Chapter 12

Promoting Fetal and Maternal Health 

CD PATIENT SCENARIO

CARE STUDY: A WOMAN WITH MID-PREGNANCY CONCERNS

Stephanie Harper is a 26-year-old woman who comes to your prenatal clinic for care. This is her

first pregnancy. She is 28 weeks pregnant.

CHIEF CONCERN:

"I’m tired and my back aches all the time."

HISTORY OF CHIEF CONCERN:

A feeling of fatigue has been present from early pregnancy. Backache has been noticeable over

the last week. Pain is sharp and mostly on right side, noticed most at end of day.

FAMILY PROFILE:

Client works as an executive secretary for a major corporation in the inner city. Works a 40-hour

week; job consists of sitting at desk for long stretches or else filing for long stretches. Fair degree

of stress as she is secretary to two people who compete for her time. Does not smoke; has taken

no alcohol since pregnancy began; no teratogenic exposure at work that she is aware of. Her

husband, Jose, 30 years old, works as a carpenter. Is also not exposed to any teratogens of which

she is aware.
Client has been married for 4 years. Lives with husband and two pedigreed dogs in a high-rise

condo in downtown city. She describes finances as "adequate." Has begun to prepare a section of

the bedroom for the baby. Unwilling to move because of the price of a bigger condo and because

present one is close to mother's house. Plans to return to work following birth; a sister will care

for baby during the day.

HISTORY OF PAST ILLNESSES:

Client had mumps at 8 years; rheumatic fever at 12 years; no residual heart disease; “some kind

of measles” during college.

HISTORY OF FAMILY ILLNESSES:

Father died at age 43 of arteriosclerotic heart disease; paternal grandmother has type 2 diabetes

mellitus.

GYNECOLOGICAL HISTORY:

Menarche at 11 years; cycle of 28 days; duration of flow 5 days, moderately heavy. Slight

dysmenorrhea. No sexually transmitted infections. Was using a diaphragm and foam as

contraceptive measure before pregnancy.

OBSTETRICAL HISTORY:

No previous pregnancies. This pregnancy was planned.

DAY HISTORY:
Nutrition: 24-hour recall:

Breakfast: one cup coffee (decaffeinated) with cream; two slices toast; one glass orange juice;

prenatal vitamin

Lunch: one cup fat free yogurt; small green salad

Snack: one dish ice cream; one glass cola (caffeine free)

Dinner: one bowl onion soup; one serving rare roast beef; one serving green peas; one slice bread

Snack: one piece apple pie; one glass skim milk

Sleep: Sleeps more than previously (6 hours per night) but backache has kept her awake the last

two nights.

Recreation: Participates on a synchronized swimming team at a local sports facility two times per

week. Walks her dogs in a nearby deer refuge daily. Exercise is minimal the rest of the week.

REVIEW OF SYSTEMS:

Head: Occasional headache if she works too long at a computer

Eyes: No blurring of vision

GI: Has noticed "heartburn" off and on during pregnancy; some tendency toward constipation

lately.

GU: Slight discomfort on voiding for last 3 days; no vaginal discharge.

Blood type: A positive. Has never had a transfusion.

PHYSICAL EXAMINATION:

Height: 5' 8"; Weight: 110 before pregnancy (BMI = 16.7 or underweight); 15 pound gain in

pregnancy; Blood pressure: 114/74.

HEENT: Normocephalic; red reflex; reads fine print without difficulty; hearing adequate for

normal conversation. Nose: mucous membrane slightly swollen but not reddened; No palpable

lymph nodes present.

Chest: Areolae of breasts enlarged and prominent; colostrum present on nipples. Numerous veins

distinguishable. Lungs sounds clear to auscultation. Respiratory rate: 22 breaths per minute.

Occasional systolic heart murmur present; heart rate: 78 beats per minute.

Abdomen: Linea nigra and numerous striae present. Fundal height: 22 cm; fetal movements

palpated; FHR = 160 beats per minute.

Back: Area tender over right kidney; no tenderness at spinal column.

Extremities: Slight varicosity formation on medial surface of right leg; occasional spider

angiomas.

Rectum: Slight internal hemorrhoids present

LABORATORY REPORTS:

Hemoglobin: 10.5 g/dl

Hematocrit: 36%

Urinalysis by reagent strip: pH: 9; protein, trace; glucose: trace; ketones: negative; blood; +2. A

clean catch urine was obtained for culture.

Stephanie was diagnosed as having a possible pylonephritis based on the urinary discomfort,

blood in urine, right sided back pain, and elevated temperature. She was instructed to increase
her fluid intake to two quarts daily and was placed on an oral antibiotic. She is to return to the

clinic in 3 days for a repeat urine culture.

CARE STUDY QUESTIONS:

1. You teach Stephanie about signs of labor. You would explain that “lightening” is

a. a vaginal discharge of pale vaginal mucus.

b. a feeling of cold across the abdomen.

c. settling of the fetal head into the pelvic inlet.

d. a sharp hot pain that announces labor.

Answer: c. “Lightening” or the settling of the fetal head is most apt to occur in women having

their first baby. It happens up to 2 weeks before labor begins.

2. Stephanie says she’s worried about contacting a sexually transmitted infection during

pregnancy. Contacting syphilis during pregnancy can result in

a. a green to brown maternal vaginal discharge.

b. deformed and unusually sharp teeth in an infant.

c. severe maternal abdominal gastrointestinal pain.

d. “blueberry” or blue lesions on the mother’s skin.

Answer: b. The teeth of children with congenital syphilis are filled with sharp, Hutchinson’s

grooves.

3. Stephanie listed a number of concerns she has with pregnancy. Based on these, the best

nursing diagnosis for her would be

b. risk for fluid volume deficit related to nausea.

c. anxiety related to constant back pain.

d. altered sexual pattern related to pregnancy.

Answer: c. Stephanie mentions pain. She does not mention nausea or alterations of her sexual

pattern. Constipation is not caused by pressure on the liver.

4. Stephanie hates showers so takes a bath daily. She asks you if it is safe to continue bathing

during pregnancy. Your best answer would be,

a. “No. Warm water leads to pelvic infections.”

b. “Yes, as long as your membranes are not ruptured.”

c. “Showering is more beneficial; you should change.”

d. “Neither showering nor bathing is good for you.”

Answer: b. Bathing should be discontinued if membranes are ruptured to reduce the possibility

of infection.

5. Stephanie states that her breasts are tender. To wash them, you would recommend that she

a. wash them with clear water.

b. wash with alcohol compresses.

c. scrub with cotton wool and soap.

d. soak them daily in milk.

Answer: a. It is important not to use soap to prevent drying and possibly cracking that could lead

to infection or make breastfeeding painful.

pregnancy is that she

a. should never swim in chlorine-treated water.

b. could use a breast- but not a sidestroke.

c. should assess for ringing in her ears afterward.

d. should not participate in high-board diving.

Answer: d. Swimming is a good exercise during pregnancy as it provides low-level exercise.

Hitting the water from a high-diving platform could conceivably result in uterine trauma so is

usually not advised.

7. Stephanie is uncomfortable using a seatbelt when she drives. A general rule to use to advise

pregnant women regarding this is

a. use one in the front seat but not the back seat.

b. never use a belt to guard against uterine rupture.

c. continue to always use a full belt.

d. use the shoulder but not the lap belt.

Answer: c. Seatbelts are as protective for pregnant women as those not pregnant, so they should

always be worn.

8. Although Stephanie is only 26, she already has varicosities. The best way to reduce these

would be to

a. discontinue all exercise during pregnancy.

c. assume a knee-chest position for 5 minutes every hour.

d. wear knee-high stockings to increase pressure on leg veins.

Answer: b. Resting with her feet elevated is effective at allowing swollen veins to drain and

relieve varicosity pain and pressure.

9. Stephanie reports she has bad back pain and is diagnosed as having a pylonephritis or urinary

tract infection. UTIs are apt to occur in pregnancy because

a. the ureters are compressed by the uterus, leading to stasis of urine.

b. the urine has increased acidity because of the addition of fetal urine.

c. the kidneys are pushed entirely sideways so do not drain readily.

d. Follicle-stimulating hormone causes ureter diameter to narrow.

Answer: a. Ureters are compressed by the pressure of the uterus. Stasis of any body fluid

increases susceptibility to infection.

10. Which of the following in Stephanie’s history makes her most likely to contact

toxoplasmosis during pregnancy?

a. She asks if her sexual partner should use a condom.

b. Her dietary history shows she eats raw meat.

c. She is reporting that she has constant back pain.

d. She owns two different types of pedigreed dogs.

Answer: b. Raw meat and cat feces are the two most common sources of the toxoplasmosis

organism.
11. Which of the following in her health history makes her most susceptible to contacting Lyme

disease?

a. She works as an executive secretary.

b. She walks her dog near deer trails.

c. She uses fresh limes for salad dressing.

d. Her husband works as a carpenter.

Answer: b. Lyme disease is spread by ticks that are found in fields where mice and deer could be

found. Hiking is a usual mode of exposure.

12. Stephanie is planning on traveling internationally so she will need some vaccines for travel

safety. Which vaccines are safe during pregnancy?

a. Any virus but no bacterium vaccine may be safely taken.

b. There are no vaccines that are safe during pregnancy.

c. Rubella vaccine is the only vaccine that is safe for pregnancy.

d. Any vaccine that does not contain a live bacterium or virus.

Answer: d. Killed or attenuated vaccines must be used to avoid a fetus contracting the infection.

Rubella vaccine uses a live virus.

13. The U.S. Food & Drug Administration (FDA) classifies drugs as to whether they’re safe or

not for pregnancy. The X classification means that the drug

a. is untested for pregnancy.

b. is marked as safe for pregnancy.

d. has no significant side effects.

Answer: c. Drugs that are known to cause fetal disorders are rated class X. An example is

accutane frequently prescribed for adolescent acne.

14. Another symptom of pregnancy that Stephanie reports is frequency of urination. What would

you advise her regarding this?

a. She should decrease her fluid intake to relieve this.

b. She is developing pregnancy-induced hypertension.

c. It fades after 3 months and reappears after lightening.

d. Sleeping prone usually helps make this seem less.

Answer: c. Frequency of urination is caused by pressure on the bladder by the enlarging uterus.

It is worse at the beginning and end of pregnancy.

15. Which of the following activities that Stephanie participates in would make you worry she

could be exposed to a teratogen at work?

a. She processes biological samples in formaldehyde.

b. She uses a lead pencil to fill in a great many forms.

c. She buys her lunch from a vending machine.

d. She serves coffee and tea to her supervisor daily.

Answer: a. Formaldehyde is a known fetal teratogen. Pencils are not filled with lead but with

graphite.
16. You want to prepare Stephanie for beginning signs of labor. You would teach her that

a. first pains are usually sharp and in the abdomen.

b. many women first experience labor as chest pain.

c. Low-back pain is often a sign of beginning labor.

d. labor pains do not begin until after membranes rupture.

Answer: c. Labor contractions tend to occur in the back and sweep forward, so low-back pain is

a frequent beginning symptom. This can occur before or after membranes rupture.

17. Stephanie tells you she has had almost constant headaches since she started her new job. She

asks you if this sounds serious. You would tell her,

a. “No. Secretaries always develop headaches from close work.”

b. “Headache can be serious; you need to call your care provider.”

c. “It’s serious only if you notice it at the end of the day.”

d. “Headache is a normal accompaniment to later pregnancy.”

Answer: b. Headache can arise from many causes. Because it can be the first indication of

pregnancy-induced hypertension, though, she needs to notify her health care provider.

18. Stephanie often soaks in a hot tub for half an hour after work. Advice you would give her

regarding this is,

a. “Hyperthermia, possibly caused by hot tubs, can be teratogenic.”

b. “Soaking this way can help prevent backache during pregnancy.”

c. “You should drink fluid while in a hot tub to prevent dehydration.”

d. “You should turn the temperature down to below your own temperature.”
Answer: a. Hyperthermia has been associated with central nervous system defects.

19. Stephanie asks you if it would be all right to have her teeth cleaned during pregnancy.

Your best answer would be,

a. “No. Teeth cleaning could release harmful bacteria into her bloodstream.”

b. “No. The vibration of the dental equipment could cause preterm labor.”

c. “Yes. If this will include a radiograph, you should have lead-apron protection.”

d. “Yes. As long as you are more than 6 to 8 weeks from your birth date.”

Answer: c. Teeth cleaning can be done anytime during pregnancy. She should be certain she

receives lead-apron protection if a radiograph is taken.

20. A sign of beginning labor you would want to teach Stephanie would be

a. a feeling of acute hunger.

b. sudden discharge from the breasts.

c. a tender ring around the umbilicus.

d. blood streaked vaginal discharge.

Answer: d. A blood streaked vaginal discharge can signify the mucous plug in the cervix is

released because of cervical dilatation.