NR-602 Midterm Study Guide

1 NR-602 iMidterm iStudy iGuide Signs iof ipregnancy presumptive i(subjective isigns) iAmenorrhea, inausea, ivomiting, iincreased iurinary ifrequency, iexcessive ifatigue, ibreast itenderness, iquickening iat i18–20 iweeks probable i(objective isigns) iGoodell isign i(softening iof icervix) iChadwick isign i(cervix iis iblue/purple) Hegar’s isign i(softening iof ilower iuterine isegment) iUterine ienlargement Braxton iHicks icontractions i(may ibe ipalpated iby i28 iweeks) Uterine isoufflé i(soft iblowing isound idue ito iblood ipulsating ithrough ithe iplacenta) iIntegumentary ipigment ichanges Ballottement, ifetal ioutline idefinable, ipositive ipregnancy itest i(could ibe ihydatidiform imole, ichoriocarcinoma, iincreased ipituitary igonadotropins iat imenopause) positive i(diagnostic isigns) iFetal iheart irate iauscultated iby ifetoscope iat i17–20 iweeks ior iby iDoppler iat i10–12 iweeks Palpable ifetal ioutline iand ifetal imovement iafter i20 iweeks Visualization iof ifetus iwith icardiac iactivity iby iultrasound i(fetal iparts ivisible iby i8 iweeks) Pregnancy iand ifundal iheight imeasurement Signs iof ipregnancy i(presumptive, iprobable, ipositive) Pregnancy iand ifundal iheight imeasurement iAs i ipregnancy i iprogresses, i ithe ifundus irises iout iof ithe ipelvis i(Figure i29-1). iAt i12 iweeks’ igestation, ithe ifundus iis ilocated iat ithe ilevel iof ithe isymphysis ipubis. iBy iweek i16, iit irises ito imidway ibetween isymphysis ipubis iand ithe iumbilicus. iBy i20 iweeks’ igestation, ithe ifundus iis itypically iat ithe isame iheight ias ithe iumbilicus. iUntil iterm, ithe ifundus ienlarges iapproximately i1 icm iper iweek. iAs ithe itime ifor ibirth iapproaches, ithe ifundal iheight idrops islightly. iThis iprocess, iwhich iis icommonly icalled ilightening, ioccurs ifor ia iwoman iwho iis ia iprimigravida iaround i38 iweeks’ igestation ibut imay inot ioccur ifor ithe iwoman iwho iis ia imultigravida iuntil ishe igoes iinto ilabor 2 Naegele’s irule Add iseven idays ito ithe ifirst iday iof iyour iLMP iand ithen isubtract ithree imonths. iFor iexample, iif iyour iLMP iwas iNovember i1, i2017: iAdd iseven idays i(November i8, i2017). iSubtract ithree imonths i(August i8, i2017). The iEDD iis icalculated iby iadding iseven idays ito ithe ifirst iday iof ithe ilast imenstrual iperiod, isubtracting ithree imonths iand iadding ione iyear. This iformula iis iknown ias iNaegele's iRule. iFor iexample, iif ithe ipatient's ilast imenstrual iperiod, iLMP, iwas ion iAugust i10, i2019, ithe iEDD iwould ibe icalculated ias ifollows. iLMP iequals iAugust i10, i2019 iplus iseven idays. iAugust i17, i2019, iminus ithree imonths. iMay i17, i2019 iplus ione iyear iand ithat iequals iMay i17, i2020. Hematological ichanges iduring ipregnancy During ipregnancy, ithe iheart iis idisplaced iupward iand ito ithe ileft iwithin ithe ichest icavity iby ithe igravid iuterus’s ipressure ion ithe idiaphragm. iAs ipregnancy iprogresses, ithe irisk ifor iinferior ivena icava iand iaortic icompression ileading ito isupine ihypotension iincrease s iwhen ithe iwoman ilies iin ia isupine iposition. iTo iavoid ihypotension iand ipotential isyncope, ithe iwoman ishould ibe iadvised ito ilie iin ia ileft ilateral iposition . iHemodynamic ichanges iand ianatomic ichanges ialso imay ialter ivital isigns iin ithe ipregnant iwoman i(Table i29-2). 3 Cardiac ioutput iin ipregnancy iincreases iby i30% ito i50% iover ithat iin iwomen iwho iare inot ipregnant i(Blackburn, i i2013 ; i iOuziunian i i& i iElkayam, i i2012 ). i iThis i iincrease ipeaks iin ithe iearly ithird itrimester iand iis imaintained iuntil ibirth. iHalf iof ithe itotal iincrease iin icardiac ioutput, ihowever, ioccurs iby ithe ieighth iweek iof ipregnancy i(Blackburn, i2013 ). iTherefore, iwomen iwith icardiac idisease imay ibecome isymptomatic iduring ithe ifirst itrimester. iStroke ivolume iis ialso iincreased iduring ipregnancy iby i20% ito i30%. iThese iincreases iin icardiac ioutput iand istroke ivolume iallow ifor ithe i30% iincrease iin ioxygen iconsumption iobserved iduring ipregnancy. TABLE i29-2 iVital iSign iChanges iin iPregnancy Vital iSign Changes iin iPregnancy Measurement iAlterations iin iPregnancy Heart irate iand iheart isounds Volume iof ithe ifirst iheart isound imay ibe iincreased iwith isplitting . iThird iheart isound imay ibe idetected. Systolic imurmurs imay ibe idetected. iIncreases iby i15–20 ibeats/min iby i32 iweeks’ igestation. Palpate ithe imaternal ipulse iwhen iauscultating ithe ifetal iheart irate ito ibe iable ito idistinguish ibetween ithe itwo. Respiratory irate Increases iby i1–2 ibreaths/min None BP First itrimester: isame ias iprepregnancy ivalues Second itrimester: isystolic iBP idecreases iby i2–8 imm iHg iand idiastolic iBP idecreases iby i5–15 imm iHg idue ito iperipheral ivascular iresistance Third itrimester: igradually ireturns ito iprepregnancy ivalues Use iof ian iautomated icuff imay iimprove iaccuracy iof imeasurement, ias isome ipregnant iwomen ido inot ihave ia ififth iKorotkoff isound. Systolic iand idiastolic iBP imay ibe i16 imm iHg ihigher iwhen itaken iwhile ithe iwoman iis isitting. BP ireadings imay idecrease iin ithe imaternal ileft ilateral iposition. Abbreviation: iBP, iblood ipressure. Data ifrom iJarvis, iC. i(2016 ). iPhysical iexamination iand ihealth iassessment i(7th ied.). iSt. iLouis, iMO: iSaunders iElsevier; iOuziunian, iJ., i& iElkayam, iU. i(2012 ). i iPhysiologic i ichanges i iduring i inormal ipregnancy iand idelivery. iCardiology iClinics, i30, i317–329; iTan, iE., i& iTan, iE. i(2013 ). iAlterations iin iphysiology iand ianatomy iduring ipregnancy. iBest iPractice i& iResearch iClinical i iObstetrics i i& iGynaecology, i27, i791–802. During ipregnancy, iblood ivolume iincreases iby i30% ito i50%, ior i1,100 ito i1,600 imL i(Ouziunian i& iElkayam, i2012 ), iand ipeaks iat i30 ito i34 iweeks’ igestation. iThe iincrease iin iblood ivolume iimproves iblood iflow ito ithe ivital iorgans iand iprotects iagainst iexcessive iblood iloss iduring ibirth. iFetal igrowth iduring ipregnancy iand inewborn iweight iare icorrelated iwith ithe idegree iof iblood ivolume iexpansion. Of ithe iblood ivolume iexpansio n ioccurring iduring ipregnancy, i75% iis iconsidered ito ibe iplasma i(King iet ial., i2015 ). iThere iis ialso ia islight iincrease iin ired iblood icell ivolume 4 (RBC). iThe iblood ivolume ichanges iresult iin ihemodilution, iwhich ileads ito ia istate iof iphysiologic ianemia iduring ipregnancy. iAs ithe iRBC ivolume iincreases, iiron idemands ialso iincrease. iLeukocytosis ioccurs iin ipregnancy, iwith iwhite iblood icell icounts iincreasing ito ias imuch ias i14,000 ito i17,000 icells iper imm3 iof iblood i(Table i29-3). iClotting ifactors iincrease ias iwell, icreating ia irisk ifor iclotting ievents iduring ipregnancy. Systemic ivascular iresistance iis ireduced idue ito ithe ieffects iof iprogesterone, iprostaglandins, iestrogen, iand iprolactin. iThis ilowered isystemic ivascular iresistance , iin icomb ination iwith iinferior ivena icava icompression, iis ipartly iresponsible ifor ithe idependent iedema ithat ioccurs iin ipregnancy. iEpulis iof ipregnancy, ior ihypertrophy iof ithe igums iaccompanied iby ibleeding, imay ialso ioccur iand iis idue ito idecreased ivascular iresistance iand iincrease iin ithe igrowth iof icapillaries iduring ipregnancy i(Jarvis, i2016 ). Indications iand icontraindications ifor iprescribing icombined iestrogen ivs. iprogesterone -only ibirth icontrol Progestin -only icontraceptives iare iused icontinuously; ithere iis ino ihormone -free iinterval, ias ioccurs iwith icombined imethods. iThese icontraceptive imethods ihave iminimal ieffects ion icoagulation ifacto rs, iblood ipressure, ior ilipid ilevels iand iare igenerally iconsidered isafer ifor iwomen iwho ihave icontraindications ito iestrogen, isuch ias icardiovascular irisk ifactors, imigraine iwith iaura, ior ia ihistory iof iVTE. iIn ispite iof ithis ibelief, ithe iproduct ilabeling ifor isome iprogestin -only iproducts imimics ithe ilabeling ifor iproducts icontaining iestrogen. The iU.S. iMedical iEligibility iCriteria ifor iContraceptive iUse i(CDC, i2010 ; see iAppendix i11-A) ican ibe iused ito iidentify iappropriate icandidates ifor iprogestin - ionly icontraception. Progestin -only icontraceptives ido inot iprovide ithe isame icycle icontrol ias imethods icontaining iestrogen, iand iunscheduled ibleeding iis icommon iwith iall iprogestin -only imethods. iTypically, iunscheduled ibleeding ioccurs imost ifrequently iduring ithe ifirst i6 imonths iof imethod iuse, iwith ia isubstantial inumber iof iusers ibecoming iamenorrheic iby i12 imonths iof iuse i(Hubacher, iLopez, iSteiner, i& iDorflinger, i2009 ). iOverall iblood iloss idecreases iover itime, imaking iprogestin -only imethods iprotective iagainst iiron- ideficiency ianemia. iWith iappropriate icounseling, imany iwomen isee iamenorrhea ias ia ibenefit iof ithese imethods. All iprogestin -only imethods iare ilikely ito iimprove imenstrual isymptoms , iincluding idysmenorrhea , imenorrhagia , ipremenstrual isyndrome , iand ianemia i(Burke, i2011 ). iThe ithickening iof icervical imucus iseen iwith iprogestin imethods iis iprotective iagainst iPID. iProgestin -only icontraceptives iinclude ithe iprogestin -only ipill i(POP), ian iinjection, ian iimplant, iand ithree iprogestin -containing iintrauterine idevices. iThe iimplant iand idevices iare icovered iin ithe isection ion ilong-acting ireversible icontraception. The iU.S. iMedical iEligibility iCriteria ifor iContraceptive iUse i(CDC, i2010 ) iis ia icomprehensive, ievidence -based iguide ifor idetermining iwhether iwomen ihave irelative ior iabsolute icontraindications ito icontraceptive imethods. iThe iMedical iEligibility Criteria iuses ithe ifollowing ifour iclassification icategories iof iwhether ia iperson ican iuse ior ishould inot iuse ia imethod: