Question

Dylan is a 36 year old female who has come for a routine 28 week prenatal check-up. She is a non-smoker, is physically active and has gained 4 kg of weight so far in her pregnancy. Dylan’s obstetrical history is G2 T0 P0 A1 L0. Both pregnancies have been assisted with in-vitro fertilization. During this first trimester, Dylan has suffered from nausea and vomiting but it has now resolved. Now, Dylan states she is exhausted all the time. The fetus is active and Dylan has been keeping track of movement by daily kick counts. Dylan’s blood pressure has been stable throughout the pregnancy.

You are the clinic nurse for the day and are caring for Dylan during her prenatal appointment.

1. What are your six priority assessments?

You step out of the room for a minute to assess Dylan’s urine.

2. Name four abnormal urine findings during pregnancy. What is the significance of each of these findings?

You have Dylan lay down to measure fundal height. The measurement you obtain is 29cm.

3. Explain how a fundal height is measured and if the finding of 29 cm is normal or abnormal for this point in Dylan’s pregnancy

4. What diagnostic tests would you anticipate the primary care provider ordering if there were an abnormal fundal height?

The next step in your prenatal check is to auscultate the fetal heart rate.

1. Describe the steps to take when assessing the fetal heart rate.

You listen for one minute and find that the fetal heart rate is 130bpm with regular rhythm and no decelerations heard.

2. Discuss the significance of these findings.

Outside the exam room, you provide a report to the primary care provider of all assessment findings and mention that Dylan states she feels exhausted all of the time. The primary care provider goes in to assess the patient. Dylan restates the constant feeling of exhaustion and the primary care provider orders a complete blood count to be done prior to the next visit.

3. Why do you think the physician is ordering a complete blood count?

Two weeks later, Dylan returns for a follow-up prenatal visit. Dylan states that the fetus is moving, but the exhaustion remains, and she has now started to feel dizzy occasionally and finds it is hard to catch her breath. Dylan’s blood work results are on file and show the following:

• RBC - 3.0 x 1012/L

• WBC – 7 x 109/L

• Hct – 0.30

• Hgb – 109 g/L

4. What are five potential impacts to the pregnancy and fetus if these values are not corrected?

5. What medication would you anticipate the primary care provider to order based on the above lab results? Provide your rationale.

6. What five teaching points would you provide around this medication and her condition?

The rest of Dylan’s prenatal check-up is unremarkable and she is about to leave with her prescription.

7. List four priority teachings you would provide at the end of this appointment.

Answer 1

Pregnancy is categorized into three stages : First , second and third trimester. Second trimester ranges from week 13 to week 28. The common symptoms during second trimester includes pain over the abdomen, breasts,thighs. The serious complications occurs during second trimester includes gestational diabetes, pregnancy induced hypertension.

In second trimester the priority concerns includes: screening urine to detect protein and glucose excretion, fetal growth monitoring, Thyroid profile , Complete blood found, Weight monitoring, Glucose tolerance test.

The abnormal urine findings during pregnancy includes :

1) High levels of protein in the urine indicates an alarm for renal impairment, preeclampsia commonly termed as pregnancy induced hypertension.

2) High levels of glucose in urine indicates the risk for gestational diabetes mellitus.

3) Urine culture with positive bacterial presence indicates bacteriuria, and indicating urinary tract infection.

Fundal height is measured to assess the size of the uterus. It is measured by using a inch tape or using fingers. Measurement starts from the top of the fundus to the symphysis pubis. It is measured in terms of centimeter. In this scenario the fundal height of 29 cm in 28 weeks is considered as normal.

The normal fetal heart rate ranges from 120 - 160 beats per minute. The fetal heart monitoring findings shows normal fetal development. It indicates there is an adequate supply of oxygen.