Chapter 9: The Prenatal Assessment Flashcards
(135 cards)
1
Q
What is a normal response to pregnancy that a woman might experience?
A
Ambivalence
- begin to question their desire to be pregnant
- occurs irrespective of how determined and committed the couple is to the goal of beginning or expanding a family
- relates to the sudden realization that life as it has been known is going to change dramatically and will be a life-long endeavor
- woman can anticipate role changes in relation to her career and relationships and a need to prepare for the role of being a mother to an infant who will be dependent on her for survival
2
Q
What is essential in helping the woman positively embrace and celebrate her journey into motherhood?
A
-recognizing ambivalence and its normalcy in relation to pregnancy during the first trimester and providing support and reassurance are essential
3
Q
The World Health Report “Make Every Woman and Every Child Count” (World Health Organization)
A
focuses on making pregnancy safer and asserts that reaching this goal centers on providing excellent antenatal care and constructing societies that support pregnant woman
-antenatal care must be consistently accessible and responsive while incorporating patient-centered interventions, thereby removing barriers that prevent access to care
4
Q
The nurses role in the WHO goal
A
promoting optimal prenatal care for all woman
5
Q
Essential Components of Prenatal Care
A
- actively listening to the woman
- provide individualized education
- respecting woman’s choices
- the woman has the right to expect continuity of care, clear explanations, consistent information, and the opportunity to discuss any aspect of her care at any time
6
Q
Essential Nursing Goals when providing care for the prenatal patient
A
- to recognize deviations from normal
- to provide individualized, evidence-based care
- actively listening to the patient
- provide culturally appropriate prenatal education designed to meet the patient’s learning style and needs
- to empower woman to become actively involved in their pregnancy by being informed recipients and shared decision makers
7
Q
Possible Nursing Diagnoses for the Prenatal Patient
A
- knowledge deficit r/t normal physiological changes of pregnancy
- altered nutrition risk: less than body requirements
- risk for fatigue
- risk for disturbance in body image
- risk for altered role performance
- altered sexual patterns
- family coping
- change in comfort level r/t advancing pregnancy
- change in sleep patterns
- altered urinary elimination due to enlarging uterus or engagement of fetal part
- anxiety
- adolescent
- family processes, altered
8
Q
When does prenatal care usually begin?
A
in the first trimester of pregnancy, when the patient is seen every 4 weeks until she reaches 28 to 32 weeks gestation
-at that time, appointments change to visits every 2 weeks and then occur weekly from 36 weeks of gestation until birth
9
Q
Prenatal Visits
A
during the first trimester, the patient is seen every 4 weeks until she reaches 28 to 32 weeks gestation
-at that time, appointments change to visits every 2 weeks and then occur weekly from 36 weeks of gestation until birth
>the number of total prenatal visits varies
10
Q
Nurses role for CAREing for the Prenatal Patient
A
-Communicate
-Advocate
-Respect
-Empower Woman
>help women become informed recipient of care
>facilitate shared decision making
11
Q
CARE Principles
A
the nurses primary role is to CARE for the patient
- Communicate
- Advocate
- Respect
- Enable/empower
12
Q
CARE Principles: Communicate
A
the exchange of information between individuals, for example, by means of speaking, writing, or using a common system of signs of behavior
- a spoken or written message
- the communicating of information
- a sense of mutual understanding and sympathy
13
Q
CARE Principles: Advocate
A
- one who argues for a cause; a supporter or defender
- one who pleads in another’s behalf; an intercessor: advocates for abused children and spouses
- the nurses role encompasses being an advocate
- an advocate verbalizes the patients wishes if the patient is unable to do so and ensures that the patient’s questions are answered in an understandable and comprehensive way
- to help the patient to become an informed recipient of care
- supports and represents the rights and interests of another individual to ensure the individuals full legal rights and access to services
14
Q
Respecting the Patient Involves what?
A
valuing the patient as an individual, listening attentively, and addressing all of her concerns
15
Q
CARE Principles: Respect
A
- to feel or show admiration and deference toward somebody or something
- to pay due attention to and refrain from violating something
- to show consideration or thoughtfulness in relation to somebody or something
16
Q
CARE Principles: Enable/Empower
A
-to provide somebody with the resources, authority, or opportunity to do something
-to make something possible or feasible
>nurses need to empower women by caring, actively listening, and recognizing their inner wisdom, strength, and abilities; in doing so, nurses gain insights to help them meet their patients needs in relation to education; health promotion; and physical, psychological, emotional, and spiritual support
17
Q
An Informed recipient of care is what and is able to do what?
A
-is an individual who has been made aware of available health-care options and the possible consequences or outcomes of the choices made
-the informed pregnant woman is able to discuss the advantages and disadvantages of various screening tools, diagnostic tests, and treatment options, and she is empowered to make an informed choice that is right for her and her family
>nurses should remain non-judgmental, and able to listen and respond accurately and objectively
18
Q
What are the Reasons during pregnancy that can be associated with Maternal Stress?
A
-difficulty with accessing care
>transportation problems, appointment schedules that conflict with work commitments, and personal or family illness may prevent the woman from keeping her prenatal appointments
-communication difficulties
-perceptions of staff disinterest
-lack of understanding about the importance of frequent prenatal visits
19
Q
How can Nurses reduce Maternal Stress
A
-using an individualized approach with a focus on communication, personalized care, and education
-use the CARE principles
-provide stress management
social support; nurses and health-care providers may give support
20
Q
The First Prenatal Visit: The Initial Interview Time should be used to do what?
A
build a positive, nonthreatening relationship, and gain her confidence
-strategies useful: active listening, validating responses when needed, maintaining eye-to-eye contact, and the use of humor as appropriate to relax the patient; honesty is essential for effective communication
21
Q
Strategies to use during the Initial Interview at the first prenatal visit
A
active listening, validating responses when needed, eye-to-eye contact, and the use of humor as appropriate to relax the patient
- honesty is essential for effective communication
- when uncertain of the answer to a question, the nurse should make a note to find the answer and report back to the patient at the end of the interview
22
Q
What should the nurse do before initiating the Interview at the first prenatal visit?
A
helpful for the nurse to review the paperwork to become familiar with the information to be gathered and to ensure an understanding of the relevance and appropriateness of the questions to be asked
23
Q
Essential Components of Caring Communication Skills
A
-qualities of “comfort”, “acceptance”, “responsiveness”, and “empathy”
>comfort and acceptance refer to one’s ability to deal with difficult topics without displaying uneasiness and accepting attitudes the patient brings to the interview without showing annoyance or intolerance
>responsiveness and empathy refer to the quality of reacting to indirect messages expressed by the patient; empathetic listening helps the nurse to understand what the patient is actually saying
24
Q
First Prenatal Visit Reminders for the Nurse
A
- manage the environment to promote privacy and provide the patient with psychological and physical comfort
- avoid medical or technical jargon
- open-ended questions
25
Comprehensive Health History Includes
- biographical data
- social history
- hx of intimate partner violence
- psychological assessment
- obstetric hx
- current pregnancy
- medical hx
- gynecological hx
26
Comprehensive Health History Assessment: Biographical Data
- contact information for the patient such as address, phone number(s), occupation and educational level, marital/relationship status, insurance data, and contact person information
- some forms may contain spiritual or cultural considerations
- woman's age and date of birth
27
How to facilitate collection of data for the healthy history assessment?
to facilitate the collection of data, a number of prenatal forms such as the Prenatal Plus Program--Initial Assessment form is available
-this form allows for the collection of info relating to the patients pregnancy hx, medical hx, nutritional and exercise patters, financial income, vocation and educational goals, living arrangements, psychosocial hx, and lifestyle choices
28
Comprehensive Health History Assessment: Social History
- educational level and occupation
- these data help to establish patients socioeconomic group
- may provide info regarding family income, standard of housing, and nutrition
- marital status
29
Comprehensive Health History Assessment: Hx of Intimate Partner Violence
-a nonthreatening approach is to ask patients directly whether they feel safe going home and whether they have been hurt physically, emotionally, or sexually by a past or present partner
>if the partner accompanied to prenatal visit, these questions are postponed until the nurse is alone with the patient
-alternate method: use a standardized form that has valid and reliable questions concerning IPV
>IVP can occur for the first time during pregnancy
30
Femicide
-the death of a woman resulting from an act of violence against that woman
>common death among pregnant woman
31
"RADAR" to guide nurses as they interview patients about relationship violence
- Routinely screen every patient
- Ask directly, kindly, and in a nonjudgmental manner
- Document your findings
- Assess the patient's safety
- Review options and provide referrals
32
Comprehensive Health History Assessment: Drug Use
drug use; defense to emotionally deal with abuse
- use of nonprescription drugs such as cocaine, amphetamines, heroin, marijuana, or ectasy
- detrimental effects; spontaneous abortion, low birth weight, placental abruption, and preterm labor)
33
Comprehensive Health History Assessment: Psychological Assessment
each patient harbors a host of unique medical and psychological factors
ex: a woman with a hx of a previous eating disorder may experience difficulty maintaining a healthy diet and achieving appropriate weight gain during pregnancy
ex: another woman may have struggled with anxiety and depression, alcohol or drug use, or issues r/t domestic violence before pregnancy
>these factors can have a significant impact on the prenatal course
34
Comprehensive Health History Assessment: The Obstetric History
include the current pregnancy and all previous pregnancies and their outcomes because complications experienced in a prior pregnancy often reoccur in subsequent pregnancies
>educate the woman about the developing embryo/ fetus during first few weeks of pregnancy; be conscious of potential teratogens
35
Presumptive Signs of Pregnancy
subjective
>these signs can be caused by other conditions
-Amenorrhea (absence of menses)
-Nausea and Vomiting ("morning sickness")
-Frequent Urination (urinary frequency)
-Breast Tenderness
-Perception of fetal movement (quickening)
-Skin changes include stretch marks (striae gravidarum) and increased pigmentation
-fatigue
36
Subjective Signs (of pregnancy)
the symptoms that the patient experiences and reports
| >because these symptoms may be caused by other conditions, they are the least indicative of pregnancy
37
Probable Signs of Pregnancy
- abdominal enlargement
- Piskacek's Sign (uterine asymmetry with a soft prominence on the implantation side)
- Hegar's Sign (softening of the lower uterine segment)
- Goodell's Sign (softening of the tip of the cervix)
- Chadwick's Sign (violet-bluish color of the vaginal mucosa and cervix)
- Braxton Hicks contractions (intermittent uterine contractions)
- positive pregnancy test
- Ballottement (passive movement of the unengaged fetus)
38
Objective Signs (of Pregnancy)
observed by the examiner
-these signs result from physical changes in the reproductive system
>these can be caused by other conditions, so a positive diagnosis of pregnancy cannot be based on these findings alone
39
Probable Signs of Pregnancy: Piskacek's Sign
uterine asymmetry with a soft prominence on the implantation side
40
Probable Signs of Pregnancy: Hegar's Sign
softening of the lower uterine segment
41
Probable Signs of Pregnancy: Goodell's Sign
softening of the tip of the cervix
42
Probable Signs of Pregnancy: Chadwick's Sign
violet-bluish color of the vaginal mucosa and cervix
43
Probable Signs of Pregnancy: Ballottement
passive movement of the unengaged fetus
44
Each Trimester is how long?
14 weeks or 3 months in duration
45
Naegele's Rule
used to calculate the expected date of birth (EDD)
-based on first day of the woman's last normal menstrual period (LMP); based on a 28-day cycle
-7 days are added
-3 months are subtracted
-a year added when necessary
>menstrual cycle irregularity and variations in cycle length most likely invalidate the use of this rule as the sole method for estimating gestational age. A gestation wheel is a useful tool for that
46
Gravid, Gravida, Gravidity
```
Gravid= state of being pregnant
Gravida= a pregnant woman
Gravidity= number of times a woman has been pregnant, irrespective of the outcome
```
47
Gravid
state of being pregnant
48
Gravida
a pregnant woman
49
Gravidity
number of times a woman has been pregnant, irrespective of the outcome
50
Nulligravida
a woman who has never experienced a pregnancy
51
Primigravida
woman pregnant for the first time
52
Secundigravida
woman pregnant for the second time
53
Multigravida
describes a woman who is pregnant for the third time (or more times)
54
Parity
refers to the number of pregnancies carried to a point of viability (20 weeks), regardless of the outcome
ex: para 1 = one pregnancy reached the age of viability
para 2= two pregnancies reached the age of viability
>para denotes number of pregnancies not number of baby/fetus
55
GTPAL
```
G= Gravida (# of pregnancies)
T= number of term pregnancies
P= number of Preterm deliveries
A= number of abortions (spontaneous and induced)
L= number of living children
```
56
What makes a pregnancy test positive?
a detectable level of human chorionic gonadotropin (hCG) must be present in the urine or blood
- hCG levels peak between days 60 and 70 of pregnancy than gradually decrease approximately over the next 40 days to reach a plateau that is maintained throughout pregnancy
- can be detected in blood as early as 1 day after implantation and in the urine around day 26
57
Human Chorionic Gonadotropin (hCG)
this must be present in the urine to have a positive pregnancy test
-these levels peak between days 60 and 70 of pregnancy then gradually decrease for the next 40 days to reach a level that is maintained throughout pregnancy
-can be detected in the blood as early as 1 day after implantation and in the urine around day 26
-hCG molecule contains both an alpha subunit and a beta subunit
>woman should be advised to use a home pregnancy test that is specific for the beta subunit of hCG because this marker prevents cross reactions with other hormones
58
Which Pregnancy Test Is advised for woman?
use a home pregnancy test that is specific for the beta subunit of hCG because this marker prevents cross reactions with other hormones
-the alpha subunit is similar in molecular structure to luteinizing hormone (LH), so woman with high LH levels (ex; those experiencing menopause) who use a pregnancy test designed to detect the complete hCG molecule risk obtaining a false-positive
>follow manufacturers recommendation to avoid unreliable results
>if home pregnancy test is negative, but signs of pregnancy persist, the test should be repeated in a week or woman should see healthcare provider
59
Chemical Pregnancy
term used to describe a situation that occurs when a home pregnancy test has confirmed the presence of hCG, but a late and often heavy menstrual period follows
>conception probably occurred but for some reason the pregnancy was unable to continue and develop into a viable embryo
60
Assessment: Medical History
-obtain contact information for the primary care provider to facilitate continuity of care
>if lack of one, nurse can explore these issues through sensitive and respectful questioning, and when appropriate, refer to local agencies that provide services such as the WIC (woman, infants, and children) program for nutritional support
-dental health, eye health, immunizations, preexisting medical conditions, environmental hazards
61
How does a nurse promote dental health
- encourage regular dental examinations
- promote twice daily brushing and flossing
- recommend use of a fluoride toothpaste
- encourage a healthy diet
- encourage chewing gum containing xylitol after meals
62
Medical Hx: Dental Health and Pregnancy
hormones of pregnancy predispose women to an increased plaque and the development of gingivitis, or gum inflammation
-link between periodontal disease in pregnancy, gingivitis, and preterm labor
63
Medical hx: Eye health
ophthalmic evaluation is recommended early in pregnancy or at any time visual changes occur
- important for women with medical conditions such as essential hypertension, Graves disease, or diabetes mellitus; and for women who wear contact lenses
- normal changes that occur: decreased intraocular pressure, corneal thickening, corneal sensitivity, and increased curvature of the cornea; all of which resolve spontaneously during post-partum
64
Medical Hx: Immunizations
-Vaccination against influenza is considered safe throughout pregnancy and is an essential element of prenatal care
-nurses and their patients also need to be aware that some infections contracted during pregnancy can be detrimental to the fetus (ex: Rubella, Varicella (chicken pox) and Rubeola (red measles))
-a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has never received the vaccine for tetanus, diphtheria, and pertussis (Tdap) or if 10 years have elapsed since immunization
>Tdap should be administered during the third or late second trimester (after 20 weeks gestation) of pregnancy
>recommend rubella vaccination after childbirth if not immune; wait at least 4 weeks to get pregnant after vaccination
65
Eye Exam Important Notes/ Patient Education
-during an exam, it is relatively common practice to dilate the pupils to facilitate ocular assessment
>occasional use of parasympatholytics (ex: atropine) and sympathomimetics (ex: epinephrine) is thought to be safe, repeated use is contraindicated because of possible teratogenic effects
-Mydriatics (medications that dilate the pupils) are contraindicated in breastfeeding mothers because they have a hypersensitive and anticholinergic effect on the infant
>all prenatal and breastfeeding patients should be advised that certain components of the eye examination may carry risks during pregnancy, and make certain eye care professional is aware if pregnant or breastfeeding
>CDC recommendations endorse Hepatitis B vaccinations during pregnancy for those at risk
66
Rubella
most commonly recognized viral infection known to cause congenital problems
-if woman contracts rubella during the first 12 weeks of pregnancy, the fetus has a 90% chance of being adversely affected
-Symptoms: intrauterine growth restriction, cardiac defects, sensorineural defects, cataracts, and microcephaly (small head)
>a maternity patient who is not immune to rubella should be offered the rubella immunization after childbirth, ideally before discharge
>if possible, be tested greater than or equal to 3 months to check for immunity
>after vaccination, be advised not to become pregnant for at least 4 weeks
67
Neonatal Pertussis
"whooping cough"
-contagious bacterial infection caused by gram-negative coccobacillis Bordetella pertussis, which causes disease through the elaboration of toxins that damage respiratory epithelium
-transmitted by respiratory droplets
-carries significant morbidity and mortality in newborns
>a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has never received the vaccine for tetanus, diphtheria, and pertussis (Tdap) or if 10 year have elapsed since immunization
68
Neonatal Pertussis
"whooping cough"
-contagious bacterial infection caused by gram-negative coccobacillis Bordetella pertussis, which causes disease through the elaboration of toxins that damage respiratory epithelium
-transmitted by respiratory droplets
-carries significant morbidity and mortality in newborns
>a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has never received the vaccine for tetanus, diphtheria, and pertussis (Tdap) or if 10 year have elapsed since immunization
>Tdap should be administered during the third or late second trimester (after 20 weeks gestation) of pregnancy
69
During the Prenatal period, why is it important to screen for Hepatitis B?
because a positive diagnosis will influence both the maternal and newborn medical management
70
Patients at higher risk for Hepatitis B
-persons with conditions that require immunosuppressive or immune modifying therapy
-blood or tissue donors
-hemodialysis patients
-HIV-positive persons
>those at higher risk for acquiring the hepatitis B virus should also be tested for the antibody to hepatitis B surface antigen
>persons negative for both markers and who are at risk for infection should be vaccinated
>CDC endorses vaccination during pregnancy who are at risk
71
Nurse Teachings: educational strategies for patients who are Hepatitis Carriers
- avoid drugs that are hepatotoxic such as acetaminophen (Tylenol)
- avoid alcohol
- if possible choose noninvasive prenatal diagnostic techniques, such as ultrasound and AFP screening rather than invasive procedures, such as chorionic villus sampling (CVS) and amniocentesis
- make sure pediatrician is aware of maternal hepatitis B status
- practice "daily living" precautions to prevent transmission to household members; covering cuts or skin lesions and not sharing toothbrushes or razors
- the neonate will receive hepatitis B immune globulin (GBIG) at birth; this action will provide antibodies to the hep B virus and give some protection to newborn; the IM injection must be administered within 12 hours of birth; the hepatitis B vaccine (Recombivax HB, Energix-B0, which includes protective antihepatitis B antibodies, may be administered at the same time as HBIG but at a different site; Hep B vaccine is given again at 1,2, and 12 months of age
- the method of birth does not appear to influence the incidence of mother-to-child transmission
- in HAV-infected women, breastfeeding is permissible with appropriate hygienic precautions
- Breastfeeding is not contraindicated in woman chronically infected with HBV if infant receives the HBIG passive prophylaxis and vaccine active prophylaxis
72
Medical Hx: Environmental Hazards
-fetus is at risk from maternal exposure to environmental toxins such as pesticides and other compounds (ex: polychlorinated biphenyl, substance used as a coolant and lubricant on electrical equipment) that can accumulate in maternal adipose tissue and possibly be transmitted to the infant via breast milk
-air pollutants
>use the Environmental and Occupational Health History Profile tool
-Direct and Passive Smoking
73
Asking the prenatal patient about the potential for pesticide exposure
-because of widespread use of pesticide, the nurse needs to assess every prenatal patient for the potential for pesticide exposure
-ask:
>do you use pesticides in your home, lawn, or workplace?
>do you use pesticides on your pets? (flea collars, dips, and once-a-month products)
>if you do use pesticides, what do you use?; Where and how often do you use them?
74
Effects of tobacco use during pregnancy
-premature rupture of the membranes
-preterm labor
-placental abruption
-placenta previa
-infants who are small for gestation age (SGA)
>the detrimental effects continue into childhood and are associated with upper respiratory infections, childhood asthma, and wheezing
>smoking cessation programs are available through CSC, the ACOG, and other organizations
75
Gynecological Hx
need to be performed to determine if any event in the patients past places the current pregnancy at risk or warrants further investigation
-women age 35 and older and foreign-born should be questioned about in utero exposure to diethylstilbestrol (DES); is a nonsteroidal, synthetic estrogen that is more powerful than natural estrogens
76
What should happen before a patient is asked to consent to any investigation?
she should be counseled about the purpose of the test, its reliability, and the implications of a negative or positive result
-explain the difference between a screening test and a diagnostic test
77
A screening test
- identifies patients at increased risk for developing a disorder or disease
- identifies patients who need diagnostic testing
78
A diagnostic test
confirms the presence of a disorder or a disease
79
Blood is drawn at the First Prenatal Visit for a number of Tests:
-patients blood group and rhesus (Rh) factor
-antibody screen (Kell, Duffy, rubella, varicella, toxoplasmosis, and anti-Rh)
-RPR/VDRL (rapid plasma reagent/ Venereal Disease Research Laboratory) screen for syphillis
-if not received Hepatitis B vaccine, she is tested for Hep B surface antigen (HbsAG) and Hep B surface antibody (HbsAB)
-a complete blood count (CBC) with hemoglobin, hematocrit, and differential count is obtained and assessed using laboratory values established for pregnancy
>Testing for antibody to HIV is recommended
>Sickle cell screen recommended for women of African, Asian, or Middle Eastern descent
>a Tine or purified protein derivative (PPD) tuberculin test may be assessed for exposure to tuberculosis
80
An STI can predispose to a number of adverse pregnancy outcomes such as?
- ectopic pregnancy
- spontaneous abortion
- preterm labor
- increased neonatal morbidity
81
What should the sexual history assessment include?
- signs or symptoms (eg. vaginal/rectal discharge, dyspareunia (painful intercourse), ulcers, rashes, or anogenital itching) that may be indicative of infection
- information concerning recent sexual partners so that when indicated, prior contacts can be notified and offered treatment
- high-risk behaviors should be noted such a intravenous drug use, acquisition of tattoos, exposure to blood or blood products, or sex with an individual from high-risk category (e.g. sex industry worker)
82
Tips for Taking a Sexual History
>Self-awareness: know your own comfort level and your ease at discussing sexual issues with patients; acknowledge areas of discomfort
>Effective Communication: if you are embarrassed this will be apparent through body language, eye-to-eye contact, tone of voice, and type of questioning chosen (e.g closed-ended questions as opposed to exploratory questions)
-use words and terms that the patient understands
-environment: ensure privacy and confidentiality
-never make assumptions or be judgmental in your response or attitude
83
Sexually Transmitted Infections
- Human Immunodeficiency Virus (HIV)
- Syphillis
- Chlamydia Trachomatis, Neisseria Gonorrhoeae
- Herpes Simplex Virus
84
Sexually Transmitted Infections: Human Immunodeficiency Virus (HIV)
infection with HIV leads to a progressive disease that results in AIDS
-perinatal transmission may occur transplacentally, at birth from exposure to maternal blood and vaginal secretions, and via breast milk
>maternal treatment with zidovudine (AZT, Retrovir) reduces the risk of perinatal transmission and the risk of infant death
>Elective C-section has been shown to reduce the risk of transmission from the mother to the infant
>recommended all pregnant women be tested for HIV as part of the routine battery of prenatal tests; patients can choose to opt out
85
How is screening for HIV done?
via a enzyme-linked immunosorbent assay (ELISA) on a blood sample; if positive, finding is confirmed via a Western blot test
86
When should repeat testing of HIV be done?
in the third trimester or rapid HIV testing should be used in labor for women with undocumented HIV status following opt-out screening
87
What happens if a rapid HIV test in labor is positive?
immediate initiation of antiretroviral prophylaxis should be initiated without waiting for the results of the confirmatory test
88
Syphilis
infection during pregnancy that can cause damage to the fetus after the 16th to 18th week of intrauterine life
-cause by spirochete Treponema pallidum
-readily treated with penicillin or erythromycin; if treated before 18th week, fetus is rarely affected
>left untreated, transplacental transmission is likely to occur (congenital syphilis) and may result in deafness, cognitive difficulties, osteochondritis, or fetal death)
89
Chlamydia Trachomatis
screening tests for chlamydia are obtained during the pelvic exam
-secretions from the cervix, vagina, and anus may be used to obtain samples from culture media
-Chlamydia trachomatis is a bacterial infection that is prevalent in sexually active populations; most appear asymptomatic and do not seek treatment
-Complications of chlamydia include salpingitis (inflammation of fallopian tubes), pelvic inflammatory disease, infertility, ectopic pregnancy, premature rupture of the membranes, and preterm birth
-Transmission to neonate may occur during birth and result in ophthalmia neonatorum and chlamydial neonatal pneumonia
>Treatment for chlamydia is with oral anti-infectives or penicillin based agents; pregnant women be tested 3 weeks after treatment
90
Neisseria Gonorrhoeae
screening tests for Gonorrhea is obtained during pelvic exam
-caused by gram-negative intracellular diplococcal bacteria Neisseria gonorrhoeae
>readily treated with antibiotics
>when left untreated, ascending maternal infection may occur after rupture of the membranes
-transmission to fetus can occur during vaginal delivery and may result in disseminated infection and ophthalmia neonatorum
91
Herpes Simplex Virus
-Herpes simplex virus type 1 (HSV-1), transmitted nonsexually and most common with fevr blisters
-Herpes simplex virus type 2 (HSV-2) is usually transmitted sexually and associated with genital lesions
>The initial HSV genital infection produces flu-like symptoms including malaise, muscle aches, and headache accompanied by dysuria and the appearance of multiple painful blister-like lesions
>HSV-2 can have adverse effects of both mother and fetus; primary infection in first trimester is associated with congenital infection and increased risk of pregnancy loss; in neonate 60% mortality rate, and those that survive suffer neurological damage
-no cure for genital herpes, although several anti-viral agents are available but safety of these medications during pregnancy is not firmly established
92
Cervical Cancer
recommendation that screening via Papanicolaou testing to be performed on all young adults beginning at 21
93
Preparing the Patient for the Physical Exam
- be given adequate private time to prepare for exam
- void if necessary
- room should be warm
- a cover for for the patient and a gown for her to wear
- ensure privacy for the patient; put a "do not disturb ---exam in progress" sign affixed to the closed door
94
What should Happen before the physical examination begins
- patient should receive an explanation of what the examination will involve and what she is expected to do
- obtain her consent to be examined
- collect all equipment needed, along with any teaching literature that the patient should receive
95
Demonstrating professionalism during the physical examination
to convey respect and minimize the transmission of infection the nurse should
- ensure that the fingernails are short and all jewelry items that may cause skin trauma have been removed
- wash hands thoroughly in the patients presence
- develop habit of always washing the hands when entering and leaving the patients room
96
A successful Physical examination involves what?
- proceed in the same order each time (head to toe) to reduce the likelihood of unintentionally omitting any component
- organized in a manner that reduces the movements the patient must make
- less threatening to the patient when less invasive procedures are performed first
- use good communication skills and to advocate for and treat the patient with respect
97
How does the general assessment begin?
by simply observing the woman
-information that can be obtained includes overall health/nutritional status; posture; ease of movement and gait; appearance (clothing and cleanliness); affect and speech pattern; eye contact; and general orientation to place, person, and time
>then obtain anthropometric measurements (height and weight); prepregnant weight
>check vital signs (BP and HR may be elevated for first prenatal visit)
98
Obtaining Information and Promoting Good Nutrition
-nurses goal: promote appropriate weight gain during pregnancy through healthy nutrition
-use a 24-hour diet recall form; helps provide info on food prep/cooking preferences and nutritional intake
-woman's caloric needs increase by 300 per day
-educate woman that prenatal vitamins are an option to ensure that their daily needs are being met, but mega-doses of vitamins can be harmful
>woman's need for folic acid doubles
99
The general physical examination consists of?
ears, nose, mouth, and throat, cardio-respiratory, musculoskeletal, and neurological function with an in depth evaluation of maternal physical adaptation to the pregnancy
100
The Focused Obstetric Examination Consists of?
- Head, Neck, and Lungs
- The Skin
- The breasts
- The abdomen
- uterine size and fetal position
- fetal heart auscultation
- the vagina and pelvis
101
Focused Obstetric Examination: Head, Neck, and Lungs
-sitting position
-head to toe
-begin with general evaluation of skin and hair
-hair can be healthier during pregnancy
-hair loss common postpartum; can be indicative of vitamin or mineral deficiency
-increased level of estrogen responsible for hypertrophy of gingival tissue, nasal stuffiness, and increased tendency for nosebleeds
-thyroid gland palpated; enlargement is common because of increased vascularity and hyperplasia of glandular tissue; the size and position are documented with presence of nodules or swelling
-anterior and posterior lung sounds are auscultated
-cardiac rhythm and rate are evaluated for adventitious sounds
>many experience systolic heart murmurs because of an increase in blood volume; may be heard clearer when woman holds breath; beginning late in second trimester, the gravid uterus causes an upward and lateral displacement of the heart and the PMI
>as pregnancy advances the patient's breathing becomes thoracic in nature (rather than abdominal) because of enlarged uterus
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Focused Obstetric Examination: The Skin
>evaluated for color consistent with ethnic background and for lesions or indicators of drug abuse (e.g. skin scratches, bruising or trace marks, nasal discharge or irritated mucosa, and constricted or dilated pupils)
- chloasma (the mask of pregnancy)
- hyperpigmentation of the areolae, vulva, abdomen, and linea (linea nigra)
103
Focused Obstetric Examination: The Breasts
-recumbent position (on side)
-depending on gestational age, advisable to place a wedge under one of her hips to prevent compression of the vena cava from the gravid uterus (supine hypotension syndrome)
-inspection reveals nodularity, striae, and enlargement and hyperpigmentation of the nipples and Montgomery tubercles
>areas of indentation and skin puckering = not normal
-Colostrum, a precursor of breast milk, may be expressed from the nipples as early as the first trimester
>the lymph odes should not be palpable
104
Promoting Breast Comfort During Pregnancy
-wear a firm, supporting bra
105
Focused Obstetric Examination: The Abdomen
abdominal shape is assessed and inspected for the presence of scars (previous surgery should be documented), linea nigra, striae gravidarum, or signs of injury (e.g. bruising)
-may able to feel fetal movements
106
Abdominal Palpation
used to evaluate the uterine size, to determine fetal position, and later in pregnancy to determine whether the presenting part has engaged into the maternal pelvis
-use of Leopold Maneuvers
107
Fundal Height
an indication of uterine size; periodic measurements of the fundal height should correlate with fetal growth
-correlates to the weeks of gestation from approximately 22 to 34 weeks of gestation
>12 weeks the fundus should be at the level of the symphysis pubis
>20 weeks the fundus should be at the umbilicus
>fundus can be measured by using a tape measure or finger breadths in combination with known maternal landmarks
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How to Measure Fundal Height by Tape Measure
usually initiated around 22 weeks gestation
-the end of the measuring tape with the zero mark is held on the superior border of the symphysis pubis
-using the abdominal midline as a guide, the tape is stretched over the contour of the abdomen on top of the fundus (McDonald's Method)
>the measurement (in cm) is recorded and equals week of gestation
109
Approximate Fundal Height in Relation to Weeks of Pregnancy
- 12 weeks= level of symphysis pubis
- 16 weeks= halfway between the symphysis pubis and the umbilicus
- 20 weeks= 1-2 finger breadths below the umbilicus (or at umbilicus)
- 24 weeks= 1-2 finger breadths above the umbilicus
- 28-30= one-third of the way between the umbilicus and the xiphoid process
- 32 weeks= two-thirds of the way between the umbilicus and the xiphoid process
- 36 weeks= at the xiphoid process
- 38 weeks= 1-2 finger breadths below the xiphoid process
- 40 weeks= 3-4 finger breadths below the xiphoid process
110
Leopold Maneuvers
used in abdominal palpation
- a four-part clinical assessment method of observation and palpation to determine the lie, presentation, and position of the fetus
- helps aid in locating fetal heart sounds
111
Fetal Heart Auscultation
determining fetal presentation facilitates fetal heart auscultation
-FHR is heard most clearly directly over the fetal upper back (the maternal right or left lower abdominal quadrants)
-normal FHR= 110-160 bpm
>if a slower HR, the maternal pulse should first be evaluated to determine if the two heart rates are synchronous; if they are, the maternal pulse as inadvertently been auscultated through the abdomen and an attempt should be made to locate the fetal pulse; if differ, the nurse should position the patient on her left side and seek assistance
>oxygen may be administered by mask and patient should take slow deep breaths; nurse continue to monitor FHR and provide explanations and reassurance to patient
112
Devices used to listen to the fetal heart
-Pinard stethoscope
-fetoscope
-doppler ultrasound stethoscope
>do not rely on technology, nurses should use clinical skills
113
Nonstress Test
provides an evaluation of the FHR in response to fetal movement and/or uterine activity
-test may be ordered in high-risk pregnancies because of maternal or fetal factors
114
Fetal Positon
```
Fetal heart tone intensity varies according to the fetal position
RSA= right sacrum anterior
LSA= left sacrum anterior
ROP= right occipitoposterior
LOP= left occipitoposterior
RMA= right mentum anterior
LMA= left mentum anterior
ROA= right occipitoanterior
LOA= left occipitoanterior
```
115
Focused Obstetric Examination: The Vagina and Pelvis
vaginal examination usually performed at the initial prenatal visit following assessment of maternal abdomen
- explain to patient what to expect and to help her to verbalize and fears
- obtain permission to conduct a vaginal exam
- demonstrate awareness of patients feelings: remain respectful and gentle, showing equipment that will be used with demonstration of how it works, and ensuring privacy with appropriate drapes
- eye-to-eye contact
- involve patient in exam (mirror can be placed so woman can view cervix and see Chadwick's sign)
- 4 components to examination
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Components of the Examination of the Vagina: 1 part
1. assessment of the external genitalia
- information regarding secondary sexual characteristics by observing patterns of hair growth
- check for pediculosis (pubic lice)
- signs of infection (redness, edema, offensive discharge)
- presence of lesions, condylomata (human papillomavirus), vesicles (herpes), ulceration (syphilitic chancre), or inflammation need to be recognized and investigated
- bruising or tenderness may be present as a result of trauma or abuse
- observation of perineal body may show evidence of a previous episiotomy or perineal tear
117
Components of the Examination of the Vagina: 2nd part
2. visual inspection of the vaginal mucosa and cervix along with the collection of specimens such as Papanicolaou test (Pap test), cultures for gonorrhea or Chlamydia, and if indicated, wet smear slides to determine the cause of vaginal discharge
>appropriate sized speculum; constructed of metal or plastic ; two types (Grave's speculum; useful for multiparous woman and the more narrow, Pedersen speculum; used for children, woman who have never been sexually active, nulliparous women, and some postmenopausal
>speculum is inserted into the vagina at an oblique angle, then rotated to a horizontal angle and gently advanced downward against the posterior vaginal wall; once in position, the speculum blades are opened to allow visualization of the cervix
-cervix and vaginal mucosa are inspected for color and for the presence of inflammation, lesions, ulcerations, or erosion
118
Components of the Examination of the Vagina: 3rd Part
includes clinical pelvimetry and the bimanual examination
>Bimanual examination= evaluation of uterine shape, position, and size
-normal uterus= anteverted (tipped forward); as it enlarges, the uterus becomes more midline and globular in shape; size of the uterus should be equal to the estimated weeks of gestation
-if larger= miscalculation of the date of conception, multiple pregnancy, hydatidiform mole, uterine fibroid tumors, or hydramnios (increase in volume of amniotic fluid
-if smaller= miscalculation of dates or missed abortion
>the manual examination provides an ideal time to evaluate vaginal and perineal muscle tone and to determine the presence of cystocele (bladder prolapse), urethrocele (urethral prolapse), or rectocele (rectal prolapse)
-Practice Kegel exercises to help maintain perineal muscle tone
>Rectovaginal Examination is performed after Bimanual examination
119
Rectovaginal Examination
part of the third part of the vaginal exam
-performed after bimanual exam
-examiner removes hand from the vagina and dons a clean pair of gloves
-a water-based lubricant is applied to the fingertips of the dominant hand
-the index finger is reinserted into the vagina; middle finger inserted into the rectum
>the rectal finger is advanced forward as the abdomen is depressed with the non-dominant hand
-palpation of the tissue between the examining fingers allows for assessment of the strength and irregularity of the posterior vaginal wall
-the fingers are withdrawn and any stool present on the glove may be tested for occult blood
120
Components of the Examination of the Vagina: 4th part
clinical evaluation of the pelvis (clinical pelvimetry)
-goal= recognize any abnormality in shape or size that may be associated with a difficult or traumatic vaginal birth
>4 pelvic types= gynecoid, the android (male), anthropoid (non-Caucasian races), and the platypelloid
-internal pelvic measurements= provide diameters of the inlet and outlet through which the fetus must pass during birth
>measurements most commonly made: diagonal conjugate, true conjugate (conjugate vera), and the ischial tuberosity diameter
-performed by physician, nurse midwife, or advanced practice nurse
121
Diagonal conjugate
distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis
-lithotomy position
-indicates the anteroposterior diameter of the pelvic inlet-- most narrow diameter and the one most likely to create a problem with misfit of the fetal head
>if greater than 12.5 cm, the pelvic inlet is considered to be adequate for childbirth
122
Components of Subsequent Prenatal Examinations
usually not as in-depth but should be designed to recognize any deviations from normal so that appropriate investigation can be made and care managed accordingly
- review woman's overall health status
- maternal well-being
- fetal well-being
- patient teaching
123
Subsequent Prenatal Examinations: Review woman's overall health status
- signs/symptoms of pregnancy
- discomforts of pregnancy
- changes in medications/over-the-counter/herbal/ homeopathic
- psychological assessment (emotional or psychological distress) including factors such as affect, sleep patterns, and diet
124
Subsequent Prenatal Examinations: Maternal Well-Being
>Record Vital signs
-ensure BP is recorded using appropriate size cuff and under same condition each visit (e.g. maternal position)
>Maternal Weight
-weight gain = 1 pound per week during second and third trimesters
-excessive weight gain= fluid retention
-weight loss= maternal disease or inadequate dietary intake: nursing assessment needed
>Evaluate for Edema: dependent edema especially in hot weather and at the end of the day is normal finding
>Where indicated, check for reflexes and clonus (involuntary muscle contractions)
-any signs of preterm labor such as uterine contractions or backache
-ensure patient knows indicators of preterm labor and knows how to seek medical advice
>Assess for signs of domestic/intimate partner abuse
125
Subsequent Prenatal Examinations: Fetal Well-Being
listen to fetal heart tones; can be heard from 12-14 weeks gestation with a Doppler stethoscope; normal= 110-160 bpm
>Discuss pattern and frequency of fetal movements
-encourage patient to monitor and record fetal movements daily
-educate patient on importance of fetal movements as an indicator of general fetal well-being
-report a decrease in fetal movements
>Evaluate uterine growth
-measure fundal height
-document findings and evaluate pattern of growth
-weeks of gestation are equivalent to measurement in centimeters (cm): McDonalds Method (measure from the top of the symphysis pubis to fundus, from approximately 24-34 weeks gestation)
-measurement less than expected= intrauterine growth restriction, oligohydramnios, or incorrect dates
-measurement greater than expected= multiple pregnancy, macrosomic infant, hydramnios (too much amniotic fluid), or incorrect dates
126
Subsequent Prenatal Visit: Patient Teaching
- education r/t stage of pregnancy (e.g. physical changes to expect; danger signs that need to be reported such as vaginal bleeding or fluid loss, abdominal pain, or visual disturbances)
- attendance in prenatal education classes
- tour of facility where patient intends to give birth
- later in pregnancy, focus of education needs to include preparation for care of the infant (e.g. car seats, male circumcision, and immunizations) so parents make informed decisions
- screening and laboratory tests: ultrasound, prenatal screening, screening for gestational diabetes, Rh screening, Hemoglobin/Hematocrit, Group B Streptococcus screening
- confirm patients contact information and ensure return appointment
- provide time to ask questions and confirm understanding; she has no other concerns that needs to be addressed
127
Screening for Gestational Diabetes
-offered around 24-28 weeks gestation
-patient drinks solution containing 50 g of glucose and then blood drawn 1 hour later
>results be below 140 mg/dL
128
Rh Screening
Rh(D) negative woman= check for Rh antibodies and if negative, 300 mcg of Rh(D) immune globulin (RhoGAM) is prescribed at 28-32 weeks gestation
129
Adolescence at Greatest Risk For Pregnancy
- adolescence who lack support, security, and love of a family home
- incarcerated juveniles
130
Four developmental tasks a teenager has to meet to successfully adapt and fulfill the role of being a mother
- gain acceptance of pregnancy
- set goals
- view self as mother
- grow up
131
Considerations in the older Gravida: Chronic medical conditons
for woman over 35
- preexisting diabetes and hypertension
- benign uterine leiomyomas (fibroid tumors) occur with greater frequency in woman over age 35 and may interfere with cervical dilation during labor and cause postpartum hemorrhage
- vaginal bleeding, preeclampsia, multiple gestation, gestational diabetes, preterm labor, dysfunctional labor, and C-section are increased during labor
- fetus at greater risk fir low birth weight, macrosomia, chromosomal abnormalities, and congenital malformations
132
Considerations in the older Gravida: detrimental lifestyle habits
alcohol, drug and tobacco use
133
Considerations in the older Gravida: physical examination
- focus on identification of breast abnormalities and circulatory problems
- continue with monthly breast self-examination because the incidence of breast cancer is increased in the older woman
- inspection of the lower extremities; varicosities are common in older woman
- first trimester, assess presence of fetal heart sounds; incidence of hydatidiform mole is increase in woman over 40
134
Screening for Fetal Chromosomal Abnormalities
- offered a screening test for down syndrome
- child affected by down syndrome increases with maternal age
- provide information concerning the tests
135
Summary Points of the Chapter
- education and involvement in prenatal care empowers patients and their families to make informed decisions
- the first prenatal visit includes a health history, physical examination, and laboratory testing; establishing good rapport through effective communication is essential in creating an environment to which the patient is likely to return
- Prenatal follow up visits are shorter than the initial assessment, but they are important in monitoring maternal-fetal health and in providing anticipatory guidance for the patient and family
- early and ongoing prenatal care is key to an optimal maternal-fetal outcome; families should be involved in activities for health promotion and educated about strategies for self-care during the childbearing year
- the diagnosis of pregnancy is based on three types of signs: presumptive, probable, and positive; presumptive and probable signs may be caused by conditions other than pregnancy; positive signs can have no other cause
- the teenage pregnant patient is at risk for a number of obstetric complications including anemia, preeclampsia, and preterm birth
- factors including education, culture, spiritual beliefs, and family support and income impact the occurrence of adolescent pregnancy
- preconception and prenatal care for the woman over 35 focuses on the recognition and management of chronic medical problems and strategies to promote a healthy lifestyle
