Week 1 Learning outcomes-study guide

Question 1

1. Describe the physiological changes that occur during pregnancy and their etiologies.

Answer 1

listed on the following cards

Question 2

Uterus , Cervix and Vagina

Answer 2

increased levels of estrogen and progesterone -hypertrophie of uterine wall , softening of vaginal muscle and connective tissue and preparation for expansion of tissue , uterus contract ability increases in response to increased estrogen levels leading to Braxton Hicks contractions , hypertrophie of cervical glands leads to formation of mucus plug(protective barrier between uterus fetus and vagina) , increased vascularity and hypertrophy of vaginal and cervical glands leads to increase in Leukorrhea, cessation of menstrual cycle (amenorrhea) and ovulation.
•enlargement and stretching of uterus to accommodate developing fetus and placenta -increase uterine size 20 times that of non pregnant uterus , weight of uterus increases from 70 grams to 1100 grams , capacity increases from 10 milliliters to 5000 milliliters 80% of that to uteroplacental
.•expanded circulatory volume leads to increased vascular congestion -blood flow to uterus is 500 to 600 milliliters per minute at term ,
goodells sign- softening of cervix ,
hagars sign-softening of lower uterine segment , chadwicks sign blueish coloration of cervix vaginal mucosa and vulva
• acid pH of vagina -acid environment inhibits growth of bacteria , acid environment allows growth of candida Albicans leading to increased risk of candidiasis- yeast infection

Question 3

Cardiovascular System

Answer 3

• Decrease in peripheral vascular resistance -decrease in blood pressure
• increase in blood volume by 40% to 45% -hypervolemia of pregnancy
• increasing cardiac output by 40% -increased heart rate Of 15 to 20 beats per minute
• BMR increased 10% to 20% by 3rd trimester -increased stroke volume of 25% to 30%
• increase in peripheral dilation -systolic murmurs , load and wide S1 split , load S2 , obvious S3 , increase in heart size
• increase in RBC count by 30% -In response to increased oxygen requirements of pregnancy RBC volume increases up to 33% with iron supplementations up to 18% without supplementation -physiological anemia of pregnancy
• Increase in plasma volume by 50%-Peaking at 32 to 34 weeks staying until term
-hemodilution is caused by increase in plasma volume being relatively larger than the increase in RBCS which results in decreased hemoglobin and hematocrit values=anemia ;
• Cardiac work is eased as the decrease in blood viscosity facilitates placental perfusion
• iron deficiency anemia=hemoglobin less than 11 grams per deciliter and hematocrit less than 33% maternal iron stores are insufficient to meet demands for iron in fetal development blood volume increases by 1500 milliliters to support uteroplacental demands and maintenance of pregnancy this is referred to as hypervolemia of pregnancy heart enlarges do too these factors
• hypercoagulation occurs during pregnancy to decrease risk of postpartum hemorrhage changes place women at risk for thrombosis and coagulopathies -Plasma fibrin increase of 40% fibrinogen increase of 50% coagulation inhibiting factors decrease
• increase in WBC count -values up to 16,000 mm3 in the absence of infection
• increase demand for iron and fetal development -iron deficiency anemia hemoglobin less than 11 grams per deciliter and hematocrit less than 33%
• plasma fibrin increase of 40% ,fibrinogen increase of 50% , decreasing coagulation inhibiting factors , protective of inevitable blood loss during birth - hypercoagulability
• Blood pressure decrease in first trimester due to a decrease in peripheral vascular resistance blood pressure returns to normal by term
• a systolic heart murmur or a third heart sound Gallup may be heard by mid pregnancy
• peripheral dilation increased

• increased Venous pressure and decreased blood flow to extremities due to compression of iliac veins and inferior vena cava -edema of lower extremities varicosities and legs and vulva hemorrhoids
•
• Cardiac output increases 30 to 50% peaks at 25 to 30 weeks

Question 4

supine hypotensive syndrome

Answer 4

• supine hypotensive syndrome supine hypotensive syndrome is a hypotensive condition resulting from a woman lying on her back in mid to late pregnancy in superimposition enlarged uterus compresses inferior vena cava causing reduced blood flow back to right atrium and a drop in cardiac output and blood pressure that results in the woman feeling dizzy and faint

Question 5

Respiratory System

Answer 5

• hormones of pregnancy stimulate respiratory center and act on lung tissue to increase and enhance respiratory function , increase of oxygen consumption by 15% to 20% - increase in title volume by 35% to 50% , slight increase in respiratory rate , increase in inspiratory capacity , decrease in expiratory volume , slight hyperventilation , slight respiratory alkalosis .
• estrogen progesterone and prostaglandins cause vascular engorgement and smooth muscle relaxation -dyspnea , nasal and sinus congestion , epistaxis (nose bleeds)
• upward displacement of diaphragm by enlarging uterus -shift from abdominals to thoracic breathing
• estrogen causes a relaxation of the ligaments and joints of the ribs , slight decrease in lung capacity -chest and thorax expand to accommodate thoracic breathing and upward displacement of diaphragm
• Increased oxygen demand is due to 15% increase in metabolic rate and 20% increased consumption of oxygen there is a 40 to 50% increase in minute ventillation mostly due to increase in title volume rather than in respiratory rate pulmonary function is not compromised in a normal pregnancy
• slight respiratory alkalosis -decrease in PCO 2 leads to increase in pH more alkaline and decrease in bicarbonate this change promotes transport of CO2 away from the fetus
• Diaphragm is displaced upward about four centimeters , increased chest circumference of 6 centimeters increase in kostal angle of greater than 90 degrees , these changes may contribute to physiological dyspnea that is common during pregnancy .

Question 6

Renal System

Answer 6

• increased cardiac output an increased blood and plasma-increased renal blood flow of 50 to 80% in first trimester and then decreases ,
-increased progesterone cause a relaxation of smooth muscles -urinary frequency and incontinence and increased risk of UTI
• dilation of renal pelvis and ureters , ureters become elongated with decreased motility , decreased bladder tone with increased bladder capacity -increased risk of UTI
• pressure of enlarging uterus on renal structures , displacement of bladder and 3rd trimester
• increased glomerular filtration rate -increased urinary output
• increased renal excretion of glucose and protein -glucosuria and proteinuria(small amounts) exceeded tubal reabsorption threshold of protein and glucose due to increased volume small amount of protein area and glucosuria can be normal important to assess and monitor for pathology
• shift in fluid and electrolyte balance the need that’s increased
• In supine and upright maternal position blood pools lower body decrease in cardiac output GFR and urine output causing excess sodium and fluid retention
• a left lateral recumbent maternal position can maximize cardiac output renal plasma volume and urine output stabilize fluid and electrolyte balance minimize dependent edema maintain optimal blood pressure
• renal system secretes both maternal and fetal waste products
• Bladder capacity increases bladder tone decreases due to progesterone effect on smooth muscle relaxation and stretching
• urinary stasis -progesterone reduces tone of renal structures allowing pooling of urine stasis promotes bacterial growth and increases the woman’s risk for your UTI’s and pyelonephritis

• Urinary frequency urgency an nocturia begin early pregnancy continue varying degrees through pregnancy
UTI’s are common in pregnancy and may be asymptomatic symptoms of UTI urinary frequency discaria urgency sometimes pus or blood in urine if left untreated it can lead to pyelonephritis or premature labor
• decreased renal flow in 3rd trimester -dependent edema
• increased vascularity -hyperemia of Bladder and urethra

Question 7

Gastrointestinal System

Answer 7

• nausea and vomiting- NVP
  • increased levels of HCG and altered carbohydrate metabolism -nausea and vomiting during early pregnancy
  • Uterine enlargement displaces stomach liver and intestines as pregnancy progresses -GI tract relaxation and slowing of processes =heartburn bloating and Constipation
  • hemorrhoids varicosities and ** canal common due to increased venous pressure are exacerbated by Constipation puritis (itching)
  -gallstones-relaxation of smooth muscle results distention of Gallbladder slows emptying of bile-
  • pruritis-Abdominal Pruritis maybe early sign of Cholestasis(reduced bile flow from liver)
  • ptyalism-Increase in saliva
  • bleeding gums periodontal disease increased vascularity of gums can result in gingivitis
  • increased heartburn
  • increase progesterone slow the digestive process and movement of stool -bloating flatulence and Constipation
  • increased progesterone levels decreased muscle tone of Gallbladder and result in prolonged emptying time -increased risk of gallstone formation and Cholestasis
  • changes in sense of taste and smell -increased or decrease in appetite , nausea , -pica:abnormal craving for and ingestion of non food substances such as clay or starch
  • displacement of intestines by uterus -flatulence abdominal distention abdominal cramping and pelvic heaviness
  • increased levels of estrogen=gingivitis bleeding gums increased risk of periodontal disease

Question 8

Musculoskeletal system

Answer 8

• increased progesterone and relaxin- lead to –softening of joints
increased joint mobility
widening and increased mobility of the sacroiliac and symphysis pubis -altered gate waddle gate , facilitates birthing process , low back pain or pelvic discomfort , pelvis tilts forward leading to shifting of center of gravity- change in posture and walking style increasing lordosis(Abnormal curvature anterior curvature of lumbar spine) , increased risk of falls
•
• Diastasis recti separation of rectus abdominis muscle in the midline caused by the abdominal distention at benign condition that can occur in 3rd trimester
• distension of abdomen related to expanding uterus reduced abdominal tone and increased breast size -round ligament spasm
• increased estrogen and relaxing levels lead to increased elasticity relaxation of ligaments -increased risk of joint pain and injury
• abdominal muscles stretched due to enlarging uterus -diastasis recti

Question 9

Integumentary system

Answer 9

• estrogen and progesterone levels stimulate increased melanin= light Brown to dark Brown pigmentation -linea nigra , melasma (chloasma), increased pigmentation of nipples areola vulva scars and moles
• Melasma or mask of pregnancy brownish pigmentation of skin appears over cheeks nose and forehead more common and darker skinned women- after 16th week and is exacerbated by stretch marks due to growth plus estrogen relaxing an adreno corticoids =tearing of subcutaneous connective tissue/ collagen
• increased blood flow & BMR progesterone induced increase body temperature and vasomotor instability -hot flashes facial flushing alternating sensation of hot and cold , increased perspiration -increased thyroid activity
• increased action of adrenocorticosteroids Leads to cutaneous elastic tissues becoming fragile -striae gravidarum(stretch marks) On abdomen thighs breast and buttocks
• increased estrogen levels lead to color and vascular changes -angiomas (spider nevi), Palmar erythema: pinkish red modeling over palms of hands and redness of fingers
• increased androgens lead to increase in sebaceous gland secretions -increased oiliness of skin an increase of acne

Question 10

Endocrine system

Answer 10

• alterations in pituitary adrenal thyroid parathyroid and pancreatic functioning
  • Placenta after full development produces most hormones of pregnancy-estrogen progesterone human placental lactogen, relaxin
  hormones play role in Physiology of pregnancy causing specific alterations in nearly all body systems to support maternal needs maintenance and progression of pregnancy and fetal growth and development
  • decreased follicle stimulating hormone -amenorrhea
  • increased progesterone -maintains pregnancy by relaxation of smooth muscles leading to decreased uterine activity which results in decreased risk of spontaneous abortions , decreases gastrointestinal motility and slows digestive processes
  • increased estrogen-uterine and breast development , facilitates increase in vascularity , hyperpigmentation , alters metabolic processes and fluid and electrolyte balance
  • increased prolactin -lactation
  • increased oxytocin -stimulates uterine contractions , stimulates the milk let down or ejection reflex in response to breastfeeding
  • increased HCG -maintenance of corpus luteum until placenta becomes fully functional
  • human placental lactogen /human chorionic somatomammotropin- breast development , alters carbohydrate protein and fat metabolism , facilitates fetal growth by altering maternal metabolism ;acts as an insulin antagonist
  • hyperplasia an increased vascularity of thyroid -enlargement of thyroid , heat intolerance and fatigue
  • increased BMR related to fetal metabolic activity -depletion of maternal glucose stores leads to increased risk of maternal hypoglycemia
  • increased need for glucose
  increased production of insulin
  • increase in circulating cortisol
  -increase in maternal resistance to insulin leads to increase risk of hyperglycemia

Question 11

Neurological System

Answer 11

Headache, Syncope

Question 12

Generalized or multisystem

Answer 12

Fatigue (first and third trimesters)
Reassure the woman of the normalcy of her response.

Encourage the woman to plan for extra rest during the day and at night; focus on “work” of growing a healthy baby.

Enlist support and assistance from friends and family.

Encourage the woman to eat an optimal diet with adequate caloric intake and iron-rich foods and iron supplementation if anemic.

Question 13

2 Identify nursing measures to relieve the discomforts caused by physiological changes during pregnancy.

Answer 13

As follows

Question 14

Emotional lability (throughout pregnancy)

Answer 14

Reassure the woman of the normalcy of response.

Encourage adequate rest and optimal nutrition.

Encourage communication with partner/significant support people.

Refer to pregnancy support group.

Question 15

Breasts

Answer 15

*Tenderness, enlargement, upper back pain (throughout pregnancy; tenderness mostly in the first trimester)
Encourage the woman to wear a well-fitting, supportive bra.

Instruct woman in correct use of good body mechanics.

*Leaking of colostrum from nipples (starting second trimester onward)
Reassure the woman of the normalcy.

Recommend soft cotton breast pads if leaking is troublesome.

Question 16

Uterus

Answer 16

Braxton-Hicks contractions (mid-pregnancy onward)
Reassure the woman that occasional contractions are normal.

Instruct the woman to call her provider if contractions become regular and persist before 37 weeks.

Ensure adequate fluid intake.

Recommend a maternity girdle for uterus support.

Question 17

Cervix/vagina

Answer 17

Increased secretions

Yeast infections (throughout pregnancy)

Encourage daily bathing.

Recommend cotton underwear.

Recommend wearing panty liner, changing pad frequently.

Instruct the woman to avoid douching or using feminine hygiene sprays.

Inform provider if discharge changes in color or is accompanied by foul odor or pruritus.

Dyspareunia(pain before during or after intercourse)(throughout pregnancy)
Reassure the woman/couple of normalcy of response, provide information.

Suggest alternative positions for sexual intercourse and alternative sexual activity to sexual intercourse.

Question 18

Cardiovascular

Answer 18

Supine hypotension (mid-pregnancy onward)	
Instruct the woman to avoid supine position from mid-pregnancy onward.

Advise her to lie on her side and rise slowly to decrease the risk of a hypotensive event.

Orthostatic hypotension

Advise woman to keep feet moving when standing and avoid standing for prolonged periods.

Instruct to rise slowly from a lying position to sitting or standing to decrease the risk of a hypotensive event.

Anemia (throughout pregnancy; more common in late second trimester)

Encourage the woman to include iron-rich foods in daily dietary intake and take iron supplementation.

Question 19

Dependent edema lower extremities and/or vulva (late pregnancy)

Answer 19

Instruct the woman to:

• Wear loose clothing
• Use a maternity girdle (abdominal support), which may help reduce venous pressure in pelvis/lower extremities and enhance circulation
• Avoid prolonged standing or sitting
• Dorsiflex feet periodically when standing or sitting
• Elevate legs when sitting
• Position on side when lying down

Question 20

Varicosities (later pregnancy)

Answer 20

Instruct woman in all measures for dependent edema (see above).

Suggest the woman wear support hose (put on before rising in the morning, before legs have been in dependent position).

Instruct the woman to lie on her back with legs propped against a wall in an approximately 45-degree angle to spine periodically throughout the day.

Instruct the woman to avoid crossing legs when sitting.

Question 21

Respiratory

Answer 21

Hyperventilation and dyspnea (throughout pregnancy; may worsen in later pregnancy)
Reassure the woman of the normalcy of her response and provide information.

Instruct the woman to slow down respiration rate and depth when hyperventilating.

Encourage good posture.

Instruct the woman to stand and stretch, taking a deep breath periodically throughout the day; stretch and take a deep breath periodically throughout the night.

Suggest sleeping semi-sitting with additional pillows for support.

Question 22

Nasal and sinus congestion/epistaxis (throughout pregnancy)

Answer 22

Suggest the woman try a cool-air humidifier.

Instruct the woman to avoid use of decongestants and nasal sprays and instead to use normal saline drops.

Question 23

Renal-Frequency and urgency/nocturia (may be throughout pregnancy; most common in first and third trimesters)

Answer 23

Reassure the woman of normalcy of response.

Encourage the woman to empty her bladder frequently, always wiping front to back.

Stress the importance of maintaining adequate hydration, reducing fluid intake only near bedtime.

Instruct her to urinate after intercourse.

Teach the woman to notify her provider if there is pain or blood with urination.

Encourage Kegel exercises; wear perineal pad if needed.

Question 24

Gastrointestinal

Nausea and/or vomiting in pregnancy (NVP) (first trimester and sometimes into the second trimester)

Answer 24

Reassure the woman of normalcy and self-limiting nature of response.

Avoid strong odors and causative factors (e.g., spicy foods, greasy foods, large meals, stuffy rooms, hot places, or loud noises).

Encourage women to experiment with alleviating factors:

• Eating small, frequent meals as soon as, or before, feeling hungry
• Eat at a slow pace
• Eat crackers or dry toast before rising or whenever nauseous
• Drink cold, clear carbonated beverages such as ginger ale, or sour beverages such as lemonade
• Avoid fluid intake with meals
• Eat ginger-flavored lollipops or peppermint candies
• Brush teeth after eating
• Wear P6 acupressure wrist bands
• Take vitamins at bedtime with a snack (not in the morning)
• Suggest vitamin B6, 25 mg by mouth three times daily or ginger, 250 mg by mouth four times daily

Oral or rectal medications may be prescribed for management of troublesome symptoms.

Identify, acknowledge, and support women with significant NVP to offer additional treatment options.

Question 25

Increase or sense of increase in salivation (mostly first trimester if associated with nausea)

Answer 25

Suggest use of gum or hard candy or use astringent mouthwash.

Question 26

Bleeding gums (throughout pregnancy)

Answer 26

Encourage the woman to maintain good oral hygiene (brush gently with soft toothbrush, daily flossing).

Maintain optimal nutrition.

Question 27

Flatulence (throughout pregnancy)

Answer 27

Encourage the woman to:

• Maintain regular bowel habits
• Engage in regular exercise
• Avoid gas-producing foods
• Chew food slowly and thoroughly
• Use the knee-chest position during periods of discomfort

Question 28

Heartburn (later pregnancy)

Answer 28

Suggest:

• Small, frequent meals
• Maintain good posture
• Maintain adequate fluid intake but avoid fluid intake with meals
• Avoid fatty or fried foods
• Remain upright for 30–45 minutes after eating
• Refrain from eating at least 3 hours prior to bedtime

Question 29

Constipation (throughout pregnancy; see Concept Map feature)

Answer 29

Encourage the woman to:

• Maintain adequate fluid intake
• Engage in regular exercise such as walking
• Increase fiber in diet through vegetables, fruits, and whole grains
• Maintain regular bowel habits
• Maintain good posture and body mechanics

Question 30

Hemorrhoids (later pregnancy)

Answer 30

Avoid constipation (see above).

Instruct the woman to avoid bearing down with bowel movements.

Instruct the woman in comfort measures (e.g., ice packs, warm baths or sitz baths, witch hazel compresses).

Elevate the hips and lower extremities during rest periods throughout the day.

Gently reinsert hemorrhoid into the rectum while doing Kegel exercises.

Question 31

Musculoskeletal

Low back pain/joint discomfort/difficulty walking (later pregnancy)

Answer 31

Instruct the woman to:

• Utilize proper body mechanics (e.g., stoop using knees vs. bend for lifting)
• Maintain good posture
• Do pelvic rock/pelvic tilt exercises
• Wear supportive shoes with low heels
• Apply warmth or ice to painful area
• Use of maternity girdle
• Use massage
• Use relaxation techniques
• Sleep on a firm mattress with pillows for additional support of extremities, abdomen, and back

Question 32

Diastasis recti (later pregnancy)

Answer 32

Instruct the woman to do gentle abdominal strengthening exercises (e.g., tiny abdominal crunches, may cross arms over abdomen to opposite sides for splinting, no sit-ups).

Teach proper technique for sitting up from lying down (i.e., roll to side, lift torso up using arms until in sitting position).

Question 33

Round ligament spasm and pain (late second and third trimester)

Answer 33

Instruct the woman to:

• Lie on side and flex knees up to abdomen
• Bend toward pain
• Do pelvic tilt/pelvic rock exercises
• Use warm baths or compresses
• Use side-lying in exaggerated Sim’s position with pillows for additional support of abdomen and in between legs
• Use maternity belt

Question 34

Leg cramps (throughout pregnancy)

Answer 34

Instruct the woman to:

• Dorsiflex foot to stretch calf muscle
• Warm baths or compresses to the affected area
• Change position slowly
• Massage the affected area
• Regular exercise and muscle conditioning

Question 35

Integumentary

Striae (stretch marks) (later pregnancy)

Answer 35

Reassure the woman that there is no method to prevent them.

Suggest maintaining skin comfort (e.g., lotions, oatmeal baths, nonbinding clothing).

Encourage good weight control.

Question 36

Dry skin or pruritus (itching)

later pregnancy

Answer 36

Suggestions for maintaining skin comfort:

Use tepid water for baths and showers and rinse with cooler water.

Avoid hot water (drying effect may increase itching). Use moisturizing soaps or body wash. Avoid exfoliating scrubs or deodorant soaps (has drying effect and may increase itching).

Use of lotions, oatmeal baths, nonbinding clothing may lessen itching.

Question 37

Skin hyperpigmentation

Answer 37

Limit sun exposure.

Wear sunscreen regularly.

Question 38

Acne

Answer 38

Use products developed for the face only (e.g., cleansers, sunscreen), avoid body soaps and facial scrubs (both have drying effects), body lotions/creams (clog pores); use tepid water when washing face and always follow with cold rinse to close pores before applying moisturizers (if needed) or sunscreen.

Question 39

Neurological
Headaches

Syncope

Answer 39

Maintain adequate hydration.

Rise slowly from sitting to standing.

Instruct the woman to avoid supine position from mid-pregnancy onward.

Advise her to lie on her side and rise slowly to decrease the risk of a hypotensive event.

Question 40

Describe the psychosocial changes that occur during pregnancy and the factors that influence these changes.

Answer 40

Ambivalent Feelings Toward Pregnancy-
It is common for women to experience ambivalent feelings toward pregnancy during the first trimester. These feelings decrease as pregnancy progresses. Ambivalence that continues into the third trimester may indicate unresolved conflict. When evaluating ambivalence, it is important to assess the reason for the ambivalence and its intensity.

Reorder partner relationships- Pregnancy has a dramatic effect on a couple’s relationship. Some couples view pregnancy and childbirth as a growth experience and an expression of deep commitment to their bond, while others view it as an added stressor to a relationship already in conflict. The partner’s support during pregnancy enhances the woman’s feelings of well-being and is associated with earlier and continuous prenatal care

Prenatal fear of losing control in labor- loss of control over the body and loss of control over emotions.
Some women have fears that they will lose self-esteem in labor and “fail” during labor.

The degree of fear is related to:

● The woman’s degree of trust with the medical and nursing staff, her partner, and other support persons.

● The woman’s attitude regarding the use of medication and anesthesia for labor pain management.

Expected findings:

● The woman perceives individual attention from medical staff.

● The woman perceives that she is being treated as an adult and her questions and concerns are addressed by the medical staff.

● The woman perceives that the nursing staff is compassionate, empathetic, and available.

● The woman perceives that she is being supported by her partner and family/friends.

● The woman has realistic expectations regarding management of labor pain and these expectations are met.

Question 41

maternal tasks women undergo during the course of pregnancy

Answer 41

● Ensuring a safe passage for herself and her child: the mother’s knowledge and care-seeking behaviors to ensure that both she and the newborn emerge from pregnancy healthy.

● Ensuring social acceptance of the child by significant others: the woman’s engagement of her family and social network in the pregnancy.

● Attaching or “binding-in” to the child: the development of maternal-fetal attachment.

● Giving of oneself to the demands of motherhood: the mother’s willingness and efforts to make personal sacrifices for the child.

Question 42

3. Describe the psychosocial changes that occur during pregnancy and the factors that influence these changes.

Answer 42

Ambivalent Feelings Toward Pregnancy-
It is common for women to experience ambivalent feelings toward pregnancy during the first trimester. These feelings decrease as pregnancy progresses. Ambivalence that continues into the third trimester may indicate unresolved conflict. When evaluating ambivalence, it is important to assess the reason for the ambivalence and its intensity.

Reorder partner relationships- Pregnancy has a dramatic effect on a couple’s relationship. Some couples view pregnancy and childbirth as a growth experience and an expression of deep commitment to their bond, while others view it as an added stressor to a relationship already in conflict. The partner’s support during pregnancy enhances the woman’s feelings of well-being and is associated with earlier and continuous prenatal care

Prenatal fear of losing control in labor- loss of control over the body and loss of control over emotions.
Some women have fears that they will lose self-esteem in labor and “fail” during labor.

The degree of fear is related to:

● The woman’s degree of trust with the medical and nursing staff, her partner, and other support persons.

● The woman’s attitude regarding the use of medication and anesthesia for labor pain management.

Expected findings:

● The woman perceives individual attention from medical staff.

● The woman perceives that she is being treated as an adult and her questions and concerns are addressed by the medical staff.

● The woman perceives that the nursing staff is compassionate, empathetic, and available.

● The woman perceives that she is being supported by her partner and family/friends.

● The woman has realistic expectations regarding management of labor pain and these expectations are met.

Question 43

Identification With the Motherhood Role

Answer 43

Accomplishment of this task is influenced by the woman’s acceptance of pregnancy and the relationship she has with her own mother

Events that facilitate fetal attachment include:

● Hearing the fetal heartbeat.

● Seeing the fetus move during an ultrasound examination.

● Feeling the fetus kick or move.

Expected findings:

● Moves from viewing herself as a woman-without-child to a woman-with-child

● Anticipates changes motherhood will bring to her life

● Seeks company of other pregnant women

● Is highly motivated to assume the motherhood role

● Actively prepares for the motherhood role

Question 44

Relationship to Her Mother

Answer 44

A woman’s relationship with her mother is an important determinant of adaptation to motherhood.

● Availability of the woman’s mother to her in the past and in the present.

● The mother’s reaction to her daughter’s pregnancy.

● The mother’s relationship to her daughter.

● The mother’s willingness to reminisce with her daughter about her own childbirth and child-rearing experiences.

Expected findings:

● The woman’s mother was available to her in the past and continues to be available during the pregnancy (Fig. 5–1).

● The woman’s mother accepts the pregnancy, respects her autonomy, and acknowledges her daughter becoming a mother.

● The woman’s mother relates to her daughter as an adult versus as a child.

● The woman’s mother reminisces about her own childbearing and child-rearing experiences.

Question 45

effect on a couple’s relationship.

Answer 45

There is mounting evidence that fathers and partners are influential in maternal psychological variables and smoking behavior during pregnancy

Assessment of the couple’s relationship includes:

● The partner’s concern for the woman’s needs during pregnancy.

● The woman’s concerns for her partner’s needs during pregnancy.

● The varying desire for sexual activity among pregnant women.

● The effect pregnancy has on the relationship (e.g., whether it brings them closer together or causes conflict).

● The partner’s adjustment to his or her new role.

Expected findings include the following:

● The partner is understanding and supportive of the woman.

● The partner is thoughtful and “pampers” the woman during pregnancy.

● The partner is involved in the pregnancy.

● The woman perceives that her partner is supportive.

● The woman is concerned about her partner’s needs of making emotional adjustments to the pregnancy and new role.

● Women in relationships with established open communication about sexuality are likely to have less difficulty with changes in sexual activity.

● Couples indicate that they are growing closer to each other during pregnancy.

● The partner is happy and excited about the pregnancy and prepares for the new role.

Question 46

Preparation for Labor

Answer 46

Preparation for labor means preparing for the physiological processes of labor as well as the psychological processes of separating from the fetus and becoming a mother to the child.

Expected findings:

● The woman attends childbirth classes and reads books and online resources about labor and birth.

● The woman uses smartphone applications to track her pregnancy and growing fetus.

● The woman mentally rehearses (fantasizes) the labor and birthing process.

● The woman has dreams about labor and birth and works with her partner or birthing coach to develop a birth plan.

● The woman develops realistic expectations of labor and birth.

● The pregnant woman may engage in a flurry of activity known as “nesting behavior,” hurrying to finish preparing for the newborn’s arrival.

Question 47

Prenatal Fear of Losing Self-Esteem in Labor

Answer 47

Some women have fears that they will lose self-esteem in labor and “fail” during labor. When a woman feels a threat to her self-esteem, it is important to assess the following areas

● The source of the threat

● The response to the threat

● The intensity of the reaction to the threat

Behaviors that reflect self-esteem are:

● Tolerance of self.

● Value of self and assertiveness, and decisions about her labor process.

● Positive attitude regarding body image and appearance.

Expected findings include the ability to:

● Develop realistic expectations of self during labor and birth and have an awareness of risks and potential complications.

● Identify and respect her own feelings.

● Assert herself in acquiring information needed to make decisions.

● Recognize her own needs and limitations.

● Adjust to the unexpected and unknown.

● Recover from threats quickly.

● Verbalize fears and concerns.

Question 48

Factors That Influence Maternal Adaptation

Answer 48

● Multigravidas may have the benefit of experience, but it should not be assumed that they need less help than a first-time mother (added responsibilities)

Maternal Age
Mothers who give birth at an older or younger than average age face unique circumstances and challenges.
The major developmental task of adolescence is to form and become comfortable with a sense of self. Pregnancy presents a challenge for teenagers who must cope with the conflicting developmental tasks of pregnancy and adolescence at the same time.Achieving a maternal identity is very difficult for an adolescent who is in the throes of evolving her own identity as an adult capable of psychosocial independence from her family.

Older mothers:
even with good prenatal care, there is an increased incidence of adverse perinatal outcomes. Chronic diseases that are more common in women over 35 may affect the pregnancy. Older mothers are also more likely to have miscarriages, fetal chromosomal abnormalities, low birth weight infants, premature births, and multiple births. In women older than 40, the risk increases for placenta previa, placenta abruptio, caesarean deliveries, preeclampsia, and gestational diabetes.

the lesbian woman may face unique obstacles and challenges in today’s health care environment.May have less social support, Adapt nursing assessments accordingly. Unique circumstances for partner.

Single parenting-the lesbian woman may face unique obstacles and challenges in today’s health care environment. Financial, poverty, circumstances surrounding father,

Question 49

4. Identify nursing interventions to help families adapt to the psychosocial changes that occur during pregnancy.

Answer 49

During the antepartal period, the nurse can take on a variety of roles: teacher, counselor, clinician, resource person, and role model. Nursing actions should be focused on health promotion, individualized care, and prevention of individual and family crises and are highlighted in the critical component nursing actions that facilitate adaptation to pregnancy

Question 50

#4 cont..
First trimester-nursing interventions to help families adapt to the psychosocial changes that occur during pregnancy.

Answer 50

• Begin psychosocial assessment at initial contact; assess woman’s response to pregnancy; assess stressors in woman’s life. This allows the nurse to identify issues that may require referrals and begin developing the plan of care.
• Promote pregnancy and birth as a family experience; encourage family and father or partner participation in prenatal visits; encourage questions from father and family members about the pregnancy. It is important to offer an inclusive model of care that acknowledges the needs of the family as well as the individual. Pregnancy significantly affects all family members. Meeting with family members provides additional information to the nurse and helps complete the family assessment. Positive family support is associated with positive maternal adaptation.
• Assess learning needs. This allows the nurse to provide individualized information.
• Offer anticipatory guidance regarding normal developmental stressors of pregnancy, such as ambivalence during early pregnancy, feelings of vulnerability, mood changes, and active dream/fantasy life. This allows the nurse to emphasize normalcy, health, universality, strengths, and developmental concepts, to decrease anxiety.
• Assess for increased anxieties and fear; if anxieties seem greater than normal, refer to psych care provider. Excessive anxiety, stress, and prenatal depression have a negative impact on a woman’s pregnancy and affect the physiology of the developing fetus. Specialized intervention is needed.
• Listen, validate, provide reassurance, and teach expected emotional changes. Educate partner and family members, and stress normalcy of feelings to decrease anxiety and ensure the woman feels “heard” and validated.
• If appropriate, discuss common phases through which expectant fathers progress through pregnancy. Be aware of phases of paternal adaptation when counseling parents about expected changes of pregnancy; provide anticipatory guidance regarding potential communication conflicts. This will acknowledge the partner as a significant participant in the pregnancy process and assist in improving communication and decreasing stress in the relationship.

Question 51

Second trimester-nursing interventions to help families adapt to the psychosocial changes that occur during pregnancy.

Answer 51

• Encourage verbalization of possible grief process during pregnancy related to body image changes, loss of old life, changing relationships with family and friends. The woman may be more anxious about body changes in the second trimester. She may begin to have fears or phobias. The nurse needs to acknowledge and validate the woman’s feelings and help her work toward resolving any conflicting feelings.
• Discuss normal changes in sexual activity and provide information and acknowledge the woman’s sexuality.
• Encourage “tuning in” to fetal movements; discuss fetal capacities for hearing, responding to interaction, and maternal activity. This will encourage the attachment process and help empower the woman with increased involvement in care.
• Reinforce to partner and family the importance of giving the expectant mother extra support; give specific examples of ways to help (e.g., helping her eat well, helping with heavy work, giving extra attention). This will encourage family and partner participation in the pregnancy process and promote support for the woman. A well-supported woman will likely have a more positive adaptation to pregnancy.

Question 52

Third trimester–nursing interventions to help families adapt to the psychosocial changes that occur during pregnancy.

Answer 52

• Encourage attendance at childbirth classes to promote knowledge and decrease fears. Childbirth education can give women the information they need to make informed decisions, such as educational information on the risks and benefits of vaginal delivery and cesarean delivery. Further, childbirth education can ensure that women from all population groups understand the relative risks and benefits of their choices, empowering them to make informed decisions regarding birthing options.
• Discuss preparations for birth, parenthood; explore expectations of labor. The woman will begin to focus more on the impending birth during the third trimester, and her learning needs will be more focused on this area. It is important to provide anticipatory information and guidance.
• Assess partner’s comfort level with labor coach role and reassure as needed; stress that help in labor will be available; encourage presence of second support person if appropriate. The woman’s partner may not feel comfortable providing labor support, and it is important to discuss prior to the onset of labor so all roles can be clarified.
• Refer to appropriate educational materials on parenthood. Encourage discussions of plans, expectations with partner. Give anticipatory guidance regarding the realities of infant care, breastfeeding, and so on. This will promote communication and planning with the expectant parents, as well as a positive transition to parenthood.
• If psychosocial complications develop, plan for appropriate referrals to coordinate with social workers, nutritionist, and community agencies to ensure continuity of psychosocial assessment and provide appropriate support during the woman’s pregnancy.
• Help expectant mother identify and use support systems to promote positive adaptation to pregnancy, birth, and postpartum; anticipate the need for postpartum support; and decrease the risk of postpartum depression.

Question 53

Nursing actions-assess adaptation to pregnancy

Answer 53

● Assess adaptation to pregnancy at every prenatal visit. Early assessment and intervention may prevent or greatly reduce later problems for the pregnant woman and her family.

● Identify areas of concern, validate major issues, and make suggestions for possible changes.

● Refer to the appropriate member of the health care team and follow up.

● Establish a trusting relationship, as women may be reluctant to share information until one has been formed (e.g., questions asked at the first prenatal visit bear repeating with ongoing prenatal care).

● Assess for the need for psychotropic medications and determine if any were used in the past and were effective.

● Use psychosocial health assessment screening tools.

● A variety of screening tools can be used to assess adaptation to pregnancy and to identify risk factors. Psychosocial assessment reported in the literature ranges from a few questions asked by the health care provider to questionnaires and risk screening tools focusing on a specific area such as depression or abuse

Question 54

5. Describe the benefits of prenatal care.

Answer 54

Early, adequate prenatal care has long been associated with improved pregnancy outcomes. Adequate prenatal care is a comprehensive process in which problems associated with pregnancy are identified and treated. Three basic components of adequate prenatal care have been identified: early and continuing risk assessment, health promotion, and medical and psychosocial intervention with follow-up. The aim of good prenatal care is to detect any potential problems early, prevent them if possible, and direct women to appropriate specialists or hospitals if necessary

Question 55

6. Summarize the components of the first and subsequent prenatal visits in relation to history taking, physical assessment, and ongoing risk assessment.

Answer 55

As follows

Question 56

Age, gravida/para, address, race/ethnicity, religion, marital/family status, occupation, education

Answer 56

To determine specific risks based on sociodemographic characteristics
Provide education and anticipatory guidance.
Identify psychosocial resources and available sources of support (see Chapter 5 for detailed information on psychosocial and cultural assessment).
Refer for social services, counseling services, spiritual support.

Question 57

Prior and present health status

Answer 57

To determine past and present health status
Provide education and anticipatory guidance.
Refer for additional testing/procedures.
Refer to physician specialist, counseling services, substance abuse treatment, genetic counseling, dietician, social services as indicated.
Administer rubella and/or hepatitis and flu vaccines as indicated.
Refer to cessation programs as appropriate (e.g., smoking).

Question 58

History of or current medical conditions/diseases (may include thromboembolitic blood dyscrasias, autoimmune, thyroid disorders)
Surgeries (including blood transfusions)
History of physical/sexual abuse
Medication use (prescription, over the counter, complementary)
Allergies
Immunizations

Answer 58

To identify any components in medical history that may increase risk in the well-woman population
Initiate actions to minimize risks.

Question 59

family Medical

Current health status

Genetic

Medical conditions/diseases

Answer 59

To determine both modifiable and nonmodifiable risk factors related to family and genetic history

Initiate actions to minimize risks.

Question 60

Reproductive

Menstrual

Obstetric

Gynecological

Contraceptive

Sexual
Self-Care/Lifestyle/Safety Behaviors

Answer 60

To ascertain details about menstrual cycles; past pregnancies and their outcomes; any gynecological disorders, including infertility; past or present contraceptive use; history of sexually transmitted infections; sexual orientation; past or present sexuality issues; use of safe sex practices

Assess prior pregnancy losses.
To determine:
 Frequency of health maintenance visits (well-woman and dental)
 Bowel patterns
 Sleep patterns
 Stress management
Nutrition, BMI, and exercise history

Counseling on the importance of achieving a normal BMI prior to conception
To identify tobacco, alcohol, and substance use/abuse, caffeine use
To identify use of complementary and alternative medicine modalities
To identify spiritual or religious practices
To determine safety practices such as use of seat belts, sunscreen, smoke alarms, and carbon monoxide detectors, gun safety
• Initiate actions to minimize risks.

Question 61

Psychosocial
Mental health
Social

Answer 61

To ascertain past and present psychological and emotional health
To identify social patterns and sources of emotional and social support in family and friends
Refer to mental health providers as needed.

Question 62

Cultural
Beliefs/values
Practices
Primary language

Answer 62

To identify cultural practices and beliefs/values impacting health and pregnancy
• Incorporate knowledge of beliefs and practices in care.
To determine need for translation
Obtain translation assistance as needed.
Provide educational materials in woman’s primary language.

Question 63

Environmental

Home

Workplace

Answer 63

To identify past and current exposure to environmental or occupational hazards/toxins

Refer for environmental exposure counseling, genetic counseling when indicated.

Question 64

Financial
Basic needs related to food and housing Resources
Health insurance

Answer 64

To determine adequacy of resources to meet basic ongoing needs
Refer for social services, economic support services as indicated.

Question 65

7. Recognize lifestyle choices that may be detrimental to maternal and fetal well-being.

Answer 65

Should avoid:
Illicit drugs, alcohol, tobacco (even secondhand smoke), and excessive use of caffeine.
Medications contraindicated in pregnancy (prescription, over-the-counter, and herbal supplements).
Environmental toxins. Exposure to some toxic substances—including lead, mercury, arsenic, cadmium, pesticides, solvents, and household chemicals—can increase the risk of miscarriage, preterm birth, and other pregnancy complications (U.S. Department of Health and Human Services, 2009).

Should be encouraged:
Use safer sex practices to prevent STIs.
Use seat belts in a car, ensure that smoke alarms and carbon monoxide detectors are in working order, apply sunscreen when outdoors.
Maintain adequate relaxation and sleep.
Maintain optimal oral health and treat any periodontal disease before pregnancy, as it has been associated with adverse pregnancy outcomes, including preterm birth, low birth weight, and preeclampsia (Vamos et al., 2015)
Discuss the use of complementary or alternative medicine modalities, such as acupuncture, herbal supplements, homeopathy, and massage, with her primary health care provider. Some of these interventions may need to be discontinued before a pregnancy for safety reasons.

Question 66

8. Differentiate presumptive, probable, and positive signs of pregnancy.

Presumptive-could have causes outside of pregnancy- not diagnostic

Answer 66

Presumptive- could have causes outside of pregnancy- not diagnostic
Amenorrhea: Absence of menstruation
Nausea and vomiting: Common from week 2 through 12
Breast changes: Changes begin to appear at 2 to 3 weeks
Fatigue: Common during the first trimester
Urination frequency: Related to pressure of enlarging uterus on bladder; decreases as uterus moves upward and out of pelvis
Quickening: A woman’s first awareness of fetal movement; occurs around 18 to 20 weeks’ gestation in primigravidas (between 14 and 16 weeks in multigravidas)

Question 67

Probable- These changes could also have causes other than pregnancy and are not considered diagnostic

Answer 67

~Chadwick’s sign: Bluish-purple coloration of the vaginal mucosa, cervix, and vulva seen at 6 to 8 weeks
~Goodell’s sign: Softening of the cervix and vagina with increased leukorrheal discharge; palpated at 8 weeks
~Hegar’s sign: Softening of the lower uterine segment; palpated at 6 weeks
Uterine growth and abdominal growth

~ Skin hyperpigmentation
Melasma (chloasma), also referred to as the mask of pregnancy: Brownish pigmentation over the forehead, temples, cheek, and/or upper lip
Linea nigra: Dark line that runs from the umbilicus to the pubis
Nipples and areola: Become darker; more evident in primigravidas and dark-haired women
Ballottement: A light tap of the examining finger on the cervix causes fetus to rise in the amniotic fluid and then rebound to its original position; occurs at 16 to 18 weeks
Positive pregnancy test results- Laboratory tests are based on detection of the presence of hCG in maternal urine or blood.

Question 68

Positive signs- objective

Answer 68

~Auscultation of the fetal heart, by 10 to 12 weeks’ gestation with a Doppler
~Observation and palpation of fetal movement by the examiner after about 20 weeks’ gestation
~ Sonographic visualization of the fetus: Cardiac movement noted at 4 to 8 weeks

Question 69

9. Discuss aspects of prenatal care for the adolescent and for women over the age of 35.

Answer 69

~Adolescents
Increased risk for:
Low-birth-weight and preterm neonates. 
  Preeclampsia.
Anemia.
Labor dysfunction.
Cephalopelvic disproportion

~Maternal age over 35
Increased risk for: 
Trisomy 21 (1-385) 
Screened for in the second trimester. (Quadruple screen), Refer the patient for genetic counseling with any positive results. 
 Placenta previa.
Chronic diseases.
Twins.

(needs more)

Question 70

10. Describe optimal nutrition and weight gain during pregnancy.

Answer 70

Underweight less than 18.5(BMI)-recommended weight gain 28-40lbs
Rates of weight gain 2nd and 3rd trimester mean(range) in lbs/week-1(1-1.3)

Normal weight18.5-24.9(BMI)-Recommended weight gain-25-35
37-54 for twin pregnancies
Rates of weight gain 2nd and 3rd trimester mean(range) in lbs/week-1(0.8-1)

overweight(25-29.9)(BMI)
Recommended weight gain-15-25
31-50 for twin
Rates of weight gain 2nd and 3rd trimester mean(range) in lbs/week-0.6(0.5-0.7)

Obese 30 or higher(BMI)
recommended weight gain-11-20
25-42 for twin
Rates of weight gain 2nd and 3rd trimester mean(range) in lbs/week-0.5(0.4-0.6)

Baby: 7–8 lb Placenta:1.5 lb Amniotic fluid: 2 lb Breasts: 1–3 lb Uterus: 2 lb Increased fluid volume: 2–3 lb Increased blood volume: 3–4 lb Maternal fat: 6–8 lb

evidence suggests that inadequate weight gain and/or an underweight pre-pregnancy weight increases risk for poor fetal growth and low birth weight.

excessive weight gain and/or an overweight or obese pre-pregnancy weight increases the risk for poor maternal and neonatal outcomes and may have far-reaching implications for long-term health and development of chronic disease.

Pregnancy is a time when women are open to nutritional and lifestyle education, so it is an optimal time for needed behavioral changes in overweight and obese women

Question 71

10-Nutrition

Answer 71

~Calcium • Dietary supplements • Essential fatty acids • Folic acid • Iodine • Iron
Nutrition should be discussed at all prenatal visits to reinforce the importance of appropriate weight gain, as both excessive and inadequate weight gain in pregnancy are associated with poor perinatal outcomes.

Nutritional education for women of childbearing years should include:
● Education on diet and physical activity and their role in reproductive health.
● Advise on the importance of achieving and maintaining a healthy weight prior to conception (Meehan et al., 2014).
● Encouragement to make nutritious food choices with an emphasis on fresh fruits and vegetables, lean protein sources, low-fat or nonfat dairy foods, whole grains, and small amounts of healthy fats.
● Help in choosing appropriate foods and serving sizes (Fig. 4–7).
Discuss appetite, cravings, or food aversions
. ● Obtain a 24-hour diet recall and review for obvious deficiencies.
● Based on the woman’s pre-pregnancy BMI and IOM guidelines (Box 4–2):
● Assist the woman to set weight-gain goals with a recommended weight gain of between 1 and 5 pounds during the first trimester.
● Discuss distribution of weight gain during pregnancy (Box 4–3).
● Encourage the woman to eat a variety of unprocessed foods from all food groups, including fresh fruits, vegetables, whole grains, lean meats or beans, and low-fat dairy products (USDA, 2017).
● For more detailed information on nutritional needs during each trimester of pregnancy or to design a personalized daily food plan tailored to personal life circumstances, refer the patient to www.choosemyplate.gov/moms-daily-food-plan (see Fig. 4–7).
● Encourage the woman to drink 8 to 10 glasses of fluid per day and limit caffeine to 200 mg per day.
● Certain types of fish (king mackerel, orange roughy, marlin, shark, swordfish, and tilefish) should be avoided due to high levels of mercury; however, most other fish and seafood are safe as long as fully cooked. Tuna is safe but limit white (albacore) tuna to 6 ounces per week.
Advise on prevention of food-borne illnesses:
● Wash hands frequently, before and after handling food. Use warm water and soap.
● Thoroughly rinse all raw vegetables and fruits before eating.
● Cook eggs and all meats, poultry, or fish thoroughly, and sanitize all dishes, utensils, cutting boards, or areas that contact these during food preparation.
● Discard cooked food left out at room temperature for more than 2 hours.
● Foods to avoid:
● Unpasteurized juices or dairy products
● Raw sprouts of any kind
● Unpasteurized soft cheeses like Brie, Camembert, or feta
● Refrigerated, smoked seafood
● Unheated deli meats or hot dogs
● Raw eggs
● Raw fish and shellfish
● Teas with chamomile, peppermint, licorice, or raspberry leaf

Question 72

11. Define the term intimate partner violence and discuss the significance and scope of the problem.

Answer 72

Intimate partner violence (IPV) against women consists of actual or threatened physical or sexual violence and psychological and emotional abuse by a current or former partner or spouse. IVP affects women of every age, race, religion, socioeconomic status, and educational level and is the most common form of violence against women. Pregnant women are at a higher risk for IPV, especially when the pregnancy is unplanned. Homicide is a leading cause of death in pregnant or recently pregnant women, and a significant portion of those homicides are committed by current or former intimate partners

, one out of four women in the United States has experienced IPV; however, the true prevalence may be unknown due to fear of disclosure by the victim or failure on the part of the provider to screen adequately. Recent data reports the prevalence of physical violence by an intimate partner was 31.5% among women and an estimated 47.1% of women experienced at least one act of psychological aggression by an intimate partner during their lifetimes. For some women, pregnancy is the only time they come into frequent contact with a health care provider. Early identification of IPV is necessary to minimize its serious physical and mental effects, as well as its adverse health outcomes for the fetus
The CDC reports 1 in 10 men

IPV is more common than:
Gestational diabetes
Preeclampsia
Is associated with:
Increased use of healthcare services
Patients present with multiple vague symptoms:
Frequent sore throats
bruises, in unusual places
Poor weight gain
Depression and anxiety
Increased rate of ETOH use, smoking and substance abuse

Question 73

12. Describe the different types of intimate partner violence.

Answer 73

„Physical- Neck and face most common area.
„Sexual- Any forcing of sexual attention is abuse. No means No!
„Psychological coercion, threats, stalking. Verbal insults.
„Social abuse- isolates the partner, limits the victims activities. Not allowed to have a job, go to school
„Economic- Limited and or no access to funds.

Power and control-
Coercion and threats
Intimidation
emotional abuse 
isolation
Minimizing denying and blaming
Using children and pets
using privilege 
economic abuse

Question 74

13. Identify a national health goal related to intimate partner violence and discuss how nurses may be instrumental in helping the nation to achieve this goal.

Answer 74

Assessment for abuse during pregnancy with education, advocacy, and referral to community resources should be standard for all pregnant women during routine prenatal visits and on admission in labor. AWHONN advocates for universal screening for all pregnant women and recommends the ABCs of patient care to guide nurses caring for victims of abuse (AWHONN, 2007):

A: Alone. Reassure the woman that she is not alone, that there have been others in her position before, and that help is available.
B: Belief. Articulate your belief in the victim—that you know the abuse is not her fault and that no one deserves to be hurt or mistreated.
C: Confidentiality. Ensure the confidentiality of the information that is being provided and explain the implication of mandatory reporting laws, where applicable.
D: Documentation. Descriptive documentation with photographs, taken with the woman’s permission, and a verbatim account from the patient’s perspective is helpful to accurately capture and record the nature and extent of injuries.
E: Education. Education about community resources can be lifesaving. Know where you can refer a woman for help and have information about local shelters readily available. Also ask if she knows how to obtain a restraining order
S: Safety. One of the most dangerous times for women is when they decide to leave an abusive relationship. Tell the woman to call 911 if she is in imminent danger and to consider alerting neighbors to call the police if they hear and/or see signs of conflict.

Research has documented that three simple screening questions can reliably identify abused women: Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Within the last year, has anyone forced you to engage in sexual activities?

Question 75

14. Discuss characteristics of the three phases typically included in a cycle of violence and describe how partners generally react during each phase.

Answer 75

These are the common stages of abuse( Tension building, violence , honeymoon) . The tension grows, it results in violence, and is often followed by apologies and promises never to do it again. However, the violence usually occurs again and increases in severity.

Question 76

15. Explain how to conduct intimate partner violence screening and assessments.

Answer 76

Nurses spend a lot of time with the patient and play an important role in identifying the patient.
It is important to know if patients have experienced sexual abuse in their past because it can impact their anxiety and pain during labor and during routine exams.  
Slides-Are you safe at home?
Have you been hit, slapped, kicked or
hurt by someone?
Have any of these things occurred
since you have become pregnant?
In the last year have you been sexually
abused?
Have you ever been sexually abused?

Nursing Interventions.
Some things we can say to patients.
“It’s not your fault”
“You don’t deserve to be abused”
Counsel the victim to have an escape or safety plan.
•
Don’t hide in an enclosed area where there is no means of escape
•“Do you have somewhere to go or a plan for escape if you need it?”
Pack a bag with clothes and some provisions ,if you feel safe to do so.
Use care when giving patients written materials as this could trigger violence if
the abuser sees it.
We can’t make someone leave an abusive situation, but we can educate and
assist with getting the victim to acknowledge they don’t deserve what is
happening.
ABCD and S of IPV
A- tell her she is not alone, and help is available.
B-believe. Reassure her that you believe the story. Do not minimize even if the patient does.
C- Confidential. The conversation will remain confidential. Unless she discloses that minor children are being abused.
D-Document exactly what she says. If she has bruises or is injured in any way get permission to take pictures.
S- Safety. Remember the most dangerous time is when she leaves.

Question 77

16. Describe the nurse’s role in planning and providing care for victims of intimate partner violence.

Answer 77

On previous slides

Question 78

Categories of Clinical Content for Preconception Care

Answer 78

Health promotion
• Family planning and reproductive life plan

• Weight status
• Physical activity
• Nutrient intake
• Folate
• Substance use
• STIs

Personal history
• Family history

• Known genetic conditions
• Prior cesarean delivery
• Prior miscarriage
• Prior preterm birth
• Prior stillbirth
• Uterine anomalies

Nutrition
• Calcium

• Dietary supplements
• Essential fatty acids
• Folic acid
• Iodine
• Iron

Immunizations
• Hepatitis B

• HPV
• Influenza
• Measles, mumps, and rubella (MMR)
• Tetanus, diphtheria, pertussis (Tdap)
• Varicella

Infectious diseases
• Cytomegalovirus

• Hepatitis C
• Herpes simplex virus
• HIV
• Listeriosis
• Malaria
• STIs
• Syphilis
• Toxoplasmosis
• Tuberculosis

Medical Conditions
• Asthma

• Cardiovascular disease
• Diabetes mellitus
• Eating disorders
• Hypertension
• Lupus
• Phenylketonuria (PKU)
• Psychiatric conditions
• Renal disease
• Rheumatoid arthritis
• Seizure disorders
• Thrombophilia
• Thyroid disease

Exposures
• Alcohol, tobacco, illicit substances

• Environmental
• Hobbies
• Medications

Psychosocial risks
• Access to care

• Inadequate financial resources

Special populations
• Disability

• Immigrant and refugee populations
• Survivors of cancer