nr 602 primary care of the childbearing and childrearing family
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NR 602 Midterm Study Topics
Signs of pregnancy
o Presumptive: Symptoms that are suggestive of pregnancy are considered
“presumptive signs” which means that they are the least objective or subjective signs
which can also be caused by many other conditions other than pregnancy.
• Amenorrhea: Highly suggestive of pregnancy in a healthy female with
regular & predictable periods. Difficult to determine in a female who have
irregular periods or in those who do not keep track of their menstrual cycles
• Nausea & vomiting: Common symptom (~50% of pregnancies) typically
occurring between 2-16 weeks gestation
• Breast engorgement & darkening of the areolas: Occurs as early as 6-8
weeks gestation
• Breast tenderness
• Fatigue
• Urinary Frequency
• Slight increase in body temperature: Rise in temperature coincides with
luteal phase and is the result of increased progesterone
• “Quickening”: Mother feels the baby’s movements for the 1st time; starts
at 16 weeks.
o Probable
Probable signs of pregnancy mean that there is a high likelihood of
pregnancy but there are still other conditions that may cause the findings.
Pregnancy tests are considered probable because β-hCG also presents in
molar pregnancies and ovarian cancer.
Goodell’s sign: Cervical softening (around 4 weeks)
Chadwick’s sign: Blueish coloration of the vagina & cervix (6-8 weeks)
Enlarged uterus
Positive urine or blood pregnancy test (β-hCG)
o Positive
The most reliable and most objective signs of positive pregnancy are those
where the provider can confirm the presence of a fetus
Palpation of the fetus by the health care provider
Ultrasound and visualization of the fetus
Fetal Heart Tones (FHT) auscultated by the health care provider
Pregnancy and fundal height measurement
o 12 weeks: Uterine fundus first rises above the symphysis pubis
o 16 weeks: Uterine fundus is between the symphysis pubis and umbilicus
o 20 weeks: Uterine fundus is at the level of the umbilicus
o 25-35 weeks: Measure the distance between the upper edge of pubic symphysis
and the top of the uterine fundus with a tape measure. Fundal height in
centimeters equals the number of gestational weeks (+/- 2cm). For example, a
28-week gestation fetus should have a fundal height that measures between 26
and 30cm
, Naegele’s rule
o EDC (Estimated date of confinement)
o EDD (Estimated date of delivery)
Add seven days to the first day of the last menstrual period, subtract three
months and add one year.
Hematological changes during pregnancy
o During pregnancy, the heart is displaced upward and to the left
within the chest cavity by the gravid uterus’s pressure on the
diaphragm
o The risk for inferior vena cava and aortic compression leading to
supine hypotension increases when the woman lies in a supine
position.
To avoid hypotension and potential syncope, the woman
should be advised to lie in a left lateral position.
o Cardiac output in pregnancy increases by 30% to 50%
peaks in the early third trimester and is maintained until birth.
o Half of the total increase in cardiac output, occurs by the eighth
week of pregnancy.
o women with cardiac disease may become symptomatic during the
first trimester.
o Stroke volume is also increased during pregnancy by 20% to 30%.
o increases in cardiac output and stroke volume allow for the 30%
increase in oxygen consumption observed during pregnancy.
o blood volume increases by 30% to 50%, or 1,100 to 1,600 mL
, improves blood flow to the vital organs and protects against
excessive blood loss during birth.
Fetal growth during pregnancy and newborn weight are
correlated with the degree of blood volume expansion.
o 75% of blood volume expansion is considered to be plasma
o slight increase in red blood cell volume (RBC).
o The blood volume changes result in hemodilution, which leads to a
state of physiologic anemia during pregnancy.
o As the RBC volume increases, iron demands also increase.
o Leukocytosis occurs in pregnancy, with white blood cell counts
increasing to as much as 14,000 to 17,000
o Clotting factors increase as well, creating a risk for clotting events
during pregnancy.
o Systemic vascular resistance is reduced due to the effects of
progesterone, prostaglandins, estrogen, and prolactin.
o lowered systemic vascular resistance plus inferior vena cava
compression, is partly responsible for the dependent edema that
occurs in pregnancy.
o Epulis of pregnancy, or hypertrophy of the gums accompanied by
bleeding, may also occur and is due to decreased vascular
resistance and increase in the growth of capillaries during
pregnancy
TABLE 29-2 Vital Sign Changes in Pregnancy
Vital Sign Changes in Pregnancy Measurement Alterations in
Pregnancy
Heart rate Volume of the first heart sound Palpate the maternal pulse
and heart may be increased with splitting. when auscultating the fetal
sounds Third heart sound may be heart rate to be able to
detected. distinguish between the two.
Systolic murmurs may be
detected.
Increases by 15–20 beats/min
by 32 weeks’ gestation.
Respiratory Increases by 1–2 breaths/min None
rate
BP First trimester: same as pre- Use of an automated cuff may
pregnancy values improve accuracy of
Second trimester: systolic BP measurement, as some
decreases by 2–8 mm Hg and pregnant women do not have a
diastolic BP decreases by 5–15 fifth Korotkoff sound.
, Vital Sign Changes in Pregnancy Measurement Alterations in
Pregnancy
mm Hg due to peripheral Systolic and diastolic BP may be
vascular resistance 16 mm Hg higher when taken
Third trimester: gradually while the woman is sitting.
returns to pre-pregnancy values BP readings may decrease in
the maternal left lateral
position.
Indications and contraindications for prescribing combined estrogen vs. progesterone-only
birth control
indications contraindications
Combined Estrogen Patch & Ring: no daily < 21 weeks post-partum
(ortho evra and xulane dosing, decreased risk of <21 -42 days postpartum
patch; Nuva Ring; PID and ectopic With risk factors for VTE
pregnancies, decreased risk (>35 y/o, previous VTE,
of ovarian and endometrial thrombophilia, immobility,
cancer, improves transfusion at birth, BMI>
dysfunctional uterine 30, postpartum hemorrhage,
bleeding (DUB), and post-cesarean birth,
dysmenorrhea and improves preeclampsia, or smoking)
acne. Smoking > 15 cigarettes/day
Multiple risk factors for
arterial CV disease (older
age, smoking, diabetes,
HTN).
Vascular disease
Known thrombogenic
mutations (factor V Leiden;
PT mutation, protein S,
protein C, and antithrombin
deficiencies.
Hx of CVA, current and hx
of ischemic heart disease
Peripartum cardiomyopathy
SLE
Breast cancer
Severe Cirrhosis
Liver tumor
Organ transplant
Patch& Ring: Same as COC.
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