Marquez, Caren Joy B.

Case Study 114

SCENARIO
P.M. comes to the obstetric (OB) clinic because she has missed two menstrual periods and thinks she
might be pregnant. She states she is nauseated, especially in the morning, so she completed a home
pregnancy test and it was positive. As the intake nurse in the clinic, you are responsible for gathering
information before she sees the physician.

1. What are the two most important questions to ask to determine possible pregnancy?
 What was the date of your last menstrual period? (to confirm pregnancy with other pregnancy
related symptoms)
 When was the last time you had a sexual intercourse?

2. You ask whether she has ever been pregnant, and she tells you she has never been pregnant. How
would you record this information?
Gravida 1 para 0
Nulliparous or nullipara refers to a woman who has never been pregnant or who has never given birth.

3. What additional information would be needed to complete the TPAL record?

TPAL terminology is a system used to describe obstetrical history.
T — term births (babies born after 37 weeks of gestation)
P — preterm births (refers to baby born before 37weeks of gestation)
A — abortions (miscarriage, medical termination of pregnancy)
L — living children

4. It is important to complete the intake interview. What categories will you address with P.M.?
 Past medical and surgical history
 A mental status examination is done whether PM is prepared and ready to accept this pregnancy
 Any use of medication, drug, alcohol, smoking, tobacco
 History of any allergy
 Dietary patterns
 Basic vital signs (TPR, BP, RBS, height and weight)
 Present complaints

CASE STUDY PROGRESS

According to the clinic protocol, you obtain the following for her prenatal record: CBC, blood type,
urine for urinalysis (UA) (protein, glucose, blood), vital signs (VS), height, and weight. Next, the nurse-
midwife does a physical examination, including a pelvic exam and confirms that P.M. is pregnant. P.M.
has a gynecoid pelvis by measurement, and the fetus is at approximately 6 weeks' gestation.

VITAL SIGNS
Blood pressure 116/74 mm Hg
Heart rate 88 beats/min
Respiratory rate 16 breaths/min
Temperature 98.9° F (37.2° C)

5. Do any of these vital signs cause concern? What should you do?
All vital signs are on normal range.
Blood pressure: less than 120/80 mm Hg
Heart rate: 63-105 bpm
Respiratory rate: 8-24
Temperature: 35.5-37.5C

6. P.M. tells you that the date of her last menstrual period (LMP) was February 2. How would you
calculate her due date? What is her due date?
An estimated due date can be calculated by following steps:
First, determine the first day of your last menstrual period.
Next, count back 3 calendar months from that date.
Lastly, add 1 year and 7 days to that date.

The patient’s last menstrual period began on February 2. Counting back 3 calendar months would be
November 2. Adding 1 year and 7 days would bring you to November 9, as your estimated due date.
This 3-step method is referred to as Naegele's Rule and is based on a normal 28-day menstrual cycle.

7. What is the significance of a gynecoid pelvis?

The inlet of a gynecoid pelvis is oval, with a large capacity and a wide subpubic arch. This is the typical
female pelvis. The brim of the pelvis is a transverse ellipse (almost a circle), which is ideal for birth. The
gynecoid pelvis (also known as the "real female pelvis") is seen in around half of all women in the United
States. It has a rounded pelvic inlet, shallow pelvic chamber, and short, dull ischial spines, making it the
most ideal female pelvic structure for birthing. The fetal rotation is supported by the roundish brim.

8. What specimens are important to obtain when the pelvic examination is done?
A Pap smear, often known as a Pap test, is a cervical cancer screening treatment for women. It usually
entails cells from your cervix, which is the lower, thin end of your uterus that sits at the head of your
vaginal canal. A pelvic exam is frequently performed in conjunction with a Pap smear. The Pap test may
be paired with a test for human papillomavirus (HPV), a common sexually transmitted infection that can
lead to cervical cancer, in women over the age of 30. 

CASE STUDY PROGRESS

Nursing interventions focus on monitoring the woman and fetus for growth and development;
detecting potential complications; and teaching P.M. about nutrition, how to deal with common
discomforts of pregnancy, and activities of self-care.

9. A psychological assessment is done to determine P.M.'s feelings and attitudes regarding her
pregnancy. How do attitudes, beliefs, and feelings affect pregnancy?
Hormone levels in a woman's body change dramatically during pregnancy and in the postpartum period.
This may have an impact on how they feel and act. During pregnancy, women have more emotional ups
and downs and are less able to cope with typical stresses than usual. In some ways, this is unsurprising;
there has been a tremendous amount of change in such a short time.

When a woman is pregnant, she is more likely to become agitated and anxious. This is most likely
related to the hormonal and emotional changes she is going through. Pregnancy can have an impact on
your lifestyle (for example, you may have stopped consuming alcohol) as well as your activities and
hobbies. As a result, your emotions and behaviors may be affected. You could also be worried about all
the changes that comes with childbirth and adjusting to life with a newborn.

For some women, the first trimester (which lasts up to 12 weeks) can be quite stressful. Women who
have recently discovered they are pregnant may be fatigued, nauseous, constipated, and have sore
breasts. They could be nervous, excited, fatigued, and overjoyed all at the same moment. This period
may be stressful especially if they've had trouble conceiving or experienced complications in previous
pregnancies. Above all, remember that it's acceptable to be frightened or anxious about the prospect of
a new baby; the notion of a new baby may require a lot of adjustment.

You may feel more active and capable of preparing for your kid as you reach the second trimester (about
13 weeks). You may still have mood swings or cry at times, but you should feel more upbeat and capable
of modest physical exertion than you were in the first trimester.

The third trimester (starting at 28 weeks) can be painful and exhausting. As your child grows, you may
find it difficult to obtain a good night's sleep owing to pain or the need to go to the bathroom. It's also
common to have growing concerns about labor, including what will happen and whether or not you'll be
able to handle. Childbirth classes might be beneficial in this case since they help you prepare and
connect with people who are in a similar situation. The third trimester is a common time for 'nesting.'
Women may begin to tidy and plan, sometimes in exaggerated amounts. Again, the precise etiology is
unknown, but it is most likely hormonal. If it's short-lived and not overly dramatic, rest confident that it's
just part of normal pregnancy behavior.

10. P.M. asks you whether there are any foods that she should avoid while pregnant. She lists some of
her favorite foods. Which foods, if any, should she avoid eating while she is pregnant? (Select all
that apply.)
a. Hot dogs (Hot dogs are not nutritious, and if not cooked well enough, they can contain a bacteria
known as "Listeria," which can cause food poisoning as well as significant pregnancy issues such as
miscarriages and stillbirths.)
b. Sushi (Sushi is safe to consume while pregnant, but now that you're expecting a child, stick to
completely cooked, vegetarian, or vegan options and avoid raw seafood. Sushi rolls with completely
cooked fish, as well as vegetarian or vegan rolls, are healthy for your unborn child. Listeria can be
found in any raw or smoked fish, pork, or shellfish. Listeria can be passed from mother to fetus,
resulting in miscarriage or preterm labor.)
c. Yogurt (Dairy is the best source of calcium in the diet, and it also contains a lot of phosphorus, B
vitamins, magnesium, and zinc. Yogurt is particularly useful because it contains more calcium than
most other dairy products. Probiotic bacteria, found in some kinds, help to maintain gut health.)
d. Deli meat (When you're pregnant, it's recommended not to eat deli meats unless they've been
heated to 165 degrees F shortly before serving. These meats may contain bacteria that can grow
even after being refrigerated.)
e. Cheddar cheese (Pregnant women can eat both hard and soft cheese that has been clearly labeled
as "pasteurized." Pasteurization is the process of heating milk to a specified temperature in order to
destroy microorganisms that could be harmful. Pasteurized cheese, in fact, is a wonderful source of
calcium and protein, which help your baby's bones and growth.)

11. As the nurse, you know that assessment and teaching are vital in the prenatal period to ensure a
positive outcome. What information is important to include at every visit and at specific times
during the pregnancy?
Prenatal treatment should be continued throughout your pregnancy to detect potential problems early
and lower the risk of pregnancy and delivery difficulties. Your medical history will be reviewed at your
first prenatal visit by your doctor or healthcare provider. During this session, she will most likely perform
a comprehensive physical examination as well as urine and blood testing.
She will examine you and your baby at each visit. She'll go through topics like eating good foods, being
active, and gaining the proper amount of weight during pregnancy to assist you and your baby stay
healthy. Blood tests and imaging tests, such as ultrasound, may be ordered by your healthcare
practitioner.

12. After her examination, P.M. states that she is worried because her sister had an ectopic pregnancy
and had to have surgery. She asks you, “What are the signs of an ectopic pregnancy?” Which of
these are correct? (Select all that apply.)
a. Fullness and tenderness in her abdomen, near the ovaries (An ectopic pregnancy occurs outside the
uterus, generally in the fallopian tube, where there is no room for a developing embryo, resulting in
tube rupture and internal bleeding into the abdominal cavity, as well as local swelling, both of which
create a sore abdomen.)
b. Pain, either unilateral, bilateral, or diffuse over the abdomen (The parietal peritoneum will be
irritated by the bleeding and swelling, causing pain.)
c. Nausea (Nausea and increased fatigue might occur with normal pregnancies.)
d. Dark red or brown vaginal bleeding (The tube's blood will pass via the reproductive mechanism,
down the uterus, and into the vagina.)
e. Increased fatigue (Nausea and increased fatigue might occur with normal pregnancies.)

13. P.M. asks the nurse about what should be reported to her doctor. List at least six of the “danger
signs of pregnancy.”
 severe vaginal bleeding
 severe headache with blurred vision
 severe abdominal pain
 too weak to get out of bed
 fast or difficulty in breathing
 fever
14. Changes in the body caused by pregnancy include relaxation of joints, alteration to center of
gravity, faintness, and discomforts. These changes can lead to problems with coordination and
balance. In teaching P.M. about safety during pregnancy, what will you include in your teaching?
 When lifting objects and resting or sitting, adopt appropriate body mechanics and optimal body
alignment.
 Consider teaching about orthostatic hypotension. Blood pressure is likely to decline during
pregnancy because your circulatory system expands rapidly. This is normal, and once you've given
birth, your blood pressure should recover to its pre-pregnancy level.

15. P.M. asks, “Is a vaginal exam done at every visit?” What is your response? Explain your answer.
A vaginal exam is not performed after the initial visit until the final weeks of pregnancy because it can
stimulate vaginal contractions or cause infection.

CASE STUDY OUTCOME

P.M. makes an appointment for her next checkup. You tell her that an ultrasound may be done at
about 8 to 12 weeks' gestation to check fetal growth.
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