Key Concepts Exam 1
NUR 230
Diagnosis of Pregnancy – expected s/s
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Presumptive signs- subjective signs reported by the women, can be caused by other
conditions
o Breast changes (swelling, tenderness)
o Amenorrhea (missed period)
o N/V
o Urinary frequency
o Fatigue
o Quickening (flutters)
Probable signs- Objective changes assessed by an examiner
o Goodell sign (softening of the cervix)
o Chadwick (purple/blue discoloration of the cervix)
o Hegar sign (softening of the lower uterine segment)
o Positive UPT (urine pregnancy test)
o Positive HCG (serum)
o Ballottement (finger on the cervix)
Positive Signs- Objective signs assessed by an examiner that can be attributed to the
presence of a fetus
o Fetal movement (2nd trimester)
o Audible heart tones
o Ultrasound
Recommended schedule and content of normal prenatal visits
1. Prenatal Interview <13 weeks
a. Longer and more detailed visit
b. CBC, Blood type, RH factor, STD, Pap Smear, urinalysis
c. LMP, Discomforts such as N/V, constipation, urinary frequency
d. Bleeding cramping
e. OB HX
i. # Pregnancies
ii. Method of deliveries
iii. Complications
iv. Living children and birth weight
2. 2nd trimester 14-26 weeks
a. Sequential 1 & 2 (tests baby for down syndrome, trisomy 18, spina bifida, and
smith-lemi-optix syndrome
b. 1- hour glucose tolerance test (28 weeks) screens for gestational DM, if failed will
have to take 3-hour
c. Anatomy Ultrasound scan
d. STI offered again
e. Rhogam if mom if mom is Rh- (28 weeks)
3. . 3rd trimester 27-40 weeks
a. Group B Strep (GBS- rectal swab) – 35-37 weeks (if positive mom will take a
round of abx)
b. CBC
Estimated DOB- Nagel’s Rule
o
o
First Day LMP + 7 days + 9 months = Estimated Due Date (EDD)
First Day LMP + 7 Days – 3 Months = EDD
Gravida and Para
o
Gravida= # of pregnancies
GTPAL
o
o
o
o
o
o
Gravida
Term- 47 -42 weeks
Preterm- 20-36 weeks
Abortion- anything less than 20 weeks, induced or spontaneous
Living- how many children mom has living
Remember twins are considered 1 pregnancy, but separate living
Trimesters
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1st: 1-13 weeks
2nd: 14- 26 weeks
3rd: 28-40 weeks
Normal discomforts of pregnancy
o
o
o
o
o
o
o
o
o
o
o
o
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Urinary urgency and frequency
Fatigue
N/V
Ptyalism (excessive spitting)
Gingivitis
Breast tenderness
Leukorrhea (increased cervical mucus)
Insomnia
Constipation
Food cravings
Headaches (through week 26)
Backache
Round ligament pain
Braxton hicks
Review of risk factors
o
o
o
o
o
HTN
DM
Smoker
Overweight/ Underweight
Drug use
o
o
Prescribed medications
Exposure to harmful substances (work related/ environmental)
Normal changes in vitals
o
o
o
HR increases 15-20 BPM
BP should slightly decrease from pregnancy levels
Resp Rate- may slightly increase
Endocrine changes
o
Hormones
o Human chorionic gonadotropin (hCG) maintain corpus letum production of
estrogen and progesterone until placenta is fully developed and ready to take over
(serum pregnancy test- gives estimate of how far pregnancy is)
o Progesterone- help fetus grow, keep uterus relaxed.
o Estrogen- increase vascularization, relaxes pelvic ligaments and joints. Promotes
enlargement of genitals breast and uterus.
o Serum prolactin- prepare breast for lactation (breastfeeding)
o Oxytocin- Stimulates uterine contractions, stimulates milk ejection
o Human chorionic somatomammotropin- growth hormone
o Relaxin- relaxes pelvic muscles, prepare for childbirth
o HpL- insulin antagonist-increased BG in pregnancy
Respiratory changes
o
o
o
o
Nasal congestion
Nosebleeds (Epistaxis)
Voice changes
URI
Cardiovascular Changes
o
o
o
SOB (3rd trimester)
Cardiac Output increase 30-50%
HR increase 15-20 BPM
GI changes
o
o
o
o
o
Increased N/V (typically ends by 2nd trimester)
Increased appetite
Bleeding gums
Heartburn (early as 1st trimester intensifying through 3rd trimester)
Constipation
Urinary changes
o
o
Urine output increases
Renal pelves and ureters dilate (increased risk of infection)
Integumentary changes
Melasma (chloasma or mask of pregnancy) blotchy, brownish hyperpigmentation of the
skin over the cheeks nose and forehead.
o Linea nigari (dark midline from symphysis pubis to top of fundus)
o Striae gravidarum- “stretch marks”
Angiomatas- “vascular spiders”
o
o
Psychosocial Changes
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o
o
o
1st trimester accepts pregnancy
2nd trimester: very protective of fetie, seeks knowledge, finsing enjoyment and pleasure
in pregnancy
3rd trimester: concerns over fetus
Family preparation: prepare siblings, identify ways to prepare young children: picture
books, sibling prep classes.
Nursing teachings
o
o
o
Increase fluid intake
Vaccines
Fetal kicks (10 kicks/ hr.)- can begin counting at 28 weeks (26 weeks if high risk)
PICA- nonfood cravings
o
o
o
o
o
o
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o
Ice
Dirt
Baking soda
paint
Clay
Starch
Pica should be considered as a potential factor in cases of iron deficiency anemia and
poor weight gain.
Women with pica have been found to have lower hgb levels.
Nutrition Review
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o
o
o
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1st and 2nd trimester of singleton pregnancy
o Average 2-4lbs
rd
3 trimesters underweight and normal
o 1/lb. week
nd
2 and 3rd trimester for overweight women
o 0.6lb/ week
2nd and 3rd trimester for obese women
o 0.5lb/week
Provisional recommendations for gestations
o Normal weight: 17-25kg
o Overweight: 14-23kg
o Obese 11-19kg
Recommended calorie intake
o 1st trimester
 1800 kcal/day
nd
o 2 trimester
 2200 kcal/day
3rd trimester
 2400 kcal/day
o Can be adjusted in multiple gestation pregnancies
3 L of water *food and water included* (3.8 of lactation)
28 grams of fiber (29 for lactation)
30 mg iron
600 mcg folate
2.6 mcg b12 (2.8 for lactating)
B6 can decrease N/V
Nutritional Risk in Pregnancy
o Frequent pregnancy- 3 within 2 years
o Problems with weight gain
o Any weight loss
o DM
o Chronic illnesses that may effect weight (easting disorders)
o Drugs and alcohol
o Poverty
o Poor eating habits
o Low hgb/hct
o Multifetal pregnancy
o Weight gain of 3kg/month after 1st trimester
o Weight gain of less than 1kg/month after 1st trimester
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o
o
o
o
o
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Fundal Height Measurements
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The height of the uterus above the symphysis pubis
Provides gross estimate of the duration of the pregnancy
From 18-30 weeks, the height of the fundus in centimeters is approximately the same as
the number of weeks of gestation. (+/- 2 GW)
Leopold’s Maneuvers- using abdominal palpation to determine which fetal part is in the uterine
fundus? where is the fetal back located? and what is the presenting fetal part?
Vena Cava Syndrome « Supine Hypotension »
o
o
Dizziness r/t fetus pressing on the inferior vena cave
Change mother’s position
Spontaneous Abortion (Miscarriage)- A pregnancy that ends as a result of natural causes
before 20 weeks of pregnancy
Missed Abortion (missed miscarriage)- A pregnancy in which the fetus has died but the
products of conception are retained in utero for day, weeks and even months. Usually diagnosed
after the uterus stops increasing in size or even decreases in size. Often there is no bleeding, or
cramping, the cervix remains closed. A missed abortion is often referred to as an early
pregnancy loss.
Ectopic pregnancy “tubal pregnancies”- the fertilized ovum is implanted outside the
uterine cavity. Leading cause in infertility. Will have abdominal pain, dull, lower quadrant, one
side. May have delayed menses. Abnormal vaginal bleeding and/or spotting. Risk of hemorrhage
Placenta Previa
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o
o
o
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o
The placenta is implanted in the lower uterine segment, it can completely or partially
cover the cervical os or is closes enough to the cervix to cause bleeding when the cervix
dilates
Bright vaginal bleeding
No cervical checks
Delivery by c-section
No pain
May be breech or transverse like
Abruptio placenta- premature separation of the placenta
o
o
Caused by HTN
Symptoms include:
o Dark red bleeding
o Abdominal pain
o Uterine contractions
Cervical Cerclage: a suture is placed around the cervix beneath the mucosa to constrict the
internal os of the cervix, due to cervical insufficiency, usually done to hold the cervix close
preventing preterm labor and miscarriages.
Preeclampsia- pregnancy specific hypertension and proteinuria developed after 20 weeks.
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Triad: HTN, edema and proteinuria
Headache not relieved with medication
Gestational Hypertension: the onset of HTN without proteinuria, or other systemic
findings. 2 or more readings of 140/90 after 20 weeks, with previous normal BP. Does not
persist longer than 12 weeks post-partum.
Eclampsia: the onset of seizure activity or coma in women with preeclampsia who has no hx of
preexisting pathology that can result in seizure activity.
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Higher in multifetal gestation
Women who did not receive prenatal care
Magnesium sulfate is used to prevent and treat eclampsia
Persistent headache, blurred vision, photophobia, severe epigastric or RUQ pain,
AMS
KNOW SEIZURE PRECAUTIONS!
Drugs used to control HTN in pregnancy
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Hydralazine
Labetalol
Methyldopa
Nifedipine
True Labor
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Consistent contractions
will not stop with ambulation
if false, will stop with walking and/or position changing
assess your patient frequently
assess FHR response
Active labor: you will see cervical changes!
Braxton Hicks: Contractions relieved with ambulation
Stages of Labor:
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1st stage
o Active (6-10 cm dilated)
o Latent/early (0-5 cm dilated)
2nd stage
o Fully dilation- birth
o Mother is ready to push
3rd stage
o Fetus delivered- placenta delivered
th
4 stage
o Placenta delivered- first 2 hours of birth (homeostasis)
Pain relief in labor
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o
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Pharmacological
o Assess dilation before administration
o DO NOT GIVE DURING TRANISITION
o DO NOT USE WITH MOTHERS WHO ARE DRUG DEPENDENT
o IV narcotics- opioids
 Demerol
 Stadol
Anesthesia
o General anesthesia
 Emergency delivery
o Epidural/Spinal Anesthesia
 Baseline VS, IVF 5000-1000ml
 Epidural may be given in single dose, continuously, or intermittent
 Catheter is placed until after delivery
 Spinal works immediately, smaller dose, one time use
 Epidural take up to 10 minutes, common side effect hypotension
 Spinal may be used for C/S instead of epidural
o Local infiltration
 Used to number the perineal are for episiotomy
 no side effects unless mother is allergic
Non-pharmacological
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Change in position
Breathing techniques
Music
Focal point
Minimize environmental stimuli