Difficulty: Intermediate
Setting: Obstetric clinic
Index Words: gravida, para, pregnancy-induced hypertension (PIH), prenatal assessment
Giddens Concepts: Coping, Health Promotion, Patient Education, Reproduction
HESI Concepts: Health Promotion, Patient Education, Sexuality/Reproduction, Stress and Coping
Name _________________________________ Class/Group _______________ Date _______________
Scenario
P.M. comes to the obstetric (OB) clinic because she has missed two menstrual periods and thinks she might be pregnant. She states she is nauseated, especially in the morning, so she completed a home pregnancy test and she reports that the result was positive. As the intake nurse in the clinic, you are responsible for gathering information before she sees the physician.
1. What are the 2 most important questions to ask to determine possible pregnancy?
- When was the first day of her last menstrual period?
- When was the date of her last intercourse?
2. You ask whether she has ever been pregnant, and she tells you she has never been pregnant. How would you record this information?
Because she is gravida 1, you record “G1.” Gravida refers to any pregnancy, regardless of duration.
3. What additional information would be needed to complete the TPAL record?
TPAL is derived by asking about the number of term and preterm pregnancies, number of abortions or miscarriages before 20 weeks’ gestation, and number of living children. T refers to term births (after 37 weeks), P refers to premature births, A refers to abortions, and L refers to living children. The recording would be G1, Para 0000.
4. It is important to complete the intake interview. What categories will you address with P.M.?
- Signs and symptoms she has had
- Current and past gynecologic history
- Contraceptive history
- Current and past medical history (diabetes mellitus, heart disease, sickle cell anemia)
- Allergies
- Medications, including prescriptions, over-the-counter, and herbals products
- Social and occupational history
- History of physical abuse
- Vaccinations (especially rubella)
- Partner’s history, health, and use of substances
- Risk factors (e.g., substance use, age less than 20 or over 35 years, preexisting medical conditions)
- Discomforts, concerns, questions
- Nutritional history
- History of sexually transmitted infections
CASE STUDY PROGRESS
Per the clinic protocol, you obtain the following for her prenatal record: Complete blood count, blood type with Rh factor, urine for urinalysis (protein, glucose, blood), vital signs, height, and weight. In addition, the pregnancy is confirmed with a blood or urine hCG test and an ultrasound. Next, the nurse-midwife performs a physical examination, which includes a pelvic examination. The examination and tests confirm that P.M. is pregnant. P.M. has a gynecoid pelvis by measurement, and the fetus is at approximately 6 weeks’ gestation.
Chart View
Vital Signs
| Blood pressure | 116/74 mm Hg |
Heart rate | 88 beats/min |
Respiratory rate | 16 breaths/min |
Temperature | 98.9° F (37.2° C) |
5. Do any of these vital signs cause concern? What should you do?
No, these results fall within normal ranges. Continue to monitor with each prenatal visit and document the findings.
6. P.M. tells you that the date of her last menstrual period (LMP) was February 2. How would you calculate her due date? What is her due date?
Pregnancy lasts about 9 calendar months or 10 lunar months (40 weeks). All dates are calculated using Naegele’s Rule by taking the first day of the LMP, counting back 3 months, and adding 7 days. Or, add 7 days to the LMP and count forward 9 months. For an LMP of February 2, the due date would be November 9.
7. What is the significance of a gynecoid pelvis?
A gynecoid pelvis means the bony pelvis is adequate for the fetus to pass through without difficulty. This is the most common type, occurring in 50% of women.
8. What specimens are important to obtain when the pelvic examination is done?
Specimens for the Papanicolaou test (Pap) to screen for cervical intraepithelial neoplasia, HPV testing, cervical and vagin*l smears for cytologic studies and diagnosis of chlamydia, gonorrhea, and group B streptococcus infections.
CASE STUDY PROGRESS
Nursing interventions focus on monitoring the mother and fetus for growth and development, and detecting potential complications. Educating P.M. about the importance of proper nutrition, managing the common discomforts of pregnancy, and activities of self-care will help in the wellbeing of her and her baby.
9. A psychological assessment is done to determine P.M.’s feelings and attitudes regarding her pregnancy. How do attitudes, beliefs, and feelings affect pregnancy?
Cultural and religious preferences might influence how she takes care of herself, how she views the pregnancy, how her partner responds to her and the pregnancy, and the importance of infant gender. Family and community support are also factors that might influence her self-care.
The following responses are normal unless the manifestations are extreme in either direction. Often, they are related to hormonal influences on the body.
- Ambivalence: Mixed feelings even if the pregnancy was planned
- Acceptance of the pregnancy
- Introversion: The woman focuses on herself, dreams about the baby
- Mood swings
- Negative feelings about changes in body image
10. P.M. asks you whether there are any foods she should avoid while pregnant. She lists some of her favorite foods. Which foods, if any, should she avoid eating while she is pregnant? Select all that apply.
- Sushi
- Yogurt
- Hot dogs
- Deli meat
- Cheddar cheese
Correct answers are: a, c, d
11. As the nurse, you understand that assessment and teaching are vital in the prenatal period to ensure a positive outcome. What information is important to include at every visit and at specific times during the pregnancy?
- Regular prenatal visits are scheduled every 4 weeks until 28 weeks of gestation, every 2 weeks from 30 to 36 weeks, and every week from 37 weeks to delivery.
- Fetal heart rate (FHR) should be monitored at every visit as soon as it becomes audible, usually at 10 to 12 weeks.
- Fundal height is measured to estimate fetal growth.
- Weight: Desirable weight gain varies among women. Weight gain should be individualized and monitored according to whether the woman is underweight or overweight. If P.M.’s weight is within a normal range, she should gain 3 to 5 pounds (1.4 to 2.25 kg) during the first trimester and 1 pound (0.5 kg) per week thereafter. Be alert for inadequate gain or excessive gain (4 or more pounds [1.8 or more kg]), which is often the first sign of pregnancy-induced hypertension. To maintain a healthy pattern of weight gain, P.M. needs an extra 340 kcal/day in her second trimester and 460 kcal/day in her third trimester. This is not the time to diet or “eat for two.”
- VS: A rising BP may indicate pregnancy-induced hypertension.
- Deep tendon reflexes: Hyperreflexia may indicate preeclampsia.
- Assess for edema in face, hands, legs, and feet. Edema is common in pregnancy-induced hypertension. Some edema in the feet and ankles is normal in the last trimester.
- Check urine for glucose and protein.
- A glucose test is done at 24 to 28 weeks to check for gestational diabetes mellitus (GDM).
- Address any discomforts the patient might have. These are usually trimester specific and occur as hormones fluctuate.
- Review the danger signs of pregnancy at each visit and ask whether she has experienced any of them.
- Self-care monitoring of daily fetal activity and movement after 27 weeks: She is instructed to call immediately if fetal activity decreases or ceases for 8 to 12 hours. (The time frame might vary; check with the specific primary care provider [PCP] for office protocol.)
- Stress the need to take prenatal vitamin and mineral supplements to provide folic acid and B6 to decrease the risk for neural tube defects, iron deficiency, low infant birth weight, and premature delivery.
- Food safety issues as described in the previous question.
- Stress need for adequate fluid intake: At least 8 glasses of water (2 L) daily.
12. After her examination, P.M. states that she is worried because her sister had an ectopic pregnancy and had to have surgery. She asks you, “What are the signs of an ectopic pregnancy?” Identify the correct response. Select all that apply.
- Nausea
- Increased fatigue
- Dark red or brown vagin*l bleeding
- Fullness and tenderness in her abdomen, near the ovaries
- Pain, either unilateral, bilateral, or diffuse over the abdomen
Correct answers are: c, d, e
Signs and symptoms of an ectopic pregnancy include adnexal fullness and tenderness; tenderness that progresses to a colicky pain when the tube stretches; pain that is unilateral, bilateral, or diffuse over the abdomen; and dark red or brown abnormal vagin*l bleeding. Nausea and increased fatigue might occur with normal pregnancies.
13. P.M. asks the nurse about what should be reported to her doctor. List at least 6 of the danger signs during pregnancy.
- Sudden gush of fluid from vagin*
- Bleeding from the vagin*
- Pelvic pain (cramping)
- Abdominal pain
- Temperature above 101.7° F (38.7° C)
- Dizziness, blurred vision
- Persistent vomiting
- Severe headache
- Edema in the hands, face, legs, and feet
- Seizures
- Oliguria
- Dysuria (UTI)
- Absence of fetal movement after initial movement is felt (approximately 20 weeks)
14. Common changes in the body caused by pregnancy include relaxation of joints, altered center of gravity, syncope, and generalized discomfort. These changes can lead to problems with coordination and balance. After a teaching session about safety measures, you use the Teach-Back technique to assess P.M.’s understanding. Which statement by P.M. indicates a need for more teaching?
- “I will take rest periods throughout the day.”
- “I will always wear a helmet when riding my bike.”
- “I will avoid activities that cause sudden, jarring moves to my body.”
- “Later in my pregnancy, I won’t use a seatbelt in the car because I’ll be too big.”
Correct answer: d
15. P.M. asks, “Is a vagin*l examination done at every visit?” Select the best response and provide a rationale for your answer.
- “No, a vagin*l examination will not be done again until you go into labor.”
- “No, vagin*l examinations are not routinely done until the final weeks of your pregnancy.”
- “Yes, an examination is done with each visit because it offers vital information about the status of the pregnancy.”
- “Yes, an examination is done with each visit because it allows the examiner to note any possible infections that may be developing.”
Correct answer: b
A vagin*l examination is not done after the initial visit until the final weeks of gestation because it can stimulate contractions or cause possible infection. The vagin*l examination is unnecessary because it does not offer vital information that cannot be obtained from other sources.
CASE STUDY OUTCOME
P.M. makes an appointment for her next checkup. She is excited and cannot wait to tell her family that she is pregnant.
