1. What are your six priority assessments?
My first priority assessment is to check Dylan’s blood pressure. Although it has been stable throughout her pregnancy, it should be checked at every appointment as a continual check for preeclampsia (Henderson, Thompson, & Burda, 2017). Secondly, I would further screen for preeclampsia by checking for edema in the patient’s legs and checking for protein in the urine through a urinalysis (Henderson et al., 2017). This is a priority assessment during the second half of pregnancy, since preeclampsia can cause severe complications for the mother and baby if not detected and managed (Henderson et al., 2017). Third, I would perform a blood test to screen for anemia because Dylan has complained that she is constantly exhausted and anemia is a cause of excess fatigue during pregnancy (Breymann, 2015). Fourth, I would weigh Dylan ask about her eating habits. Since Dylan has only gained 4 kg of weight so far, which is 8.8 pounds, then she needs to gain another 12 pounds. Mothers who gain less than 20 pounds have a higher risk of their child being born early and being small for their gestational age (Goldstein, Abell, & Ranasinha, 2017). Fifth, I would measure fundal height to check for proper fetal growth and amniotic fluid development (Morse, Williams, & Gardosi, 2009). Lastly, I would perform fetal heart monitoring, checking both the heart rate and rhythm to confirm that the baby is receiving sufficient oxygen (Perry, Hockenberry, Lowdermilk, & Wilson, 2017).
2. Name four abnormal urine findings during pregnancy. What is the significance of each of these findings?
The first abnormal urine finding is protein in the urine, which is a sign of preeclampsia (Henderson et al., 2017). This is a significant finding since preeclampsia can cause complications for both the mother and baby if it is not managed (Henderson et al., 2017). Secondly, sugar in the urine is a sign of gestational diabetes, which if left untreated can cause complications such as the baby’s blood sugar suddenly dropping after birth (Kamana, Shakya, & Zhang, 2015). Third, bacteria in the urine is a sign of infection, such as group B strep (Perry et al., 2017). Lastly, blood in the urine is a sign of vaginal bleeding. Although 20 percent of women experience vaginal bleeding during the first trimester, bleeding during the second and third trimester can be an indication of a more serious complication, such as placenta previa or placental abruption (Perry et al., 2017).
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.
Fundal height is measured by placing a tape measure at the top of the mother’s pubic symphysis and then measuring it to the top of the mother’s uterus (Morse et al., 2009). Fundal height generally corresponds to gestational age, the number of centimeters equaling the number of weeks pregnant (Morse et al., 2009). A fundal height is considered normal if it is within two centimeters of the gestational age (Morse et al., 2009). Therefore, at 29 cm, the fundal height is normal for this point in Dylan’s pregnancy, since she is 28 weeks pregnant.
4. What diagnostic tests would you anticipate the primary care provider ordering if there were an abnormal fundal height?
If fundal height is abnormal, then the primary care provider would most likely order an ultrasound. An abnormally larger or smaller fundal height may indicate slow fetal growth, larger than average fetal growth, or too little or too much amniotic fluid (Morse, Williams, & Gardosi, 2009). An increasing fundal height can also be a sign of concealed bleeding (Perry et al., 2017). An ultrasound can provide further insight into these potential concerns. In the case of an fundal height that is larger than expected, the primary care provider may also order a test for gestational diabetes (Kamana, Shakya, & Zhang, 2015).
5. Describe the steps to take when assessing the fetal heart rate.
Steps to take when assessing fetal heart rate are as follows: notify the patient and apply the gel; place the patient in a semi-sitting position; turn-on the doppler; auscultate the heart sounds and compare with the patient’s pulse; clean the gel off with a clean towel (Perry et al., 2017).
6. Discuss the significance of these findings.
At 130 bpm, the fetal heart rate is slightly under average for 28 weeks, but not a great cause for concern (Guinn, Kimberlin, Wigton, Socol, & Frederiksen, 1998). These findings should be compared with previous findings. A low fetal heart rate can be a sign of congenital heart disease, which is diagnosed by a fetal echocardiogram, but as previously stated, 130 bpm at 28 weeks is not high cause for concern (Guinn et al., 1998).
7. Why do you think the physician is ordering a complete blood count?
The physician may be ordering a complete blood count to check for anemia or for preeclampsia (Perry et al., 2017). Most likely, the physician is screening for anemia, since Dylan has complained of exhaustion, and fatigue is a sign of anemia (Breymann, 2015).
8. What are five potential impacts to the pregnancy and fetus if these values are not corrected?
The areas of concern that stand-out to me in these values are the low red blood cell count (RBC – 3.0 x 1012/L), the low hematocrit count (Hct – 0.30), and the low hemoglobin count (Hgb – 109 g/L). These are signs of anemia, which is a condition that reduces the blood’s capacity to carry oxygen (Perry et al., 2017). Five potential impacts to the pregnancy and fetus if these values are not corrected include an increased risk for the following: blood transfusion during birth, infection during birth, premature labor, low birth weight, and postpartum depression (Perry et al., 2017).
9. What medication would you anticipate the primary care provider to order based on the above lab results? Provide your rationale.
Based on these lab results, I would anticipate the primary care provider to order an iron supplement to correct the deficiency (Perry et al., 2017). This is because iron deficiency is the cause of the majority of anemia cases during pregnancy (Perry et al., 2017). One 325 mg of ferrous sulfate twice per day can be tolerated and sufficiently absorbed by most pregnant women to increase their iron levels to the necessary level (Perry et al., 2017). If the patient is unable to tolerate the needed amount of iron orally, then iron can be given in intravenous doses, known as parenteral iron or IV iron (Breymann, 2015).
10. What five teaching points would you provide around this medication and her condition?
The first teaching point that I would provide this patient for her condition of anemia is to eat iron-rich foods like spinach, cooked beef, egg yolks, nuts, and cooked beans (Breymann, 2015). I would also advise the patient to eat foods that help the body to absorb iron, such as orange juice, strawberries, and broccoli (Breymann, 2015). Secondly, I would advise Dylan to eat foods rich in folic acid and B vitamins, since deficiency in either of these contributes to anemia (Breymann, 2015). Recommendations would include legumes, asparagus, eggs, leafy greens, citrus fruits, and broccoli. Third, I would educate Dylan about drug interactions. If she is taking a calcium supplement or a multivitamin that includes calcium, then she should take it at a different time of day than her iron supplement because calcium supplements interferes with iron absorption (Breymann, 2015). Fourth, I would advise the patient to rest when she needs it (Dylan et al., 2017). Lastly, I would educate Dylan about signs or symptoms that are cause for concern and for which she should seek medical attention, including significant changes in fetal movements, shortness of breath, and any signs of pre-term labor (Dylan et al., 2017).
11. List four priority teachings you would provide at the end of this appointment.
The first priority teaching that I would provide at the end of this appointment is nutritional counseling. This nutritional counseling would include the aforementioned recommendations to eat iron-rich foods as well as foods that help the body to absorb iron (Breymann, 2015). As previously listed, food recommendations for iron-rich foods may include spinach, cooked beef, egg yolks, nuts, and beans, while recommendations of foods that facilitate iron absorption are orange juice, strawberries, broccoli, or other fruits and vegetables that are high in Vitamin C (Breymann, 2015). In addition, this nutritional counseling would include education about foods that are rich in folic acid and B vitamins, such as legumes, leafy greens, and citrus fruits (Breymann, 2015). The second priority teaching at the end of this appointment is for the patient to avoid any drug interactions that would minimize absorption of her prescribed iron, such as calcium (Breymann, 2015). Thirdly, I would prioritize educating Dylan about monitoring her health and recognizing signs or symptoms that require immediate medical attention. I would include signs of preeclampsia and pre-term labor (Dylan et al., 2017). Finally, my last priority teaching would be to advise Dylan about what to expect at her next appointment. This will ease her concerns and allow her to come ready and prepared.
References
Breymann, C. (2015). Iron deficiency anemia in pregnancy. Seminars in Hematology, 52(4), 339-347. doi: 10.1053/j.seminhematol.2015.07.003
Goldstein, R. F., Abell, S. K., & Ranasinha, S. (2017). Infant outcomes: A systematic review and meta-analysis. Journal of the American Medical Association, 317(21), 2207-2225. doi: 10.1001/jama.2017.3635
Guinn, D. A., Kimberlin, D. F., Wigton, T. R., Socol, M. L., & Frederiksen, M. C. (1998). Fetal heart rate characteristics at 25 to 28 weeks’ gestation. American Journal of Perinatology, 15(8), 507-510. doi: 10.1055/s-2007-994075
Henderson, J. T., Thompson, J. H., & Burda, B. U. (2017). Preeclampsia screening: Evidence report and systematic review for the US preventative services task force. Journal of the American Medical Association, 317(16), 1668-1683. doi: 10.1001/jama.2016.18315
Kamana, K. C., Shakya, S. & Zhang, H. (2015). Gestational diabetes mellitus and macrosomia: A literature review. Annals of Nutrition & Metabolism, 66(2), 14-20. doi: 1 0.1159/000371628
Morse, K., Williams, A., & Gardosi, J. (2009). Fetal growth screening by fundal height measurement. Best Practice& Research Clinical Obstetrics & Gynaecology, 23(6), 809-818. doi: 10.1016/j.bpobgyn.2009.09.004
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2017). Material child nursing care, 5th edition. St. Louis, MO: El Sevier.
