Reproductive NGN C2

The following scenario applies to the next 6 items.

Item 1 of 6
The nurse is caring for a 45-year-old client in the clinic.

 Nurses' Notes

Nurses' Notes

The client's last menstrual cycle was 3 months ago. She also reports fatigue, difficulty
falling asleep, a 7-lb (3.2-kg) weight gain in the past 2 months, and frequently feeling hot
and flushed with periods of excessive perspiration while sleeping. She reports increased
vaginal dryness and pain during sexual intercourse and a persistent loss of interest in
normal activities and difficulty concentrating.

The client has a history of fibrocystic breast changes; no surgical history. Current
medications include a copper intrauterine device inserted 8 years ago. On physical
examination, bilateral breasts are noted to be mildly tender with a rope-like texture.

Click to highlight below the 4 findings that require follow-up.

 Nurses' Notes

Nurses' Notes

The client's last menstrual cycle was 3 months ago. She also reports fatigue, difficulty
falling asleep, a 7-lb (3.2-kg) weight gain in the past 2 months, and frequently feeling hot
and flushed with periods of excessive perspiration while sleeping. She reports increased
vaginal dryness and pain during sexual intercourse and a persistent loss of interest in
normal activities and difficulty concentrating.
 Reproductive NGN C2

Nurses' Notes

The client has a history of fibrocystic breast changes; no surgical history. Current
medications include a copper intrauterine device inserted 8 years ago. On physical
examination, bilateral breasts are noted to be mildly tender with a rope-like texture.

Item 2 of 6
The nurse is caring for a 45-year-old client in the clinic.

 Nurses' Notes

Nurses' Notes

The client's last menstrual cycle was 3 months ago. She also reports fatigue, difficulty
falling asleep, a 7-lb (3.2-kg) weight gain in the past 2 months, and frequently feeling hot
and flushed with periods of excessive perspiration while sleeping. She reports increased
vaginal dryness and pain during sexual intercourse and a persistent loss of interest in
normal activities and difficulty concentrating.

The client has a history of fibrocystic breast changes; no surgical history. Current
medications include a copper intrauterine device inserted 8 years ago. On physical
 Reproductive NGN C2

Nurses' Notes

examination, bilateral breasts are noted to be mildly tender with a rope-like texture.

For each finding below, click to specify if the finding is

consistent with perimenopause or pregnancy. Each finding
may support more than one disease process.

Finding Perimenopause Pregnancy

Weight gain

Amenorrhea

Vaginal dryness

Breast tenderness

Note: Each column must have at least one response option

selected.

Item 3 of 6
The nurse is caring for a 45-year-old client in the clinic.

 Nurses' Notes: SAME

 Laboratory Results:
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Laboratory Test and Reference Range Clinic

Human chorionic gonadotropin

(hCG) Negative
(Negative)

Serum TSH
0.3-5.0 μU/mL 3.4 μU/mL (3.4 mU/L)
(0.3-5.0 mU/L)

 Complete the following sentence by choosing from the list

of options.

The nurse understands the client is most likely experiencing

Select...
Pregnancy
Perimenopause
Hyperthyroidism
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Item 4 of 6
The nurse is caring for a 45-year-old client in the clinic.

 Nurses' Notes: SAME

 Laboratory Results:

Laboratory Test and Reference Range Clinic

Human chorionic gonadotropin (hCG)

Negative
(Negative)

Serum TSH
0.3-5.0 μU/mL 3.4 μU/mL (3.4 mU/L)
(0.3-5.0 mU/L)

The client is diagnosed with perimenopause. For each

potential intervention, click to specify if the intervention is
expected or not expected for the care of the client.

Not
Potential Intervention Expected
Expected

Advise the client to take a calcium supplement

Advise the client to reduce intake of spicy foods

Request a prescription for estrogen monotherapy

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Not
Potential Intervention Expected
Expected

Prepare the client for removal of the copper

intrauterine device

Advise the client to use water-soluble vaginal

lubricants during intercourse

Note: Each row must have one response option selected.

Item 5 of 6
The nurse is caring for a 45-year-old client in the clinic.

 Nurses' Notes: SAME

 Laboratory Results: SAME

Laboratory Test and Reference Range Clinic

Human chorionic gonadotropin

(hCG) Negative
(Negative)

Serum TSH
0.3-5.0 μU/mL 3.4 μU/mL (3.4 mU/L)
(0.3-5.0 mU/L)
 Reproductive NGN C2

The nurse is teaching the client about combination

estrogen/progesterone oral menopausal hormone therapy
(MHT). What information is appropriate for the nurse to include
in the teaching?

"MHT decreases your risk for developing a venous

1. thromboembolism."

"Stop taking MHT if you develop breast cancer."

2.

"You can take this medication for the rest of your life."
3.

"Your risk for endometrial cancer is decreased when taking

4. MHT."

Item 6 of 6
The nurse is caring for a 45-year-old client in the clinic.

 Nurses' Notes: SAME

 Laboratory Results: SAME
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The nurse is teaching the client about management of

perimenopause. Which of the following statements by the
client indicates teaching has been effective? Select all that
apply.

"Drinking less alcohol can help my bones become stronger."

1.
"Experiencing menopause earlier in life increases my risk for
2. osteoporosis."
"I can take selective serotonin reuptake inhibitors instead of
3. hormones for hot flashes."

"I will avoid performing weight-bearing exercises."

4.
"I will take a vitamin D supplement with my calcium
5. supplement."
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 Explanation Item 1 of 6

Menopause is a normal physiological decline in estrogen that

commonly occurs in clients age >45 and is retrospectively
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diagnosed once menses has been absent for 12 months.

Findings that require follow-up include:

 Last menstrual period 3 months ago (ie, secondary

amenorrhea), which can be related to perimenopause but
requires follow-up to rule out other etiologies (eg,
pregnancy, polycystic ovary syndrome, thyroid
dysfunction). A copper intrauterine device (IUD) does not
affect ovulation; therefore, clients will continue to have a
regular menses.

 Vasomotor symptoms (eg, excessive perspiration at

night, hot flashes), which can be caused by hormonal
changes (eg, hyperthyroidism, perimenopause)

 Pain during sexual intercourse, which can be caused by

vaginal atrophy associated with perimenopause, pelvic
inflammatory disease, sexually transmitted infections, or
endometriosis. Vaginal dryness makes vulvovaginal
atrophy more likely.

 Persistent loss of interest in normal activities and

difficulty concentrating, which is concerning for
depression and thoughts of self-harm.

(Incorrect) Presence of a copper IUD inserted 8 years

ago does not require follow-up because copper IUDs can
remain in place for approximately 10 years.
 Reproductive NGN C2

(Incorrect) Fibrocystic breast changes occur when glandular

tissue proliferation leads to diffusely nodular breasts and breast
tenderness. On examination, bilateral breasts typically have
multiple nodulocystic masses (eg, rope-like texture). Fibrocystic
breast changes are benign and do not require follow-up.

Educational objective:
Findings that may indicate menopause include last menstrual
period 3 months ago, excessive perspiration at night, pain
during sexual intercourse, and persistent loss of interest in
normal activities.

1. last menstrual cycle was 3 months ago

2. excessive perspiration while sleeping
3. pain during sexual intercourse and a
4. persistent loss of interest in normal activities and difficulty concentrating
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Item 2 of 6

 Explanation

Perimenopause is the transitional phase preceding

menopause when ovarian function declines and estrogen levels
decrease, suppressing ovulation and resulting in amenorrhea.
Because estrogen is responsible for supporting secondary sex
characteristics (eg, hair growth, breast development, vaginal
tissue), decreased estrogen leads to characteristic
menopausal changes, including hair loss, vaginal dryness,
and breast tenderness. Weight gain (particularly around the
abdomen) may also occur due to decreased metabolism.
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Pregnancy results in amenorrhea because ovulation ceases

once an embryo is implanted. Manifestations of pregnancy
include gradual weight gain from an increase in adipose tissue
stores, increased circulating blood volume, and expanding
uterine contents (eg, developing fetus, placenta, amniotic
fluid). Breast tenderness occurs due to an increase in
estrogen during pregnancy. Hair loss can occur during the
postpartum period due to a decrease in estrogen after delivery.
Hormonal changes during pregnancy can cause increased
vaginal mucus production, not dryness.

Educational objective:
Perimenopause is the transitional phase that precedes
menopause when ovarian function declines and estrogen levels
decrease, resulting in hair loss, weight gain, amenorrhea,
vaginal dryness, and breast tenderness. Pregnancy results in
amenorrhea because ovulation ceases once an embryo is
implanted. Manifestations of pregnancy include gradual weight
gain and breast tenderness.

consistent with

perimenopause 1234

pregnancy124
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Item 3 of 6

 Explanation

Vasomotor symptoms (eg, hot flashes or "night sweats"),

insomnia, and irregular menses can occur with perimenopause,
hyperthyroidism, or pregnancy. Menopause and thyroid
disorders can present with overlapping clinical manifestations,
and both are common in women age 40-50. Based on the
negative pregnancy test and normal TSH levels, the nurse can
discern that the client is most likely experiencing
perimenopause.
 Reproductive NGN C2

(Incorrect) Human chorionic gonadotropin (hCG) is a hormone

produced by the placenta during pregnancy to thicken the
uterine lining and stop ovulation. hCG levels start to rise after
implantation of a viable embryo and continue to rise until
approximately 10 weeks gestational age. Pregnancy is ruled
out with a normal hCG level.

(Incorrect) Manifestations of hyperthyroidism also include

tremor, weight loss, hyperreflexia, diarrhea, hypertension, and
palpitations. A low TSH level would indicate hyperthyroidism;
however, the client's TSH is within normal limits.

Educational objective:
Vasomotor symptoms, insomnia, and irregular menses can
occur with either perimenopause, hyperthyroidism, or
pregnancy. Perimenopause is most likely when the client has a
negative human chorionic gonadotropin level and normal TSH
level.

Perimenopause
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Item 4 of 6

 Explanation

Treatment for clients with perimenopause involves managing

effects of physical changes associated with declining hormonal
function. Expected interventions include:

 Taking a calcium supplement to help prevent loss of

bone density (eg, osteopenia, osteoporosis) associated
with decreasing estrogen levels

 Avoiding spicy foods to decrease vasomotor symptoms

(eg, hot flashes, night sweats). Vasomotor symptoms are
the result of estrogen withdrawal in the hypothalamus,
 Reproductive NGN C2

affecting the thermoregulatory system and causing

paradoxical peripheral vasodilation, heat loss, and
perspiration.

 Using water-based lubricants during intercourse to

decrease pain. Vulvovaginal atrophy is caused by low
estrogen levels that lead to decreased lubrication and pain
during sexual intercourse. Topical vaginal estrogen is
also an option for symptoms that are primarily urogenital
to avoid systemic effects of oral/transdermal estrogen.

Estrogen monotherapy is not expected because clients with

an intact uterus (ie, no history of hysterectomy) are prescribed
combined estrogen/progesterone to decrease the risk for
endometrial hyperplasia or carcinoma due to unopposed
estrogen. Clients with a previous hysterectomy (ie, no uterus)
can be prescribed estrogen-only therapy.

Preparing the client for removal of the copper intrauterine

device is not expected at this time because spontaneous
ovulation and pregnancy can still occur due to fluctuating
estrogen levels during perimenopause.

Educational objective:
Treatment of perimenopause includes avoiding spicy foods to
decrease vasomotor symptoms, taking calcium supplements to
prevent bone density loss, using water-based lubricants during
intercourse to decrease pain, and continuing use of
 Reproductive NGN C2

contraception because pregnancy is still possible. Clients with

an intact uterus may also be prescribed a short-term regimen of
combined estrogen/progesterone.

Expected 125

Item 5 of 6

 Explanation

Breast cancer risk factors

 Hormone replacement therapy

 Nulliparity
Modifiable
 Increased age at first live birth
 Alcohol consumption

 Genetic mutation or breast cancer in first-degree relatives

 White race
Nonmodifiable
 Increasing age
 Early menarche or later menopause

First-line treatment for moderate to severe vasomotor

symptoms of menopause includes estrogen-
based menopausal hormone therapy (MHT), formally known
 Reproductive NGN C2

as hormonal replacement therapy. Manifestations of

menopause largely arise due to estrogen withdrawal, and
treatment with MHT can alleviate symptoms significantly.

Contraindications to estrogen use include a history of

thromboembolism, coronary heart disease, endometrial cancer,
and breast cancer. High levels and long-term exposure to
estrogen increases the risk for estrogen receptor–positive
breast cancers. Therefore, a client who develops breast cancer
while on estrogen-based therapy should discontinue estrogen
use (Option 2).

(Options 1, 3, and 4) Estrogen use is associated with an

increased risk for venous thromboembolism and endometrial
cancer. Although healthy clients who receive MHT are at
minimal risk for adverse outcomes, MHT should be taken for
the shortest amount of time possible due to the risk for
complications; MHT should not be taken for life.

Educational objective:
Estrogen-based menopausal hormone therapy (MHT) is first-
line treatment for moderate to severe vasomotor symptoms of
menopause. Contraindications and complications of estrogen
include thromboembolism, coronary heart disease, endometrial
cancer, and breast cancer. MHT should be taken for the
shortest amount of time possible due to the risk for
complications.
 Reproductive NGN C2

Item 6 of 6

 Explanation

Osteoporosis risk factors

Nonmodifiable Modifiable

 Advanced age
 Postmenopausal
 Low body weight  Smoking
 White or Asian race  Excessive alcohol intake
 Malabsorption disorders  Sedentary lifestyle
 Hypercortisolism,  Medications (eg, glucocorticoids,
hyperthyroidism, anticonvulsants)
hyperparathyroidism  Vitamin D deficiency, inadequate
 Inflammatory disorders calcium intake
(eg, rheumatoid  Estrogen deficiency (eg, premature
arthritis) menopause,
 Chronic liver or renal hysterectomy/oophorectomy)
disease
 Female sex

Teaching for clients with perimenopause includes:

 Reproductive NGN C2

 Avoiding excessive alcohol, tobacco, and caffeine,

which can cause metabolic changes that impair calcium
absorption and result in bone tissue loss. If the client
smokes, smoking cessation is encouraged because
quitting leads to stabilization of bone density over
time (Option 1).

 Experiencing menopause earlier in life increases the risk

for osteoporosis (ie, low bone density) because the
decrease in estrogen causes the rate of bone resorption
(ie, conversion of calcium in bones to calcium in blood) to
exceed bone formation (Option 2).

 Understanding nonhormonal treatment options for

vasomotor symptoms, including selective serotonin
reuptake inhibitors (eg, fluoxetine) and serotonin-
norepinephrine reuptake inhibitors (eg,
venlafaxine) (Option 3).

 Taking vitamin D with a calcium supplement to

promote calcium absorption and bone health. Vitamin D
supplementation helps build and maintain bone density by
allowing for effective and efficient synthesis of calcium in
the body (Option 5).

(Option 4) Clients are encouraged to perform weight-bearing

exercises (eg, yoga, walking, lifting light weights), which aid in
building and maintaining bone density.
 Reproductive NGN C2

Educational objective:
Clients who experience menopause earlier in life have an
increased risk for osteoporosis. Interventions to promote bone
health and reduce risk include avoiding excessive alcohol,
tobacco, and caffeine; performing weight-bearing exercises;
and taking a vitamin D and calcium supplement. Nonhormonal
treatment options for vasomotor symptoms include selective
serotonin reuptake inhibitors and serotonin-norepinephrine
reuptake inhibitors.
1235
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