyle, is to assure women that their pregnancy is progressing well.

The nurse is visiting the family of a newly pregnant patient whose spouse was ambivalent about the pregnancy during the first prenatal visit. Which observation indicates that the spouse is accepting the pregnancy? A) Spouse leaves the house when the nurse arrives. B) Spouse sits with the pregnant patient during the nurse's visit. C) Spouse shouts down the stairs about the location of clean laundry. D) Spouse tells the patient what needs to be obtained from the grocery store.

Ans: B Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 230 Feedback: If childbearing is to be a family affair, it is important to determine a partner's degree of acceptance of the pregnancy and how well prepared the spouse is of assuming a new parenting role. After confirmation of pregnancy, include the partner in health care information or suggestions. The spouse sitting with the pregnant patient during the nurse's visit indicates that the spouse is accepting the pregnancy. Leaving the house, shouting down the stairs about laundry, and giving a list of grocery items could indicate indifference or no interest in the pending pregnancy. These actions do not support acceptance of the pregnancy.

While conducting the first prenatal health history visit, the nurse learns that a pregnant patient is taking various herbal remedies and over-the-counter medications for minor ailments. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time? A) Risk for injury to fetus related to lifestyle choices B) Deficient knowledge regarding exposure to teratogens during pregnancy C) Health-seeking behaviors related to strong cultural desire to have a healthy child D) Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 227 Feedback: The patient is taking herbal remedies and over-the-counter medications, many of which can be teratogenic to the developing fetus. This is the most appropriate nursing diagnosis for the nurse to select for this assessment finding. There is no enough information to determine if the fetus is at risk because of the patient's lifestyle choices. The patient has not asked for specific information so health-seeking behavior diagnoses would not be appropriate for the patient at this time.

A pregnant woman works as a secretary at a large corporation. She states that she wants to take a leave of absence from work for pregnancy but is afraid she will lose seniority standing because of this. You would advise her that A) medically, it is not wise for any woman to work past the seventh month of pregnancy. B) legally, her employer cannot penalize her this way. C) ethically, she has no right to ask for special favors. D) personally, she is selfish to think of herself ahead of the baby this way.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Understand Page: 263 Feedback: Pregnancy is not viewed as a condition that is detrimental to career advancement, so women cannot be discriminated against because of pregnancy.

A woman in a prenatal clinic tells the nurse that her pregnancy was unplanned and unwanted. At what point in pregnancy does the average woman change her mind about an unwanted pregnancy? A) around the third month B) when quickening occurs C) after lightening happens D) after the seventh month

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 206 Feedback: Quickening, or feeling the baby move inside the body, is such a dramatic event that it can cause a woman's perceptions about the pregnancy to change.

The nurse is concerned that a pregnant patient is not adjusting emotionally to being pregnant. Which statement indicates that the patient may need additional counseling? A) "I cannot wait to lose all of this excess weight." B) "I need to get right back to work after delivery." C) "My mother has been so helpful during this time." D) "My dad has already purchased toys for the baby!"

Ans: B Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Feedback: The statement that the patient needs to get back to work after delivery could indicate that the patient feels the pregnancy is robbing her of financial stability or ruin chances of a promotion. Desiring to lose weight after pregnancy does not indicate that the patient is not adjusting emotionally to being pregnant. The statements about parental support do not indicate that the patient is not adjusting emotionally to being pregnant.

During pregnancy, which situation would interfere with mother-child bonding? A) A woman's neighbor is planning an extensive vacation. B) A woman's father has been very ill during the pregnancy. C) A woman's husband was awarded a large year-end bonus. D) A woman's sister recently had a baby boy.

Ans: B Client Needs: Psychosocial Integrity Cognitive Level: Analyze Page: 207 Feedback: Any event during pregnancy that has the potential to reduce the time the woman spends working through the developmental tasks of pregnancy can interfere with bonding.

A pregnant woman's husband does not voice concerns at prenatal visits. Which observation would lead the nurse to suspect that the husband is emotionally involved in the pregnancy? A) He states he definitely wants a girl. B) He walks around furniture as if his abdomen is enlarged. C) He states he is concerned about the loss of his free time. D) He has refused to paint the baby's room blue.

Ans: B Client Needs: Psychosocial Integrity Cognitive Level: Analyze Page: 209 Feedback: Many partners experience physical symptoms such as nausea, vomiting, and backache to the same degree or even more intensely than their partners during a pregnancy; some begin to gain weight along with their partner. This is known as couvade syndrome. As a woman's abdomen begins to grow, partners may perceive themselves as growing larger too, as if they were the ones who were experiencing changing boundaries the same as the pregnant woman. These symptoms apparently result from stress, anxiety, and empathy for the pregnant woman. Men who identify with their wife's pregnancy may act as if their abdomen is enlarging, the same as they may take on nausea of pregnancy.

After an examination, an advanced practice nurse confirms that a patient is pregnant. What did the nurse assess in this patient? Select all that apply. A) Painful breast tissue B) Positive pregnancy test C) Fetal movements felt by the nurse D) Visualization of the fetus by ultrasound E) Fetal heart rate separate from the patient's

Ans: C, D, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 212 Feedback: There are only three documented or positive signs of pregnancy—demonstration of a fetal heart separate from the mother's, fetal movements felt by an examiner, and visualization of the fetus by ultrasound. Painful breast tissue is a presumptive sign of pregnancy. A positive pregnancy test is a probably sign of pregnancy.

A nurse is 5 weeks pregnant and works on a care area where chemotherapy is administered to patients. Which statement indicates that this nurse needs additional health teaching about avoiding teratogens during pregnancy? A) "I care for about five patients a day." B) "I find giving emotional support taxing." C) "Latex gloves irritate my hands, so I don't use them." D) "I never accompany patients to the X-ray department."

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 263 Feedback: The nurse is not using latex gloves and is exposed to chemotherapeutic agents, which are known teratogens during pregnancy. This nurse needs additional instruction to reduce exposure from the chemotherapy agents. Caring for five patients a day does not necessarily increase the nurse's exposure to teratogens. Emotional support does not increase the nurse's exposure to teratogens. Avoiding X-rays is a positive action to avoid teratogens.

The nurse is reviewing the signs of labor with a patient entering the last phase of the third trimester of pregnancy. What should the nurse include as an indication that the labor is beginning? A) Excessive fatigue and headache B) Sharp, right-sided abdominal pain C) Sudden gush of clear fluid from the vagina D) An increased pulse rate and upper abdominal pain

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 279 Feedback: Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. Excessive fatigue, headache, abdominal pain, or increased pulse rate are not indications that labor is beginning.

A pregnant patient is concerned that she is allergic to something because her hands have been red and itchy since becoming pregnant. What should the nurse explain as the cause of the patient's symptoms? A) Allergy to fetal protein B) Reduced serum protein C) Increased estrogen level D) Chorionic gonadotropin hormone secretion

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 265 Feedback: Palmar erythema, or palmar pruritus, occurs in early pregnancy and is probably caused by increased estrogen levels. Constant redness or itching of the palms can make a woman believe she has developed an allergy. This type of itching in early pregnancy is normal and is not caused by an allergy to fetal protein, reduced serum protein, or chorionic gonadotropin hormone secretion.

A pregnant patient who works as a secretary at a large corporation wants to take a leave of absence from work but is afraid of losing seniority. What should the nurse advise the patient? A) The patient should not ask for special favors. B) The leave of absence should occur after the baby is born. C) The employer cannot penalize the patient for being pregnant. D) It is not wise for any woman to work past the seventh month of pregnancy.

Ans: C Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 263 Feedback: Women who are unable to continue working while pregnant are protected from loss of employment benefits during pregnancy by federal law. According to federal law, an employer cannot deprive women of seniority rights because they take a maternity leave. The patient is not asking for special favors. The maternity leave can occur before the delivery because the Family Medical and Leave Act can be used once the baby is delivered. There is no time limit about how long a pregnant patient can work.

At her 16-week checkup, a client's blood pressure is slightly decreased from her prepregnancy level. The nurse evaluates this change based on which statements concerning blood pressure during pregnancy? A) Normally, blood pressure increases steadily throughout pregnancy. B) Blood pressure remains stable until decreasing the day of the birth. C) A decrease in the second trimester may occur because of placental growth. D) Blood pressure progressively decreases throughout the entire pregnancy.

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 213 Feedback: Because the placenta "traps" a great deal of blood for fetal circulation as it expands at about 3 months, maternal blood pressure may temporarily be slightly decreased. Otherwise, blood pressure stays fairly constant throughout pregnancy.

The nurse is caring for a woman in a prenatal clinic who thinks she might be pregnant. Which assessment is a probable sign of pregnancy? A) fatigue B) nausea and vomiting C) a positive pregnancy test D) amenorrhea

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Remember Page: 210 Feedback: Most probable signs of pregnancy are objective signs; laboratory testing is probable, not positive, because error can occur.

To prepare his 4-year-old son for a new baby, a father should use which statement? A) "The new baby will need your bed so we're buying you a new one." B) "It will be fun to have a sister or brother to give your old toys to." C) "A new baby will make our family bigger but not change our love for you." D) "Mother will need to spend a lot of time with the new baby."

Ans: C Client Needs: Psychosocial Integrity Cognitive Level: Apply Page: 210 Feedback: It is important that siblings see a new family member as adding to the family (not displacing them) to prevent jealousy.

A pregnant patient tells the nurse that she is not happy to learn about the pregnancy. At which point in the pregnancy does the nurse realize that the patient will change her mind about the pregnancy? A) Around the third month B) After the seventh month C) When quickening occurs D) After lightening happens

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 206 Feedback: Quickening or feeling the baby move inside the body is a dramatic event and causes the pregnant woman's feelings about the pregnancy to change. Quickening occurs during the second trimester of the pregnancy, which is after the third but before the seventh month. Lightening occurs near the end of the pregnancy.

A woman tells the nurse that she is going to use a home pregnancy test to determine whether she is pregnant. Which precautions should the nurse give her? A) Use a diluted urine specimen. B) Wait until after two missed menstrual periods. C) Arrange for prenatal care if the test is positive. D) Refrain from eating for 4 hours before testing.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Understand Page: 205 Feedback: Home pregnancy testing can be accurate as soon as a period is missed; it should not take the place of prenatal care.

When explaining what will occur during the first prenatal visit physical examination, a pregnant patient asks why a Papanicolaou smear is being done at this time. What should the nurse respond to the patient? A) It helps to date the pregnancy. B) It detects if uterine cancer is present. C) It predicts whether cervical cancer will occur. D) It detects cancer cells of the cervix, vulva, or vagina.

Ans: D Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 244 Feedback: A Pap smear is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not present. A Pap smear is not used to date a pregnancy, detect uterine cancer, or predict if cervical cancer will occur.

How should the nurse document a pregnant patient's gestational status using the GTPAL system after collecting the following data? Currently 18 weeks pregnant Patient's fourth pregnancy Delivered one nonviable fetus at 26 weeks Experienced one miscarriage Delivered one viable fetus at 38 weeks' gestation A) 3, 2, 1, 2, 1 B) 4, 2, 2, 1, 1 C) 3, 2, 1, 1, 1 D) 4, 1, 1, 1, 1

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 237 Feedback: GTPAL is a more comprehensive system for classifying pregnancy status. By this system, the gravida classification remains the same, but para is broken down into T: the number of full-term infants born (infants born at 37 weeks or after), P: the number of preterm infants born (infants born before 37 weeks), A: the number of spontaneous miscarriages or therapeutic abortions, and L: the number of living children. The patient has been pregnant four times. The patient delivered one viable infant at 38 weeks. The patient delivered one nonviable fetus at 26 weeks. The patient had one miscarriage. The patient has one living child.

A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching? A) "I maintain a high fluid intake." B) "I'll try not to stand for long periods." C) "I dorsiflex my feet and ankles frequently." D) "I wear knee-highs rather than pantyhose."

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 260-266-267 Feedback: Women with varicosities should not wear knee-high stockings as they put pressure on leg veins and reduce venous return.

An adolescent who is pregnant asks the nurse which sport would be safe for her to learn during pregnancy. Which activity would the nurse suggest as safe? A) bicycling B) jogging C) skiing D) swimming

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 261 Feedback: Sports that require balance (bicycling, skiing) become difficult during pregnancy. Jogging can be difficult because of lax knee cartilage.

Which two tests are generally performed on urine at a prenatal visit? A) protein and sodium B) pH and glucose C) occult blood and protein D) protein and glucose

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 238 Feedback: Protein is assessed to help detect hypertension of pregnancy; glucose is assessed to help detect gestational diabetes.

Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks' gestation. A) 3, 2, 1, 2, 1 B) 4, 2, 2, 1, 1 C) 3, 2, 1, 1, 1 D) 4, 1, 1, 1, 1

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 237 Feedback: The GTPAL system is used to classifying pregnancy status. G = gravida, T= term, P = preterm, A = number of abortions, L= number of living children.

Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit? A) "Do you have a peptic ulcer?" B) "Have you ever had a heart attack?" C) "Have you had any neurologic diseases?" D) "Have you had any urinary tract infections?"

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 233 Feedback: Urinary tract infections are associated with preterm birth. If the patient has a history of this type of infection, then interventions can be directed to help the patient avoid a urinary tract infection while pregnant. Although a part of the review of systems, asking about peptic ulcers, heart attacks, and neurologic diseases may not have as significant an impact on the developing fetus as having urinary tract infections.

The nurse is preparing to measure the diagonal conjugate of a pregnant patient's pelvis. Which anatomic landmarks will the nurse use to make this measurement? A) Medial surface of the ischial tuberosities B) Posterior surface of sacrum and the axis of the ischial tuberosities C) Interior surface of the sacral prominence and the posterior surface of the symphysis pubis D) Anterior surface of the sacral prominence and the posterior surface of the symphysis pubis

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 249 Feedback: The diagonal conjugate is the measurement between the anterior surface of the sacral prominence and the posterior surface of the symphysis pubis. The ischial tuberosity diameter measurement is the distance between the ischial tuberosities or the transverse diameter of the outlet and is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus. Measurements are not made from the posterior surface of the sacrum and the axis of the ischial tuberosities or the interior surface of the sacral prominence and the posterior surface of the symphysis pubis.

The nurse is emphasizing the importance of adequate rest and sleep with a pregnant patient. Which position should the nurse suggest the patient use? A) On the back with a pillow under the head B) On the stomach with a pillow under her breasts C) On the back with a pillow under the knees and hips D) On the side with the weight of the uterus on the bed

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 261 Feedback: A good resting or sleeping position for a pregnant patient is a left-sided Sims' position, with the top leg forward. This position puts the weight of the fetus on the bed, not on the woman, and allows good circulation in lower extremities. Lying on the back could cause the weight of the uterus to occlude the inferior vena cava impeding blood flow to the patient and fetus. Stomach lying is not a reasonable option with the size of the uterus.

Cervical polyp

Possible Symptoms: Red, vascular, protruding pedunculated tissue that bleeds readily with trauma Significance and Suggested Therapy: May be discovered because of vaginal spotting on coitus, tampon insertion, or vaginal examination. Removed vaginally by excision. Often associated with chronic cervical inflammation.

A 20-year-old woman you see in a prenatal clinic has an accessory nipple. Which of the following teaching points would be most important to make with her? A) The tendency for accessory nipples is familial. B) Such growths fade with menopause. C) Bleeding from such growths is not uncommon. D) Such growths deepen in color during pregnancy.

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 241 Feedback: Pigment changes can be expected during pregnancy. Alerting women to this can decrease anxiety.

During an assessment, a patient who is 5 months pregnant tells the nurse that she has to change her diet because she is just becoming too fat. Which nursing diagnosis should the nurse use to guide interventions for the patient at this time? A) Powerlessness B) Imbalanced nutrition C) Deficient knowledge D) Disturbed body image

Ans: D Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Feedback: The diagnosis of disturbed body image is the most appropriate because the patient is equating the weight gain of pregnancy as being fat. The patient may or may not have a knowledge deficit. There is no evidence to support the diagnosis of imbalanced nutrition. There is also no evidence to support that the patient is experiencing powerlessness.

The nurse is assessing a patient who is 3 months pregnant. Which breast changes would the nurse expect to assess in this patient? A) Enlarged lymph nodes B) Slack, soft breast tissue C) Deeply fissured nipples D) Darkened breast areolae

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 216 Feedback: As the pregnancy progresses, the areola of the nipples darkens, and its diameter increases. Enlarged lymph nodes; slack, soft breast tissue; and deeply fissured nipples are not expected breast changes in a pregnant patient.

SECOND TRIMESTER: ACCEPTING THE BABY As soon as fetal movements can be felt, psychological responses of both partners usually begin to change. The Woman

Goal: to accept she is having a baby, a step up from accepting the pregnancy What happens: -This change usually happens at quickening, or the first moment a woman feels fetal movement. Until a woman experiences for herself this proof of the child's existence and although she ate to meet nutritional needs and took special vitamins to help the fetus grow, it seemed more like just another part of her body. With quickening, the fetus becomes a separate identity. -Women often use the term "it" to refer to their fetus before quickening but begin to use he or she afterward. Some women continue to use it, however, so doing so is not a sign of poor attachment but an individual preference as some women believe referring to the child as "she" or "he" will bring bad luck or disappointment if the sonogram report was wrong. shopping for baby clothes for the first time, setting up the crib, or seeing a blurry outline on a sonogram screen may suddenly make the coming baby seem real and desired

A bimanual examination (two fingers of an examiner are placed in the vagina, the other hand on the abdomen) can demonstrate, during a pregnancy, that the uterus feels more anteflexed, larger, and softer to the touch than usual. At about the sixth week of pregnancy (at the time of the second missed menstrual flow), the lower uterine segment just above the cervix becomes so soft when it is compressed between examining fingers on bimanual examination that the wall feels as thin as tissue paper . This extreme softening of the lower uterine segment is known as

Hegar's sign

Carcinoma of the vulva

Possible Symptoms: A shallow vulvar ulcer that does not heal Vulvar cancer occurs most often in postmenopausal women; represents only 3%-4% of all reproductive tract cancers in women. Significance and Suggested Therapy: Therapy is vulvectomy—vagina is left intact, and sexual relations and pregnancy, with cesarean birth to prevent tearing of fibrotic vulvar tissue, may be possible afterward.

Polycystic ovary syndrome

Possible Symptoms: A syndrome of chronic follicular cysts, anovulation, insulin resistance, and excess testosterone production leading to perimenopausal onset of hirsutism, obesity, subfertility, and elevated triglycerides Significance and Suggested Therapy: Excess testosterone secretion by ovaries leads to inhibition of follicle-stimulating hormone and anovulation, causing subfertility. Weight loss, reduction in triglycerides and cholesterol levels, clomiphene citrate therapy to induce ovulation, and a combination of spironolactone (Aldactone) with estrogen-progestin oral contraceptives to reduce hirsutism are all used as therapy.

Endometrial cyst

Possible Symptoms: Chocolate-brown cyst on tender enlarged ovary; may cause acute pain if rupture occurs Endometriosis is the cause; occurs in women age 20-40 years. Significance and Suggested Therapy: Therapy is surgical excision; ovary may or may not be removed depending on extent of cyst.

Cysts or infection of Skene or Bartholin glands

Possible Symptoms: Cysts appear as asymptomatic swelling at the sides of the urinary meatus or vestibule; if infected, glands appear swollen and reddened and can be painful Significance and Suggested Therapy: Such cysts are surgically incised to prevent blockage of the gland duct. Infections are treated with antibiotics.

Cervical carcinoma

Possible Symptoms: Postcoital spotting, unexplained vaginal discharge, or spotting between menstrual periods Significance and Suggested Therapy: The most frequent type of reproductive tract malignancy seen; risk factors include coitus with multiple partners or uncircumcised males, herpes type 2 or human papillomavirus (HPV) infections. Diagnosed by Pap test or colposcopy. Therapy is conization, radiation, or surgical excision. Pregnancy is possible following cervical carcinoma; cesarean birth may be necessary because of fibrotic cervical tissue. HPV vaccine can reduce the incidence.

Psychological Changes of Pregnancy

Pregnancy is such a huge change in a woman's life; it brings about more psychological changes than any other life event besides puberty How a woman adjusts to a pregnancy depends a great deal on psychological aspects, such as the environment in which she was raised, the messages about pregnancy her family communicated to her as a child, the society and culture in which she lives as an adult, and whether the pregnancy has come at a good time in her life

Supine hypotension syndrome

Pregnancy:Lying supine compresses the vena cava, blood return to the heart decreases Reason: Decreased cardiac output and hypotension leading to faintness and palpitations and possibly fetal hypoxia**

Folic acid

Prepregnancy: Pregnancy:Need 400 μg daily Reason: Low folic acid leads to large nonfunctioning red blood cells and increase risk for fetal neural tube and abdominal wall defects

Blood volume (ml)

Prepregnancy:4,000 Pregnancy:5250 Reason: Compensate for blood loss at birth, ensure transport of nutrients to fetus*

Red blood cell mass (mm3)

Prepregnancy:4.2 million Pregnancy:4.65 million Reason: Increased blood volume requires increased RBCs

PROBABLE SIGNS

Week 6: Chadwick's sign Color change of the vagina from pink to violet Week 6:Goodell's sign Softening of the cervix 6 Hegar's sign Softening of the lower uterine segment Week 6: Sonographic evidence of gestational sac Characteristic ring is evident Week 16: Ballottement When lower uterine segment is tapped on a bimanual examination, the fetus can be felt to rise against the abdominal wall Week 20: Braxton Hicks contractions Periodic uterine tightening occurs Week 20: Fetal outline felt by examiner Fetal outline can be palpated through abdomen

Alcohol (ethanol)

Wine, beer, whiskey Social use Fetal alcohol spectrum disorder

Changes in the Expectant Family Most parents are aware that their older children need preparation when a new baby is on the way; however, knowing preparation is needed and being prepared to explain where babies come from are two different things. For this reason, many couples appreciate suggestions from healthcare providers as to how this task can be accomplished. Both preschool and school-age children may need to be assured periodically during pregnancy

a new baby will be an addition to the family and will not replace them or change their parents' affection for them.

Amenorrhea Amenorrhea (i.e., an absence of a menstrual flow) occurs with pregnancy because of the suppression of

follicle-stimulating hormone (FSH) by rising estrogen levels. In a healthy woman who has menstruated previously, the absence of a menstrual flow strongly suggests impregnation has occurred. Amenorrhea is, therefore, only a presumptive symptom of pregnancy.

EVIDENCE-BASED PRACTICE How women feel about being pregnant has a great deal to do with how anxious they are about becoming pregnant. To investigate whether women look forward to a second birth or whether anxiety about their first birth makes them reluctant to have a second child, researchers interviewed 908 women who had given birth to at least one child, asking them to "please describe your feelings when you think about giving birth in the future." Results showed that two thirds of women who responded had mostly positive feelings; one third of women stated they were frightened of future childbirth. The qualitative analysis resulted in an overall theme of women feeling a mixture of both dread and delight at the thought of a second pregnancy Based on the previous study, which statement by Lauren would make the nurse believe she's having a typical reaction to her second pregnancy? a. "I'm feeling good about having a second baby, but a bit worried at the same time." b. "I think having a second child is going to be totally wonderful. I'm sure it will be so much easier." c. "I'm really looking forward to watching my two children play together in the future." d. "I'd rather my husband had this one; knowing what it all involves makes it even harder."

a. "I'm feeling good about having a second baby, but a bit worried at the same time."

Stress Incontinence As part of any woman's gynecologic history, assess for the possibility of stress incontinence (incontinence of urine on laughing, coughing, deep inspiration, jogging, or running). Urinary incontinence occurs with these actions because they cause the diaphragm to descend, which then increases overall

abdominal pressure and bladder tension; increased tension leads to sudden emptying if the woman lacks strength in her perineal muscles or bladder supports. Commonly, this weakness occurs from past difficult births, the birth of large infants, grand multiparity, or instrument births. During pregnancy, stress incontinence can become intensified from the increasing abdominal pressure of the growing uterus. Some women, however, accept this incontinence as a normal consequence of childbearing and may not report it unless asked.

Two exceptions to the rule that deformities usually occur in early embryonic life are the effects caused by the organisms of syphilis and toxoplasmosis. These two infections can cause

abnormalities in organs that were originally formed normally. Intimate partner violence is another teratogen that can be responsible for injury to a fetus at any stage of pregnancy

Because of individual variations in metabolism, it is impossible to define a safe level of alcohol consumption. Women, therefore, should be screened for

alcohol use at a first prenatal visit and are best advised to abstain from alcohol completely for the remainder of their pregnancy. If necessary, refer women with alcohol addiction to an alcohol treatment program as early in pregnancy as possible to help them reduce their alcohol intake.

Estimating Pelvic Size Once a woman has given birth vaginally, her pelvis has been proven adequate for vaginal birth, so it is unnecessary for pelvic measurements to be repeated unless she had an intervening history or trauma to the pelvis between pregnancies. Types of pelvises found in women can be categorized into four groups :

android, anthropoid, gynecoid, platypelloid.

5.Cultures for chlamydia and gonorrhea should be collected for each patient at the initial pelvic examination. By identifying these often asymptomatic infections, the patient can be appropriately treated with

antibiotics and the risk of neonatal morbidity reduced. A test of cure should be done for these conditions as well as a repeat culture between 35 and 37 weeks. -All patients aged 25 years and under should have a repeat gonorrhea and chlamydia test at 35 to 37 weeks regardless of prior infection status.

Green tea, a common breakfast drink, was thought to interfere with the absorption of folic acid, but this has not been confirmed in further studies. As folic acid is needed in pregnancy to help prevent birth defects, women should ?

avoid it in pregnancy or when hoping to soon become pregnant . As with medicine, women should not take herbs in pregnancy until they discuss the herbs' safety with their obstetric provider.

INFORMATICS The nurse is reviewing Sandra's electronic health record. While doing so, the nurse asks Sandra to clarify and confirm her surgical history. Why is it important to ask Sandra about past surgery during a pregnancy health history? a. Previous use of general anesthetics is a risk factor for preterm labor. b. Adhesions from surgery could potentially limit uterine growth. c. Previous experience with surgery means that she will likely be comfortable in a hospital setting. d. Abdominal incisions are associated with potential uterine rupture.

b. Adhesions from surgery could potentially limit uterine growth.

Caution women not to take herbal remedies, muscle relaxants, or other analgesics (or any other medication) for

back pain without first consulting their obstetric provider.

Leukorrhea, a whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen level and the increased blood supply to the vaginal epithelium and cervix in pregnancy. A daily

bath or shower to wash away accumulated secretions and prevent vulvar excoriation usually controls this problem. -Wearing cotton underpants and sleeping at night without underwear can be helpful to reduce moisture and possible vulvar excoriation. Some women may need to wear a perineal pad to absorb the discharge. Caution women not to use tampons because this could lead to stasis of secretions and subsequent infection. -Advise women to contact their obstetric provider if there is a change in the color, odor, or character of this discharge as these suggest infection. -Caution women not to douche; douching is contraindicated generally and especially throughout pregnancy because fluid could be forced into the uterine cervix

4.Blood typing (including Rh factor). Blood type is documented because blood may have to be made available if a woman has

bleeding during pregnancy and to detect the possibility of ABO and Rh isoimmunization.

Teratogenic Maternal Stress There is some evidence that a pregnancy filled with anxiety and worry beyond the usual amount could produce physiologic changes through their effects on the sympathetic division of the autonomic nervous system. The primary change this would cause includes constriction of the peripheral blood vessels (i.e., a fight-or-flight syndrome). If the anxiety is prolonged, the constriction of uterine vessels (the uterus is a peripheral organ) could substantially interfere with the ?

blood and nutrient supply to a fetus It's not easy to help a woman resolve complex problems of this type during pregnancy because they are complicated. To prevent maternal stress from becoming severe, advise counseling for women with low stress levels at prenatal care visits before the levels become extreme.

EVIDENCE-BASED PRACTICE Almost all women experience a number of minor discomforts during pregnancy. To investigate whether these symptoms are serious enough to lead to depression, researchers scored 1,507 Australian women during their first pregnancy on a depression inventory questionnaire. The women were also asked what minor body changes they were experiencing. The most frequent body changes reported were exhaustion (86.9%), morning nausea (64.3%), back pain (45.6%), constipation (43.5%), and severe headache or migraine (29.5%). Women who reported five or more physical health problems were 3 times more likely to also report depressive symptoms Based on the previous study, which statement by Julberry would give the nurse the most concern that she should be assessed at her next prenatal visit as to whether she could be depressed? a. "I wake up every morning with backache. Do I need a new mattress?" b. "I like the job I do, although I come home exhausted almost every day." c. "Between the headache, the backache, and the nausea, pregnancy isn't fun." d. "The amount of constipation I have is a surprise; I don't usually get that."

c. "Between the headache, the backache, and the nausea, pregnancy isn't fun."

TEAMWORK & COLLABORATION A member of the care team is relating some statements made by Julberry Adams. Which statement would alert the nurse and the care team that there is a need to review self-care practices during pregnancy with the patient? a. "I take either a shower or tub bath because I know both are safe." b. "I wash my breasts with clear water, not with soap, every day." c. "I know if my partner uses a condom it can tear fetal membranes." d. "I'm wearing low-heeled shoes to try to avoid backache."

c. "I know if my partner uses a condom it can tear fetal membranes."

INFORMATICS Julberry Adams has done some online research about the ankle edema that she typically experiences by the end of each day. Which statement by her would reveal that she has read accurate information about the cause of this? a. "I know this is a beginning complication; I'll call my doctor tonight." b. "I understand this is from eating too much salt; I'll restrict that more." c. "I'll rest with my feet up to take pressure off my leg veins." d. "I know this is from gaining too much weight; I'll start to diet tomorrow."

c. "I'll rest with my feet up to take pressure off my leg veins."

SAFETY Julberry Adams makes the following statements. Which one would the nurse rate as the safest practice? a. "My brother takes medicine for heartburn; if I think of it, I'll borrow his." b. "I'm going to get a measles shot; I don't want measles while I'm pregnant." c. "There are so many medicines for headache; I'll ask my doctor what to take." d. "I know all over-the-counter medicine is safe; that's why it's over the counter."

c. "There are so many medicines for headache; I'll ask my doctor what to take."

TEAMWORK & COLLABORATION Lauren Maxwell is aware she's been showing some narcissism since becoming pregnant. How would the nurse describe this phenomenon to an unlicensed care provider? a. She feels pulled in multiple directions. b. She feels a need to sleep more than usual. c. Her thoughts tend to be mainly about herself. d. She often feels emotionally "numb."

c. Her thoughts tend to be mainly about herself.

PATIENT-CENTERED CARE Sandra Czerinski feels healthy, so she asks the nurse why she needs to bother coming for prenatal care. What benefit should the nurse cite when responding to Sandra's statement? a. Discovering any allergies can reduce the risk of preterm labor. b. It allows for the collection of accurate epidemiologic and demographic data. c. It provides time for education about pregnancy and birth. d. It provides important time to interact with a prenatal group.

c. It provides time for education about pregnancy and birth.

SAFETY The nurse is reviewing danger signs of pregnancy with Sandra. In the interests of safety, which of the following would the nurse tell her to report if it should occur? a. Her uterus becomes palpable over the symphysis pubis before 12 weeks. b. Blue veins appear and can be readily observed on both of her breasts. c. She gains more than 3 lb a week beginning at 20 weeks. d. She tends to lose her balance when she wears high-heeled shoes.

c. She gains more than 3 lb a week beginning at 20 weeks.

In early pregnancy, be certain you establish a trusting relationship with a woman so she will see you as a person who is

capable of counseling her and helping her solve problems and in whom she will be able to confide about any worries she has. Continue to assess a woman's health and nutritional status as well as the well-being of her fetus at all prenatal visits. Physical changes can be learned through health history, physical assessment, and laboratory tests. An assessment in psychological areas is obtained primarily through interviewing and should include societal, cultural, family, and personal influences as a woman adapts to pregnancy.

Hyperthermia and Hypothermia Hyperthermia to a fetus can be detrimental to growth because it interferes with

cell metabolism. This can occur from the use of saunas, hot tubs, or tanning beds; from a work environment next to a furnace, such as in welding or steel making; or from a high maternal fever early in pregnancy (4 to 6 weeks). For this reason, advise pregnant women not to use hot tubs, saunas, or tanning beds during pregnancy.

A herpes simplex 2 viral infection appears as clustered, pinpoint vesicles on an erythematous (reddened) base on the vulva that feel painful when touched or irritated. It is important that these are detected during pregnancy because the presence of herpes lesions on the vulva or vagina at the time of birth may necessitate a what type of delivery?

cesarean birth to prevent exposing the fetus to the virus during passage through the birth canal. Note the presence of a herpes infection in the woman's record so she can receive prophylactic treatment at the end of her pregnancy to prevent neonatal transmission during birth which could result in a life-threatening neonatal infection

Because pregnancy brings with it such a major role change, it can cause extreme stress in a woman who was not planning to be pregnant or if she finds her lifestyle

changing dramatically after she becomes pregnant. Stress in pregnancy, like stress at any time, can make it difficult for a woman to make decisions, be as aware of her surroundings as usual, or maintain time management with her usual degree of skill. This may cause people who were dependent on her before pregnancy to feel neglected because now that she is pregnant, she seems to have strength only for herself. If a woman was in a violent relationship before the pregnancy, the increased stress of pregnancy is apt to cause even more violence. Privately asking whether intimate partner violence has ever occurred in the past to help predict if it could occur during pregnancy is an important part of prenatal interviewing

Metal and Chemical Hazards Pesticides and carbon monoxide, such as from automobile exhaust, should be avoided as these are examples of

chemical teratogens. Arsenic, a byproduct of copper and lead smelting, used in pesticides, paints, and leather processing; formaldehyde, used in paper manufacturing; and mercury, used in the manufacture of electrical apparatuses and found in high proportions in swordfish and tuna, are all teratogens that can be found at work sites.

At about the 16th week of pregnancy, colostrum secretion begins in the breasts. The sensation of a fluid discharge from the breasts can be frightening unless a woman has been cautioned of this possibility. Teach her to wash her breasts with

clear tap water (no soap, because that could be drying and cause her nipples to crack) daily to remove the colostrum and reduce the risk of infection. After washing, she should dry her nipples well by patting them with a soft towel. -If colostrum secretion is profuse, a woman may need to place gauze squares or breast pads inside her bra, changing them frequently to maintain dryness. Otherwise, constant moisture next to the breast nipples can cause nipple excoriation, pain, and fissuring. Asking about colostrum at prenatal visits provides a good time to also discuss the benefits of breastfeeding for both a woman and her child

IMPLEMENTATION At the beginning of a pregnancy, a woman may feel constantly nauseated; toward the end, the extra weight and the strain of waiting may make her feel tired and short of breath. Endocrine changes can make her feel moody and quick to cry. Help women at prenatal visits to voice their ?

concerns about the changes happening to them so any worry brought on by these changes does not lead to a stressful 9 months for them or prevent solid bonding with their baby.

Evidence confirms that when women consume a large quantity of alcohol during pregnancy, their babies demonstrate a high incidence of characteristic

congenital craniofacial deformities including short palpebral fissures, a thin upper lip, an upturned nose, as well as cognitive impairment fetal alcohol spectrum . Fetuses cannot remove the breakdown products of alcohol from their body. The large buildup of these leads to vitamin B deficiency and accompanying neurologic damage.

Respiratory System A local change that often occurs in the respiratory system is marked

congestion, or "stuffiness," of the nasopharynx, a response, again, to increased estrogen levels

Environmental Teratogens Teratogens such as impure air or water can be as damaging to a fetus as those that are directly or deliberately ingested. Women are exposed to these through

contact at home or at work sites. Breathing air filled with pollutants, for example, has been shown to lead to fetal growth restriction

Couvade Syndrome Many partners experience physical symptoms such as nausea, vomiting, and backache to the same degree or even more intensely than their partners during a pregnancy; some begin to gain weight along with their partner. As a woman's abdomen begins to grow, partners may perceive themselves as growing larger too, as if they were the ones who were experiencing changing boundaries the same as the pregnant woman. These symptoms apparently result from stress, anxiety, and empathy for the pregnant woman. The phenomenon is common enough that it has been given a name:

couvade syndrome (from the French word "to hatch"). The more a partner is involved in or attuned to the changes of the pregnancy, the more symptoms a partner may experience. A close marital relationship, which this reflects, can increase the strength of the partner-infant attachment . Such symptoms are only worrisome and require psychological attention if they become so extreme that they create intolerable emotional stress.

As vascularity of the breasts increases, blue veins may become prominent over the surface of the breasts. The sebaceous glands of the areola:Montgomery's tubercles, which keep the nipple supple and help to prevent nipples from

cracking and drying during lactation, enlarge and become protuberant.

Whether partners are able to form a close relationship with each other, as well as accept a pregnancy and a coming child, depends on the same factors that affect the pregnant woman's decision making:

cultural background, past experience, and relationships with family members Although partners may be inarticulate about such emotional factors, they may be able to convey such feelings by a touch or a caress, which is one reason a partner's presence is always desirable at a prenatal visit and certainly in a birthing room.

FAMILY INFLUENCES The family in which a woman was raised can be influential to her beliefs about pregnancy because it is part of her

cultural environment. If she and her siblings were loved and their births were seen as a pleasant outcome of their family, she is more likely to have a positive attitude toward learning she is pregnant than if she and her siblings were blamed for the breakup of a marriage or a relationship, for example. A woman who views mothering as a positive activity is more likely to be pleased when she becomes pregnant than one who does not value mothering.

PATIENT-CENTERED CARE Julberry Adams tells the nurse she has developed painful hemorrhoids. She admitsthat she is embarrassed to discuss this problem but acknowledges that it needs to be addressed. The best advice to give her would be which of the following? a. "Take a tablespoon of mineral oil with each of your meals." b. "Omit most of the fiber from your diet. This will prevent constipation." c. "Lie on your stomach daily to drain blood from rectal veins." d. "Witch hazel pads feel cool against swollen hemorrhoids."

d. "Witch hazel pads feel cool against swollen hemorrhoids."

PATIENT-CENTERED CARE Lauren Maxwell's doctor told her she had a positive Chadwick's sign. When she asks the nurse what this means, the best answer would be which of the following? a. "Your abdomen feels soft and tender, a normal finding." b. "Your uterus has tipped forward, a potential complication." c. "Your cervical mucus feels sticky, just as it should feel." d. "Your vagina looks dark in color, a typical pregnancy sign."

d. "Your vagina looks dark in color, a typical pregnancy sign."

QUALITY IMPROVEMENT Sandra reports that the palms of her hands are always itchy, and the nurse notices scratches on them when you perform a physical examination. The nurse's plan of care should specify that this problem is most likely due to what factor in women who are pregnant? a. Anxiety or fear about the pregnancy b. A potential Rh incompatibility c. Peripheral edema related to changes in fluid and electrolyte levels d. A common reaction to increasing estrogen levels

d. A common reaction to increasing estrogen levels

INFORMATICS Lauren Maxwell did a urine pregnancy test but was surprised to learn a positive result is not a sure sign of pregnancy. As the nurse is recording her result in the electronic health record, she asks what a positive sign would be. The nurse should cite what finding? a. She has noticed consistent abdominal and uterine growth. b. She can feel her fetus move more than once per hour. c. A serum tests reveals hCG. d. A fetal heartbeat can be seen during an ultrasound exam

d. A fetal heartbeat can be seen during an ultrasound exam

TEAMWORK & COLLABORATION Sandra has not had a pelvic examination since she was in high school. Consequently, the nurse-midwife has asked the nurse to help make her more at ease during her first prenatal pelvic examination. What action should the nurse take? a. Have her take a deep breath and hold it as long as she can during the examination. b. Tell her to bear down slightly as the speculum is inserted. c. Encourage her to moan in a low-pitched tone because this will push down the diaphragm. d. Teach her to breathe slowly and evenly while being examined.

d. Teach her to breathe slowly and evenly while being examined.

Measure vital signs, including blood pressure, respiratory rate, and pulse rate, again, for baseline levels. A sudden increase in blood pressure and a sudden weight gain are both

danger signs that gestational hypertension may be occurring. A sudden increase in pulse or respirations could suggest undetected bleeding. If close monitoring of blood pressure will be necessary during pregnancy, teach a support person or the woman herself how to do this so the woman can continue assessing blood pressure at home.

Another important action of all prenatal visits is to screen for

danger signs that might reveal a complication is beginning. Screening at a first prenatal visit to detect subtle signs of any of these conditions includes an extensive health history, a complete physical examination (including a pelvic examination), and obtaining blood and urine specimens for laboratory analysis. Ultrasonography has decreased the need to manually measure pelvic diameters for this purpose.

Herbs are not regulated by the FDA in the same way as medications; therefore, they are not rated with regard to their safety in pregnancy. Even though most are safe, American ginseng, used to improve general well-being, has been associated with birth

defects; and St. John's wort, an herb taken as a mood enhancer, can interfere with the action of seizure-control drugs, such as phenytoin (Dilantin) and phenobarbital (Phenobarb), and so should be avoided by women prescribed such drugs

EFFECTS OF TERATOGENS ON A FETUS The timing of the teratogenic insult is a second factor that makes a significant difference. If a teratogen is introduced before implantation, for example, either the zygote is

destroyed or it appears unaffected. If the insult occurs when the main body systems are being formed (in the second to eighth weeks of embryonic life), a fetus is very vulnerable to injury. During the last trimester, the potential for harm again decreases because all the organs of a fetus are formed and are merely maturing

Often, the abdominal wall has difficulty stretching enough to accommodate the growing fetus, causing the rectus muscles underneath the skin to actually separate, a condition known as

diastasis. If this happens, after pregnancy, the separation can be assessed through physical exam, and physical therapy can be offered for persistent diastasis.

Occasionally, a woman notices stress incontinence (involuntary loss of urine on coughing or sneezing) during pregnancy. Although this is largely unpreventable, doing Kegel exercises (alternately contracting and relaxing perineal muscles;not only helps strengthen urinary control but also

directly strengthens perineal muscles for birth

8.Serum antibody titers for rubella, hepatitis B (HBsAg), hepatitis C, varicella (chickenpox) may be assessed. These tests determine whether a woman is protected against these

diseases if exposure should occur during pregnancy. Vaccines against these diseases can then be offered in the postpartum period. HBsAg testing may be repeated at about 36 weeks.

Because the uterus enlarges so much during pregnancy, the diaphragm, and ultimately, the lungs, receive an increasing amount of pressure. Toward the end of pregnancy, this can actually do what to the diaphragm ?

displace the diaphragm by as much as 4 cm upward. Even with all this crowding, however, a woman's vital capacity (the maximum volume exhaled after a maximum inspiration) does not decrease during pregnancy because, although the lungs are crowded in the vertical dimension, they can still expand horizontally

Lead poisoning generally is considered a problem of young children who eat lead-based paint chips, but it can be a fetal hazard as well. Women may ingest lead by

drinking water that travels through old pipes that are leaking lead, by "sniffing" lead-based gasoline, or eating paint chips (paint tastes sweet and may be eaten as a symptom of pica). Lead ingestion during pregnancy may lead to a newborn who is both cognitively and neurologically challenged

Concept Mastery Alert Tubal surgery following an ectopic pregnancy may cause tubal scarring, which increases the patient's risk of a subsequent

ectopic pregnancy.

Interviewing a woman alone and then inviting the support person and family to join her while you talk about pregnancy symptoms with them as a family can be an

effective compromise. In addition, providing some private interview time with a partner allows the partner to express any of his or her concerns or worries. If a woman wishes, a partner can accompany her during the physical examination. After confirmation of pregnancy, include the partner in healthcare information or suggestions.

Dyspnea As the expanding uterus places pressure on the diaphragm, lung compression and shortness of breath result. A woman will notice this primarily at night if she lies flat. She will definitely notice it on exertion. To relieve nighttime dyspnea, advise her to sleep with her head and chest

elevated so the weight of the uterus falls away from her diaphragm. As pregnancy progresses, she may require two or more pillows to sleep at night and she may need to limit her activities during the day to prevent exertional dyspnea. Always question women about this important symptom at prenatal visits to be certain the sensation is not continuous, which could describe a respiratory disorder

2.A genetic screen for common

ethnically inherited diseases. African American women, for example, may have a blood sample taken to screen for sickle-cell trait or disease and glucose-6-phosphate dehydrogenase (G6PD). Asian and Mediterranean women may have this done for β-thalassemia, those with Jewish ancestry may have this done for Tay-Sachs disease, Caucasian women may be tested to see if they are a carrier for cystic fibrosis

HEALTH ASSESSMENT DURING THE FIRST PRENATAL VISIT Women should schedule a first prenatal visit as soon as they suspect they are pregnant. Although evidence-based practice is investigating whether the number of prenatal visits traditionally scheduled is still needed during a usual pregnancy, after the first prenatal visit, return appointments are usually scheduled

every 4 weeks through the 28th week of pregnancy, every 2 weeks through the 36th week, then every week until birth. Women categorized as high risk are followed more frequently.

External Genitalia A pelvic examination begins with inspection of the

external genitalia. Any signs of inflammation, infection, ulcerations, lesions, vaginal discharge, or circumcision are noted.

Fatigue

extremely common in early pregnancy, probably because of increased metabolic requirements -Much of it can be relieved by increasing the amount of rest and sleep. -can increase the amount of morning nausea a woman experiences. If she becomes too tired, she may not eat properly and nutrition can suffer. If she remains on her feet without at least one break during a day, the risk for varicosities and the danger of thromboembolic complications increase -For all these reasons, ask women at prenatal visits whether they manage to have at least one short rest period every day -A woman who works outside her home at a job that requires her to be on her feet most of the day might use part of her lunch hour to sit with her feet elevated

Headache Many women experience headaches during pregnancy, apparently from their expanding blood volume, which puts pressure on cerebral arteries. Trying to reduce any possible causative situations, such as

eye strain or tension, may lessen the number of headaches they experience. Resting with an ice pack on the forehead and taking a usual adult dose of acetaminophen usually furnishes adequate relief Compounds with ibuprofen (Motrin, Advil) (class C drugs) are not usually recommended because they cause premature closure of the ductus arteriosus in the fetus. Additionally, they have been found to contribute to fetal renal damage, low amniotic fluid, and fetal intracranial hemorrhage.

For obstetric purposes, the pelvis is further divided into the

false pelvis (the superior half) and the true pelvis (the inferior half) The false pelvis supports the uterus during the late months of pregnancy and aids in directing the fetus into the true pelvis for birth. The false pelvis is divided from the true pelvis only by an imaginary line, the linea terminalis. This imaginary line is drawn from the sacral prominence at the back of the pelvis to the superior aspect of the symphysis pubis at the front.

Emotional Lability Mood changes occur frequently in a pregnant woman, partly as a symptom of narcissism (i.e., her feelings are easily hurt by remarks that would have been laughed off before) and partly because of hormonal changes, particularly the sustained increase in estrogen and progesterone. Mood swings may be so common that they can make a woman's reaction to her

family and to healthcare routines unpredictable. She may cry over her children's bad table manners at one meal, for example, and find the situation amusing or even charming at the next. Caution families that such mood swings occur beginning with early pregnancy so they can accept them as part of a normal pregnancy

Cigarette smoking is associated with infertility in women. If used by a pregnant woman, it has been shown to cause ?

fetal growth restriction. In addition, a fetus may be at greater risk for being stillborn and, after birth, may be at a greater risk than others for sudden infant death syndrome -Low birth weights in infants of smoking mothers result from vasoconstriction of the uterine vessels, an effect of nicotine. This limits the blood supply to a fetus

Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium transmitted to humans by the bite of an infected female Anopheles mosquito. Healthcare providers can contact it from infected blood products. During pregnancy, women can transmit malaria to a

fetus. Most malaria infections in the United States occur among people who have traveled to areas where malaria is epidemic, such as Africa or South America. A number of drugs, such as chloroquine (Aralen) in the first trimester and mefloquine (Lariam) in the second or third trimesters, are helpful. Women who will be visiting an area known to be epidemic for malaria can begin treatment as prophylaxis up to 2 weeks before travel

Ankle Edema As long as proteinuria and hypertension are absent, ankle edema of this nature is a normal occurrence of pregnancy. It is probably caused by general

fluid retention and reduced blood circulation in the lower extremities because of uterine pressure. This simple edema can be relieved best by resting in a left side-lying position because this increases the kidney's glomerular filtration rate and also allows for good venous return. Sitting for half an hour in the afternoon and again in the evening with the legs elevated is also helpful. Caution women to avoid wearing constricting clothing such as panty girdles or knee-high stockings because these impede lower extremity circulation and venous return.

BASELINE HEIGHT/WEIGHT AND VITAL SIGN MEASUREMENT A woman's weight and height are measured at a first prenatal visit to establish a pregnancy BMI to serve as a baseline for

future comparison. Record this assessment with her prepregnancy BMI, if available, to determine how much weight she has already gained or lost . When obtaining women's weight, be certain to convey an air of "weight gain is healthy" so a woman feels comfortable gaining 30 to 40 lb during pregnancy (many patients, especially younger ones, with a lower BMI need to gain 40 lb to help ensure a healthy fetus).

Clothing Maternity clothing should be comfortable. Women should be cautioned to avoid ?

garters, extremely firm girdles with panty legs, and knee-high stockings during pregnancy because these may impede lower extremity circulation. Suggest wearing shoes with a moderate-to-low heel to minimize pelvic tilt and possible backache as well as to reduce the risk of falling.

A sonogram can be scheduled between 16 and 20 weeks gestation to verify healthy fetal structures and gender. Be certain women know that a sonogram done under 8 weeks will show only the presence of a

gestation sac, not a moving, kicking fetus, so their expectations of what they will see are not disappointing

Visualization of the Fetus by Ultrasound Ultrasound is the most common method for confirmation of pregnancy today. If a woman is pregnant, a characteristic ring, indicating the

gestational sac, will be revealed on an oscilloscope screen as early as the fourth to sixth week of pregnancy. This method also gives information about the site of implantation and whether a multiple pregnancy exists. By the eighth week, a fetal outline can be seen so clearly that the crown-to-rump length can be measured to establish the gestational age of the pregnancy. Seeing the fetal outline on a sonogram is also clear proof for a couple that they are pregnant if they had any doubt up to that point

Past Surgery Any type of past surgery on the reproductive tract is important to document because it can influence a woman's ability to conceive and give birth. For example, if a woman had tubal surgery following an ectopic pregnancy, her statistical risk of another tubal pregnancy is

greater than usual because of possible tubal scarring. If she had uterine surgery, a cesarean birth may be necessary because her uterus may not be able to contract as efficiently as usual because of a surgical scar or she may be at risk for uterine rupture. If she has undergone frequent dilatation and curettage of the uterus or cervical biopsies, her cervix may be weakened or unable to remain closed for 9 months, leading to preterm birth unless she has a surgical procedure (cerclage) to prevent premature dilation

The Initial Interview Because obtaining an initial health history can be time-consuming, a woman may be asked to complete some necessary forms before arrival. Appropriate interviewing techniques, however, are important to obtain a thorough and meaningful

health history and the rapport established by face-to-face interviewing with healthcare personnel may be as much a reason a woman returns for follow-up care as her desire to be assured her pregnancy is progressing normally

The rubella virus usually causes only a mild rash and mild systemic illness in a woman, but the teratogenic effects on a fetus can be devastating, such as

hearing impairment, cognitive and motor challenges, cataracts, cardiac defects (most commonly patent ductus arteriosus and pulmonary stenosis), restricted intrauterine growth (i.e., small for gestational age), thrombocytopenic purpura, and dental and facial clefts, such as cleft lip and palate

Sexual History Be certain to obtain a sexual history, including the number of sexual partners and the use of safer sex practices, to establish a woman's risk for contracting a sexually transmitted infection such as ?

herpes (a viral infection spread by direct contact) or hepatitis C (a viral infection spread by contact with blood or by intercourse with a partner who is infected). Include history taking regarding patients' sexual orientation and gender identity as there are increasing numbers of patients who grow more comfortable discussing their lesbian, gay, bisexual, and transgender healthcare requirements with their providers. It is the responsibility of the healthcare team to be aware of recent evidence-based practices to best serve these patients

The major causes of serious illness or death during pregnancy for women today are ?

hypertension, hemorrhage, embolism, infection, morbid obesity, anesthesia-related complications such as intrapartum cardiac arrest

Dental Care There is a strong correlation between poor oral health and preterm birth, so maintaining good oral health during pregnancy is important . Without adequate brushing, gingival tissue tends to

hypertrophy and, unless a pregnant woman brushes her teeth well, pockets of plaque form readily between the swollen gum line and teeth, possibly leading to periodontal diseases

Physical Examination Prenatal The next step in health assessment is physical examination. Ask a woman to void for a clean-catch urine specimen before the examination because this will provide a urine specimen for either

immediate dipstick or laboratory testing of bacteria, protein, glucose, and ketone determinations. In addition, an empty bladder makes the pelvic examination more comfortable and, by reducing bladder size, allows for easier identification of pelvic organs. If you are not already familiar with obtaining a clean-catch urine specimen

Increase or decrease in fetal movement. Because a fetus normally moves more or less the same amount every day, an unusual increase or decrease in movement suggests a fetus responding to a need for more oxygen. Be certain to ask a woman about typical fetal movements and whether she has noticed any

increase or decrease in this rate. If there has been a change, she is a candidate for further testing such as a fetal "kick count" or a nonstress test

CHANGES IN THE BREASTS Typical changes are a feeling of fullness, tingling, or tenderness that occurs because of the increased stimulation of breast tissue by the high estrogen level in her body. As the pregnancy progresses, breast size

increases because of growth in the mammary alveoli and in fat deposits. The areola of the nipple darkens, and its diameter increases from about 3.5 cm (1.5 in.) to 5 cm or 7.5 cm (2 or 3 in.)

Cervical Changes In response to the increased level of circulating estrogen produced by the placenta during pregnancy, the cervix of the uterus becomes more vascular and edematous than usual. A mucus plug, called the operculum, forms to seal out bacteria and help prevent ?

infection in the fetus and membranes. Increased fluid between cells causes it to soften in consistency, and increased vascularity causes it to darken from a pale pink to a violet hue:Goodell's sign

Caution women not to wait but to void as often as necessary, as urine stasis can lead to

infection. When a woman reports frequency of urination, be certain this is the only urinary symptom she is experiencing. Ask her about any burning or pain on urination or whether she has noticed any blood in her urine, which are signs of a urinary tract infection.

From the information obtained about common infectious diseases and immunizations, you can estimate the degree of antibody protection a woman has against these diseases if she is exposed to them during her pregnancy. Pregnant women appear to develop more complications from influenza (the flu), for example, than others, so a woman who will be pregnant during the flu season (October through May) should receive an

influenza vaccine

For a baby to be born vaginally, he or she must be able to pass through the

inlet, the cavity, and the outlet of the pelvic bone. This is not a problem for the average fetus; it may, however, be a problem if the mother is a young adolescent who has not yet achieved full pelvic growth (girls younger than age 14 years are most prone to this difficulty) or a woman who has had a pelvic injury from something such as an automobile accident

Narcotics such as meperidine (Demerol) and heroin have long been implicated as having serious impacts on

intrauterine growth. The use of marijuana alone apparently does not, although the accompanying lifestyle may lead to fetal growth restriction and preterm birth

A woman should telephone her obstetric provider immediately when her membranes rupture as two risks are associated with ruptured membranes:

intrauterine infection and prolapse of the umbilical cord (which could cut off the oxygen supply to the fetus) . In most instances, the fetal head is already snugly fitting the cervix, so prolapse is not a concern. If labor does not spontaneously begin by 24 hours after membrane rupture and the pregnancy is at term, labor will likely be induced to help reduce the risk of infection.

Syphilis, a sexually transmitted infection, is of great concern for the maternal-fetal population. Despite the availability of accurate screening tests and proven medical treatment, it is growing in incidence; it places a fetus at risk for

intrauterine or congenital syphilis When this layer atrophies at about the 16th to 18th week of pregnancy, however, the spirochete can cross and cause extensive fetal damage. If syphilis is detected in the mother and treated with an antibiotic such as intramuscular benzathine penicillin (Bicillin L-A) in the first trimester, a fetus is rarely affected. If left untreated beyond the 18th week of gestation, hearing impairment, cognitive challenge, osteochondritis, and fetal death are possible. -The newborn with congenital syphilis may have congenital anomalies, extreme rhinitis (sniffles), and a characteristic syphilitic rash, all of which identify the baby as high risk at birth

A candidal infection causes an

itching and burning sensation in addition to producing a clumpy cheese-like discharge that may cause bleeding if scraped away from the vaginal walls

Radiation Radiation produces a range of malformations depending on the stage of development of the embryo or fetus and the strength and length of exposure. If the exposure occurs before implantation, for example, the growing zygote apparently is

killed. If the zygote is not killed, it survives apparently unharmed. The most damaging time for exposure and subsequent damage is from implantation to 6 weeks after conception (a time when many women are not yet aware they are pregnant). The nervous system, brain, and the retinal innervation are growing rapidly at this time and so are most affected In addition to immediate fetal damage, evidence demonstrates that radiation can have long-lasting effects on the health of a child. There appears to be an increased risk of cancer in children who are exposed to radiation in utero. Exposure of the fetal gonads could lead to a genetic mutation that will not be evident until the next generation

Teratogenic Drugs Many women assume the rule of being cautious with drugs during pregnancy applies only to prescription drugs and continue to take over-the-counter drugs or herbal supplements freely during pregnancy. Although not all drugs cross the placenta heparin, for example, does not because of its

large molecular size

In an anthropoid, or "ape-like," pelvis, the transverse diameter is narrow; the anteroposterior diameter of the inlet is

larger than usual. Even though the inlet is large, the shape of the pelvis does not accommodate a fetal head as well as a gynecoid pelvis.

If a woman has a positive result, a chest X-ray will be prescribed to assess her current disease status. Women are often reluctant to have X-rays done during pregnancy because they know radiation is harmful to a growing fetus. You can assure her that her fetus will be protected as long as she is given a

lead apron to cover her abdomen.

Even with this danger of radiation, X-rays to maternal parts other than the pelvis, including computerized tomography (CT) can be performed safely during pregnancy as long as a

lead pelvic shield is provided

Uterine Changes The most obvious alteration in a woman's body during pregnancy is the increase in size of the uterus to accommodate the growing fetus. Over the 10 lunar months of pregnancy, the uterus increases in

length, depth, width, weight, wall thickness, and volume. • Length grows from approximately 6.5 cm to 32 cm. • Depth increases from 2.5 cm to 22 cm. • Width expands from 4 cm to 24 cm. • Weight increases from 50 g to 1,000 g. • Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm; toward the end of pregnancy, the wall thins to become supple and only about 0.5- cm thick. • The volume of the uterus increases from about 2 ml to more than 1,000 ml. This makes it possible for a uterus to hold a 7-lb (3,175-g) fetus plus 1,000 ml of amniotic fluid for a total of about 4,000 g

Acyclovir (Zovirax) or valacyclovir (Valtrex) can both be safely administered to women who develop

lesions during pregnancy as well as to their newborns at birth . Either drug is recommended daily as prophylaxis at 36 weeks of pregnancy to prevent a lesion at the time of birth. The primary mechanism for protecting a fetus, however, is disease prevention. Urging women to practice safer sex is important to lessen their exposure to this and other sexually transmitted infections.

Hypotension -Supine hypotension is a symptom that occurs when a woman

lies on her back and the uterus presses on the inferior vena cava, impairing blood return to her heart

This settling of the fetus into the midpelvis is termed

lightening because a woman's breathing is so much easier that she feels as if her load is lightened. The point at which lightening will occur is not predictable in a multipara (a woman who has had one or more children). In such women, it may not occur until labor begins.

Extra pigmentation generally appears on the abdominal wall because of melanocyte-stimulating hormone from the pituitary. A narrow, brown line:

linea nigra may form, running from the umbilicus to the symphysis pubis and separating the abdomen into right and left halves

After the woman empties her bladder, have her lie in a

lithotomy position (on her back with her thighs flexed and her feet resting in the examining table stirrups;. If a woman is uncomfortable in a lithotomy position, the exam can be done with her lying flat on a bed or table with her knees raised. Make sure her buttocks extend slightly beyond the end of the examining table if possible. Place a pillow under her head or slightly elevate the head of the examination table to help her relax her abdominal muscles. Properly drape her with a draw sheet over her abdomen that extends over her legs for modesty.

A woman who is not immunized before pregnancy cannot be immunized during pregnancy because the vaccine contains a

live virus that would have effects similar to those occurring with a subclinical case of rubella. After rubella immunization, a woman is advised not to become pregnant for about 3 months, until the rubella virus is no longer active. Immediately after a pregnancy, assess whether a woman who has a low rubella titer would like to be immunized to provide protection against rubella in future pregnancies. -all pregnant women should avoid contact with children with rashes. Infants who are born to mothers who had rubella during pregnancy may be capable of transmitting the disease for a time after birth

Chlamydia is called a "silent" or "invisible" infection because it shows almost no external symptoms but internally may cause a

mucopurulent cervical discharge and slight cervical redness . Cultures for gonorrhea and chlamydia should be collected during the initial pelvic exam and between 35 and 37 weeks for patients aged 25 years and under.

The Confirmation of Pregnancy A medical diagnosis of pregnancy serves to date when the birth will occur and also helps predict the existence of a high-risk status. Most women who come to a healthcare facility for a diagnosis of pregnancy have already guessed they are pregnant based on a

multitude of subjective symptoms as well as having completed a home pregnancy test, so a healthcare visit is more a confirmation of pregnancy than a diagnosis. If a pregnancy was planned, this official confirmation of pregnancy produces a feeling of intense fulfillment and achievement. If the pregnancy was not planned (remember almost half of pregnancies are unintended), it can result in an equally extreme crisis state.

A third factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead and mercury, for example, attack and disable

nervous tissue . Thalidomide (Immunoprin), originally used to treat nausea in pregnancy, is now prescribed for cancer therapy, and it may cause limb defects Tetracycline (Apo-Tetra), a common antibiotic, causes tooth enamel deficiencies, and possibly, long bone deformities. The rubella virus affects many organs, with the eyes, ears, heart, and brain the four most commonly attacked

6.Maternal serum α-fetoprotein (MSAFP) and pregnancy-associated plasma protein A. Both of these levels will be elevated if a

neural tube or abdominal defect is present in the fetus; they may be decreased if a chromosomal anomaly is present. These tests are not routinely done at a first prenatal visit because they are most accurate if scheduled between 16 and 18 weeks of pregnancy. If levels are elevated or decreased, a sonogram or amniocentesis will be prescribed to clarify fetal health

PROBABLE SIGNS In contrast to presumptive symptoms, probable signs of pregnancy are

objective and so can be verified by an examiner. Although they are more reliable than presumptive symptoms, they still do not positively diagnosis a pregnancy

EMOTIONAL RESPONSES THAT CAN CAUSE CONCERN IN PREGNANCY Because of all the tasks that need to be worked through during a pregnancy, emotional responses can vary greatly, but common reactions include grief, narcissism, introversion or extroversion, body image and boundary concerns, couvade syndrome, stress, mood swings, and changes in sexual desire. These are all normal, so it is helpful to caution a pregnant woman and her partner that these common changes may:

occur so they're not alarmed if they appear. Otherwise, a partner can misinterpret the woman's mood swings, decreased sexual interest, introversion, or narcissism not as changes from pregnancy but as a loss of interest in their relationship.

Breast Tenderness

one of the first symptoms noticed in early pregnancy and may be most noticeable on exposure to cold air. For most women, the tenderness is minimal and transient, something they are aware of but not something that overly concerns them. If the tenderness is enough to cause discomfort, encourage a woman to wear a bra with a wide shoulder strap for support and to dress warmly to avoid cold drafts if cold increases symptoms. If actual pain exists, the presence of conditions such as nipple fissures or other explanations for the pain, such as breast abscess, need to be ruled out.

To avoid back strain and worsen the condition, advise women to

squat rather than bend over to pick up objects. Also encourage women to always lift objects by holding them close to the body. For some women, a firmer mattress during this time may be required. Sliding a board under the mattress is a cost-effective alternative for achieving a firmer sleeping surface rather than buying a new mattress. Pelvic rocking or tilting, an exercise also helps to prevent and relieve backache.

SUPPORT PERSON'S ROLE Both partners and young children accompany women for prenatal care. Some women bring a female friend or a relative as their best support person. If family members are present, should they be included in an initial interview? As a whole, interviewing is most effective if it is a

one-to-one interaction because a woman may be unwilling to mention certain concerns when her family is present for fear of worrying them. If childbearing is to be a family affair, however, it is important to determine a partner's degree of acceptance of the pregnancy and how well prepared he or she is of assuming a new parenting role. Including the fetus's siblings in a prenatal visit also provides them an opportunity to be involved.

A candidal infection in the newborn, for example, causes thrush or

oral candidiasis.

Abnormalities that can be noted by bimanual examination include

ovarian cysts, enlarged fallopian tubes (perhaps from pelvic inflammatory disease), and an enlarged uterus. An early sign of pregnancy (Hegar's sign) is elicited on bimanual examination as well

If a woman is past 12 weeks of a pregnancy, assess whether the fundus of the uterus is

palpable, measure the fundal height (from the top notch of the symphysis pubis to the superior aspect of the fundus), and plot the height on a graph

Perineal Hygiene Women have increased vaginal discharge during pregnancy and so need to maintain good

perineal hygiene. Caution them to always wipe front to back after voiding to prevent bringing contamination forward from the rectum. Even if the vaginal discharge seems excessive, douching is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix, leading to a uterine infection. -In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth

After this history of previous pregnancies is obtained, rate the woman's status with respect to the number of times she has been

pregnant, including the present pregnancy (her gravida status) and the number of children over the age of viability (20 weeks gestation) she has previously delivered (her para status).

Hemorrhoids (i.e., varicosities of the rectal veins) occur commonly in pregnancy because of

pressure on these veins from the bulk of the growing uterus -Daily bowel evacuation to prevent constipation, drinking adequate fluid, eating adequate fiber, and resting in a modified Sims position are all helpful measures to both prevent these and relieve pain. -a stool softener such as docusate sodium (Colace) may be recommended if a woman already has hemorrhoids when she enters pregnancy -applying witch hazel, a cold compress, or over-the-counter hemorrhoid cream are other helpful measures to relieve pain.

If she is not high risk, she will have this test prescribed routinely at the 24th to 28th week of pregnancy. A glucose challenge test analyzes how well a woman's body is able to

process sugar or whether the insulin-antagonistic effects of placental hormones are counteracting pancreatic insulin and causing an elevated blood glucose (a sign of gestational diabetes, which as many as 2% to 5% of woman develop during pregnancy). Normally, a woman's plasma glucose level should not exceed 130 to 140 mg/dl at 1 hour after glucose ingestion

URINALYSIS Urine is tested for ?

proteinuria (protein in urine), glycosuria (glucose in urine), nitrites (bacteria in urine), pyuria (white blood cells in urine suggesting an infection). All four of these can be assessed by point of care tests, or the urine can be sent for microscopic examination in a laboratory.

it is important not to dismiss a report of lower extremity edema as insignificant until you are certain a woman does not exhibit any signs such as

proteinuria, edema of other, nondependent body parts, or has had a sudden increase in weight as these, in conjunction with ankle edema, are beginning signs of gestational hypertension

With infection, the epithelium of the cervical canal often enlarges and spreads onto the area surrounding the os, giving the cervix a

reddened appearance that bleeds easily (erosion;

As the uterus grows larger, it pushes the intestines to the sides of the abdomen, elevates the diaphragm and liver, compresses the stomach, and puts pressure on the bladder. It usually remains in the midline during pregnancy, although it may be pushed slightly to the right side because of the larger bulk of the sigmoid colon on the left. A woman may worry there will not be enough what ?

room inside her abdomen for this much increase in size. You can assure her the abdominal contents will readily shift to accommodate uterine enlargement

When bacteria in the mouth interact with sugar, this lowers the pH of the mouth, creating an acid medium that can lead to etching or destruction of the enamel of teeth (i.e., tooth decay). Because 9 months is a fairly long time to be without preventive dental care, in addition to stressing brushing on arising, after meals, and at bedtime, encourage pregnant women to see their dentists regularly for

routine examination and cleaning. Encourage women to snack on nutritious foods, such as fresh fruits and vegetables rather than sugar-rich snacks to reduce the amount of sugar in contact with their teeth. If a woman has trouble avoiding sweet snacks such as candy, suggest eating snacks that dissolve easily (like a chocolate bar) rather than one that remains in the mouth a long time (like chewy caramel). This helps to minimize the level of sugar in the mouth and its long-term contact with teeth.

Women who travel abroad may need additional safety measures such as a vaccine for protection against cholera or antibiotic prophylaxis for malaria before they can safely enter certain countries . The influenza vaccine is recommended if it is flu season (October through May for all pregnant women . Before accepting or allowing any immunization, however, a woman should ask her provider to verify it will be

safe. All live virus vaccines (e.g., measles, mumps, rubella, and yellow fever) are contraindicated during pregnancy and should not be administered unless the risk of the disease outweighs the risk to the pregnancy because live virus vaccines can cross the placenta and infect the fetus. Pregnancy does not alter indications for rabies vaccine because without the vaccine, a fatal disease could occur. Tetanus is also treated the same in pregnant women as in others.

Screening for HIV is done by an enzyme-linked immunosorbent assay (ELISA) on a blood sample. If this is positive, the finding is confirmed by a

second test (a Western blot). Testing for HIV early in pregnancy allows a woman who is found to be HIV antibody positive the opportunity to begin therapy with a combination of anti-retrovirals which can decrease the risk of her infant acquiring the virus. It also allows a woman the option of choosing to terminate a pregnancy if she chooses. Because there is still no cure for HIV infection, some women may choose not to have a blood titer taken because they would rather not know they have the illness. Screening is increased in states who use the opt out method for HIV testing. This means that the patient will have HIV testing done along with their other serum testing unless they specifically ask not to be tested for this virus.

Allow a woman the opportunity to talk with the person performing the examination while sitting up, before being placed in a lithotomy position, because this can enhance her sense of ?

self-esteem and control. Many women want their support person to remain with them at the head of the table during the examination. In addition, it is customary, especially on an initial visit, for a nurse or nursing assistant to be in the room with a woman for a pelvic examination to offer additional support. This is true whether the examiner is male or female.

Cocaine, particularly in crack form, is potentially harmful to a fetus because it causes

severe vasoconstriction in the mother, thus compromising placental blood flow and perhaps dislodging the placenta. Its use is associated with spontaneous miscarriage, preterm labor, meconium staining, and intrauterine growth restriction

Although pregnancy is a happy time for most women, certain external life contingencies such as an unwanted pregnancy, financial difficulties, lack of emotional support, or high levels of stress can ?

slow the psychological work of pregnancy or attachment to the child During prenatal visits, ask such questions as "Is pregnancy what you thought it would be?" or "Has anything changed in your home life since you last came to clinic?" to reveal if any situation that could potentially interfere with bonding has occurred. It is unrealistic to believe any one healthcare professional has all the solutions to the problems couples reveal when asked these questions . An interprofessional approach (referral to a nutritionist, a primary healthcare provider, or social services) is often necessary to help solve some of these multifaceted problems.

Abdominal Discomfort When a woman stands up quickly, she may experience a pulling pain, sometimes sharp and frightening, in her right or left lower abdomen from tension on a round ligament. She can prevent this from happening by always rising

slowly from a lying to a sitting or from a sitting to a standing position. Because round ligament pain may simulate the abrupt pain that occurs with ruptured ectopic pregnancy, a woman's description of the pain needs to be evaluated carefully. If ectopic pregnancy is suggested, she should be referred to her obstetric provider

Bathing During pregnancy, sweating tends to increase because a woman excretes waste products for both herself and the fetus. She also has an increase in vaginal discharge. For these reasons, daily tub baths or showers are recommended. Women should not ?

soak for long periods in extremely hot water or in hot tubs, however, as heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis As pregnancy advances, a woman may have difficulty maintaining her balance when getting in and out of a bathtub. If so, she should change to showering or sponge bathing for her own safety. If membranes rupture or vaginal bleeding is present, tub baths become contraindicated because there might be a danger of developing a uterine infection.

Menstrual History A woman's past experience with her reproductive system may have some influence on how well she accepts a pregnancy as well as whether she'll develop a complication. Information to obtain includes her age of menarche (first menstrual period) and how well she was prepared for it. Ask about her usual cycle, including the interval, duration, amount of menstrual flow, and any discomfort she feels. If she has discomfort with periods, document when the discomfort occurs, how long it lasts, and what she does to relieve it. This is important because :

some women with severe dysmenorrhea can be looking forward to pregnancy because it will mean 9 months without discomfort. However, if she describes menstrual cramps as "horrible" and wonders "how I live through them some months," you can anticipate that she might need additional counseling to help her prepare for the pain of labor. Anticipate the need for counseling in the postpartum period about active ways to relieve menstrual discomfort when menstrual periods resume

Be certain to ask also about any allergies, including any drug sensitivities. This information will not only be important for prenatal treatment of any potential infections or conditions that may occur during pregnancy but also will alert the birth team if

someone has an allergy and is unable to communicate that for any reason. Any past surgical procedures are also important to document because adhesions resulting from past abdominal surgery such as a ruptured appendix could interfere with uterine growth. If a birthing parent has had a prior cesarean birth, the details will be important to know for planning route of delivery and to evaluate placental location.

As the uterus increases in size, the abdominal wall must stretch to accommodate it. This stretching (plus possibly increased adrenal cortex activity) can cause rupture and atrophy of small segments of the connective layer of the skin, leading to

streaks :striae gravidarum on the sides of the abdominal wall and sometimes on the thighs During the months after birth, striae gravidarum lighten to a silvery color (striae albicantes or atrophicae), and, although permanent, they become barely noticeable.

Next, the Skene glands that empty into the urethra and Bartholin glands that enter into the posterior vagina are checked for size and consistency. If they are swollen or emit a discharge, the discharge is cultured because an infection here could be caused by something as simple as

streptococci; it may also be a more serious infection such as gonorrhea or chlamydia that could cause subfertility in the woman and conjunctivitis in her newborn.

Be certain a woman knows to avoid resting flat on her back because

supine hypotension syndrome (i.e., faintness, diaphoresis, and hypotension from the pressure of the expanding uterus on the inferior vena cava) can develop in this position. If needed, placing a rolled pillow behind her can act as a reminder not to turn onto her back. Also, be certain women know not to rest with their knees sharply bent either when sitting or lying down because of the increased risk of venous stasis that this causes below the knee.

The Pelvis: Establishing Adequacy for Childbirth The pelvis is a bony ring formed by four united bones: the two innominate (flaring hip) bones, which form the anterior and lateral portion of the ring, and the coccyx and sacrum, which form the posterior aspect. The pelvis serves both to

support and protect pelvic organs.

Most manufacturers of home pregnancy test suggest a woman wait until at least the day of the missed menstrual period to

test. If a woman thinks she is pregnant but gets a negative result, she could repeat the test 1 week later if she still has not had a menstrual flow. If symptoms of pregnancy persist after two tests, she needs to see her healthcare provider as she might have another condition causing the amenorrhea; she would need appropriate diagnosis and therapy for this. After a positive pregnancy test, the first step should therefore be to arrange for prenatal care

ASSESSMENT OF BODY SYSTEMS Physical examination always begins with an inspection of general appearance to form an overall impression of a woman's health and well-being. General appearance is important because the manner in which people dress, the way they speak, and the body posture they assume all suggest how they feel about

themselves. Remember that not all women are thoroughly happy about being pregnant. After the general assessment, examine the patient head-to-toe by beginning with the head and scalp and ending with the extremities and the skin

EMPLOYMENT Changes in public assistance laws that encourage women to seek employment have led to more women working during pregnancy than ever before. Unless a woman's job involves exposure to

toxic substances, lifting heavy objects, other kinds of excessive physical strain, long periods of standing or sitting, or having to maintain body balance, there are few reasons a woman cannot continue to work throughout pregnancy. Women may, however, experience some discrimination from fellow workers

Typical infections that might be found during a pelvic examination are

trichomoniasis, candidal (yeast) infection, gonorrhea, and chlamydia

Abdominal or chest pain. Abdominal or chest pain at any time is a signal something is abnormal, so a woman should also report these immediately. Some women may think abdominal pain is normal because the growing uterus is deflecting other organs from their usual alignment, but a pregnant uterus normally expands painlessly. Abdominal pain is therefore a sign of some other problem, such as a

tubal (ectopic) pregnancy, separation of the placenta, preterm labor, or something unrelated to the pregnancy but perhaps equally serious, such as appendicitis, ulcer, or pancreatitis. Chest pain and shortness of breath may indicate a pulmonary embolus, a complication that can follow thrombophlebitis.

TUBERCULOSIS SCREENING (MANTOUX TEST) The incidence of tuberculosis is on the rise as more people with lowered immune system function, such as a woman with HIV infection, contract tuberculosis and then spread it to others through coughing. Consequently, a woman's primary care provider may prescribe a purified protein derivative (PPD) tuberculin test for a woman as a test for

tuberculosis.

Restless leg syndrome is the

uncontrollable urge to move the legs, often accompanied by itching, tingling, or aching to such an extent a person has difficulty falling or staying asleep

plotting uterine growth at each visit this way can help detect any unusual variation in

uterine or fetal growth. If an abnormality is detected, further investigation with ultrasound can be scheduled to determine the cause of the unusual increase or lack of growth.

Circulation to the uterus increases so much that toward the end of pregnancy, one sixth of a woman's blood supply is circulating through the

uterus at any given time; this means uterine bleeding in pregnancy has to always be regarded as serious because it could result in sudden and major blood loss. Caution women to contact their healthcare provider if any vaginal bleeding occurs during pregnancy.

The inlet is the entrance to the true pelvis, or the upper ring of bone through which the fetus must pass to be born

vaginally. It is at the level of the linea terminalis or is marked by the sacral prominence in the back, the ilium on the sides, and the superior aspect of the symphysis pubis in the front. If you looked down at the pelvic inlet, the passageway would appear heart-shaped because of the jutting sacral prominence. It is wider transversely (sideways) than in the anteroposterior dimension.

Laboratory Tests The commonly used laboratory tests for pregnancy are based on the use of a

venipuncture or a urine specimen to detect the presence of human chorionic gonadotropin (hCG), a hormone created by the chorionic villi of the placenta, in the urine or blood serum of the pregnant woman. -Because these tests are only accurate 95% to 98% of the time, positive results from these tests are considered probable rather than positive signs. - trace amounts of hCG appear in her serum as early as 24 to 48 hours after implantation and reach a measurable level (about 50 milli-International Unit/ml 7 to 9 days after conception.

A gynecoid, or "female," pelvis has an inlet that is

well rounded forward and backward and has a wide pubic arch. This pelvic type is ideal for childbirth.

PELVIC EXAMINATION A pelvic examination reveals information on the health of both a woman's internal and external reproductive organs. The following equipment is required:

• A speculum (a metal or plastic instrument with movable flat blades; • A spatula and/or broom for cervical sampling • Clean examining gloves • Lubricant • A glass slide or liquid collection device for a Pap smear • A culture tube • Two or three sterile cotton-tipped applicators or cytobrushes for obtaining cervical cultures • A good examining light • A movable stool at correct sitting height

In addition to nausea, other gastrointestinal tract changes occur:

• Although the acidity of stomach secretions decreases during pregnancy, heartburn can readily result from reflux of stomach contents into the esophagus, caused by both the upward displacement of the stomach by the uterus, and a relaxed cardioesophageal sphincter, caused by the action of relaxin produced by the ovary. • As the uterus increases in size, it pushes the stomach and intestines toward the back and sides of the abdomen. At about the midpoint of pregnancy, this pressure may be sufficient to slow intestinal peristalsis and the emptying time of the stomach, leading to renewed heartburn, constipation, and flatulence. • Pressure from the uterus on veins returning from the lower extremities can lead to hemorrhoids. • The entire gastrointestinal tract may become less active from the combined actions of relaxin and progesterone. This natural slowing of the stomach and intestine can be helpful because the blood supply is reduced • Some pregnant women notice hypertrophy at their gum lines and bleeding of gingival tissue when they brush their teeth. There also may be increased saliva formation (hyperptyalism), probably as a local response to increased levels of estrogen. This is an annoying but not a serious problem. • A lower-than-normal pH of saliva may lead to increased tooth decay if tooth brushing is not done conscientiously. This can be a problem for homeless women or any women who do not have frequent access to a place to brush their teeth.

To help ensure the safety of drugs during pregnancy, the U.S. Food and Drug Administration (FDA, n.d.) rates drugs according to five categories in relation to pregnancy . Always look for a drug's listed category before administering it to a pregnant woman to be certain it will be safe to administer. In addition, two principles always govern drug intake during pregnancy:

• Any drug or herbal supplement, under certain circumstances, may be detrimental to fetal welfare. Therefore, during pregnancy, women should not take any drug or supplement not specifically prescribed or approved by their obstetric provider. • A woman of childbearing age should not take any drug other than one prescribed by a obstetric provider to avoid exposure to a drug should she become pregnant. The classic example of a drug that can cause harm in pregnancy is thalidomide (Immunoprin), which was once liberally prescribed for morning nausea in Europe. Never approved for use in the United States, thalidomide caused amelia or phocomelia (i.e., total or partial absence of extremities) in 100% of instances when taken between the 34th and 45th day of pregnancy.

Nursing Care Planning Based on Family Teaching mood swings

• Avoid fatigue because when you're tired, your normal defenses are most likely to be down. • Reduce your level of stress by setting priorities. Ask yourself if everything you're doing really needs to be done. • Don't let little problems grow into big ones; attack them when they first occur. • Try to view situations from other people's perspective. They're not as involved in your pregnancy as you are so things that don't seem important to you may be important to them. • Let others know you're aware you're having trouble with emotions since you became pregnant. Your family and friends will be more than willing to help you through this time if they realize your shifting emotions are a concern to you.

Home Pregnancy Tests A number of brands for pregnancy testing are available over the counter, take only 2 to 3 minutes to complete, and have a high degree of accuracy (97% to 99%) if the instructions are followed exactly because they can detect as little as 35 milli-International Unit/ml of hCG. For the test, a woman dips a reagent strip into her stream of urine. A color change or the appearance of two bars on the strip denotes pregnancy. Tips to give the woman for successful testing include:

• Check the expiration date on the package to be certain the kit has not expired; an outdated kit can give false-positive results. • Read the instruction pamphlet provided with the test, noting especially the time period you should wait before reading the result, and follow this instruction carefully. • A concentrated urine sample such as a first urine in the morning tests best. Don't drink a large quantity of water beforehand because this can dilute a urine sample. • Read the test results at the exact time the instructions dictate. Reading the strip after the designated time can cause inaccurate results (e.g., denoting that you are pregnant when you are not). • Some prescription medicines, like methadone or chlordiazepoxide, may cause false-positive results. Contact your healthcare provider if you get an unexpected positive result and ask if any medication you are taking could cause that result. • Early prenatal care is the best safeguard to ensure a successful pregnancy. If your test result is positive, your next step should be to make a healthcare appointment as early as possible to begin care.

SEXUAL ACTIVITY Sexual changes occur during pregnancy. . Asking a woman at a prenatal visit if she has any questions about sexual activity allows her to voice concerns about coitus . This conversation allows a woman to feel more comfortable and secure that coitus is not harming her fetus. You may need to replace myths with facts, such as:

• Coitus on the expected due date does not initiate labor. • Orgasm does not initiate preterm labor. • Coitus does not cause rupture of the membranes o May continue as long as woman is comfortable

Women who are unable to continue working are protected from loss of employment benefits during pregnancy by federal law (Public Law 95-555) unless they work for a company with fewer than 15 employees. According to federal law, an employer cannot:

• Deprive women of seniority rights, in pay or promotion, because they take a maternity leave • Treat women returning from maternity leave as new hires, starting over on the eligibility period for pension and other benefits • Force pregnant women to leave their job if they are able to and want to continue working • Refuse to hire women just because they are pregnant or fire them for the same reason • Refuse to cover employees' normal pregnancy and birth expenses in the company health plan or pay less for pregnancy than for other medical conditions • Refuse to pay sick leave or disability b

Chief Concern The chief concern is the reason the woman has come to the healthcare setting—in this instance, the fact that she is or thinks she is pregnant.

• Document the date of her last menstrual period, whether it was normal for her and whether she has used a home test pregnancy kit. • Elicit information about the usual signs that occur with early pregnancy, such as nausea, vomiting, breast changes, or fatigue. • Ask if she is feeling any discomfort with her pregnancy, such as constipation, backache, or frequent urination. • Ask also about any danger signs of pregnancy, such as bleeding, abdominal pain, continuous headache, visual disturbances, or swelling of the hands and face. • Document whether the pregnancy was intended. If you feel uncomfortable asking about this directly, use a statement such as "All pregnancies are a bit of a surprise. Is that how it was with this one?" Another way to word such a question might be "Some couples plan on having children right away; some plan on waiting. How was it with you?" If a woman says the pregnancy was not intended, explore with her if she has reached a decision about whether to continue with the pregnancy. A question such as "Some women change their mind about wanting a baby once they realize they are pregnant; some don't. How has it been for you?" is an effective way to obtain this type of information because it indicates that either answer is possible and acceptable. You just want her to tell you which is happening.

Urinary System Like other systems, the urinary system undergoes specific physiologic changes during pregnancy, including alterations in fluid retention and renal, ureter, and bladder function. These changes, result from:

• Effects of high estrogen and progesterone levels • Compression of the bladder and ureters by the growing uterus • Increased blood volume that increases kidney production of more urine • Postural influences

The overall purposes of prenatal care are to:

• Establish a baseline of present health • Determine the gestational age of the fetus • Monitor fetal development and maternal well-being • Identify women at risk for complications • Minimize the risk of possible complications by anticipating and preventing problems before they occur • Provide education about pregnancy, lactation, and newborn care

The following body systems and questions about conditions constitute the minimum information to be addressed in a review of systems for a first prenatal visit:

• Head: Headache? Head injury? Seizures? Dizziness? Fainting? • Eyes: Vision? Glasses or contacts needed? Diplopia or double vision? Infection? Glaucoma? Cataract? Pain? Recent changes? Last vision examination and outcome? • Ears: Infection? Discharge? Earache? Hearing loss? Tinnitus? Vertigo? • Nose: Epistaxis (nose bleeds)? Discharge? How many colds a year? Allergies?Postnasal drainage? Sinus pain? • Mouth and pharynx: Dentures? Condition of teeth? Toothaches? Any bleeding of gums? Hoarseness? Difficulty in swallowing? Tonsillectomy? Last dental examination and outcome? • Neck: Stiffness? Masses? • Breasts: Lumps? Secretion? Pain? Tenderness? • Respiratory system: Cough? Wheezing? Asthma? Shortness of breath? Pain?Serious chest illness, such as tuberculosis or pneumonia? • Cardiovascular system: History of heart murmur? History of heart disease such as rheumatic fever or Kawasaki disease? Hypertension? Any pain? Palpitations?Anemia? Does she know her blood pressure? Has she ever had a blood transfusion? • Gastrointestinal system: What was her prepregnancy weight? Vomiting? Diarrhea? Constipation? Change in bowel habits? Rectal pruritus? Hemorrhoids? Pain? Ulcer? Gallbladder disease? Hepatitis? Appendicitis? • Genitourinary system: Urinary tract infection? Hematuria? Frequent urination? Sexually transmitted infection? Pelvic inflammatory disease? Hepatitis B? HIV?Did she have a problem getting pregnant? Is subfertility a concern? • Extremities: Varicose veins? Pain or stiffness of joints? Any fractures ordislocations? Carpal tunnel syndrome? Restless leg syndrome? • Skin: Any rashes? Acne? Psoriasis?

Remember that pregnancy symptoms are subtle, so a woman may not regard certain information as important, causing her to provide vague answers instead of specific information in these areas. She may be unaware, for example, that she is the only person who knows the answer to a question such as "How do you feel about being pregnant?" or "Have you been taking anything for your nausea in the morning?" For best success, remember the following:

• Interviewing is best accomplished in a private, quiet setting. -Pregnancy is too private an affair to be discussed in a crowded hallway or a full waiting room. • Caution a woman that a first visit may be lengthy because of all the things that need to be accomplished. -This prevents a woman from trying to fit the visit in between other errands or from having to terminate the interview because of another appointment. • Be certain to ask how a patient wants you to address her taking into account gender identification. Make certain she also knows your name and understands your role. If she views you as someone only gathering preliminary data, she may be willing to discuss superficial facts (name, address, phone number, and the like) but will resist discussing more intimate things (her feelings toward this pregnancy, the difficulty she has reworking old fears, or how scared she is about birth).

Family Profile Obtaining information about the woman's family structure and function early in an interview helps you get to know her, identify her important support persons, shape the nature and kind of questions you want to ask, and evaluate the possible impact of the woman's culture on care. It also lays a foundation for health teaching. Areas important to ask about include:

• Marital status and support people available, and if a partner will be accompanying her for visits. As a rule, both married and unmarried women want you to know their married status because they want to alert you if they do not have a firm support person available. • Educational level of her and her partner (helps you estimate the level of teaching you will need to plan). • If she works outside the home, exactly what her job consists of; for example, does it involve heavy lifting, long hours of standing in one position, or handling a toxic substance (all actions that may need to be modified during pregnancy)? • Size and structure of the apartment or house. You'll need this information so you can talk with her in the coming months about space for a baby. If she is restricted from climbing stairs more than once or twice a day during the last part of pregnancy or after birth, knowing whether essential rooms are located on the ground floor is helpful. • Family composition. It is important to assess not only the structure of the home but also who the patient lives with and what the relationships are. This is helpful for identifying support persons in addition to identifying any potential issues that may exist in the living situation. • Lifestyle. Are finances a problem? Does the woman take usual safety precautions such as use of a seat belt when in her car? Does she smoke, drink alcohol, or use recreational drugs? Does she have smoke and carbon monoxide monitors in her home? • Document whether a woman has recently experienced any lifestyle changes such as a change in status from independence to dependence, a chronic illness, the death or loss of a significant person, a geographic move, financial hardship, or lack of support people. These are all examples of stressful situations that could hinder a woman's ability to accept her pregnancy and child.

OBSTETRIC HISTORY Do not assume the current pregnancy is a woman's first pregnancy simply because she is very young or says she has only recently been married. She may have had an adolescent pregnancy or this could be a second marriage. For each previous pregnancy, document the newborn's sex and the place and date of birth. Review the pregnancy briefly by asking:

• Was the pregnancy intended? • How did the pregnancy go, overall? Did she have any complications, such as vaginal spotting, swelling of her hands or feet, falls, or surgery? • Did she take any medication? If so, what and why? • Did she receive prenatal care? If so, when did she start? • What was the duration of the pregnancy? • What was the duration of labor? Was it what she expected? Worse? Better? • What was the type of birth? Vaginal or cesarean? Vertex or breech? In a healthcare facility or at home? What type of anesthesia, if any, was used? • Did she have stitches following birth? • Did she have any complications following birth, such as excessive bleeding or infection? • What was the infant's birth weight and sex? Did the infant cry right away? What was the infant's Apgar score? • Was any special care needed for the baby, such as suctioning, oxygen, or an incubator? • Was the baby discharged from the healthcare setting with her? • What is the child's present state of health?