Exam 1
1 Conception & Fetal Development
F
● ollicular phase: day 1-14
● Luteal phase: day 14-28
● Order that hormones elevate during a monthly menstrual cycle:
○ GRH (gonadotropin-releasing hormone)
○ FSH (follicle-stimulating hormone): causes egg to mature
○ LH (luteinizing hormone)
○ Progesterone: maintains pregnancy
Early first signs of pregnancy → Bladder frequency
Order of sperm’s path until ejaculation: testes →epididymis → vas deferens → seminal vesicles → prostate → urethra
The Sperm & Ovum
● ZP (zona pellucida) binds the sperm & prevents additional sperm from penetrating the ovum
Travel in Fallopian Tube to Implantation in Uterus
● Zygote: fertilized ovum (coupling of chromosomes)
● Cleavage(day 1): cell division of zygote
● Morula(day 3): mass of blastomeres → splits intotrophoblasts &
blastocysts
● Blastocyst(day 4): a ball of cells that forms aftera fertilized egg divides
and separates into layers → turns into baby
○ Trophoblasts: cells that form the outer layer of a blastocyst → turns into placenta
Placenta
● Produces hormones: hCG, Human placental
lactogen, Progesterone, Estriol
● Metabolic Functions: Respiration, Nutrition,
Excretion, Storage
● Chorionic Villi: nourish the baby, obtain O2 &
nutrients from maternal blood stream, dispose of
CO2 & waste products into maternal blood stream
Fetal Membranes
● Chorion: the outermost membrane surrounding
an embryo
○ Develops from trophoblast
○ Becomes thecovering of fetal side of the placenta
○ Contains major umbilical blood vessels
● Amnion: the innermost membrane that encloses the embryo
○ Develops frominterior cells of theblastocyst
○ Becomescovering of the umbilical cord
○ Covers chorion of the fetal surface of the placenta
Amniotic Fluid
● Amount ↑ as pregnancy progresses
● Fetus swallows fluid; fluid flows in & out of fetal lungs
● Week 11: fetus urinates into fluid, ↑ volume
etal circulation: umbilical vein (oxygenated blood)→ ductus
F
venosus (bypass the liver) → inferior vena cava → right atrium (little
bit into right ventricle) → foramen ovale (bypasses lungs) (but little
bit goes into pulmonary artery → ductus arteriosus → aorta) → left
atria → left ventricle → aorta → body → umbilical artery
(deoxygenated blood)
The Embryonic Period:week 2-8 after conception; criticalto optimize mom’s health during time period
● Most critical time in the development of organ systems and main external features
● Crown-Rump Length (CRL): measure from top of headto butt
● By the end of the week 8 post conception, all organ systems & external structures are present
● Teratogen:agent that acts directly on the developingfetus, causing abnormal embryonic or fetal development
○ During first 2 weeks post conception - all or nothing
Fetal Stage:week 9 until birth
● Changes not as dramatic as in embryonic stage
● Less vulnerable to teratogens except to those impacting the CNS
● Viability: ability of the fetus to survive outsidethe uterus on its own → in Massachusetts
○ Abortion = baby is < 20 weeks or < 500 grams
Death certificate = baby is > 20 weeks or > 500 grams
○
Term: 37 weeks 1 day
●
Fetal Systems
● Hematopoietic System
○ Hematopoiesis (production of blood) begins in liver in week 6 → Women risk isoimmunization (produce
antibodies against fetal RBCs)
○ Miscarriage → need to know baby’s blood type
● Respiratory System
○ Pulmonary surfactants: used to determine degree offetal lung maturity – ability of lungs to function after
birth; helps lungs not collapse
■ Lecithin (L): required for postnatal lung expansionpresent 21 weeks / ↑ after 24 weeks
■ Sphingomyelin (S): remains constant in amount
■ Ratio →2:1 is considered mature: ~35 weeks gestation
● Gastrointestinal System →mature by 36 weeks
● Hepatic System
○ Babies have more RBCs → byproduct of RBCs is bilirubin → excreted through voiding
● Renal Systembegin functioning week 9
○ Urine excreted in amniotic fluid
● Neurological System →ONTD (open neural tube defects)develops in the 4th week
● Reproductive System →can tell gender by week 12
● Immunologic System
○ IgG: passively acquired immunity from mother
■ Only Ig that crosses the placenta
■ Fights specific bacterial toxins
○ IgM: fetus produces end of the 1st trimester
○ IgA: present in colostrum (passive immunity to breastfedinfant)
2 Maternal Adaptation to Pregnancy
Gravidity & Parity
● Gravidity: pregnancy
● Parity: the number of pregnancies in which the fetus/fetuseshave reached viability (20 weeks, 500 grams)
● Gravidity & parity status are abbreviated using a 5 digit code
1. G - total number of pregnancies (including present)
2. T - # term births - also noted as “F” for full term
3. P - # of preterm births
4. A - # abortions (SABs or TABs)
5. L - # currently living
Sara’s Pregnancy History
● Sara is pregnant for the 1st time → G1 P0
● Sara carries the pregnancy to term & the infant survives → G1 1-0-0-1
● Sara is pregnant again → G2 1-0-0-1
● Sara’s second pregnancy ends in abortion → G2 1-0-1-1
● During Sara’s 3rd pregnancy, she gives birth to preterm twins → G3 1-1-1-3
Signs of Pregnancy
● Positive Signs ● Probable Signs
○ Visualization of fetus by US or XR ○ Positive pregnancy test
○ Presence of fetal heart tones (FHT) ○ Goodell’s Sign: soft cervix, ~6-8 weeks
○ Fetal movements palpated by examiner ○ Chadwick’s Sign: blue discoloration of
● Presumptive Signs the vulva, vagina, or cervix (d/t ↑
○ Breast changes vascularity)
○ Amenorrhea ○ Hegar’s Sign: softening of the cervix and
○ N/V lower uterine segment
○ Urinary frequency ○ Braxton Hicks Contractions: painless,
○ Fatigue irregular contractions
○ Quickening: 1st time a pregnant person ○ Ballottement: when baby’s head bumps
feels their fetus move in their uterus abdomen with 2 fingers in vagina
(~18-22 weeks)
Pregnancy Diagnosis
● Human chorionic gonadotropin (hCG): biologic markerfor pregnancy, production begins with implantation
○ Serum: detected a few days post conception
■ Quantitative - gives #
■ # should double in 48 hr in early pregnancy; if # doesn’t double → think ectopic pregnancy
○ Urine: (ELISA) detected 8-11 days post ovulation,5 days before missed period
■ Qualitative
■ Test first morning urine (FMU)
○ Level rises until hCG peaks at 60-70 days of gestation
● Can detect baby with ultrasound ~6 weeks
Estimating Date of Birth
● EDC (estimated date of confinement) = EDD (estimated date of delivery)
● Naegele’s Rule
○ Assumes 28 day cycle with conception on day 14
○ Subtract 3 months (from first day of last menstrual period)
○ Add 7 days to first day of LMP
○ Add 1 year
When assessing lab values in a pregnant client which does the nurse expect to see elevated?
a. Glucose: ↓ in pregnancy (fasting glucose 65-95)
b. Fibrinogen: (clotting factor) pregnancy is a hypercoagulablestate so mom doesn’t bleed out → ↑ risk of DVT
c. Hematocrit: (% of RBCs in blood volume) ↓ in pregnancy → 33 = tolerated
d. Bilirubin: remains stable
Mother Body Changes
● Uterine Changes:growth of the uterus in first trimesterstimulated by estrogen & progesterone; ↑ 1 cm q week
○ Lightening/Fetal Drop: descent of fetus into pelvisin 3rd trimester, ~38-40 weeks
■ Nulliparous (women have never given birth): occurs 2 weeks before labor
■ Multiparous (woman who has given birth to at least one child): occurs at start of labor
● Vagina & Vulva
○ Leukorrhea: ↑ WBCs → thick, whitish, yellowish orgreenish vaginal discharge
○ ↑ vascularity results in edema & varicosities of vulva
● Breasts: ↑ pigmentation of nipple & areola, ↑ vascularity (striae gravidarum)
○ Lactation inhibited until drop in estrogen after birth
● Cardiovascular System:position of heart - shift up& to the left – altered PMI (apex)
○ ↑ BV (~30-50%), CO, SV, pulse, & heart size
○ BP should stay the same as BP before pregnancy
■ Diastolic begins to ↓ at end of 1st trimester & continues to ↓ until 24-32 weeks
■ Returns to pre-pregnancy levels by term
○ ↓ in hemoglobin & hematocrit
■ Results in physiologic anemia
■ If < 11 g/dl or 33% then considered anemia
○ WBC count ↑ in 2nd trimester & peaks in 3rd trimester
● Venous system: compression of iliac veins & inferiorvena cava
○ Compression of vena cava when lying flat on back → ↓ CO → supine hypotension
○ As soon as uterus in abdomen can’t lie supine (~ after 20 weeks)
● Coagulation Times:↑ risk of thrombosis in pregnancy& postpartum d/t (↑ fibrinogen)
● Respiratory System: Estrogen causes upper respiratorytract to become more vascular
● Renal System:Larger volume of urine is held in pregnancy→ urinary stasis → ↑ risk of UTIs
○ Bladder irritability, nocturia, frequency
○ Bladder frequency in beginning & end of pregnancy
● Integumentary System: hyperpigmentation, linea nigra(pigmented vertical line on abdomen), facial
chloasma/melasma (brown/gray patches on the face, begins 16 wks), striae gravidarum (stretch marks)
● Gastrointestinal System(progesterone’s impact)
○ Morning sickness, swollen gums that easily bleed, heartburn, constipation,
● Endocrine System
○ ↑ levels ofestrogen&progesterone
■ Produced first by ovary in CL (corpus luteum) until placenta produces at 14 weeks
○ hCGproduced by fertilized ovum & chorionic villimaintains CL until placenta takes over
○ Oxytocin: stimulates uterine contractions & let downreflex (process of releasing milk from the breast into
the milk ducts)
○ Prolactin: responsible for initial lactation
○ hCS(human chorionic somatomammotropin): antagonistto insulin → ↑ free fatty acids, ↓ maternal
metabolism of glucose favoring fetal growth
When assessing psychological adaptation in 8 week pregnant women the nurse expects to see:
a. Ambivalence(mixed feelings)
b. Depression
c. Anxiety
d. Ecstasy
What is likely to ↑ a father’s interest & involvement in a pregnancy?
a. Learning results of pregnancy test
b. Attending childbirth education class
c. Meeting the obstetrician or midwife
d. Hearing the fetal heartbeat
When interviewing a 38 week Muslim woman, which question is inappropriate for a nurse to ask?
a. Do you plan to breastfeed your baby?
b. What do you plan to name your baby?
c. Which pediatrician do you plan to see?
d. How do you feel about having an episiotomy?
3 Nursing Care in Prenatal Period
Gestational Age:how far along a pregnancy is, calculatedin weeks from the first day of a woman's last menstrual period
● Assessment of LMP (most accurate when know LMP)
● Pregnancy has duration of 280 days from first day of LMP
○ 9 calendar months,
● Clinicians measure pregnancy gestation using lunar months (28 days/4 weeks), assumes ovulation & conception
on day 14 of 28 day cycle
○ 10 lunar months/40 week gestational period
● Notation of Gestational Age (memorize)
○ 1st trimester: week 1-13
○ 2nd trimester: week 14-26
○ 3rd trimester: week 27-delivery
○ Written in fractional weeks or decimals
Assessment of Gestational Age
● Accurate LMP: Naegele’s rule (best predictor)
○ Subtract 3 months (from first day of LMP) → Add 7 days → Add 1 year
● Uterine size: fundal height measurement in centimeters
○ At umbilicus at 20 weeks gestation, rises ~1 cm each week
● Quickening: first time feel baby move
○ 16-20 weeks depending on pregnancy history
● Audible fetal heart tones: electronic doppler at 10-12weeks
● Ultrasound: accurate measure of gestational age infirst half of pregnancy
○ Goes in vagina w/ probe to measure crown-rump length
○ If within 6 days of LMP go with LMP
Prenatal visits
● Starting at 8-10 weeks: q 4 weeks until 28 weeks
● Q 2 weeks 28-36 weeks
● Q 1 week 36-delivery
The First Prenatal Visit: 8-10 weeks pregnant(longestappointment)
● Complete Health History
● I nitial laboratory testing
○ Medical/surgical: asthma, diabetes, HTN, ● Symptom & physical assessment
heart disease, Rh sesnitized ● Review of danger signs
○ Gynecologic, Obstetric ● Early prenatal education & description of course
○ Social, Mental Health of prenatal care
○ Family, Support system Ask: “how are you feeling”
●
Vaccines
● Vaccines you can’t give in pregnancy: MMR, Varicella,Yellow fever, Polio
● Vaccines you can give in pregnancy: Hep B, Hep A,Rabbies, Flu (not mist), Covid, RSV
TORCH Infections
● T - toxoplasmosis
● O - other infections
● R - rubella
● C - cytomegalovirus
● H - herpes
Toxoplasmosis:parasitic infection that invades tissues& damages the brain
● Symptoms: Fever, fatigue, headache, swollen lymphglands, muscle, aches/pain (flu-like)
● Contracted by:
○ Touching the hands to the mouth after gardening or cleaning a cat’s litter box
○ Eating/raw or partly cooked meat
○ Touching the hands to the mouth after touching raw or uncooked meat
Other Viruses
● Hepatitis B - HBSAg
● HIV
● Syphilis: RPR, VDRL or FTA-ABS (only if positive)
● Herpes
● Strep B
Rubella:contagiousviral infectionbest known byits distinctive red rash
● Exposure associated with SAB (spontaneous abortion), congenital anomalies, hearing loss, psychomotor
retardation
● Diagnosis: based on antibody titers
○ ≥ 1:8 = Immunity → good
○ < 1:8 = Susceptibility → bad
● S/S: rash, muscle aches, joint pain
● If non-immune, pregnant woman should obtain vaccine after delivery
● Newborn: hearing loss cataracts cardiac defects
● NO pregnancy for at least 1 month post vaccine
Cytomegalovirus (CMV):chronic infection (type ofherpesvirus)
○ 50-85% of the general population have antibodies to CMV
● Only at risk if develop CMV during pregnancy
● Transmitted: close contact-kissing, sexual contact,breast feeding, transplacental
○ People at ↑ risk if work with children or immunocompromised
● Diagnosis: based on presence of CMV in urine or CMVantibodies in serum
● Women are usually asymptomatic & show no s/s of infection
● Fetal/neonatal complications: intellectual disability, hearing deficits, microcephaly
Herpes:viral infection causing painful, recurrentoral/genital lesions
● Diagnosis: culture, symptoms
● Transmission to infant occurs through vaginal delivery during active outbreak or d/t ascending infection
after ROM (rupture of membranes)
● Fetal-neonatal risks: SAB (spontaneous abortion), preterm labor, development of HSV, death
● If genital herpes in pregnancy: start antiviral at36 weeks
● If genital herpes at time of delivery: C/S
Screening/Assessments Done at Each Prenatal Visit(very important)
● Blood pressure ● V aginal discharge, bleeding, leaking of fluid
○ Don’t want > 140/90 (LOF)
● Fundal height ● Abdominal pain
● Maternal weight(little weight gain in beginning; ● Preeclampsia
+10 lbs by 20 weeks then 1 lb per week) ○ Visual changes
● Fetal heart tones(10-12 weeks) ○ Reflexes
● Urine: pH, protein, glucose, ketones, nitrites ○ Headache
● Fetal movement(depending on gestational week, ● Vomiting
starts 16-20 weeks) ● Urinary complaints
● Constipation
Fundal Assessment
● At umbilicus at 20 weeks
Use of US in Pregnancy
● First Trimester ● Second Trimester
○ Number, size, & location of gestational sac ○ Fetal viability, number, position,
○ Presence/absence of fetal cardiac & body gestational age, growth pattern, anomalies
movements ○ Amniotic fluid volume
○ Presence/absence of uterine abnormalities ○ Placental location & maturity
or adnexal masses ○ Uterine fibroids & anomalies
○ Date of pregnancy ○ Adnexal masses
○ Presence/absence of IUD ○ Cervical length
Pregnancy Weight Gain
● Gain of about 10 lbs by 20 weeks gestation
● Gain 1 lb/week until 40 weeks gestation
● PROBLEM: > 3kg (6.5 lb)/month
Initial Laboratory Testing(very important)
● CBC
● epatitis B (HBsAg)
H
○ H&H ● STI’s & vaginitis
● Blood type & Rh factor ● Pap test
● Antibody screen (want to be negative) ● UA & C&S (culture & sensitivity)
● Renal function tests ● PPD (postpartum depression)
● Rubella/Varicella ● HIV
● RPR/VDRL (syphilis)
