Chapter 11: Maternal Adaptation during Preganancy
The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective?
"I will need to take iron supplementation throughout my pregnancy even if I am not anemic." Explanation: Iron is recommended for all pregnant women because it is almost impossible for the pregnant woman to get what is required from diet alone, especially after 20 weeks' gestation when the requirements of the fetus increase. Pregnant women can get many nutrients from seafood including phosphorus, but there are specific recommendations about types of fish to avoid because of the risk of mercury poisoning. Milk production actually requires higher levels of zinc, which can be obtained from a healthy diet. Calcium requirements do not increase above prepregnancy levels during pregnancy because calcium absorption is enhanced during pregnancy. It can be unsafe for the pregnant woman to eat anything she wants and gain too much weight. A woman who gains too much weight during pregnancy is at risk for delivering a macrosomic baby.
A pregnant client reports an increase in a thick, whitish vaginal discharge. Which response by the nurse would be most appropriate?
"This discharge is normal during pregnancy." Explanation: During pregnancy, vaginal secretions become more acidic, white, and thick. Most women experience an increase in a whitish vaginal discharge, called leukorrhea, during pregnancy. The nurse should inform the client that the vaginal discharge is normal except when it is accompanied by itching and irritation, possibly suggesting Candida albicans infection (a monilial vaginitis), which is a very common occurrence in this glycogen-rich environment. Monilial vaginitis is a benign fungal condition and is treated with local antifungal agents. The client need not refrain from sexual activity when there is an increase in a thick, whitish vaginal discharge.
A client in her second trimester of pregnancy is anxious about the blotchy, brown pigmentation appearing on her forehead and cheeks. She also reports increased pigmentation on her breasts and genitalia. Which statement by the nurse is most appropriate?
"This is called facial melasma (chloasma) and should fade after the birth." Explanation: The skin and complexion of pregnant women undergo hyperpigmentation, primarily as a result of estrogen, progesterone, and melanocyte-stimulating hormone levels. The increased pigmentation that occurs on the breasts and genitalia also develops on the face to form the "mask of pregnancy," or facial melasma (chloasma). This is a blotchy, brownish pigment that covers the forehead and cheeks in dark-haired women. The nurse would inform the client that this is a normal occurrence in pregnancy and should fade after birth.
A woman's prepregnant weight is within the normal range. During her second trimester, the nurse would determine that the woman is gaining the appropriate amount of weight when her weight increases by which amount per week?
1 lb (0.45 kg) Explanation: The recommended weight gain pattern for a woman whose prepregnant weight is within the normal range would be 1 lb (0.45 kg) per week during the second and third trimesters. Underweight women should gain slightly more than 1 lb (0.45 kg) per week. Overweight women should gain about 2/3 lb (0.30 kg) per week.
A woman comes to the clinic for her first prenatal checkup. The woman has a body mass index (BMI) of 22. The nurse would anticipate that this client should gain approximately how much weight during her pregnancy?
25 to 35 lbs (11 to 16 kg) Explanation: A woman with a BMI of 18.5 to 24.9 is of normal weight and should gain 25 to 35 pounds (11 to 16 kg) during the pregnancy. For a woman who is underweight (BMI <18.5), the total weight gain range is 28 to 40 pounds (13 to 18 kg). For a woman who is overweight (BMI = 25-29.9), total weight gain range should be 15 to 25 pounds (7 to 11 kg). For a woman who is obese (BMI = 30 or higher), the total weight gain range should be 11 to 20 pounds (5 to 9 kg)
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks' pregnant. The nurse would expect this woman's heart rate to be approximately
85 beats per minute. Explanation: During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per minute.
During an exam, the nurse notes that the blood pressure of a client at 22 weeks' gestation is lower, and her heart rate is 12 beats per minute higher than at her last visit. How should the nurse interpret these findings?
Both findings are normal at this point of the pregnancy. Explanation: A pregnant woman will normally experience a decrease in her blood pressure during the second trimester. An increase in the heart rate of 10 to 15 beats per minute on average is also normal, due to the increased blood volume and increased workload of other organ systems. Hormonal changes cause the blood vessels to dilate, leading to a lowering of blood pressure.
A client presents to the clinic because she thinks she may be pregnant. On examination, the nurse notes that the client's cervix and vaginal mucosa appear a bluish-purple color. The nurse interprets this finding as which sign?
Chadwick sign Explanation: Common probable signs of pregnancy include a bluish-purple coloration of the vaginal mucosa and cervix (Chadwick sign), softening of the lower uterine segment or isthmus (Hegar sign), and softening of the cervix (Goodell sign). There is no such thing as Braxton sign; however, there are the Braxton Hicks contractions, which occur throughout the pregnancy preparing the uterus for delivery.
A new mother asks the postpartum nurse if her baby is getting enough nourishment from breastfeeding within the first 24 hours following birth. The nurse would provide her what information?
Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well. Explanation: Colostrum is present prior to delivery and provides the infant with adequate nutrition for the first 3 days of life, at which time the mother's actual milk should come in. Formula is not recommended. Infants need nutrition shortly after birth to keep their blood glucose normal.
The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective?
I will need to take iron supplementation throughout my pregnancy even if I am not anemic." Explanation: Iron is recommended for all pregnant women because it is almost impossible for the pregnant woman to get what is required from diet alone, especially after 20 weeks' gestation when the requirements of the fetus increase. Pregnant women can get many nutrients from seafood including phosphorus, but there are specific recommendations about types of fish to avoid because of the risk of mercury poisoning. Milk production actually requires higher levels of zinc, which can be obtained from a healthy diet. Calcium requirements do not increase above prepregnancy levels during pregnancy because calcium absorption is enhanced during pregnancy. It can be unsafe for the pregnant woman to eat anything she wants and gain too much weight. A woman who gains too much weight during pregnancy is at risk for delivering a macrosomic baby
A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition?
Place the client in the left lateral position. Explanation: The symptoms experienced by the client indicate supine hypotension syndrome. When the pregnant woman assumes a supine position, the expanding uterus exerts pressure on the inferior vena. The nurse should place the client in the left lateral position to correct this syndrome and optimize cardiac output and uterine perfusion. Elevating the client's legs, placing the client in an orthopneic position, or keeping the head of the bed elevated will not help alleviate the client's condition.
During pregnancy, one of progesterone's actions is to allow sodium to be "wasted" or lost in the urine. The nurse would expect to see which hormone increased to help counteract this loss?
aldosterone Explanation: Aldosterone is secreted by the adrenal glands, and it normally regulates the absorption of sodium in the kidney. During pregnancy, aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. ADH (antidiuretic hormone) is secreted by the kidneys and aids in resorption of fluids in the kidneys. Glycogen assists in the balancing of blood glucose, breaking down to glucose when needed by the body. Cortisol is important in helping the body handle stress.
Many changes occur in the body of a pregnant woman. Some of these are changes in the integumentary system. What is one change in the integumentary system called?
melasma (chloasma) Explanation: The so-called mask of pregnancy, melasma (also known as chloasma) can appear as brown blotchy areas on the forehead, cheeks, and nose of the pregnant woman. This condition may be permanent, or it may regress between pregnancies.
The nurse is preparing to teach a community class to a group of first-time parents. Which information should the nurse include concerning what the pregnant woman's partner may experience as a normal response?
physical symptoms similar to the mother Explanation: Couvade syndrome is the occurrence of physical symptoms by the partner, similar to the physical symptoms of the mother. Other emotional symptoms may occur, but they are typically on a person-to-person basis.
The partner of a pregnant client in her first trimester asks the nurse about the client's behavior recently, stating that she is very moody, seems happy one moment and is crying the next and all she wants to talk about is herself. What response would correctly address these concerns?
Pregnant women often experience mood swings and self-centeredness but this is normal. Explanation: During the first trimester of pregnancy, the woman often has mood swings, bouts of irritability and is hypersensitive. The partner needs to know that these are all normal behaviors for a pregnant woman
A nurse is assessing a pregnant client. The nurse understands that hormonal changes occur during pregnancy. Which hormones would the nurse most likely identify as being inhibited during the pregnancy?
FSH and LH Explanation: During pregnancy, FSH and LH are both inhibited as there is no need to develop a follicle and release an ovum. There is an increase in the secretion of T4 and MSH. There is a decrease in the production of GH and MSH but not an inhibition.
The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?
Darkened breast areolae Explanation: As part of the pigment changes that occur with pregnancy, breast areolae become darker. The breast tissue should not be softer or slacker than before. There should not yet be any lymph enlargement, and the nipples should not have fissures.
A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client?
Have you been sexually active in the past 2 months? Explanation: The client is presenting with presumptive or subjective symptoms of pregnancy. Given her symptoms and age, asking about sexual activity is the most appropriate question. Whether she is taking an oral contraceptive will not assist in identifying the cause of her symptoms. If she has vaginal itching, the underlying cause of her symptoms needs to be identified before treatment can be prescribed. Asking about family history is part of a comprehensive health history, but is not the priority based on the client's presentation.
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?
Meats Explanation: Meats are the best source of heme-rich iron and should be included in her diet if she is not following a vegetarian diet. Grains and legumes are non-heme iron sources. Dairy products will add various vitamins and calcium to the diet.
The nurse is presenting a nutritional plan to a primigravida client who is questioning the addition of iodized salt to her diet. Which explanation should the nurse prioritize in answering this client?
Thyroid activity, which depends on iodine intake, increases during pregnancy. Explanation: Hyperplasia of glandular tissue and increased vascularity can cause the thyroid gland to increase in size. Iodine is a necessary mineral for optimal thyroid function. So as the thyroid increases, the need for additional iodine increases. Progesterone formation is not dependent on iodine. The activity of the adrenal gland does not influence iodine's effectiveness.
A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to:
encourage her to identify someone that she can talk to and share the pregnancy experience. Explanation: A pregnant woman without social support needs to identify someone with whom she can share the experience of pregnancy because social support is a crucial part of adapting to parenthood. Telling her to move home and telling her that she will feel better as the pregnancy progresses do not address the issue of isolation. Also, moving home may not be a possibility for this woman. The nurse should maintain a professional relationship and not commit to a long-term relationship with a client.
A mother comes in with her 17-year-old daughter to find out why she has not had a menstrual cycle for a few months. Examination confirms the daughter is pregnant with a fundal height of approximately 24 cm. The nurse interprets this finding as indicating that the daughter is approximately how many weeks pregnant?
24 Explanation: By 20 weeks' gestation, the fundus of the uterus is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy. Therefore for this client, the additional 4 cm would be the equivalent of 4 additional weeks making the gestational age of 24 weeks.
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply.
breast changes amenorrhea morning sickness Explanation: Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). Probable signs are signs that appear in the first and early second trimesters, seen via objective criteria, but can also be indicators of other conditions (e.g., hydatidiform mole). Positive signs affirm that proof exists that there is a developing fetus in any trimester and are objective criteria seen by a trained observer or diagnostic study, (e.g., ultrasound.)
A pregnant client is concerned because she has noticed that she is developing brown blotches on her forehead and nose. The nurse realizes that the client understood the teaching about this problem when the client makes which statement?
"These spots are from hyperpigmentation caused by the pregnancy and may be permanent." Explanation: The brown blotches the client is experiencing on her face is called melasma (chloasma) or the "mask of pregnancy." Hyperpigmentation is one of the skin changes that pregnant women experience. This condition may be permanent or may regress between pregnancies. Linea nigra is the darkened line in the middle of the abdomen seen on some pregnant women. Melasma does not go away in the third trimester and there is no evidence that it will get worse with each pregnancy.
A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?
Blood is trapped in the vena cava in a supine position. Explanation: Supine hypotension syndrome, or an interference with blood return to the heart, occurs when the weight of the fetus rests on the vena cava. Cerebral arteries should not be affected. Mean arterial pressure is high enough to maintain perfusion of the uterus in any orientation. The sympathetic nervous system will not be affected by the supine position.
Which change related to the vital signs is expected in pregnant women?
Blood pressure decreases. Explanation: Pulse and temperature often increase, while lung space is decreased in pregnant women. It is common for blood pressure to decrease during pregnancy.
A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?
Fetal movement felt by examiner Explanation: The positive signs of pregnancy are fetal image on a sonogram, hearing a fetal heart rate, and examiner feeling fetal movement. A pregnancy test has 95% accuracy; however, it may come back as a false positive. Hegar sign is a softening of the uterine isthmus. Chadwick sign may have other causes besides pregnancy.
The nursing instructor is teaching a class on the nutritional needs of the pregnant client. The instructor determines the session is successful when the students correctly choose which supplement as being known to prevent up to 70% of CNS birth defects?
Folic acid Explanation: Folic acid is noted to help prevent up to 70% of CNS birth defects; however, the folic acid needs to be in the body prior to the pregnancy to be most effective. Iodine affects thyroid development. Zinc is required for enzyme formation and gene expression. Vitamin A helps develop vision
A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet?
Fortified cereals Explanation: The best source to recommend are the fortified cereals to meet the amino acid needs necessary for the development of her infant's nervous system during pregnancy. She should be encouraged to include fortified cereals to meet these needs. The carrots, sweet potatoes, mangoes, nuts, and seeds will add other nutrients to her diet. A vegan will not eat milk and cheese, as they are animal products
A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she has been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely?
Fundal height has dropped since the last recording. Explanation: Between 38 and 40 weeks of gestation, the fundal height drops as the fetus begins to descend and engage into the pelvis. Because it pushes against the diaphragm, many women experience shortness of breath. By 40 weeks, the fetal head begins to descend and engage into the pelvis. Although breathing becomes easier because of this descent, the pressure on the urinary bladder now increases, and women experience urinary frequency. The fundus reaches its highest level at the xiphoid process at approximately 36, not 39, weeks. By 20 weeks' gestation, the fundus is at the level of the umbilicus and measures 20 cm. At between 6 and 8 weeks of gestation, the cervix begins to soften (Goodell sign) and the lower uterine segment softens (Hegar's sign).
A nurse is explaining how hormones affect the pregnancy. Which hormone would the nurse describe as being responsible for stimulating uterine contractions during labor and birth?
oxytocin Explanation: Oxytocin is responsible for stimulating the uterine contractions that bring about delivery. Progesterone and estrogen help maintain the pregnancy, and prolactin helps with stimulating milk production after the delivery.
An obstetrical nurse is conducting a program for pregnant women who are in their first trimester. The program focuses on the changes occurring in the woman's body as a result of the pregnancy. When describing the effect of changing hormonal levels, which information would the nurse most likely include? Select all that apply.
Maintenance of the endometrium so that the embryo can implant Maternal metabolic changes to make nutrients available for mother and fetus Relaxation of the ligaments that connect the pelvic bones, allowing them to spread slightly Preparing the breasts for lactation, keeping the milk from coming in until birth occurs Explanation: The hormonal effects of pregnancy include the following: • Maintaining the endometrium so that the embryo can implant, causing changes in the mother's metabolism so that nutrients are available for both • Relaxing the ligaments that connect the pelvic bones, allowing them to spread slightly • Preparing the breasts for lactation, keeping the milk from coming in until birth occurs • Increasing the mother's blood volume and red blood cell mass to increase oxygen • Increasing the blood supply to the gastrointestinal tract and slowing peristaltic waves
In preparing for a prenatal class to discuss the hormonal changes during pregnancy, which information would the nurse most likely include?
Over-the-counter antacids can be used to treat acid reflux with the health care provider's knowledge. Explanation: Elevated progesterone levels cause smooth muscle relaxation, which can result in relaxation of the cardiac sphincter and reflux of the stomach contents into the lower esophagus. OTC antacids will usually relieve the symptoms but should be discussed with the health care provider first. The hormonal changes are necessary for the pregnancy to continue, and the woman will return to her usual nonpregnant hormonal levels after the baby is born. Taking hormonal replacement therapy is not recommended. Using herbs should be done only with the knowledge of the health care practitioner due to the side effects and contraindications of some herbs during pregnancy. Some herbs will cause a spontaneous abortion (miscarriage).
A client in her 20th week of gestation expresses concern about her 5-year-old son, who is behaving strangely by not approaching her anymore. He does not seem to be taking the news of a new family member very well. Which strategy can the nurse discuss with the mother to deal with the situation?
Provide constant reinforcement of love and care to the child. Explanation: The nurse should instruct the parents to provide constant reinforcement of love and care to reduce the sibling's fear of change and possible replacement by the new family member. The parents should neither avoid talking to the child about the new arrival nor pay less attention to the child. The nurse should urge parents to include siblings in this event and make them feel a part of the preparations for the new infant. The nurse should instruct the parents to continue to focus on the older sibling after the birth to reduce regressive or aggressive behavior that might manifest toward the newborn. The child is exhibiting sibling rivalry, which results from the child's fear of change in the security of his relationships with his parents. This behavior is common and does not require the intervention of a child psychologist.
The nurse-midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell sign. Which description illustrates this alteration?
The cervix softens. Explanation: At about the 8th week of gestation, the cervix softens, a probable sign known as Goodell sign. The cervix also looks blue or purple when examined; this is Chadwick sign, and may occur as early as the 6th week of pregnancy. At about 6 weeks, the lower uterine segment softens, a probable sign called Hegar sign. A softening of the uterine fundus, where the embryo has implanted, also occurs by about the 7th week, and the fundus enlarges by the 8th week.
The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The intestines are displaced by the growing fetus. Explanation: The growing fetus is displacing the intestines and interfering with peristalsis, delaying the passage of fecal matter and resulting in constipation. This is common and expected; however, the client should take measures to prevent hemorrhoids that can occur as the result of the pressure and straining. Progesterone, not hCG, can delay gastric emptying and decrease peristalsis. Reference:
A woman in her 16th week of pregnancy comes to the health center for a follow up visit. Which physiologic change would the nurse expect to assess? Select all that apply.
a uterus that is palpable colostrum that can be expelled from the nipples Explanation: A uterus is palpable by the end of the 12th week of pregnancy, and by the 16th week of pregnancy colostrum can be expelled from the nipples. Blood pressure in women usually does not rise because the increased heart action takes care of the greater amount of circulating volume. Because of melanocyte-stimulating hormone from the pituitary, extra pigmentation can lead to linea nigra and melasma (chloasma) about the 24th week of pregnancy. Varicosities in the vulva, rectum, and legs tend to occur in the third trimester due to the pressure of the expanding uterus.
During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called?
couvade syndrome Explanation: Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partner. This phenomenon is called couvade syndrome.
A new mother voices concerns about breastfeeding her infant. The nurse would explain to the mother the two hormones that control lactation and letdown are:
prolactin and oxytocin. Explanation: Prolactin and oxytocin are both important hormones in regulation of breastfeeding. Prolactin helps in producing the breast milk and oxytocin stimulates letdown during breastfeeding. The other hormones do not play a role in breastfeeding or milk production.
A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation (dilatation) and enlargement of the birth canal. What is this hormone? You Selected:
relaxin Explanation: Relaxin, secreted by the corpus luteum of the ovary as well as the placenta, is responsible for helping to inhibit uterine activity and to soften the cervix and the collagen in joints. Softening of the cervix allows for dilation (dilatation) at birth; softening of collagen allows for laxness in the lower spine and so helps enlarge the birth canal. The effect of estrogen is to cause breast and uterine enlargement. Progesterone has a major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breasts for lactation. Human placental lactogen (hPL), also known as human chorionic somatomammotropin, serves as an antagonist to insulin, making insulin less effective and thereby allowing more glucose to become available for fetal growth
The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?
ultrasound picture of her fetus Explanation: A positive sign of pregnancy is visualization of the fetus by ultrasound at 6+ weeks. Amenorrhea is a presumptive sign and can be caused by a variety of factors. Positive hCG in the blood and uterine growth are both probable signs but can be caused by hydatidiform or tumors.
