Antepartum Care 2024 study guide:UNFOLDING Reasoning, Exams of Nursing

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Antepartum Care

2024 study

guide:UNFOLDING

Reasoning

Anne Jones, 17 years old

History of Present Problem: Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods. Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Personal/Social History: Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents.

What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance:

• 17 y/o reports 2 missed periods
• Reports some spotting
• c/o breast tenderness/swelling
• c/o frequent urination
• c/o nausea in the morning
• positive pregnancy test -All are signs of pregnancy RELEVANT Data from Social History: Clinical Significance:
• high school senior
• job requires standing for long periods
• denies ETOH use
• denies tobacco use
• reports a poor diet
• has not let anyone know about potential pregnancy -Patient is going to need a nutrition consult to help her accommodate healthier eating habits -Patient’s age/ eating habits puts her at risk for preeclampsia -Patient should be educated on the importance of not picking up smoking or alcoholic drinking -Patient is at risk for not having a support system if she does not let anyone know about pregnancy Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment:

T: 98.6 F/37.0 C (oral) P rovoking/Palliative: Breast tenderness

P: 76 ( regular) Q uality: Tender to touch and movement

R: 18 (regular) R egion/Radiation: Both breasts

BP: 125/80 S everity: 4/10 but better if wears a bra

O2 sat: not assessed T iming: For the past couple of months

How will the nurse interpret each of these findings? (Address each one) RELEVANT VS Data: Clinical Significance: T: 98.6 F P: 76 (Regular) R: 18 (Regular) BP: 125/ 4/10 Breast tenderness for past couple of months Temp, Pulse, Resp are not clinically significant. BP is clinically significant. Could potentially be a sign of impending preeclampsia. Patient should be monitored and educated on better eating habits. Breast tenderness is not clinically significant due to the increased hormone production Current Assessment:

GENERAL

APPEARANCE:

Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm), weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite. BMI 18 RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale Chest: Breasts tender on palpation, areola darkened and occasional veins present Abdomen: Soft; no masses, uterus palpable below the level of the symphysis pubis, Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ Pelvic Exam: Vagina and cervix deep purple in color, uterus slightly enlarged. Hegar’s sign present How will the nurse interpret each of these assessment findings? (Address each one) RELEVANT Assessment Data: Clinical Significance:

• 5lb weight loss
• No appetite
• Pale conjunctiva
• Bleeding gums
• Uterus palpable below level of symphysis pubis
• Varicose veins
• Vagina/cervix deep purple Loss of appetite stems from nausea. 5lb weight loss is from the patient not having appetite. Patient should be educated on attempting to eat bland foods and increasing her fluid intake. Pale conjunctiva is an indicator of anemia. CBC should be monitored. Bleeding gums is an indicator of gingivitis. If gums are tender, it could impact patient’s eating habit. Risk of infection is increased. Uterus is palpable below symphysis pubis. This indicates that patient is less than 8 weeks pregnant. Varicose veins are present due to standing for long periods of time. Patient should be educated on wearing compression socks as well as trying to limit her standing. Purple discoloration on vagina and cervix is caused due to the increased blood flow. Shows a positive Chadwick’s sign Lab Results:

Prenatal Panel Hemoglobin RPR/VDRL HBs AG Blood type Antibody screen Rubella HCG ELISA 11.0 mg/dL Negative Negative B- Negative Nonimmune 20, mlU/ml Negative How will the nurse interpret each of these lab results? (Address each one)

Lab: Clinical Significance: TREND:

Improve/Worsening/Stable:

• Hemoglobin 11.
• Negative RPR/VDRL
• Negative HBsAG
• B- blood type
• Negative antibody screen
• Nonimmune Rubella
• HCG 20,
• ELISA negative
  • Hemoglobin on the lower limit of normal range. Need to monitor CBC
  • Negative RPR/VDRL indicates patient does not have syphilis
  • Negative HBsAG indicates patient does not have hepatitis
  • Blood type indicates patient is Rh negative. Should have antibody testing
  • Negative antibody result indicates patient will need to be monitored and have RhoGAM later in pregnancy.
  • Rubella immunity is not present. Patient and baby are at increased risk for Rubella
  • HCG within normal range
  • ELISA negative indicates patient does not have HIV
    • Hemoglobin needs to be monitored and if indicated be addressed to improve
    • RPR/VDRL, HBsAG, Blood typing, HCG, ELISA are all stable
    • Rubella risk is worsened due to no ability to immunize during pregnancy Urine and Micro Color: Clarity: Sp. Gr. Protein Glucose Ketones Leukocytes/ Nitrites Blood Chlamydia / Gonorrhea Yellow Clear 1.010 neg neg neg none none positive / negative How will the nurse interpret each of these lab results? (Address each one)

RELEVANT Lab(s): Clinical Significance:

• Yellow in color
• Clear
• Specific Gravity 1.
• Negative Protein
• Negative Glucose
• Negative Ketones
• No Leukocytes
• No blood
• Positive Chlamydia
• Negative Gonorrhea
  • Color, clarity, specific gravity, protein, glucose, ketones, leukocytes, blood are not clinically significant. All within normal ranges.
  • Chlamydia should be treated to lower the risk of premature birth, miscarriage, and still birth Planning: Creating a Plan of Care with a PRIORITY Lab

Lab: Values Clinical Significance: Nursing Assessments/Interventions Required: HGB:

Normal Value: 12- Critical Value: < 10 Hgb 11.0 is the lowest limit of normal range for pregnancy Assess patient for symptoms such as shortness of breath and fatigue. Possibly start patient on an iron supplement as well as prenatal vitamin. Provide patient teaching on when to contact provider if symptoms worsen. Lab: Values Clinical Significance: Nursing Assessments/Interventions Required: Chlamydia Gonorrhea: POSITIVE Normal Value: Negative Critical Value: Positive Infection can cause miscarriage, premature birth, or stillbirth Notify treating physician so that a plan for treatment can be started. Provide patient education regarding the importance of safe sex even while pregnant. Include all the risks associated with unsafe sex. Clinical Reasoning Begins…

1. Describe the physiology of the primary problem. What nursing concepts does this primary problem represent?

Problem: Physiology of Changes in OWN Words: Primary Concept:

Chlamydia

Chlamydia is a preventable sexually transmitted infection. Chlamydia is one

of the most commonly reported STIs in America. Chlamydia can be

prevented by the use of condoms or abstinence. Pregnant mothers that are

infected should be treated as soon as possible to decrease their risk of a

miscarriage, premature birth, or stillbirth.

Sexually

Transmitted

Infections

Collaborative Care: Nursing

2. What nursing priorities will guide your plan of care?

Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

- Patient education on safe sex practices - Patient education on the risks that can occur with unsafe sex

• Patient education regarding signs/symptoms to watch for in the incidence of reinfection - Education on safe sex practices can help prevent reinfection, and infection of any other potential infections or diseases - Educating the patient on the risks that this infection can have on her baby can with hope prevent mother from being unsafe - If the patient knows what signs to look for it can help prevent any future potential infections from going untreated, then causing more harm - Patient will practice safe sex all throughout pregnancy. Patient’s infection will be cleared and there will be no incident of reinfection.

3. What body system(s) will you assess most thoroughly based on the primary/priority need?

PRIORITY Body System: PRIORITY Nursing Assessments:

Reproductive System

Assess labs frequently. Question patient about any

potential symptoms at each check. Reinforce teaching

and provide patient with time to ask any questions.

4. What is the worst possible/most likely complication(s) to anticipate based on the primary need for this patient? Complication: Premature Birth/Miscarriage/Stillbirth Nursing Interventions to PREVENT this Complication: Assessments to IDENTIFY Problem EARLY: Nursing Interventions to TREAT the complication:

• Early treatment
• Early Detection
• Patient Education
• Awareness of continued unsafe sex
• Patient shows understanding of risks
• Patient shows understanding of what symptoms to watch for
• Communication with physician

5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?

Psychosocial PRIORITIES: Rationale: Expected Outcome:

What psychosocial needs should the nurse address?

- Potential fear of rejection - Fear of who to confide in - Potential conflict between self and parents Spiritual needs? -religion not assessed Cultural needs? -culture practices not assessed Psychosocial: Becoming a teen mother can often come with the fear of not being accepted by peers. Patient has not told neither her boyfriend nor parents about the pregnancy; this is suspect for not being comfortable enough to confide in either group. The potential conflict between patient and parents can stem from multiple issues such as school, help raising the baby, and financial burdens. Describe caring and compassion as a nurse caring for this patient: The nurse should always remain nonjudgmental. Help reassure the mother that her confidentiality is a high priority. Urge/help the mother to create a support system. What physical comfort measures will the nurse need to address? The nurse should address the patient’s nausea, weight loss, diet habits, and sexual activity. The patient will have a support system in place. The patient will remain in school as desired as well as have a supportive relationship with parents. The patient will be comfortable expressing any needs or questions to nurse without worry of being judged. Patient will practice safe sex. Patient will have better eating habits to help prevent further complications. EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: All 5 principles play a huge part in nursing. Building rapport with your patient is the beginning of your relationship. Always be respectful and nonjudgmental of your patient. Respect their wishes and concerns. Never have a demeaning The patient will have confidence in the ability to confide in staff regarding any concerns.

_- Rapport

• Trust
• Respect
• Genuineness
• Empathy_ attitude towards your patient. It may not always be possible to empathetic of a patients situation, but you can always show that you genuinely care about their wellbeing. TWELVE-WEEKS LATER… Anne returns to the office for her fourth visit. She is now 20 weeks pregnant. She states her morning sickness has gotten better and she felt the baby move a few weeks ago. She has gained 10 lbs. (4.5 kg) since the first visit. She had her MFAP and triple marker blood screening labs drawn at 16 weeks which were all negative. She has told her parents, and they are supportive. She also told her boyfriend, but he does not want to be involved. RELEVANT Data: Clinical Significance:
• Morning sickness better
• Feeling movements
• 10lb weight gain
• MFAP/Triple Marker negative
• Support System
• Not showing signs of Hyperemesis
• Shows that baby is healthy and thriving
• Increased weight due to decreased nausea
• No signs of birth defects
• Positive for mental health as well as safety. Helps ensure that mother is taking care of herself and someone to help assist if any problems may arise

Current VS: First visit: Current PQRST:

T: 98.6 F/37.0 C (oral) 98.6 F/37.0 C (oral) P rovoking/Palliative: Standing for long time

P: 80 ( regular) 76 ( regular) Q uality: Dull

R: 18 (regular) 18 (regular) R egion/Radiation: Lower back

BP: 120/70 125/80 S everity: Mild, 3/

O2 sat: not assessed not assessed T iming:^ occasional

Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with soft murmur heard at the left sternal border, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids appear pale Chest: Breasts tender on palpation, areola darkened and occasional veins present Abdomen: Soft; no masses, uterus palpable at midway between symphysis pubis and umbilicus, light linea nigra present Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ Fetal Heart Rate: 150 bpm, Lower Left Quadrant (LLQ)

Lab Results: Prenatal Labs Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG (^) Chlamydia / Gonorrhea Genetic screenings This visit: 10.1 mg/dL Positive^ / Negative Negative Prenatal panel from first visit 11.0 mg/dL Negative Negative B- Nonimmune 20, mlU/ml Positive / Negative How will the nurse interpret each of these findings? (Address each one) RELEVANT VS Data: Clinical Significance:

• Blood pressure
• 3/10 occasional lower back pain related to long standing - Better. Still slightly elevated. Continue to monitor. - Patient should not be on feet for long periods of time. If insists, patient should be educated on signs of back labor due to increased risk for prematurity related to age and STI status. RELEVANT Assessment Data: Clinical Significance:
• Left sternal border murmur
• Slight bleeding at gumline
• Conjunctiva pale
• Uterus palpable midway to umbilicus
• Varicose veins
• New murmur present indicated for additional monitoring.
• Better. Still at risk for infection.
• Indicator of anemia
• Measuring on track
• Patient teaching regarding compression socks should be reinforced RELEVANT Lab Data: Clinical Significance:
• Hemoglobin 10.
• Positive Chlamydia
• Decreased level by 1.1. May warrant for adjustments to medications.
• May need alternative medication to help fight infection 1. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

Evaluation of Current Status: Modifications to Current Plan of Care:

Overall status has not improved. Food intake and blood pressure are the only things that have improved. Anemia has worsened. Patient is still positive for chlamydia. A new murmur has been noted. Patient nutrition should be readdressed to determine if iron rich foods can be added. Patients medications should be adjusted if patient is taking iron to potentially more often. Provider should assess new vaginal swab to determine why antibiotics are not working. Provider should determine if murmur is from new increased blood flow and if interventions need to be taken.

2. Based on your evaluation, what are your CURRENT nursing priorities and plan of care?

CURRENT Nursing PRIORITY: Iron Deficiency Anemia

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

• Monitor lab results •^ Patient^ is^ trending^ down^ to^ a^ critical^ level. Close monitoring needs to be done as well as interventions
• Patient should be reeducated on when it is time to contact her provider. Education regarding symptoms to look out for. Diet changes may be warranted.

Patient’s

• Patient Education hemoglobin will

increase to within

normal range

Patient will verbalize and demonstrate understanding of education Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family?

Education PRIORITY: Iron Deficiency Anemia

PRIORITY Topics to Teach: Rationale:

• Eating a diet with iron rich foods
• The importance of taking prenatal

vitamin and iron supplements daily

• Importance of communication
• Risk for infection
  • To help increase hemoglobin and prevent further complications
  • To help increase hemoglobin and prevent further complications
  • The patient needs to know that her communicating any discomforts will help determine any additional interventions needed as well as if anything is worsening
  • Patient is at an increased risk for infection. Patient should know this information and be urged to practice safe sex, report any wounds, and be able to monitor for signs of infection Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?

What Patient is Experiencing: How to Engage:

The patient is more than likely feeling some sense of fear or uncertainty. Patient is potentially feeling some fatigue. To engage myself I can empathize with the patient and let her know that we are going to do everything that we can to help her feel better. Let her know that it is ok to feel worried, but it is important to communicate her feelings instead of keeping them to herself. Use Reflection to THINK Like a Nurse What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength?

What Did You Learn? What did you do well in this case study?

I learned mostly about preeclampsia and the I think I did well at incorporating a lot of patient

risks for it. education and monitoring.

What could have been done better? What^ is^ your^ plan^ to^ make^ any^ weakness^ a^ future^ strength?

I think I could be better at assessing labs rather than having to research all of the values. I plan to gain better confidence in my knowledge on lab values.