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Physiologic Changes During Pregnancy Exam Guide, Exams of Nursing

A.T. Still University of Health Sciences (ATSU)Nursing

An overview of the physiologic changes that occur during pregnancy, including changes in the uterus, cervix, ovaries, vagina, breasts, GI system, urinary system, skin, musculoskeletal system, eyes, CNS, metabolism, and endocrine system. It also covers supine hypotension, Goodell's sign, Hegar's sign, cardiac changes, respiratory changes, physiologic anemia, and presumptive, probable, and positive signs of pregnancy. Additionally, it discusses psycho-social adjustment for both maternal and paternal figures, antepartum testing, and the importance of nursing assessment.

Typology: Exams

2022/2023

Available from 04/12/2023

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NURS230 EXAM GUIDE PHYSIOLOGIC CHANGES DURING
PREGNANCY
Chap 11
Physiologic changes during pregnancy
•Uterus:
oenlargement due to hypertrophy, thickening of walls, increase in vascular and
lymphatic system, Braxton hicks
•Cervix:
oestrogen stimulates glandular tissue, development of mucous plug, Goodell
and Chadwick sign
•Ovaries:
o ovum production stops, HcG maintains corpus luteum, secretes progesterone
•Vagina:
ohypertrophy, increased vascularity, hyperplasia from estrogen, increased
secretions, loosening of connective tissues, increased blood flow
•Breasts:
oglandular hyperplasia and hypertrophy, darkened areolas, prominent veins,
striae, colostrum (antibody rich yellow secretion that converts to milk following
birth)
•GI:
onausea and vomiting, hyperemia (bleeding of the gums), many symptoms related
to uterine pressure, liver changes, slow gallbladder emptying
•Urinary:
opressure on the bladder causes frequent urination, dilation of kidneys, increased
GFR and renal plasma flow, possible glycosuria
•Skin:
ohyperpigmentation, facial chloasma (melasma gravidarum), striae, vascular spider
nevi, decreased hair growth, hyperactive sweat glands
•Musculoskeletal:
opelvic joints relax (waddling gait), center of gravity changes, separation of
rectus abdomen
•Eyes:
o decreased intraocular pressure, thickening of cornea, may affect contact lenses
•CNS:
odecreased attention span, concentration, and memory, sleep problems
•Metabolism:
oweight gain (25-35lb above pre-pregnancy weight recommended), nutrient
metabolism (increased protein retention, fetal demands high during 2nd half of
pregnancy, higher rate of fat absorption, fat deposits increase from 2-12%, body
switches from glucose to lipid metabolism), carbohydrate demand increases,
gestational diabetes, increased demand for iron, retention of calcium
•Endocrine:
othyroid: serum thyroxine and BMR increase, TSH decreases
oparathyroid: concentration of PTH increases, parallels fetal Ca requirements
opituitary: thyrotropin and adrenotropin alter metabolism, prolactin (lactation).
oxytocin and vasopressin
oadrenal: increased aldosterone
opancreas: increased insulin needs
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PREGNANCY

Chap 11

Physiologic changes during pregnancy

- Uterus: o enlargement due to hypertrophy, thickening of walls, increase in vascular and lymphatic system, Braxton hicks - Cervix: o estrogen stimulates glandular tissue, development of mucous plug, Goodell and Chadwick sign - Ovaries: o ovum production stops, HcG maintains corpus luteum, secretes progesterone - Vagina: o hypertrophy, increased vascularity, hyperplasia from estrogen, increased secretions, loosening of connective tissues, increased blood flow - Breasts: o glandular hyperplasia and hypertrophy, darkened areolas, prominent veins, striae, colostrum (antibody rich yellow secretion that converts to milk following birth) - GI: o nausea and vomiting, hyperemia (bleeding of the gums) , many symptoms related to uterine pressure, liver changes, slow gallbladder emptying - Urinary: o pressure on the bladder causes frequent urination, dilation of kidneys, increased GFR and renal plasma flow, possible glycosuria - Skin: o hyperpigmentation, facial chloasma (melasma gravidarum) , striae, vascular spider nevi, decreased hair growth, hyperactive sweat glands - Musculoskeletal: o pelvic joints relax (waddling gait), center of gravity changes, separation of rectus abdomen - Eyes: o decreased intraocular pressure, thickening of cornea, may affect contact lenses - CNS: o decreased attention span, concentration, and memory, sleep problems - Metabolism: o weight gain (25-35lb above pre-pregnancy weight recommended) , nutrient metabolism (increased protein retention, fetal demands high during 2nd half of pregnancy, higher rate of fat absorption, fat deposits increase from 2-12%, body switches from glucose to lipid metabolism), carbohydrate demand increases, gestational diabetes, increased demand for iron, retention of calcium - Endocrine: o thyroid: serum thyroxine and BMR increase, TSH decreases o parathyroid: concentration of PTH increases, parallels fetal Ca requirements o pituitary: thyrotropin and adrenotropin alter metabolism, prolactin (lactation). oxytocin and vasopressin o adrenal: increased aldosterone o pancreas: increased insulin needs

PREGNANCY

Supine Hypotension

- AKA vena caval syndrome, aortocaval compression

  • the growing uterus compresses the inferior vena cava, leading to decreased venous return (when the pt is in supine position) Goodell’s Sign - softening of the cervix Hegar’s Sign - softening of the uterus Cardiac changes
  • uterus puts pressure on diaphragm, BV increases 40-50%, cardiac output increases, decrease in systemic and pulmonary vascular resistance, pulse increases, BP decreases slightly, femoral venous pressure rises, supine hypotensive syndrome, erythrocyte volume increases, leukocyte and platelet production, plasma fibrinogen increases, anemia Respiratory changes
  • TV increases, O2 consumption increases, breathing changes from abdominal to thoracic, vascular congestion of nasal mucosa Physiologic anemia
  • Plasma volume increases more than RBC’s during pregnancy, resulting in lowered Hgb and Hct levels.
  • Decreased Hgb leads to decreased iron, resulting in physiologic anemia. Presumptive, Probable and Positive Signs of Pregnancy 1. Presumptive: amenorrhea (no period), nausea and vomiting (morning sickness), fatigue, frequent urination, breast changes, quickening (mothers perception of fetal movement)
  1. Probable : changes in pelvic organs, Hegar’s sign, Ladin sign, McDonald sign, Braun von Fernwald sign, Piskacek sign, enlargement of abdomen, braxton hicks, striae, uterine souffle, skin pigmentation, fetal outline (Ballottement) , pregnancy tests of blood or urine
  2. B subunit radioimmunoassay (RIA)
  3. Enzyme linked immunosorbent assay (ELISA)
  4. Fluoroimmunoassay (FIA) b. Positive: auscultation of fetal heartbeat using Doppler, fetal movement (palpable at 20wks), visualization of the fetus via ultrasound Psycho-social adjustment- Maternal and Paternal - Maternal: o intendedness o ambivalence o acceptance (1st- baby does not seem real, 2nd- quickening, pregnancy glow, 3rd- physical discomfort and nesting) o introversion o mood swings o body image changes o ensuring a safe passage through birth, pregnancy, labor o seeking of acceptance of the child from others o seeking of commitment and acceptance of oneself as a mother o learning to give oneself on behalf of one’s child - Paternal: o view of role has changed (nurturing, caring parent and provider) o benefit of being involved decreases maternal stress levels

PREGNANCY

  • Lag in the progression of fundal height from visit to visit may indicate intrauterine growth restriction (IUGR), or oligohy-draminos, and sudden increase in height may indicate the presence of twins, hydramnios, or a large-for-gestational-age (LGA) fetus. Cultural importance: It is important for nurses to avoid stereotyping women based on race, culture, or ethnicity. Nurses have an obligation to be aware of other cultures and develop a culturally sensitive plan of care. Danger signs in pregnancy to educate on:

Danger sign: Possible Cause:

Sudden gush of fluid from vagina Premature rupture of membranes Vaginal bleeding Abruptio placenta previa Lesions of cervix or vagina “Bloody show” Cervical, vagina infection Friable cervix (irritation of cervix) from intercourse, infection, or pregnancy Abdominal pain Premature labor, abruptio placentae Temperature about 38.3 C (101 F) and chills Infection Dizziness, blurring of vision, double vision, spots before eyes Hypertension, preeclampsia Persistent nausea and vomiting Hyperemesis gravidarum Severe Headache Hypertension, preeclampsia Edema of hands or face Preeclampsia Seizures or convulsions Preeclampsia, eclampsia Epigastric Pain Preeclampsia, ischemia in major abdominal vessel Dysuria UTI Absent or decreased fetal movement Maternal medication, obesity, fetal death, fetal distress Signs of Preterm Labor:

  • Painful menstrual-like cramps
  • Dull low backache

PREGNANCY

  • Suprapublic pain or pressure
  • Pelvic Pressure or heaviness
  • Change in character or amount of vaginal discharge (bloody, thinner, thicker)
  • Diarrhea
  • Uterine contractions felt every 10 minutes for 1 hour Leaking of water from vagina Antepartum Testing: Initial Prenatal visit:
  • Pap smear
  • Complete blood count (CBC), HIV screening
  • Rubella titer
  • ABO and Rh typing
  • Urine culture
  • Hepatitis B and sexually transmitted infection (STI) screening Testing Throughout Pregnancy:
  • Gestational diabetes mellitus (GDM)
  • Hemoglobin (Hgb) and hematocrit (Hct)
  • Group B streptococcus (GBS)
  • Hemoglobin electrophoresis
  • Varicella Immunity
  • Purified protein derivative of tuberculin (PPD) Testing for fetal aneuploidy (trisomy) and neural tube defects:
  • Down syndrome
  • Trisomy 18, trisomy 13
  • Turner syndrome
  • Quadruple screen
  • First trimester ultrasound Importance of nursing assessment: The patient’s history is a screening tool that identifies factors that can affect the course of a pregnancy Initial prenatal assessment should include:
  • Current pregnancy
  • Past pregnancies
  • Gynecologic history
  • Current medication history
  • Past medical history
  • Family medical history
  • Genetic history
  • Religious/cultural history
  • Occupational history
  • Birth father’s physical history
  • Father’s social history
  • Personal information about the women Risk Factors: Any findings that have been shown to have potential negative effects on pregnancy outcomes either for the women or her unborn child. Factor: Maternal Implications Fetal/neonatal Implications

PREGNANCY

PREGNANCY

V A) ↑ risk renal damage Thyroid disorder ↑ infertility ↑ spontaneous abortion Hypothyroidism ↓ basal metabolic rate (B M R), goiter, myxedema ↑ risk miscarriage ↑ risk preterm labor/birth ↑ risk preeclampsia ↑ risk congenital goiter ↑ risk I U G R/S G A ↑ risk anemia ↑ risk stillbirth Hyperthyroidism ↑ risk postpartum hemorrhage ↑ risk preeclampsia Danger of thyroid storm Intellectual disability (cretinism) ↑ incidence congenital anomalies ↑ I U G R/S G A ↑ neonatal hyperthyroidism Renal disease (moderate to severe) ↑ risk renal failure ↑ risk I U G R/S G A ↑ risk preterm birth Diethylstilbestrol (D E S) exposure ↑ Infertility, spontaneous abortion ↑ cervical insufficiency ↑ risk breech presentation ↑ risk preterm birth Obstetric Considerations Previous Pregnancy Stillborn ↑ emotional/psychologic distress ↑ risk I U G R/S G A ↑ risk preterm birth Recurrent abortion ↑ emotional/psychologic distress ↑ risk abortion Cesarean birth ↑ possibility repeat cesarean birth ↑ risk preterm birth

PREGNANCY

  • not minor to the pregnant woman
  • result of physiologic, anatomic changes
  • specific to either the first or second/third trimesters
  • First Trimester o Nausea and Vomitting ▪ due to elevated HcG ▪ treatment: antihistamine receptor blockers, benzamines, phenothiazines, acupressure, dietary changes o Urinary Frequency ▪ pressure of enlarging uterus on bladder ▪ health promotion education // frequent bladder emptying, adequate fluids o Fatigue ▪ sleep inducing effects of progesterone ▪ health promotion education // schedule to allow for naps o Breast Tenderness ▪ well fitting bra o Increased Vaginal Discharge ▪ Leukorrhea is common ▪ monilial vaginitis more likely ▪ health promotion education // daily bathing, never douching o Nasal Stuffiness / Epistaxis ▪ edema of nasal mucosa from elevated estrogen ▪ health promotion education // cool air vaporizers, saline nose drops o Ptyalism ▪ excessive, bitter saliva ▪ health promotion education // mouthwashes, chewing gum or hard candy
  • Second and Third Trimesters o Heartburn (pyrosis) ▪ regurgitation of gastric acid into esophagus ▪ health promotion education // avoid overeating, fried foods, and lying down after eating, low sodium antacids o Ankle Edema ▪ difficulty of venous returns ▪ health promotion education // dorsiflexion, elevate legs + hip o Varicose Veins ▪ poor circulation in lower extremities ▪ health promotion education // elevation of legs + one hip, supportive hose, elastic stockings o Flatulence ▪ decreased GI motility, swallowing air ▪ health promotion education // regular bowel habits, exercise + nutrition o Hemorrhoids ▪ varicosities formed by straining ▪ health promotion education // avoid constipation, contact provider if bleeding, harness, tenderness occurs o Constipation ▪ common, general bowel sluggishness

PREGNANCY

▪ health promotion education // increase fluids, roughage, bowel habits, exercise o Back Ache ▪ curvature of lumbosacral vertebrae ▪ health promotion education // pelvic tilt, support belts o Leg Cramps ▪ can be caused by extension of foot ▪ health promotion education // stretching, massage, warm packs o Faintness ▪ sudden change of position / crowds ▪ health promotion education // understand symptoms, move slowly when changing position o Restless Leg Syndrome ▪ need to move legs or tingling sensation ▪ health promotion education // associated w iron deficient anemia o Round Ligament Pain ▪ due to growing uterus ▪ health promotion education // understand sensation to reduce anxiety, heating pad o Carpal Tunnel Syndrome ▪ compression of median nerve, commonly bilateral ▪ health promotion education // avoid aggravating activities, use a splint Risk of preterm Labor

  • low income / low education level
  • poor diet
  • living at high altitudes
  • multipartity greater than 3
  • weight less than 100 lbs
  • age younger than 16, older than 35
  • smoking / illicit drugs / alcohol consumption
  • preexisting medical disorders (diabetes, cardiac disease, anemia, hypertension, thyroid disorder, rental disease, etc.) Medications and pregnancy
  • First trimester = greatest risk
  • FDA categories - A, B, C, D, X
  • pregnant women should avoid all medication if possible Exercise
  • Exercise to prepare for childbirth: o Pelvic Tilt // reduces back pain o Abdominal Exercises // tighten abdominal muscles w each breath, partial sit ups o Perineal Exercises // Kegels strengthen pubococcygeus muscle o Inner Thigh Exercises // sit cross legged whenever possible
  • Activity and Rest o Improved self image, increased energy, improved sleep, relief of tension, controls weight gain, promotes regular bowel function o prevents complications, moderate exercise, healthcare provider exam Immunizations
  • ideally administered prior to becoming pregnant

PREGNANCY

  • Foodborne illness: Salmonella and listeria

PREGNANCY

  • Lactase deficiency: Fewer enzymes to break down lactase
  • Cultural, ethnic, religious influences
  • Sharing food
  • Socioeconomic factors
  • Knowledge about basic components
  • Attitudes and feelings about pregnancy
  • Eating disorders: Anorexia nervosa, bulimia nervosa Nutritional intake:
  • Dietary reference intakes (DRIs)
  • Recommended dietary allowance (RDA)
  • Adequate intake (AI)
  • During second and third trimesters, consume an extra 300 kcal/day Adolescent nutritional needs:
  • Risk Factors: Emotional, social, and economic
  • More likely to be underweight
  • Increased need for: Iron, folic acid, zinc, calcium, Vitamins A, D, E, B
  • Irregular eating patterns:
  • Rarely follow three-meals-a-day
  • Day-to-day intake varies drastically Postpartum Nutritional status:
  • Assess new mother’s weight, labs, clinical signs
  • Weight loss at birth
  • Rate of weight loss
  • Evaluate weight
  • Assess clinical symptoms Nutritional Care of formula-feeding mothers:
  • Dietary requirements return to prepregnancy levels: Reduce intake by 300 kcal
  • Understanding of nutrition: Refer to dietitian if excessive weight gain Nutritional Care of Breastfeeding mothers:
  • Nutrient needs increase during breastfeeding
  • Calories: Increase caloric intake by 200 kcal/day over pregnancy level
  • Protein: 65 mg/day for first 6 months, 62 mg/day thereafter
  • Calcium: Intake should be 1000 mg/day
  • Iron: Continued supplementation for 2-3 months after parturition
  • Fluids: 8-10 8 oz glasses of fluid daily
  • Some foods that affect babies are onions, turnips, cabbage, chocolate, spices, seasonings. PICA: Craving, eating of substances such as soil, slay, corn starch, soap, baking powder, ice, freezer frost, burned matches, paint, or ashes. Chap 15 Adolescents- development stage
  • Psychosocial development: o developing an identity, gaining autonomy and independence, developing intimacy in a relationship, developing comfort with one’s own sexuality, developing a sense of achievement
  • Early adolescence - o very egocentric, concrete thinker, rapid physical changes