antepartum

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  1. Signs and symptoms of Pregnancy
    • Presumptive signs (subjective) cause it could be something else
    • Fatigue- 12 weeks
    • breast tenderness 3-4 weeks
    • N/V 4-14 weeks
    • Amenorrhea- missed period 4 weeks
    • Urinary frequency 6-12
    • hyperpigmentation of skin 16 weeks
    • uterine enlargement (might)
    • u might feel some fetal movement usually occurs 16-20.
    • breast enlargment
  2. S/S of pregnancy probable (objective)
    • Braxton hicks contraction 16-28
    • positive pregnancy test 4-12 (proable)
    • abdominal enlargement 14
    • ballottement 16-28 u can feel the head move
    • Goodell's sign 5 weeks- soften of cervix
    • chadwick sign 6-8 weeks blueish tint to the vaginal mucosa
    • Hegar's sign 6-12- soften of the lower uterine segment
  3. Pregnancy test
    Human chorionic gonadotropin (hCG) is earliest biochemical marker of pregnancy

    • when we see this we release hcg hormone in our blood and urine
    • this can begin 24-48 hrs after implantation
    • serum can be detected in blood as early as 7-9 days
    • urine test can be done on the first day of missed period
    • Chorocarcenoma/ovarian cancer will give u an high hcg
    • pregnancy help to esta pregnancy
    • also uterine tumors can change the size of the uterus
  4. signs of pregnancy Positive present
    • those signs attributed only to the presence of a fetus
    • hearing fetal heart beat and separating it from the mother by a doppler 10-12 weeks
    • fetal movement felt by the examiner (20 weeks)
    • visualization of fetus by u/s 4-6 weeks
  5. Preconception risk factor for adverse pregnancy outcomes
    • things u need stop while trying to get pregnant
    • Isotretinoins accuitaine- used for acne 
    • alcohol misuse
    • anti-epileptic drugs valproic acid
    • DM- mom should have good glycemic control
    • folic acid deficiency- make sure they are taking this inc growth of spine
    • HIV/AIDS- cont treatment and if they are newly dx then u would begin treatment at 14 weeks
  6. More preconception risk factors
    • we screen this when peeps come in for 1st prenatal visit but best when done preconception
    • hypothyroidism- we need to know
    • maternal phenylketonurea- PKU
    • Rubella- we draw this lab-u would not vaccine during pregnancy but after she delivers
    • obesity- weight management 
    • oral anticoagulant
    • STI- treat
    • smoking
  7. Preconception Care PHM
    • immunization status
    • underlying medical conditions
    • reproductive health care practices 
    • sexuality and sexual practice
    • nutrition
    • lifestyle practices
    • psychosocial issues- depression
    • medication and drug use
    • support system- who will be there for them.
  8. Vaccine
    • cannot get a live virus 
    • Flu while pregnant**
    • tdap while pregnant
    • if u going to travel speak with PCP
    • update ur childhood vaccines
    • check titer
  9. Comprehensive Health History
    • Reason for seeking care
    • -suspicion of pregnancy- why do they think they are pregnant
    • - date of last menstrual period- important
    • - s/s of pregnancy 
    • - urine or blood test for hcg

    past medical, surgical and personal history we need to know about

    • woman's reproductive hx: menstrual obstetric, and gynecologic hx 
    • esp herpes- do they have active lesions - u can deliver vaginally if u don't have open active legions
    • STI's are important to know cause we need to know risk
  10. Reproductive Hx
    • Menstrual cycle 
    • - age at menarche (when u first started ur period)
    • - days in cycle 
    • - flow characteristics
    • - discomforts
    • - use of contraception
  11. 1st Prenatal Visit
    • Establishing a good trusting relationship
    • focus on education for overall wellness
    • detection and prevention of potential problems
    • comprehensive health hx, physical examination, and lab test
  12. Obstetric history
    • Gravida: a pregnant woman
    • - gravida I (primigravida)- 1st pregnancy
    • - gravid II (secundigravida)- second pregnancy etc
    • a number of pregnancy a woman had

    • Para: a woman who has produced a pregnancy of 20 weeks or more and delivered a newborn whether born alive or dead
    • - primapara: one birth after a pregnancy of at least 20 weeks 
    • - multipara: two or more pregnancy resulting in viable offspring
    • - nullipara: no viable offspring; para 0
  13. Obstetric Hx con GTPAL
    • G: gravida the current pregnancy
    • T- Term number of pregnancy between 38-42 weeks
    • P- para number of pregnancy viable past 20 weeks preterm
    • A- abortions the number of pregnancy ending before 20 weeks
    • L- living number of children currently living
  14. Menstrual Hx
    • Date of last menstrual period (LMP)
    • calculation of estimated or expected date of birth (EDB) or delivery EDD)

    • Nagele rule
    • use first date of LMP
    • subtract 3 months
    • and add 7 days
    • add 1 yr 

    • we can use gestational or birth calculator
    • ultrasound can also help us with age of fetus
  15. Physical Examination
    • baseline bp- so important for pregnancy complication 
    • Vital signs
    • - head to toe assessment
    • - chest
    • - abdomen, including fundal height if appropriate
    • - extremities
    •     - at risk for deep vein thrombosis
    • hyper coagulation state - more at risk for blood clots we have to do good assessment of legs
  16. Pelvic examination
    • examination of external and internal genitalia
    • bimanual examination: feeling the cervix
    • pelvic shape- md can feel pelvic shape: gynecoid (better for for delivery), andriod (narrow more manly), anthropoid (narrow c-section), platypelliod
    • pelvic measurements: diagnal conjugate, true obstertric conjugate, and ischial tuberosity
  17. Fundal Height
    another way to identity pregnancy and to determine where pregnancy is

    most pregnancy at 36 weeks is the highest for your fundal height and after this you should go thru lighting when the babies drop down in the pelvis
  18. Estimating Pelvic size
    • Type
    • four types andriod, anthropoid, gynecoid*, platypelloid- oval which makes it harder
    • also depends on the size of baby

    • Measurements
    • diagonal conjugate see figure 10.11
    • true conjugate or conjugate vera
    • ischial tuberosity diameter
  19. Diagonal conjugate and true conjugate
    • Diagonal Conjugate
    • diameter 12.5cm or more- adequate pelvis (solid line) Anterior-Posterior diameter of the sacral prominence and inferior margin of symphysis pubis -which makes it tight...
    • Measuring your tail bone to the symphysis pubis
    • True conjugate
    • obstetric  conjugate 
    • average diameter is 11.5 cm
    • dotted 
    • distance anterior surface of the sacral prominence and symphysis 

    • this is the actually measurement of how the baby can move thru the pelvis
    • measuring the diameter of the pelvic 
  20. Ischial tuberosity
    • diameter 10.5 cm consider adequate 
    • transverse diameter of the outlet
    • smallest part the baby comes out of..
  21. Laboratory Tests
    • Urinalysis
    • complete blood count
    • blood typing
    • Rh factor
    • Rubella titer
    • Hepatitis B surface antigen
    • HIV, VDRL, and RPR testing (sphyllis) 
    • Cervical smears - pap smears
    • Ultrasound - to determine dates
  22. Follow up visits
    • Visit Schedule 
    • - every 4 weeks up to 28 weeks
    • - every 2 weeks 29-36 weeks
    • - every 1 week 37 weeks to birth
    • during visits
    • - weight, BP, always compare to baseline, urine for protein, ketones, nitrates, fundal height, fetal movements and kick counts 

    • kick counts is something mom can do at home and if baby stops moving contact MD right away. 
    • quickening fetal movement- 16-20 be aware of movement check sometime everyday
    • FHR 110-160
  23. follow up visit 24-40 weeks
    • 24-28 weeks
    • - 1 hour glucose tolerance test (GTT), abnormal followed with a 3 hour GTT (fasting)
    • - Rhogam for RH negative mother

    • between weeks 29-36 weeks
    • - assess for edema

    • Between weeks 37-20 weeks
    • - screening GBS, chlamydia, gonnorrhea
    • - assessment of fetal presentation
  24. Physiologic adaptation of preg, reproductive changes
    • Uterine changes
    • - uterus inc in length, depth, width, weight wall thickness and volume to accoummodate the growing fetus
    • - braxton Hicks contraction
    • - hegar's
    • - amenorrhea 

    • Cervical changes
    • - in response to increase estrogen
    • - Goodell's, operculum (mucous plug), chadwick's sign 

    • Vaginal changes
    • chadwick;s

    • Ovarian changes
    • - ovulation stops

    • Breast changes
    • -larger tender, may ever start to leak (estrogen and progesterone)
  25. supine hypotensive syndrome
    laying on your back can cause u to press on your vena cava which will drop your bp and u may start to feel dizzy

    • tilt to the left so that your heart doesn't to work so hard
    • baby determines which side mom should lay on
  26. General Body System adaption GI system
    • Hypertrophy of gum causing bleeding, gingivitis 
    • hyperptyalism
    • Decrease gastric mobility
    • - constipation
    • - hemorrhoids
    • - heartburn
    • - inc risk of gallstone formation
    • - incr absorption of bilirubin into the blood stream causing generalized itching jaundice
    • - morning sickness- bc hcg levels off
  27. Physiologic changes cardiovascular system
    • Blood volume increases by 50%
    • - blood volume inc occurs gradually begins at week 10-12
    • - peaks at 32-34 weeks
    • - decreases slightly at week 40

    u have more plasma to rbc---rbc perfuse our lungs - u can get anemia because there is more plasma to rbc (why moms will be on iron

    • Heart
    • Cardiac output increase 30%-50% by 32 weeks
    • declines to 20% incr at 40 weeks
    • incr heart rate by 10-15 bpm
    • slight hypertrophy of the heart0 stress can enlarge hrt
    • palpitations not uncommon
    • may have a slight audible murmur
  28. Cardiovascular changes BP/peripheral blood flow
    • BP
    • -drops 5-10 Hg in the 2nd trimester, otherwise remains the same
    • - any rise in pregnancy should be investigated to rule out gestational htn
    • - cardiac output increases by 45-50%

    • Peripheral blood flow
    • decrease due to large uterus during 3rd trimester
    • increased incidence of edmea and varicosities of the leg vulva or rectum
  29. cardiovascular Blood constitution
    • RBC''s incre 25-33% higher
    •  - physiologic anemia of pregnancy
    •  - increase iron needs due to additional oxygen demands

    • Fibrinogen volume increase by 50%. Fibrinolytic activity depressed
    • more at risk for DVT

    • Increase WBC
    • slightly elevated
    • protective to the fetus 

    decrease protein levels- bc baby takes but we can increase with diet

    • increase lipids and chol
    • supply increase supply for the baby
  30. Respiratory System
    • Displacement of the diaphram by the uterus causes SOB
    • incr oxygen comsumption
    • total lung capacity decr because of shift up
    • incre respiratory rate to blow of CO2 (hyperventalition) 18-20 per min
    • incre nasal congestion, stuffiness, epitaxis and changes in voice

    • Temperature
    • incre initially but returns to normal by 16 weeks
  31. Urinary system
    • change are result of: hormonal influences of estrogen and progesterone
    • incre maternal blood volume- filtation rate for mom and baby
    • Changes to accomodae: increa workload and incr GFR
    • Anatomical changes: activity
  32. Urinary system part 2 renal
    • Fluid retention (incre by 7.5L)
    • - provides sufficient fluid volume for valuable placental exchange
    • - Aids the incre of maternal blood volume
    • - provides source of nutrition for fetus
    • Increased Renal function:
    • - during pregnancy a women's kidneys need to excrete not only the waste products of her body but also those of the growing fetus
    • Ureter and Bladder function:
    • -Frequency- r/t to pressure on bladder
    • - poor emptying r/t pressure on the urethra which may result in infection

    • Kidneys work hard to accomodate
    • it can cause UTI
  33. Musculoskeletal system
    • softening of the pelvic ligaments and joints including slight separation of symphysis pubis
    • change in the center of gravity (lordosis forward curve of the lumbar spine)
    • calcium and phosphorus needs increase

    change position slowly bc she is at risk for falling
  34. Integumentary system
    • Strie gavidarum- stretch marks
    • diastasis- abd muscles separate
    • linea nigra
    • melasma of mask of pregnancy
    • Vascular change: varicose veins, vascular spiders
    • palmer erythema
    • decrease hair growth
    • increase prespiration- caused by incre blood volume to the skin
  35. endocrine Thyroid, parathyroid pituary gland anterior and posterior
    • Thyroid and Parathyroid:
    • - increase thyroid secretion starting in the 1st trimester
    • - basal metabolic rate incre
    • - parathyroid incre utilizes of calcium and vit d

    • Pituary Gland:
    • Anterior
    • FSH and LH secreting is inhibited (anovulation)
    • TSH decre
    • GH decre related to action of hpl
    • prolactin incr
    • Posterior pituary
    • - oxytocin gradually incre- kicks u into labor
    • vasopressin (ADH)
  36. Endocrine pancreas and placenta
    • Pancreas: 
    • - responsible for the production of insulin which facilitates entry of glucose into the cell
    • - second half of pregnancy- insulin less effective r/t to estrogen progestrone, prolactin from the placenta. antagonist

    • Placenta
    • produces the largest amount of estrogen and progesterone, hcg, human placental lactogen and relaxin

    Andrenal gland:activity increased to incre the levels of corticosteroids and aldosterone (stress)
  37. Immune
    • Decreased during pregnancy to prevent the women's body from rejecting the fetus (foriegn body)
    • Immunoglobin G decreased (adaptive)
    • an increase of WBC (innate) simultaneously may counteract the decre in IgG
    • - women may be more prone to infection however counteracted by the increase WBC 
  38. Nutrition preconception
    • 1st trimester crucial for embryonic and fetal organ developement 
    • Healthful diet before conception ensures adequate nutrients are available for developing fetus
    • folic acid is important in periconceptual period
    • - NTD are more common in infants of women with poor folic acid intake
    • - 400 mcg/day reccommended for all women of reproductive age

    make sure to have color on your plate
  39. Fat needs
    • an essential fatty acid necessary for new cell growth is linoleic acid
    • - vegatable oil, safflower oil, corn oil, olive oil, peanut oil, and cottonseed oil
    • important to instruct woemn to make sure to consume a source of this nutrient during pregnancy

    OMEGA 3 fatty acid - from fish but be aware of the type u are eating- high mecury fish
  40. Caloric intake needs
    non preg- 2200 depending on activity

    pregnant- extra calorie extra 300 2500

    lactating- extra 500
  41. Protein
    • nutritional element basic to human growth
    • DRI daily requirement for women is 60 g/day
    • DRI for preg 80 g/day
    • high protein supplements is not reccommended
    • milk, meat, eggs, cheese, legumes, whole grains. and nuts are high in protein
    • women who are lactose intolerance can add a lactase supplement which predigest milke and take calcuim supplements
  42. Fluid need
    • 8 glasses per a day for preg and lactating women
    • dehydration increases the risk for cramping, contraction, preterm labor

    • Fiber need
    • constipation can occur in pregnancy due decrease in peristalsis due to the pressure of the uterus
    • increase fiber, cereals, fruits and veggies
  43. Vitamins and minerals
    folic acid Neurotube and rbc production, calcium, iron, vit c
  44. Folic acid
    • belongs to the vita b vitamins
    • found primarily in fresh fruits and vegatables
    • necessary for RBC production
    • decrea folic acid leads to neural tube defects
    • prenatal vitamines contain 0.4-0.1mg of 
  45. Maternal weight Gain
    • current recommended weight gain is 25-35lbs (normal weight gain)
    • any woman
    • BMI is a more accurate method for identifying women at risk for nutritional deficits
  46. Weight gain
    • it should be gained thru out pregancy
    • maternal and fetus are at risk when gain too much or too little
    • prepregnant weight is within normal weight
    • - 1st trimester weight gain 3.5-5lbs
    • - second and third 1/lb a week
    • review teaching guidelines 11.1 p 305
  47. Foods to avoid
    • alcohol- fetal alcohol syndrome
    • caffeine- stimulant
    • artificial sweetners- saccarine is eliminated from fetal blood stream (not good)
    • weight loss diets- reduction of calories is contraindicated during pregnancy may leas to fetal ketoacidosis and poor fetal growth
  48. Common problems affecting nutritional Health
    • N/V: hyperemesis gravideum if last longer than 4 months
    • cravings: result from a physiological need for more carbs or particular vitamin
    • Pica: may indicate iron deficiency anemia, Iron supplements may cure pica (H&H changes)- people like to chew on ice
    • Pyrosis heartburn- result from decre gastric motility and pressure of enlarging uterus
    • Hypercholestorolemia: increase progesterone levels cause increased chol levels
  49. Emotional response of preg
    • ambivalence
    • introversion v extroversion
    • acceptance
    • mood swings
    • body image and boundary
    • grief
    • narcissism 
    • stress
  50. Reva Ruben: Maternal role task
    • ensuring safe passage thru pregnancy and birth
    • seeking acceptance of infant by others (fathers)
    • seeking acceptance of self in maternal role to infant (binding in)
    • learning to give on oneself

    • 1st concern with self
    • 2nd concerned with the fetus and how it is growing
    • 3rd trim- accepted  role of motherhood
  51. Pregnancy and partners/siblings
    • Pregnancy and partners
    • every couple is different in their reaction
    • couvade syndrome- when dad gains weight the mom
    • changes in sexual desire
    • pregnancy and siblings- sibling reaction to pregnancy is age dependent. the introduction to a new baby can start the rivalry which results in fears of change with their relationship with parents. preparing siblings is imperative.
  52. Assessment of Fetal well-being
    • Ultrasonography
    • doppler flow studies- to hear heart beat
    • Alpha-fetoprotein analysis- elevated NTD and decrease Downs
    • marker screening test- hcg
    • aminiocentesis
    • chorionic villus sampling
    • precutaneous umbilical blood sampling
    • non stress test; contraction stress test
    • biophysical profile
  53. U/s and doppler
    • Ultrasonography: 
    • - non invasive
    • - fetal heartbeat and any malformations are identity, fetal growth is monitored along with anniotic fluid and placental grading

    • Doppler flow studies:
    • - the color images can help detect diastolic blood flow with the umbilical vessels

    • Nursing management:
    • - educate pt procedure- full bladder needed during early pregnancy- tell the difference between the baby and bladder
  54. Amniocentesis
    • aspiration of amniotic fluid for analysis
    • may be performed as early as 14 weeks
    • - used for analysis with history of chromosomal abnormalities
    • -Neural tube defects- AFP testing 16-18 weeks (elevated labs) checking for underlying problems
    • - lung maturity of fetus less than 37 weeks- DM mom babies have lower lung maturity
    • - fetal hemolytic disease- destruction of blood cells

    anytime they go into ur abdomen u offer a risk to the pregnancy
  55. post procedure assessment amniocentesis
    Instructions: report signs of infection, an increase in contractions, a change in fetal movement activity, from normal . reinforce the need to do fetal kick counts and review techiques
  56. Nursing management for amniocentesis
    • explain procedure
    • before procedure do a non stress
    • NST prior to procedure 
    • obtain VS
    • have pt empty bladder
    • Post procedure:
    • admin Rhogam if acceptable 
    • Assess maternal VS and fetal heart q 15 mins for 1 hr
    • observe puncture site for bleeding and drainage
    • tell pt to rest when go home
    • instruct her to report fever, leaking amniotic fluid, vaginal bleeding, uterine contractions, and decre fetal movement

    all about education to know s/s to look out for
  57. Chorionic Villi Sampling CVS
    used to detect numerous genetic disorders  except NTD

    usually done if pt has a hx of genetic problems

    hard to be in this position

    always give rhogam if mom is Rh-
  58. Alpha Fetoprotein analysis, marker screening, triple + quadruple screening test
    AFA- 16-18 weeks- done test for NTD and this would be elevated if this is the case. if lower baby can have downs

    • Marker screening:
    • - triple and quadruple- test for more disorders

    knowing and identifying whats next. educating and being there for the patient

    sometimes this is related to incorrect dating and sometimes the blood test may not be as accurate
  59. nuchal translucency screening
    • done in the 1st trimester 11-14 weeks
    • associated with more chromosmal defects
    • amniocentensis to rule this out
    • confirms the dx. 16-18 weeks
    • guided by u/s
  60. Percutaneous Umbilical Blood sampling PUBS
    • done late in 2nd trimester can be done after 16 weeks
    • procedure: needle inserted thru the moms abdomen and then uterine wall and then to the umbilical cord. 
    • drawing blood from the cord to check babies well being 
  61. Fetal heart sounds
    • rate 120-160 bpm
    • can be heard 10-12 weeks with doppler
    • sounds like a gallop
  62. Fetal movement
    • quickening- fetal movement felt by the mother at 16-20 weeks- indicates a healthy fetus- u should feel baby everyday
    • Kick counts
    • mothers are educated to count how many times fetus moves a day
    • check sometime everyday
    • it should be about 10 movements within that hr period

    if u fall on abdomen u should always come in to check
  63. Fetal heart rate
    • fetal heart rate 110-160
    • rhythm strip testing
    • - FHR and uterine contraction are monitored
    • Baseline heart rate: average of the heart rate for 10 mins - when the hr settles looking for average settling
    • Short term variablity: small changes that occur from second to second - u need an internal led on the baby (EKG)
    • long term variability: difference of heart rate that occur over 20 mins (with u/s u have toco measures contraction on top of fundus, then u/s for the hr)
  64. Contraction stress test
    this tells us how our baby and placenta is going to react to labor

    give them meds oxytocin to give them contraction- we like them to have 3 contraction less 40 sec or longer in 10 mins...and monitor fetal heart rate in response to this. 

    • we are looking to see if we have placenta insufficiency
    • baby with intrauterine growth problems.
    • post term pregnancy

    • Normal finding:
    • FHR does not decre after the contractions  bc it prefuses the placenta when it is released- no decelerations and it is consider a negative stress test

    positive- means we have decelerations after a contraction taking longer for the blood to get the baby. 
  65. Non stress test
    • measure the response to the fetal heart rate to fetal movement
    • reactive- when fetal movement occurs the heart rate should increase (meaning we have two accelaration 15x15 in 20 mins)
    • non reactive: further evaluation
    • - fetal movements without accelerations
    • - absence of 2 accelerations using the 15x15 in 20 mins
    • - decrease fetal movement

    sometimes we give the mom button to press everytime she feels the baby move

    • acceleration means the heart rate goes up by 15 beats and then comes back down. 
    • FHR bradycardia and tachycardia is something to worry about- this has to be sustained

    u want to ask did the pt eat, taken any meds that could mess with hr
  66. Vibroacoustic stimulation
    used to wake the baby up if no movement. it is a sharp sound

    non invasive and u can repeat in 10 mins
  67. Biophysical Profile
    if stress test was non reactive

    • good score 8-10 fetus is well
    • each section is scored a 2
    • all sonogram and non stress test

    • Fetal breathing- 1 episode of breathing 30 sec sustain within 30 min 
    • fetal movements- 20 mins 3 separate episodes of movement
    • fetal tone- how does the baby should be reflexed
    • amniotic fluid volume- if low could cause cord compression 
    • fetal heart reactivity (non stress test)
  68. Danger signs of pregnancy
    1st trimester- spotting or bleeding, painful urination, server persistent vomiting, fever higher than 100.4, lower abdominal pain with dizziness and accomplished by shoulder pain

    • 2nd trimester
    • regular uterine contractions, pain in calf, often increase with foot reflexion, sudden gush or leakage of fluid from vagina and absence of fetal movement for more than 24 hr

    • 3rd trimester
    • sudden weight gain, per orbital of facial edema, severe upper abdominal pain, epigastric area or headache with visual changes decreases fetal movement any of the other signs/symptoms
  69. 1st trimester discomforts s/s
    • urinary frequency or incontenence
    • fatigue
    • N/V
    • breast tenderness
    • constipation
    • nasal stuffiness, bleeding gums, epitaxis
    • cravings
    • leukorrhea- incr vaginal discharge 
  70. 1st trimester
    palpitation, urination, abdominal comfort
    Palpitation: r/t to increase blood volume 

    • Frequent urination
    • may last for up to three months and disappear s in the middle and comes back towards the end
    • r/o infection and gestational diabetes
    • kegal excerises can help with stress incontinence

    • Abdominal discomfort
    • may be related to round ligaments pain-
  71. 1st trimester discomfort fatigue and N/V
    • Fatigue
    • - r/t increased to to incr metabolic demands, incre levels of progesterone and relaxin, psychosocial changes 
    • - r/o anemia, infection and blood dyscrasias
    • - encourage short rest periods thru out the day
    • - if sedentary during the day encourage short walks

    • N/V
    • - may interfere with nutrition
  72. 1st trimester breast tenderness, constipation
    • Breast tenderness
    • - r/t to incr of estrogen and progestrone

    • Constipation
    • - decrease in gastric motility
    • - suggest more fiber, fluid and excerise
    • - bulk forming laxative like metamucil
  73. 1st trimester nasal stuffiness, craving, leukorrhea, plalmer erythema
    • Nasal stuffiness, bleeding of gums, epitaxis
    • - incre of estrogen cause edema on the mucous membane in the nasal cavaty, and gums

    • Cravings: r/o pica 
    • leukorrhea- increa white vaginal discharged caused by estrogen

    palmer erythema- itching of hands due to increase estrogen
  74. 2nd trimester
    • backache
    • varicosities- takes pressure of your perineal
    • hemmorhoids
    • flatulence with bloating
  75. 2nd trimester discomforts
    • backache: 
    • - caused by increased lordosis of the spine 
    • - may also be sign of kidney infection, ulcers muscoloskeletal back disorder

    • Leg cramps:
    • - decreas serum calcium and mag
    • - pressure of the gravid uterus
    • - sudden stretching of the leg muscles
  76. 3rd trimester discomforts
    • return to 1st trimester discomforts
    • SOB dyspnea
    • heartburn and indigestion
    • dependent edema
    • braxton hicks
  77. Braxton hicks contractions
    occur in early pregnancy but not felt by woman

    • by middle/late pregnancy, they become stronger and women who tense may experience minimal pain
    • -rhythmatic pattern of even light contractions can be a beginning sign of labor

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