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Maternity and Pediatric Nursing

Chapter 12
Nursing Management During Pregnancy

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Objectives
1.

Define the key terms used in this chapter.

2.
Identify the information typically collected at the initial prenatal
visit.
3.

Explain the assessments completed at follow-up prenatal visits.

4.
Discuss the tests used to assess maternal and fetal well-being,
including nursing management for each.
5.
Outline appropriate nursing management to promote maternal
self-care and minimize the common discomforts of pregnancy.
6.

List the key components of perinatal education.

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Key Terms
Alpha- Fetoprotein
Aminocentesis
Biophysical Profile
Chorionic Villus Sampling(CVS)
Gravida
Para
High-Risk Pregnancy
Natural Childbirth
Perinatal Education
Preconception Care

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Preconception Care
Immunization status
Underlying medical conditions
Reproductive health care practices
Sexuality and sexual practices
Nutrition
Lifestyle practices
Psychosocial issues
Medication and drug use
Support system
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1st Prenatal Visit


Establishment of trusting relationship
Focus on education for overall wellness
Detection and prevention of potential problems
Comprehensive health history, physical examination,
and laboratory tests

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Comprehensive Health History


Reason for seeking care
Suspicion of pregnancy
Date of last menstrual period
Signs and symptoms of pregnancy
Urine or blood test for hCG
Past medical, surgical, and personal history
Womans reproductive history: menstrual, obstetric,
and gynecologic history
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Comprehensive Health History


Reason for seeking care
Suspicion of pregnancy
Date of last menstrual period
Signs and symptoms of pregnancy
Urine or blood test for hCG
Past medical, surgical, and personal history
Womans reproductive history: menstrual, obstetric,
and gynecologic history
Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Comprehensive Health History


Reason for seeking care
Suspicion of pregnancy
Date of last menstrual period
Signs and symptoms of pregnancy
Urine or blood test for hCG
Past medical, surgical, and personal history
Womans reproductive history: menstrual, obstetric,
and gynecologic history
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Menstrual History
Menstrual cycle
Age at menarche
Days in cycle
Flow characteristics
Discomforts
Use of contraception

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Menstrual History (contd)


Date of last menstrual period (LMP)
Calculation of estimated or expected date of birth (EDB)
or delivery (EDD)
Nageles rule
Use first day of LNMP

11/21/07

Subtract 3 months

8/21/07

Add 7 days

8/28/07

Add 1 year

8/28/08 = EDB

Gestational or birth calculator or wheel (see Figure


12-3)
Ultrasound
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Pregnancy Wheel

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Obstetric History
Gravida: a pregnant woman
Gravida I (primigravida): first pregnancy
Gravida II (secundigravida): second pregnancy, etc.
Para: a woman who has produced one or more viable
offspring carrying a pregnancy 20 weeks or more
Primapara: one birth after a pregnancy of at least 20
weeks (primip)
Multipara: two or more pregnancies resulting in viable
offspring (multip)
Nullipara: no viable offspring; para 0
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Obstetric History (contd)


Terminology
G (gravida): the current pregnancy
T (term births): the number of pregnancies ending
>37 weeks gestation, at term
P (preterm births): the number of preterm
pregnancies ending >20 weeks or viability but before
completion of 37 weeks
A (abortions): the number of pregnancies ending
before 20 weeks or viability
L (living children): number of children currently living
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Question
Is the following statement True or False?
A multipara refers to a woman who is pregnant for the first
time.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
False.
A multipara refers to a woman who has had two or more
pregnancies resulting in viable offspring.

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Physical Examination
Vital signs
Head-to-toe assessment
Head and neck
Chest
Abdomen, including fundal height if appropriate
Extremities

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Physical Examination (contd)


Pelvic examination
Examination of external and internal genitalia
Bimanual examination
Pelvic shape: gynecoid, android, anthropoid,
platypelloid
Pelvic measurements: diagonal conjugate, true
(obstetric) conjugate, and ischial tuberosity

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Ricci, 2009
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(Obstetric) conjugate, and ischial tuberosity

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Laboratory Tests
Urinalysis
Complete blood count
Blood typing
Rh factor
Rubella titer
Hepatitis B surface antigen
HIV, VDRL, and RPR testing
Cervical smears
Ultrasound
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Follow-up Visits
Visit schedule:
Every 4 weeks up to 28 weeks
Every 2 weeks from 29 to 36 weeks
Every week from 37 weeks to birth

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Follow-up Visits (contd)


Assessments
Weight & BP compared to baseline values
Urine testing for protein, glucose, ketones, and
nitrites
Fundal height (see Figure 12-5)
Quickening/fetal movement (see Box 12-3)
Fetal heart rate (see Nursing Procedure 12-1)
Teaching: danger signs
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Fundal Height

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Question
Is the following statement True or False?
A woman who is 24 weeks pregnant would arrange
for a follow-up visit every 2 weeks.

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Answer
False.
A woman who is 24 weeks pregnant would have follow-up
visits scheduled every 4 weeks until she reaches 29
weeks gestation.

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Assessment of Fetal Well-Being


Ultrasonography (see Figure 12-6)
Doppler flow studies
Alpha-fetoprotein analysis
Marker screening tests
Amniocentesis (see Figure 12-7)
Chorionic villus sampling (CVS)
Percutaneous umbilical blood sampling (PUBS)
Nonstress test; contraction stress test
Biophysical profile
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Ultrasound

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PUBS

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1st Trimester Discomforts


Urinary frequency or incontinence (see Teaching
Guidelines 12-1)
Fatigue
Nausea and vomiting
Breast tenderness
Constipation
Nasal stuffiness, bleeding gums, epistaxis
Cravings
Leukorrhea
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2nd Trimester Discomforts


Backache
Varicosities of the vulva and legs
Hemorrhoids
Flatulence with bloating

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3rd Trimester Discomforts


Return of 1st trimester discomforts
Shortness of breath and dyspnea
Heartburn and indigestion
Dependent edema
Braxton Hicks contractions

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Nursing Management to Promote SelfCare


Personal hygiene
Avoidance of saunas and hot tubs
Perineal care
Dental care
Breast care
Clothing
Exercise (see Teaching Guidelines 12-2)

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Nursing Management to Promote SelfCare (contd)


Sleep and rest
Sexual activity and sexuality
Employment (see Teaching Guidelines 12-3)
Travel (see Teaching Guidelines 12-4)
Immunizations and medications

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Question
While assessing a woman at 18 weeks gestation, which of
the following would the nurse report as unusual?
A. Urinary frequency
B. Backache
C. Leukorrhea
D. Flatulence with bloating

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Answer
A.
During the second trimester, urinary frequency
typically improves when the uterus becomes an
abdominal organ and moves away from the bladder
region. Backache and flatulence with bloating are
common during the second trimester. Leukorrhea
begins in the first trimester and continues
throughout pregnancy.

Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preparation for Labor, Birth, and


Parenthood
Perinatal education
Childbirth education
Lamaze (psychoprophylactic) method: focus on
breathing and relaxation techniques
Bradley (partner-coached childbirth) method:
focus on exercises and slow, controlled
abdominal breathing
Dick-Read (natural childbirth) method: focus on
fear reduction via knowledge and abdominal
breathing techniques
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Preparation for Labor, Birth, and


Parenthood (contd)
Options for birth setting
Hospitals: delivery room, birthing suite
Birth centers
Home birth
Options for care providers
Obstetrician
Midwife
Doula
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Preparation for Labor, Birth, and


Parenthood (contd)
Feeding choices
Breastfeeding: advantages and disadvantages
Bottle feeding: advantages and disadvantages
Teaching
Final preparation for labor and birth

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REVIEW
1. Which of the following biophysical profile findings
indicate poor oxygenation to the fetus?
A. Two pockets of amniotic fluid
B. Well flexed arms and legs
C. Nonreactive fetal heart rate
D. Fetal breathing movements

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REVIEW
The correct response is C:
A nonreactive fetal heart rate is one of the biophysical
profile findings that indicates poor oxygenation to the
fetus.

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REVIEW
2. The nurse teaches the pregnant client how to perform
Kegal exercises as a way to accomplish which of the
following?
A. Prevent perineal lacerations
B. Stimulate postdates labor
C. Increase pelvic muscle tone
D. Lose pregnancy weight quickly

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Review
The correct response is C:
Kegel exercises help to tighten and strengthen pelvic
floor muscles to improve tone. They can help prevent
stress incontinence in women after childbirth. These
exercises dont strengthen the perineal area on the
outside to prevent lacerations, but rather the internal
pelvic floor muscles. Kegel exercises have nothing to do
with the start of labor for postdate infants. A drop in
progesterone levels and an increase in prostaglandins
augment labor, not exercise. Kegel exercises dont burn
calories.
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REVIEW
3. During a clinic visit, a pregnant client at 30 weeks gestation
tells the nurse, Ive had some mild cramps that are pretty
irregular, What does this mean? the cramps are probably:
A. The beginning of labor in its very early stages
B. An ominous finding that the client is about to have
a miscarriage.
C. Related to over hydration in the client.
D. Braxton-Hicks contractions which occur though out
pregnancy

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REVIEW
The correct response is D.
The uterus is constantly contracting throughout
pregnancy, but the contractions are irregular and not
usually felt by the woman, nor do they cause dilation of
the cervix. Braxton Hicks contractions are not the start of
early labor, since there arent any measurable cervical
changes. They are normal throughout the pregnancy, not
an ominous sign of an impending abortion. A womans
hydration status is not related to Braxton Hicks
contractions; they occur regardless of her fluid status.

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REVIEW
4. a pregnant clients last normal mesntrual period was on
August 10. Using Nagels rule , the nurse calculates that
her estimated date of birth(EDB) will be which of the
following?
A. June 23
B. July 10
C. July 30
D. May 17

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REVIEW
The correct response is D:
Using Nageles rule, 3 months are subtracted and 7 days
are added, plus 1 year from the date of the last
menstrual period

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Questions ???
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