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Essentials of Maternity, Newborn, and Women's Health Nursing

Chapter 11: Maternal Adaptation During Pregnancy

1. Jessica and Mike are new clients at your obstetrics office. You are asking them about the reason for their visit. Jessica says she thinks she is pregnant because she missed a period. Mike tells you Jessica is always nauseated in the morning and eats all the time the rest of the day. They have not been using birth control and have wanted to have children since they got married last summer. Jessica says her clothes are feeling tighter and her breasts seem tender. Mike says he has noticed that Jessica has been frequently getting up to go to the bathroom at night. (Learning Objectives 2 and 4)   

What subjective symptoms have led Jessica and Mike to presume she is pregnant? What other conditions could be the cause of Jessica’s symptoms? How can a pregnancy be confirmed as probable? Diagnosed as positive?

Discuss the nutritional needs of Jessica and her baby.

2. Beth (age 18) is experiencing her first pregnancy and is now 24 weeks gestation. She tells you that she is “amazed by the changes that have happened to my body already.” Beth wants to understand what additional changes are going to occur to her “besides just getting a really huge belly.” Additionally, Beth relates to you that she is in her senior year of high school, is no longer involved with the baby’s father, and lives at home with her mother and 12-year-old brother. (Learning Objectives 3 and 5)

Explain to Beth (in terms she can understand) what general body adaptations she will experience throughout the remainder of her pregnancy.

What psychosocial adaptations may Beth experience as a result of being a teenage, single mother living at home?

Case Studies

Essentials of Maternity, Newborn, and Women's Health Nursing

Chapter 13: Labor and Birth Process

1. Emily, age 32, has an obstetrical history of G1, T0, P0, A0, L0. Emily’s week of gestation is 39.1. Emily telephones the health care provider’s office and tells the nurse she believes she is in labor. Based on her assessment, the nurse advises her to have her husband bring her to the labor and birth unit. Emily arrives and is admitted. She is talkative and excited about being in labor and describes her contractions and discomfort as mild.

The following are the assessment findings of the examining nurse: Maternal vital signs are stable. Fetal heart tones with the external fetal monitor are reassuring. Vaginal exam indicates the cervix is 3 cm dilated, 40% effaced, membranes intact with the presenting part engaged.

Ten minutes after the vaginal exam by the nurse, Emily says, “I think I just wet my pants.” (Learning Objectives 2, 6, 7, and 8)

What questions might the nurse have asked Emily to determine that she may be in true labor? What prenatal history information should the nurse have obtained during the telephone call?

Explain the meaning of the nurse’s assessment findings. Identify the stage and phase of labor, listing the physiologic and psychological changes during this stage. What positions and activities would be appropriate for Emily based on the assessment data? Why?

Describe the nursing interventions that would be appropriate for the nurse to implement based on Emily’s statement that “I think I just wet my pants.”

2. Diane, age 22, has been in labor for 8 hours. Her cervical exam reveals she is 3 cm, 30% effaced and –1 station. Diane has been feeling most of her pain in her lower back. (Learning Objectives 3, 4, and 5)

Given your understanding of the 5 P’s and the cardinal movements of labor, discuss why Diane is having back labor and why her progress is slow.

What strategies may the nurse implement to assist Diane in progressing in her labor?

Case Studies

Essentials of Maternity, Newborn, and Women's Health Nursing

Chapter 14: Nursing Management During Labor and Birth

1. Desiree, a 28-year-old G2P1, is admitted to the labor and birth unit. Her birth plan indicates that she is planning natural childbirth without pharmacological interventions. She has attended childbirth education classes. Desiree is considered low risk based on her personal and family health history and physical exam. Her pregnancy has progressed without complications. She is approximately 38 weeks pregnant. Vaginal assessment reveals cervical dilation at 10 cm, 100% effaced, and +1 station. Position of the fetus is LOA. The external fetal monitor indicates a reassuring fetal heart rate at 130 beats per minute. Maternal status is stable. (Learning Objectives 1, 2, 6, and 9)

Based on the vaginal assessment, identify the stage of labor and appropriate nursing interventions for this stage of labor.

Explain how the nurse determined that the external fetal monitor would be appropriate for Desiree. What factors would necessitate a change to internal fetal monitoring during labor?

Desiree says, “I’m not sure I can cope with the pain much longer.” How would you respond, considering her birth plan, stage of labor, and assessment data?

2. Emily, a 26-year-old G3P2, has been in labor for 5 hours and is 7 cm, 90% effaced and +2 station. She has external fetal monitoring in place, which reveals a baseline fetal heart rate of 120 bpm, minimal variability, and occasional variable decelerations. Suddenly, as a contraction is beginning to subside, the fetal heart rate drops to a low of 80 bpm and has a slow return to the baseline 1 minute after the contraction has ended. (Learning Objectives 4 and 5)

A. What is happening to Emily’s baby at this point in time? What does this mean?

B. What role do you, as the nurse, play regarding fetal assessment and what interventions do you need to implement/recommend at this point in time?

Answer 1

1.Some of the symptoms Desiree expressed is related to pregnancy which includeNausea and vomiting,syncope,urinary urgency and frequency,breast tenderness,increased va gin al discharge,nasal stuffiness,fatigue,heartburn,ankle edema,varicose vein,headache,haemorrhoid,constipation,backache,leg cramps and shortness of breath.

Pregnancy probable signs are

• Uterine enlargement
• Hegars sign
• goodells sign
• Chadwick sign
• Ballotment
• Braxton Hicks contractions
• Positive pregnancy test for determination of HCG.

2.Physiological maternal changes include

Cardiovascular system-circulating blood volume increases,plasma increases and total red blood cell volume increases.Heart size increases and elevated slightly upward.

Respiratory system

• Oxygen consumption increases by approximately 15% to 20%.Diaphragm is elevated because of the enlarged uterus.retention of sodium and water may occur.

Gastrointestinal system

• Nausea and vomiting may occur as a result of the secretion of HCG .
• Poor apetite may occur because of decreased gastric motility.
• Alterations in taste and smell may occur.
• Constipation may occur because of an increase in progesterone production.

Renal system

Frequency of urination increases in the first and third trimester of pregnancy

Endocrine system

Basal metabolic rate increases and metabolic function increases.

Reproductive system

Uterus enlarges,size and number of blood vessels and lymphatics increase and irreguar contractions occur.

Cervix becomes shorter ,more elastic.In va gina hypertrophy and thickening occurs .Breasts changes occur because of the increasing effects of estrogen and progesterone.

Skin -Some changes occur because the level of melanocytes -stimulating hormone increase as a result of an increase in estrogen and progesterone levels.Vascular spider nevi may occur on the chest ,neck,face arms and legs.

Changes in the center of gravity may occur on the second trimester and are caused by the hormones relaxin and progesterone.

b Major concerns related to adolescent pregnancy include poor nutritional status,emotional and behavioural difficulties ,lack of support systems,increased risk of still birth,low birthweight infants,fetal mortality,cephalopelvic disproportion,and increased risk of maternal complications.The role of the nurse is to reduce the risk and consequences of adolescent pregnancy is two fold -first is to encourage early and continued prenatal care and second to refer the adolescent ,if necessary ,for appropriate assistance ,which can help counter the effects of a negative socio economic environment.

1.The nurse ask Emily whether the uterine contractions occur every 15 to 30minutes and last about 30 to 60 seconds and whether they are of moderate intensity.Based on the assesment findings the patient is in first stage of labour in latent phase.During this stage effacement and dilatation of cervix occurs.Uterine contractions occur every 15 to 30 minutes.Mother becomes more talkative and eager in latent phase,becoming tired and restless and anxious as labour intensifies and contraction become stronger.

Nursing interventions

• Encourage mother and partner to participate in care.
• Assist with comfort measures ,changes of position and ambulation.
• Keep mother and partner informed of progress.
• Offer fluids and ice chips.
• Encourage voiding every 1 to 2 hours.