NR-602 Primary Care of the Childbearing &

Childrearing Family Practicum

NR 602: MIDTERM STUDY GUIDE

Signs of pregnancy (presumptive, probable, positive)

• Presumptive Signs of Pregnancy: Symptoms that are suggestive of pregnancy are considered

“presumptive signs” which means that they are the least objective or subjective signs which can

also be caused by many other conditions other than pregnancy.

• Amenorrhea: Highly suggestive of pregnancy in a healthy female with regular & predictable

periods. Difficult to determine in a female who have irregular periods or in those who do not

keep track of their menstrual cycles

 • Nausea & vomiting: Common symptom (~50% of pregnancies) typically occurring

between 2-16 weeks gestation

 • Breast engorgement & darkening of the areolas: Occurs as early as 6-8 weeks gestation

 • Breast tenderness

 • Fatigue

 • Urinary Frequency

 • Slight increase in body temperature: Rise in temperature coincides with luteal phase and

is the result of increased progesterone

 • “Quickening”: Mother feels the baby’s movements for the 1st time; starts at 16 weeks.

• Probable signs of pregnancy: mean that there is a high likelihood of pregnancy but there are still

other conditions that may cause the findings.

• Pregnancy tests are considered probable because β-hCG also presents in molar

pregnancies and ovarian cancer.

• Positive Signs of Pregnancy: The most reliable and most objective signs of positive pregnancy

are those where the provider can confirm the presence of a fetus

 • Palpation of the fetus by the health care provider

 • Ultrasound and visualization of the fetus

 • Fetal Heart Tones (FHT) auscultated by the health care provider

Pregnancy and fundal height measurement

• Fundal height can provide valuable information on assessing the gestational

age of the fetus as well as to monitor fetal growth.

o 12 weeks: Uterine fundus first rises above the symphysis pubis

o 16 weeks: Uterine fundus is between the symphysis pubis and umbilicus

o 20 weeks: Uterine fundus is at the level of the umbilicus

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o 25-35 weeks: Measure the distance between the upper edge of pubic symphysis and the

top of the uterine fundus with a tape measure. Fundal height in centimeters equals the

number of gestational weeks (+/- 2cm). For example, a 28 week gestation fetus should

have a fundal height that measures between 26 and 30cm.

* Between 25-35 weeks the fundal height should measure equally to the number of gestational

weeks (+/- 2cm).

Naegele’s rule

• The EDD is calculated by adding seven days to the first day of the last menstrual period,

subtracting three months and adding one year.

*For example, if the patient's last menstrual period, LMP, was on August 10, 2019, the EDD

would be calculated as follows. LMP equals August 10, 2019 plus seven days. August 17, 2019,

minus three months. May 17, 2019 plus one year and that equals May 17, 2020.

Hematological changes during pregnancy-See Table 29.2 p. 777

• blood volume increases by 30% to 50%, or 1,100 to 1,600 mL and peaks at 30 to 34 weeks’

gestation.

• The increase in blood volume improves blood flow to the vital organs and protects against

excessive blood loss during birth.

• Fetal growth during pregnancy and newborn weight are correlated with the degree of blood

volume expansion.

• Of the blood volume expansion occurring during pregnancy, 75% is considered to be plasma

• There is also a slight increase in red blood cell volume (RBC).

• The blood volume changes result in hemodilution, which leads to a state of physiologic anemia

during pregnancy.

• As the RBC volume increases, iron demands also increase.

• Leukocytosis occurs in pregnancy, with white blood cell counts increasing to as much as 14,000

to 17,000 cells per mm3 of blood (Table 29-3).

• Clotting factors increase as well, creating a risk for clotting events during pregnancy.

• Systemic vascular resistance is reduced due to the effects of progesterone, prostaglandins,

estrogen, and prolactin.

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• This lowered systemic vascular resistance, in combination with inferior vena cava compression,

is partly responsible for the dependent edema that occurs in pregnancy.

• Epulis of pregnancy, or hypertrophy of the gums accompanied by bleeding, may also occur and

is due to decreased vascular resistance and increase in the growth of capillaries during

pregnancy

Indications and contraindications for prescribing combined estrogen vs. progesterone-only birth

control: See Appendix 11-A p. 248

• Most COC formulations now contain between 20 to 35 mcg of ethinyl estradiol plus one of 8

available progestins.

• Consider the “quick start” method when initiating oral contraceptives.

▪ If last menstrual period (LMP) was within the last 5 days, the method can be started

immediately.

▪ In unprotected sex within last 2 weeks, start the contraceptive method today and advise

patient to return to the clinic for a pregnancy test in 3 weeks.

▪ Instruct women who are using the pill, patch, ring, injection, or implant to use backup

contraception for the first 7 days.

▪ Research shows that there are no significant differences in the number of bleedingspotting days or any other bleeding parameter between the immediate and conventional

starters.

• Indications:

▪ Women with dysmenorrhea and menorrhagia

▪ Women who want to regulate menses

▪ Women who will use a daily method consistently

• Benefits of COC

▪ Decreased blood loss and anemia

▪ Decreased menstrual cramps and pain with more predictable menses

▪ Can be used to manipulate the timing of menses

▪ Decreases risk of ovarian cancer and endometrial cancer

▪ Reduces risk of ectopic pregnancy

▪ Effective to treat acne, hirsutism and other androgen excess/sensitivity states

▪ Reduced vasomotor symptoms and effective contraception in perimenopausal women

▪ Increased bone mineral density

▪ Decreased pain and frequency of sickle cell disease crises

• Disadvantages of COC

▪ Decreased libido and anorgasmia is unusual, but possible

▪ Mood changes, depression, anxiety, irritability

▪ No protection against STDs or HIV

▪ Nausea & vomiting, especially in the first few cycles

▪ Breast tenderness or pain

▪ Headaches may increase

• Special Situations for COC

▪ Endometriosis-continuous use are most effective in reducing severe symptoms (skip

placebo week); must use monophasic pills

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▪ Functional ovarian cysts-higher dose estrogen COCs may be slightly more effective

▪ Breastfeeding women-progestin-only method (norethindrone)

• Contraindications of COC:

▪ Multiple risk factors for arterial cardiovascular disease, such as smoking, diabetes,

hypertension

▪ Known thrombogenic mutations

▪ Current or history of current ischemic heart disease, history of stroke, history of or

current deep venous thrombosis or pulmonary embolism

▪ Vascular disease

▪ Complicated valvular heart disease

▪ Hypertension (systolic ≥160 or diastolic ≥ 100)

▪ Smoking (>15 cigarettes/day and age 35 or older)

▪ Migraine headache with aura

▪ Major surgery with prolonged immobilization

▪ Current breast cancer

▪ Active viral hepatitis

▪ Severe cirrhosis

▪ Benign or malignant liver tumors

▪ Breastfeeding <6 weeks postpartum

“Mini-pills,” progestin-only pills

• There are currently two formulations--norethindrone (Micronor) and norgestrel

(Ovrette).

• Candidates:

▪ Progestin-only pills are useful for women who want immediately reversible hormonal

contraception but for whom estrogen is contraindicated because of breastfeeding,

cardiovascular disease, and migraine with aura, for example.

• Advantages:

▪ Progestin-only pills (COCs also are used) can be used to correct dysfunctional uterine

bleeding.

▪ no estrogen-related side effects that COCs have, such as nausea, headache, and

bloating, but they do cause irregular vaginal bleeding.

▪ These pills protect against cancer of the uterus and ovaries, benign breast disease, and

pelvic inflammatory disease.

• Contraindication:

o The only contraindication to taking progestin-only pills is current breast cancer.

• Disadvantages:

▪ The primary side effect is irregular menstrual bleeding, including spotting or

breakthrough bleeding, amenorrhea, or shorted cycles. Irregular bleeding decreases in

many users by cycle 12. Less common side effects are headache, breast tenderness,

and dizziness.

• Counseling:

▪ The pill must be taken at the same time each day.

▪ If a pill is more than 3 hours late, a backup method of contraception should be used

for at least the next 48 hours. Inform women about emergency contraception