Maternity Exam 1

What makes a pregnancy sign "presumptive"?

It is subjective — reported by the client about how they feel

It has NOT been verified

Could have other causes

What makes a pregnancy sign "probable"?

It is objective — observed or found by the HCP during assessment or examination

Strongly suggests pregnancy but not 100% confirmatory

What makes a pregnancy sign "positive"?

It is confirmatory — directly confirms the presence of a fetus

100% diagnostic of pregnancy

List the presumptive signs of pregnancy

1. Amenorrhea (missed period)

2. Fatigue

3. Nausea/Vomiting

4. Urinary frequency

5. Breast changes (tenderness)

6. Quickening (client feels fetal movement)

7. Uterine enlargement

8. Home pregnancy test

Why is a home pregnancy test presumptive?

The client reports taking it at home; it has not been verified by a provider

List the probable signs of pregnancy

1. Abdominal enlargement (visible baby bump)

2. Hegar's sign (softening of the isthmus (lower segment) of the uterus caused by increased blood flow to the uterus)

3. Chadwick's sign (bluish-purple discoloration of the cervix and vaginal tissues due to increased blood flow)

4. Goodell's sign (softening of the cervix)

5. Ballottement (when the examiner palpates the abdomen and feels a floating mass (the fetus) rebound)

6. Braxton Hicks contractions (Irregular, painless tightening of the uterus usually reported by the client but can also be felt by the examiner on assessment)

7. Positive pregnancy test in the office (provider-ordered)

8. Fetal outline felt by examiner

Why is a provider-ordered pregnancy test a PROBABLE sign and not positive?

Because a urine/blood hCG test confirms the hormone but does not directly visualize or confirm a live fetus. Other conditions can elevate hCG

List the positive (confirmatory) signs of pregnancy

1. Fetal heart sounds (distinct from the birthing person's heart rate)

2. Visualization of fetus by ultrasound

3. Fetal movement felt by the examiner

SCENARIO: A Doppler detects FHR of 150 bpm, distinct from the client's pulse of 76 bpm. What sign is it?

POSITIVE b/c fetal heart sounds confirmed by examiner, distinct from maternal pulse

SCENARIO: A client reports urinary frequency, food aversions, vomiting, and a late period. She took a home pregnancy test. What sign is it?

PRESUMPTIVE b/c all are client-reported symptoms; home test is also presumptive (not provider-ordered).

SCENARIO: A provider palpates what seems to be a fetus and orders an hCG lab test. What sign is it?

PROBABLE b/c fetal outline felt by examiner (probable) + provider-ordered pregnancy test (probable).

SCENARIO: A nurse notes the cervix has a bluish hue on exam and soft consistency. What signs are these?

PROBABLE b/c Chadwick's sign (bluish cervix) and Goodell's sign (soft cervix), both found on objective examination

Why can't uterine enlargement alone confirm pregnancy?

It is a PROBABLE sign b/c uterine enlargement can have other causes (fibroids, other conditions)

What is the key difference between quickening (presumptive) and fetal movement (positive)?

QUICKENING = client reports feeling movement (subjective/presumptive)

POSITIVE fetal movement = the EXAMINER feels the baby move during palpation

Why does blood pressure drop in the 2nd trimester?

Progesterone relaxes vascular smooth muscle, increasing elasticity of blood vessels → decreased peripheral resistance → lower BP

Normal in weeks 13-28

What's the clinical significance of increased cardiac output?

The heart must pump more blood per minute to supply both maternal and fetal circulation

Output can increase by up to 50% — important in clients with pre-existing cardiac disease

Why does hemoglobin appear low in pregnancy?

Plasma volume increases disproportionately more than red blood cell production

This dilutes Hgb concentration — called physiologic (dilutional) anemia. Not a true anemia in most cases

A client at 24 weeks has Hgb 10.6 and asks if she's anemic. What do you say?

Explain that some drop in Hgb is expected in pregnancy due to plasma expansion

However, 10.6 is on the low end — assess for symptoms (fatigue, pallor) and consider iron supplementation with provider

Why are pregnant clients at higher DVT risk?

Pregnancy is naturally hypercoagulable — clotting factors increase to prevent hemorrhage at delivery

Combined with venous stasis from uterine compression and reduced mobility, DVT risk is elevated

How does tidal volume change in pregnancy, and why?

Increases

each breath brings in more air to meet higher oxygen demands of mother and fetus

When is shortness of breath in pregnancy normal vs. concerning?

Mild dyspnea on exertion is normal

Concerning if O₂ sat drops below 95% or lung sounds are abnormal

What nursing education addresses pregnancy-related constipation?

Increase fluid and fiber intake, encourage ambulation, reassure it is normal due to progesterone

Why are pregnant clients at increased risk for gallstones?

Progesterone slows gallbladder emptying, allowing bile to stagnate and stones to form

A 22-week client has heartburn and constipation. What additional finding escalates concern?

A change in blood pressure

heartburn + elevated BP could signal preeclampsia

What postural change occurs in pregnancy and what causes it?

Lumbar lordosis increases as the center of gravity shifts forward with uterine growth

Why do ligaments loosen in pregnancy and what risk does this create?

Relaxin loosens joints and widens the symphysis pubis — increases fall risk and causes gait changes

What education would you give a 30-week client with back pain from standing at work?

Suggest back exercises, frequent sitting/lying breaks, avoid prolonged standing, and wear compression stockings

What vaginal discharge is normal in pregnancy vs. abnormal?

Normal: thin, white, odorless leukorrhea

Abnormal: foul odor, discoloration, itching, burning, or fluid leakage

Why is HBsAG tested in pregnancy?

if its positive = active Hep B; newborn needs prophylaxis at delivery to prevent transmission

What are the 3 methods used to date a pregnancy?

1) Naegele's Rule / LMP (last menstrual period)

2) Uterine sizing (fundal height — measured from symphysis pubis to fundus after 20 weeks)

3) Ultrasound (most accurate in 1st trimester, 7-10 weeks)

What is Naegele's Rule used for in antepartum care?

It uses the last menstrual period (LMP) to estimate the estimated date of confinement (EDC)

It is one of the primary methods to date a pregnancy

When is ultrasound MOST accurate for pregnancy dating?

Within the first trimester — ideally 7-10 weeks

Accuracy decreases as pregnancy progresses

What does the Quad Screen test for and when is it done?

Done at 15-22 weeks

Combines 4 blood markers to screen for Down syndrome and neural tube defects (NTDs)

Abnormal levels (too high or too low) indicate possible risk — does NOT confirm diagnosis

What is Cell-Free DNA (cfDNA) testing?

A prenatal screening test that looks for fetal DNA circulating in the birthing person's blood to screen for chromosomal abnormalities

It is a screening test — not diagnostic

What is the difference between screening tests and diagnostic tests?

Screening estimates risk — tells us there is a possibility something could be abnormal, but doesn't confirm it

Diagnostic confirms — involves genetic testing such as karyotyping the fetus (e.g., CVS or amniocentesis)

What is Chorionic Villus Sampling (CVS) and when is it done?

A diagnostic test done at 10-13 weeks

Samples chorionic villi from the placenta

Can be done transvaginally or transabdominally depending on placenta location and fetal positioning

What is amniocentesis and when is it done?

A diagnostic test done around 15 weeks

A needle passes through the abdominal wall to obtain a small sample of amniotic fluid for fetal genetic karyotyping

What do the routine first-visit labs screen for?

ABO/Rh blood type

Antibody screen

CBC

Rubella immunity

Pap smear

GC/CT (STIs)

RPR (syphilis)

HBsAg (hepatitis B)

HIV

Hemoglobin electrophoresis (sickle cell trait)

When is glucose screening done and what does it screen for?

24-28 weeks

Screens for gestational diabetes mellitus (GDM) using a glucose challenge test (GCT)

When is GBS screening done and why is it important?

35-37 weeks

Group B Streptococcus (GBS) colonization can be transmitted to the neonate during delivery, causing serious neonatal infection

Positive result requires IV antibiotics in labor

What is hemoglobin electrophoresis screening for?

Signs of sickle cell disease or trait — disproportionately impacts people of color

Done as part of first-visit routine labs

What folic acid dose is recommended for all childbearing-age women?

400 mcg daily for all childbearing-age women

600-800 mcg for pregnant women

Higher doses needed for: history of NTD baby, obesity (BMI >30), diabetes, anti-seizure medication use

What components are included in the first antepartum visit assessment?

1) Pregnancy verification & dating

2) Medical, OB, and social history

3) Head-to-toe physical assessment

4) Screening labs

5) Support systems & patient goals

6) Initial education

What is the EDC and how is it determined?

EDC = Estimated Date of Confinement (due date)

Determined using: LMP date, initial exam findings, Doppler FHR, ultrasound measurements, and repeat ultrasound.

The consensus EDC is established from these data points

What is fundal height measurement and when does it start?

Measurement from the symphysis pubis to the top of the uterine fundus

Begins after 20 weeks gestation

Used to assess fetal growth and uterine sizing

What is the Gravida/Para (G/P) system?

G = Gravida (total number of pregnancies)

P = Para (number of births at ≥20 weeks)

Example: G1P0 = pregnant for the first time, no prior births

What is Rh incompatibility and when does it become a problem?

Occurs when an Rh-negative birthing person carries an Rh-positive fetus (partner is Rh+)

In a 2nd pregnancy, maternal IgG antibodies (anti-Rh) cross the placenta and attack the fetal Rh+ red blood cells — causing hemolytic disease of the fetus/newborn

What is RhoGAM and when is it given?

RhoGAM (Rh immunoglobulin) is given to Rh-negative birthing persons to prevent sensitization

Routinely at 28 weeks (covers through delivery — lasts ~14 weeks). After delivery if baby is Rh+. After any bleeding episode or invasive procedure (e.g., amniocentesis, CVS)

What is the anatomy scan (fetal survey) ultrasound and when is it done?

Done at 18-22 weeks

Examines fetal anatomy to screen for structural abnormalities

This is a screening test — findings suggest possible problems but do not confirm diagnosis

When are prenatal records typically sent to labor & delivery?

At key gestational milestones: 20, 28, 36, 38, and 40 weeks — to ensure L&D has up-to-date information if the patient presents

What are the 7 emergency warning signs during pregnancy that require immediate nursing action?

1) Vaginal bleeding

2) Leaking fluid (suggests ruptured membranes)

3) Decreased/absent fetal movement after 28 weeks

4) Tight abdomen or continuous sharp pains (labor or placental abruption)

5) Intractable vomiting

6) Fever > 100.4°F

7) Contractions prior to 37 weeks (preterm labor)

A pregnant client reports decreased fetal movement at 30 weeks. What is the nursing action?

This is an emergency sign

Notify the provider immediately

Fetal kick counts (movement < 10 in 2 hours) and/or a non-stress test (NST) would be warranted to assess fetal wellbeing

A patient is Rh-negative at 28 weeks. What nursing action is required?

Administer RhoGAM at 28 weeks per standing orders to prevent maternal sensitization

Document administration

Educate the patient on why it is given and that it will be repeated after delivery if baby is Rh+

A client presents at 38 weeks with rhythmic back-to-front pain every 15 min x 4 hours, worsening over time, and bloody show. What nursing actions are indicated?

These are signs of labor: regular contractions that worsen, radiating from back to front, not relieved by position change or hydration, plus bloody show (pink vaginal discharge)

Action: Triage in L&D, continuous EFM, cervical exam, notify provider, prepare for admission if in active labor

How do nurses evaluate pregnancy progress?

1) Dating the pregnancy (accurate gestational age is essential for all milestones)

2) Tracking major pregnancy milestones

3) Initial and ongoing assessments each visit

4) Fetal testing — evaluates how the fetus and birthing person are progressing

A client is Rh-negative and has a first-trimester bleed. What should the nurse do?

Administer RhoGAM

Any bleeding episode, even in the first trimester, can cause fetal-maternal hemorrhage and sensitize an Rh-negative birthing person

RhoGAM is indicated after any bleeding or invasive procedure — not just at 28 weeks

A 26-week client reports irregular, mild uterine tightening that go away with rest and fluids. What is the nursing assessment?

These are likely Braxton-Hicks (practice/false labor) contractions — expected finding

Educate client on the difference between true and false labor

Instruct to call if contractions become regular, increase in intensity, or are accompanied by bleeding, leaking fluid, or decreased fetal movement

What GI symptoms does a 14-week pregnant client commonly report?

Nausea (especially morning), heartburn after meals, and constipation

What physiologic changes cause GI discomforts in pregnancy?

Progesterone slows GI motility and decreases lower esophageal sphincter tone

What non-pharmacologic advice addresses nausea and heartburn in pregnancy?

Small, frequent meals

Avoid trigger foods

Increase fluids and fiber

Light exercise

What medications are safe for GI discomforts in pregnancy?

Vitamin B6 (nausea)

Antacids (heartburn)

Stool softeners (constipation)

What GI symptoms require the client to seek immediate help?

Persistent vomiting

Severe abdominal pain, or inability to tolerate fluids >24 hours

What respiratory symptoms does a 30-week pregnant client commonly report?

Mild shortness of breath with activity and lightheadedness when standing quickly

What physiologic changes cause shortness of breath in pregnancy?

Increased O₂ demand, diaphragm elevation, increased tidal volume, and heightened CO₂ sensitivity

What non-pharmacologic strategies address dyspnea in pregnancy?

Change positions slowly

Pace activity

Use upright posture

Rest as needed

What medication is used for normal respiratory changes in pregnancy?

None — normal pregnancy-related dyspnea does not require pharmacologic treatment

When should a pregnant client with breathing difficulty seek immediate help?

Sudden/severe shortness of breath

Chest pain

Cyanosis, or persistent dizziness/syncope

What reproductive symptoms does a 12-week pregnant client commonly report?

Increased thin vaginal discharge and breast tenderness

What causes increased vaginal discharge and breast tenderness in pregnancy?

Elevated estrogen and increased blood flow to reproductive tissues

What non-pharmacologic advice addresses vaginal discharge in pregnancy?

Good perineal hygiene and avoiding douching

What medications are indicated for normal reproductive discomforts in pregnancy?

None — only if infection or pathology is identified

What reproductive symptoms require the client to seek help?

Foul-smelling/discolored discharge

Vaginal itching/burning

Bleeding, or fluid leakage

What musculoskeletal symptoms does a 28-week pregnant client commonly report?

Lower back pain and sharp pulling pain in the lower abdomen when changing positions (round ligament pain)

What physiologic changes cause back and round ligament pain in pregnancy?

Shift in center of gravity, increased lumbar lordosis, and ligament/joint relaxation

What non-pharmacologic advice addresses musculoskeletal discomforts in pregnancy?

Good posture

Supportive footwear

Prenatal exercises

Heat or cold as tolerated

What medication can be used for musculoskeletal pain in pregnancy?

Acetaminophen, if approved by the provider

What musculoskeletal symptoms require the client to seek immediate help?

Severe/worsening pain

Neurologic symptoms, or pain with fever or contractions

What does the T.E.A.C.H. framework stand for?

Target the symptom

Explain the cause

Advise non-pharmacologic strategies

Choose safe medication if needed

Highlight when to seek help

What is a key "points to ponder" principle about pregnancy discomforts?

"Normal" does not mean "ignored" — ongoing assessment is essential even when changes are expected.

What are the 5 Ps of Labor?

1. Passage

2. Passenger

3. Position

4. Powers

5. Psyche

What does "Passage" refer to in labor?

The shape and dimensions of the pelvis (birth canal)

Four types: Gynecoid, Anthropoid, Android, Platypelloid

Which pelvic type is most favorable for vaginal delivery?

Gynecoid — round shape

the most common and most desirable for vaginal birth

What happens with an Anthropoid pelvis?

It is stretched/elongated

Less ideal; baby may present in occiput posterior (OP) position, making labor longer and more painful

What happens with an Android (heart-shaped) pelvis?

Associated with a male-shaped pelvis; harder to achieve vaginal delivery due to narrower outlet

What is the risk with a Platypelloid pelvis?

Baby's head is more likely to get stuck sideways (transverse arrest) due to the wide, flat shape

What does "Passenger" refer to in labor?

The fetus — including fetal presentation, fetal lie, and fetal attitude

What are the three considerations for fetal positioning?

1. Fetal presentation (what comes out first) 2. Fetal lie (how fetal spine aligns with maternal spine)

3. Fetal attitude (chin-to-chest flexion)

What is the most favorable fetal attitude and why?

Complete flexion (chin tucked to chest) — presents the smallest diameter of the head, making it easiest to navigate the pelvis

What is the difference between vertex and breech presentation?

Vertex = head comes out first (most favorable)

Breech = buttocks or feet first

Which breech type is considered best, and which is worst?

Best: Frank breech (bottom first, legs straight up)

Worst: Footling breech (one or both feet present first — highest risk of cord prolapse)

What does LOA stand for, and why is it important?

Left Occiput Anterior — the fetal occiput faces the left anterior of the maternal pelvis

This is the most favorable position for vaginal delivery

What is fetal station and what is the reference point?

Station measures fetal descent relative to the maternal ischial spines

0 = at spines

negative = above

positive = below (toward delivery)

Max is +3 (crowning)

What does "Powers" refer to in labor?

The contractility of the uterus — coordinated uterine contractions that cause cervical change and fetal descent

What is tachysystole?

Contractions that are too close together (more than 5 in 10 minutes)

Can compromise fetal oxygenation by not allowing adequate uterine relaxation

What does "Position" refer to in the 5 Ps?

The birthing person's position during labor

Upright and mobile positions can facilitate fetal descent and labor progress

What does "Psyche" refer to in the 5 Ps?

The mental/emotional status of the birthing person — includes motivation, trust, support, preparation, culture, and sense of control

Fear and anxiety can slow labor

What are the 7 Cardinal Mechanisms of Labor in order?

Engagement → Descent → Flexion → Internal Rotation → Extension → External Rotation → Expulsion

What is synclitism vs. asynclitism?

Synclitism: fetal head aligned with the anterior-posterior plane of the pelvis (ideal)

Asynclitism: fetal head is tilted/out of alignment — can slow descent

What defines TRUE labor?

Regular contractions

contractions get stronger over time

pain starts in the back and radiates to lower abdomen

bloody vaginal discharge

cervical change

What defines FALSE labor (Braxton Hicks)?

Irregular contractions

contractions slow or stop with position changes

discomfort felt only in the front of the abdomen

no cervical change