Maternal Nursing Exam 1 (adaptations to pregnancy, nursing care, nutrition)

uterus & pregnancy

-increased E&P→growth in 1st trimester d/t increased vascularity, hyperplasia, hypertrophy, decidua development

-increased weight & volume

-more spherical/globular, rises into abdominal cavity (12 weeks)

-visible at week 14

-widens/shortens week 38-40 (“lightening”)

-lower softening (Hegar sign) at week 6→anteflexion→urine frequency

-Braxton HIcks→increased blood flow (4 mo)

-uterine and funic souffle (bruit)

-10x more blood flow

-ballottement: fetus passive movement at weeks 16-18 (via examiner palpation)

-quickening: fetal movement at weeks 14-18+

cervix during pregnancy

-becomes firm & closed, velvety, friable

-soft, elastic, dilated for labor

-softens at tip at week 6 (Goodell sign; indicator of pregnancy)

-mucous plug (operculum) has Ig

ovaries during pregnancy

-ovulation stops d/t decreased FSH & LH (d/t increased E&P)

-E&P made by corpus luteum till week 6-10, then placenta takes over production

vagina & vulva during pregnancy

-thicker mucosa, looser CT, hypertrophy of muscles, lengthens

-increased vascularity

—appears blue at 6-8 weeks = Chadwick sign

—increased sexual arousal in 2nd trimester

—increased edema & varicosities

-increased discharge (white or gray & musty)

-microbiome & pH changes

—increased Candidiasis

breasts during pregnancy

-fullness, increased sensitivity, heaviness, possible tingling or pain

-nipples & areolas: increased size/erection/pigment

-increased blood vessel visibility

-striae gravidarum

-estrogen stimulates lactiferous duct growth

-progesterone stimulates mammary lobe development

-prolactin→colostrum towards end of 1st trimester

—secreted in 2nd trimester

CVS & pregnancy

-BV increases 40-50%, peaks to 1200-1600 mL at week 32 (to meet uterus needs, hydrate, create reserve)

-CO increases 30-50%, peaks at week 25-30 (helps meet O2 need)

-HR increases 10-20 bpm

-DBP decreases till 24-32 weeks, then returns

—supine hTN syndrome from compressed vena cava→CO drops 30 mmHg

-cardiac hypertrophy, moves up & left (PMI rises 1-1.5 cm)

-S1 & S2 split, S3 heard, murmurs over left sternal border

-RBCs increase 20-30% (physiologic anemia)

—anemic = Hgb <11 or Hct <33% (T1); Hgb <10.5 or Hct <32% (T2)

-WBC increases from 2 mo to second or third trimester (not lymphocytes)

-5-6x more TE problems d/t more clot factors

BP in pregnancy

CO = SV x HR (all increase during pregnancy)

BP = CO x PR/SVR

-CO increases

-BP does not increase because PR decreases (d/t vasodilation from progesterone)

respiratory system & pregnancy

-O2 intake increases 40%

-diaphragm moves up 4 cm, costal angle decreases, ribs flare, ligaments relax, transverse diameter increases 2 cm

-TLC does not change, TV increases 40%

-chronic mild hyperventilation

-more chest breathing

-dyspnea

-estrogen→edema & hyperemia in URT (→stuffy nose, epistaxis, voice change, infections, impaired hearing)

GI tract in pregnancy

-gums become hyperemic, spongy, swollen, and bleed

—epulis (nodule) may form at 3 months; prevent with soft brush

-ptyalism

-decreased muscle tone/motility→reflux & heartburn, slower emptying, reverse peristalsis

-increased chance of hernia

-constipation

-gallbladder: distends, increases empty time, thicker bile, higher cholesterol (increased gallstones)

GI problems in pregnancy

N/V

-d/t increased hCG, prostaglandin, gastric dysrhythmia, psychological factors

-usually from week 4 to end of T1

discomfort

-d/t pelvic pressure, ligament tension, flatulence, distention, cramping, uterine contraction

appendix moves up & right

pica

urinary system in pregnancy

-larger & more relaxed kidneys/ureters

-urine rate decreases→lag between urine formation & reaching bladder

-irritable bladder, nocturia, frequency, urgency (early and towards end)

-GFR increases 50%→low CRT/BUN/uric acid

-body water increases 6.5-8.5 L

-increased tubular reabsorption

-increased H2O excretion→thirst

-leg edema

-glucosuria somewhat normal

-proteinuria is a sign of preeclampsia

skin & pregnancy

-hyperpigmentation of nipples/axillae/vulva at 16 weeks

-melasma/chloasma = blotchy brown over face after week 16

-linea nigra

-angiomatas = vascular spiders, arterioles on upper body from month 2-5

-palmar erythema

-possible itch, acne changes, thin/soft nails, hirsutism

-striae gravidarum do not disappear with time

female hormones in pregnancy

-hCG from ovum & chorionic villi maintains E&P production

-progesterone from corpus luteum, then placenta

—stops FSH & LH

—relaxes smooth muscles & decreases uterine contractility

—fat deposit, decreased insulin use

-estrogen from corpus luteum, then placenta

—stops FSH & LH

—fat deposit, decreased insulin use

—genital/uterine/breast enlargement

—increases vascularity

—interferes with folic acid metabolism

—increases proteins

—retains sodium & water

—decreases HCl & pepsin

other hormones in pregnancy

-prolactin from anterior pituitary prepares breasts for lactation

-oxytocin from posterior pituitary

—stimulates uterine contractions

—stimulates milk ejection

-hCS from placenta

—acts as GH

—develops breasts

—decreases glucose metabolism, increases fatty acids

-thyroid hormones support maternal metabolism and fetal growth

-parathyroid hormone controls Ca2+ & Mg2+ metabolism

-more insulin produced to compensate for antagonists

-cortisol from adrenals

—stimulates insulin production

—increases resistance to insulin

-aldosterone from adrenals causes renal sodium reabsorption

musculoskeletal & pregnancy

-pelvis tilts forward

-lordosis, anterior head flexion→UE aching/numbness/weakness

-back pain, leg cramps

-pubis widens at 28-32 weeks

-ab muscles stretch & tone decreases

-rectus abdominal muscles separate (T3)

-relaxed d/t progesterone

-educate on good posture

CNS/PNS in pregnancy

-headache

-lightheaded, syncope

-fatigue T1, insomnia T2-T3

-thicker cornea, decreased IOP, corneal changes

-increased smell/sensation

-carpal tunnel (T3)

endocrine system in pregnancy

-thyroid: increased TH & BMR (25%), maternal thyroxine develops fetal CNS

-pituitary: increased size, more prolactin, ACTH & cortisol decrease then increase

-pregnancy hormones antagonize insulin, pancreas makes more insulin

immune system in pregnancy

-increases, then decreases

-T1 = proinflammatory, T2 = antiinflammatory, T3 = proinflammatory

signs of pregnancy

-possible = mom is having symptoms

-probable = HCP can detect signs (e.g. urine test)

-positive = fetal evidence

trimesters

1st = 0-13 6/7 weeks

2nd = 14-27 6/7

3rd = 28-40 6/7

dx of pregnancy

-hCG = earliest (implantation)

—detectable 7-8 days before missed period

—serum or urine

—too early could→false negative

-ELISA

—OTC, at-home

—urine

—too early→false negative

-anticonvulsants & tranquilizers→false positive

-diuretics & promethazine→false negative

-tumors interfere

EDB

estimated day of birth

-Nagele’s rule = LMP minus 3 mo plus 7 days plus 1 yr

—or add 9 mo and 7 days to LMP

—usually, birth will be w/in 7 days of EDB

process of accepting pregnancy

mom:

1) accept fact of pregnancy

2) accept fetus as distinct from self (5 mo)

3) preps for child & acknowledges motherhood

dad:

1) announcement (accept fact of pregnancy)

2) moratorium (accept reality of pregnancy)

-possible rivalry between infant and wife, need to reorder personal relationships

3) focusing (find his role)

when to have prenatal visits

-initial visit during T1

-monthly till 28 weeks

-every 2 weeks till 36 weeks

-weekly till birth

*less if low-risk

first prenatal visit

-should be before 10 weeks

-interview

-physical exam by HCP

-tests: urine, cervical, blood (blood type, Rh, RBC Ab, CBC, rubella, varicella, STIs)

first prenatal interview

-current S/S

-coping, desire for pregnancy

-menarche age, menstrual hx, contraception, reproductive health, infertility, sexual hx, OB hx

-last LMP date

-health hx

-med use, vax, supplements, substance use

-nutrition

-fam hx

-social/cultural/economic/occupational hx

-mental hx/screening

-IPV/DV (every visit)

-ROS

OB terms

-gravida = woman who is pregnant

-gravidity = pregnancy

-nulligravida = never been pregnant

-primigravida = 1st time pregnant

-multigravida = 2+ time pregnant

-parity = number of pregnancy that reached 20 weeks

-nullipara = never completed pregnancy

-primipara = completed one pregnancy

-multipara = completed 2+ pregnancies

term definitions for pregnancy

preterm = pregnancy ends at 20-36 6/7 weeks

-late preterm = pregnancy reaches 34-36 6/7 weeks

term = 37-41 6/7 weeks

-early term = 37-38

-full term = 39-40

-late = 41

postterm = 42+

document OB hx

G - # of pregnancies (including current)

T - # that reached 20+ weeks

P - # that ended in birth between 20-36 weeks 6 days (preterm)

A - # of abortions before 20 weeks/under 500 g

L - # of living children

*e.g. G4 P2 P0 A1 L2 or G4 P2012

*P for para = # that reached 20+ weeks

follow-up prenatal visits

-brief interview

-physical assessment

-fundal height

-fetal assessment (GA, US, FHTs, movement)

-tests

-genetic screening

-education

fundal height

-measure beginning in T2

-should be equal to GW (±2)from 18-30 weeks

—if bladder is empty

-too low = IUGR, too high = polyhydramnios or multiple babies

-method:

—mom lays supine with pillow under head and wedge one hip

—measure with tape from upper symphysis pubis to upper fundus…

tests at prenatal visits

-urine each time

-Hgb & Hct at 28-32 weeks

-Ab at 28 weeks if mom is Rh-

-GDM at 24-28 weeks

-cultures for strep B (GBS) at 36-37 week

-cfDNA at 10+ weeks (amniocentesis)

-genetic screens 11-14 weeks

-US 18-22 weeks

prenatal education

-travel

—avoid after viability, no planes after 36 weeks

—not to places with bad water or Zika/malaria

—avoid long plane/car ride (DVT risk)

-vax (no live; Tdap, hep B, and flu are okay)

-Rh

—if mom is negative and baby is positive, will need Rx for HDFN (Rh Ig at 26-30 weeks, then 72 hours PP)

-hygiene (sweat will increase)

-UTIs: S/S & prevention

—drink 2.5 L/day

-expected changes

-nutrition

-physical activity (150 min moderate per week)

-posture (lateral recumbent is best when sleeping)

-rest

-meds & vitamins

-substance use

-Kegel exercises

-oral health (risk for gum issues)

-clothing

-job & safety

-breastfeeding (clean with warm water only)

-sexuality

S/S in pregnancy to report immediately

-vaginal bleeding

-RUQ pain w/ HA

-gush of fluid (membrane rupture)

-no fetal movement for 30 min

-severe abdominal pain

most important vitamin in pregnancy

folate (B9)

-deficit causes NTDs

-need 400 mcg/day supplemented

—4 mg/day if hx of NTD

—start taking 1 month before conception

-food sources: liver, legumes, asparagus, spinach, papaya, cereal, broccoli, beans, avocado, orange, pasta, rice, bread, egg, corn

weight gain in pregnancy

-need more nutrients to support fetal growth, tissue growth, increase in TBV, mammary development, & increased BMR

-should gain:

—25-35 lb if normal BMI (2-3 lb/wk in T1, then 1 lb/wk)

—28-40 if underweight

—15-25 if overweight (0.6 lb/wk)

—11-20 if obese (0.5 lb/wk)

-over 6.6 lb in 1 month causes preeclampsia risk

obesity in pregnancy

increased risk of GDM, HTN, assisted or Cesarean birth, SSI, VTE, depression

macro needs in pregnancy

-kcal:

—340 more kcal in T2

—452 more in T3

-fat:

—20-35% of daily kcal

—avoid trans fats

—need 300 mg DHA, AA, omega-3

-carbs:

—175 g/day, 45-64%

—25-35 g fiber

-also need iron supplement

—27 mg/day

—allows increase in TBV

—take with vitamin C or citrus foods

-avoid fat-soluble vitamin supplements

F&E needs in pregnancy

-8-12 cups water/day

—prevents preterm labor

—also milk or decaf tea

-foods supply 700 mL

-sodium <2300 mg

—do not over-restrict (peripheral edema is usually normal)

-need potassium (8-10 servings fruit & veggies)

-under 200 mg caffeine

-avoid aspartame if pt has PAH deficiency

managing N/V in pregnancy

-dry starchy foods

-less fluid in morning

-eat q2-3h, small amounts at a time

-do not skip meals

-move/get up slowly

-fresh air

-cool, non-smelly foods

-avoid spicy or strong flavors

-do not brush teeth right after eating

-salty or tart foods help, herbal tea, ginger

-motion sickness wristbands

-meds or vitamin B6