Nursing 209

N209: Reproductive Health Study Guide 2nd Edition 11/5/2018

This study guide is subject to copyright.

Acknowledgements We would like to thank the authors for their patience, support, and expertise in contributing to this study guide; and Christina Wulff for her invaluable efforts in reading and editing the text. We would also like to thank those at Achieve whose hard work and dedication to fulfilling this project did not go unnoticed. Lastly, we would like to thank the Achieve students who have contributed to the growth of these materials over the years. Copyright © 2018 by Achieve All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2015 Achieve PO Box 10188 #29831 Newark, NJ 07101-3188 Tel: 888.900.8380 Visit the Achieve website at http://www.achievetestprep.com/student

N209: Reproductive Health Study Guide

©2018 of 109 Table of Contents Chapter One: Human Sexuality .........................................................................................................................................6 1.1 Puberty............................................................................................................................................................................6 1.2 Female Reproductive Development ....................................................................................................................7 1.3 Male Reproductive Development .........................................................................................................................7 1.4 Sexual Preferences and Activity............................................................................................................................8 1.5 Gender Development.................................................................................................................................................8 1.6 Sexual Response ..........................................................................................................................................................9 1.7 Sexual Dysfunction ..................................................................................................................................................10 1.8 Sexually Transmitted Diseases...........................................................................................................................11 1.9 Birth Control Methods ...........................................................................................................................................14 1.10 Medications and Sexual Dysfunction.............................................................................................................15 1.11 Age-Related Changes to Sexuality...................................................................................................................16 1.12 The Nursing Process ............................................................................................................................................17 Chapter One Practice Exam.........................................................................................................................................19 Chapter Two: Preconception Period............................................................................................................................20 2.1 Preconception ...........................................................................................................................................................20 2.2 Infertility .....................................................................................................................................................................21 2.3 The Nursing Process ...............................................................................................................................................24 Chapter Two Practice Exam........................................................................................................................................25 Chapter Three: Antepartal Period.................................................................................................................................26 3.1 Maternal ......................................................................................................................................................................26 3.2 Pregnancy Symptoms.............................................................................................................................................26 3.3 Physiological Changes in Pregnancy ................................................................................................................27 3.4 Psychosocial Changes in Pregnancy .................................................................................................................29 3.5 Pregnancy at Risk ....................................................................................................................................................30 3.6 Gestational Problems .............................................................................................................................................32 3.7 Pregnancy Medications..........................................................................................................................................33 3.8 Diagnostic Testing ...................................................................................................................................................34 3.9 Fetal Growth ..............................................................................................................................................................36 3.10 Factors Influencing Fetal Growth ...................................................................................................................37 3.11 Fetal Circulation.....................................................................................................................................................40 3.12 Maternal-Placental Circulation ........................................................................................................................41 3.13 The Nursing Process ............................................................................................................................................42 Chapter Three Practice Exam.....................................................................................................................................43 Chapter Four: Intrapartal Period ..................................................................................................................................44 4.1 Labor.............................................................................................................................................................................44 Achieve Page 3

N209: Reproductive Health Study Guide of 109 4.2 Process of Labor .......................................................................................................................................................45 4.3 Labor Complications...............................................................................................................................................46 4.4 Fetal Labor Concerns..............................................................................................................................................47 4.5 Delivery Interventions ...........................................................................................................................................47 4.6 Labor Medications ...................................................................................................................................................48 4.7 Alternative Birth Options......................................................................................................................................49 4.8 The Nursing Process ...............................................................................................................................................50 Chapter Four Practice Exam .......................................................................................................................................52 Chapter Five: The Postpartal Family............................................................................................................................53 5.1 Maternal Changes ....................................................................................................................................................53 5.2 Psychosocial Adaptation .......................................................................................................................................55 5.3 Postpartum Complications...................................................................................................................................57 5.4 Postpartum Medications .......................................................................................................................................59 5.5 Postpartum Nutrition.............................................................................................................................................60 5.6 Neonatal Adaptation...............................................................................................................................................61 5.7 Endocrine System ....................................................................................................................................................61 5.8 Sympathetic Nervous System..............................................................................................................................63 5.9 Fetal Circulation, Breathing, and Oxygenation.............................................................................................64 5.10 Neurological Development ................................................................................................................................66 5.11 Sensory Development..........................................................................................................................................66 5.12 Behavioral Adaptation ........................................................................................................................................66 5.13 Gastrointestinal Adaptation..............................................................................................................................66 5.14 Urinary Adaptation...............................................................................................................................................67 5.15 Immunological Adaptation................................................................................................................................67 5.16 Nutritional Needs ..................................................................................................................................................68 5.17 Newborn Medications .........................................................................................................................................69 5.18 Newborn Screening ..............................................................................................................................................69 5.19 Neonatal Complications......................................................................................................................................71 5.20 The Nursing Process ............................................................................................................................................76 Chapter Five Practice Exam ........................................................................................................................................78 Chapter Six: Congenital Anomalies, Genetic Disorders, and Developmental Problems ..........................79 6.1 Congenital Heart Defects ......................................................................................................................................79 6.2 Respiratory Defects.................................................................................................................................................83 6.3 Digestive Defects ......................................................................................................................................................84 6.4 Genitourinary Defects ............................................................................................................................................88 6.5 Musculoskeletal Disorders ...................................................................................................................................89 6.6 Chromosomal Defects ............................................................................................................................................91 6.7 Neurological Defects...............................................................................................................................................93 6.8 The Nursing Process ...............................................................................................................................................95 ©2018 Achieve Page 4

N209: Reproductive Health Study Guide Chapter 6 Practice Exam ..............................................................................................................................................97 Chapter Seven: Reproductive Disorders ....................................................................................................................98 7.1 Normal Reproductive Function in a Female..................................................................................................98 7.2 Normal Reproductive System in a Male ..........................................................................................................99 7.3 Hormone and Structural Alterations............................................................................................................. 100 7.4 Alternative Treatments for Reproductive Disorders.............................................................................. 106 7.5 The Nursing Process ............................................................................................................................................ 107 Chapter Seven Practice Exam.................................................................................................................................. 108 Answer Keys ....................................................................................................................................................................... 109

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Chapter One: Human Sexuality Sexuality, as defined by the World Health Organization, is “a central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors.” • Sexuality: The physical, emotional, and sociocultural factors that affect sexual response. • Primary sexual characteristics: Any body structure directly related to reproduction that is present at birth (testes, penis, uterus, or vagina). • Puberty: The stage of adolescence in which an individual becomes physiologically capable of sexual reproduction. • Secondary sexual characteristics: Physical characteristics which are gender specific and appear at puberty but do not have a direct reproductive function (development of pubic hair, breast development, and voice changes). 1.1 Puberty • Onset: The onset of puberty is between the ages of 7-11 in girls, and 9 ½ -13 in boys. • Initiated by: The pituitary gland at the base of the brain releases hormones (LH and FSH) that signal a girl’s ovaries and a boy’s testicles to begin producing the female sex hormone, estrogen, and the male sex hormone, testosterone. This sex hormone then instructs reproductive structures (the ovaries, uterus, fallopian tubes, and vagina in girls; the testes, penis, vas deferens, and epididymis in boys) to develop or mature. The growing ovaries and testicles secrete increasing amounts of sex hormones, further fostering the process of puberty. • The whole process of puberty takes approximately 3-4 years. • Precocious puberty: This is when a child’s body begins changing into that of an adult (puberty) too soon. o For girls: Puberty is generally considered to be too early if it begins at age seven or eight. African-American and Hispanic girls tend to start puberty slightly earlier than Caucasian girls. o For boys: Puberty is generally considered too early before the age of nine years. • Rapidly progressing puberty: This is puberty that from start to finish is less than two years. Risk factors for precocious puberty include: o Girls are much more likely to develop precocious puberty o African-American children are affected more often than other races o Significant childhood obesity o Radiation treatment for cancer

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N209: Reproductive Health Study Guide o Contact with sex hormones, such as an estrogen or testosterone replacement therapy cream (used by parents) o Medical conditions, such as McCune-Albright syndrome or congenital adrenal hyperplasia, in which there is abnormal androgen production; hypothyroidism is thought to contribute in rare cases 1.2 Female Reproductive Development In the United States, the average age for menstruation to begin is age 12; however, it ranges from ages 8 to 15. It usually starts about two years after breast development begins. The menstrual cycle prepares the body for pregnancy each month; the average cycle is 28 days but ranges from 21-35 days in adults, and 21-45 days in young teens. Menstrual Cycle Phases Menstrual: This phase is from the onset of menses to the last day of bleeding. When no pregnancy occurs, the corpus luteum dies and progesterone levels fall, which causes the body to shed the uterine lining. This typically lasts 4-7 days. Proliferative (follicular): Follicles inside the ovaries develop and mature for ovulation. Levels of FSH increase, which stimulates the maturation of follicles that contain an ovum, or egg. The ovaries then produce estrogen, causing the uterine lining to thicken. When estrogen levels have peaked, FSH levels slow and the pituitary gland begins to secrete a luteinizing hormone, or LH. This causes the mature follicles to rupture and release the ovum that will then travel to the fallopian tubes. The release of the ovum is called ovulation, and occurs 14 days before the beginning of the next menstrual cycle. Secretory (luteal): After ovulation, LH causes the burst follicle to develop into the corpus luteum. When conception and implantation do not occur, the pituitary gland reduces the LH and FSH production, causing the corpus luteum to deteriorate, which then causes estrogen and progesterone to decrease. This triggers the shedding of the endometrium, causing the cycle to begin again. 1.3 Male Reproductive Development Puberty begins in the male between the ages of 9-15. When puberty begins, the pituitary gland secretes hormones that stimulate the testicles to produce testosterone, which brings about the physical changes of puberty. The stages of puberty can vary in timing, but generally follow a set sequence. During the first stage, the scrotum and testes grow larger. Next, the penis becomes longer and the seminal vessels and prostate gland grow. Hair begins to appear in the pubic area and later on the face and underarms. During this time, the voice deepens. Boys undergo a period of rapid growth during puberty as they reach their adult height and weight. A male who has reached puberty will produce millions of sperm each day. When the sperm complete their development, they travel to the

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N209: Reproductive Health Study Guide vas deferens or sperm duct. There, the seminal vesicles and prostate gland produce a whitish fluid, which mixes with sperm to form semen. 1.4 Sexual Preferences and Activity Sexual preferences include: • Sexual orientation: Attraction or preference to persons of the opposite sex or gender, same sex or gender, or to both sexes/genders • Gender identity: Refers to a person’s innate, deeply felt psychological identification as a man, woman, or some other gender, which may or may not correspond to their sex at birth • Heterosexual: A person who is attracted romantically or sexually to persons of the opposite sex or gender • Homosexual: A person who is attracted romantically or sexually to persons of the same sex or gender • Bisexual: A person who is attracted romantically or sexually to both males and females • Pansexual: A person who is attracted to any gender, or non-gendered person, identifying with any sexual orientation • Transsexual: A person who has a strong desire to assume the physical characteristics and gender role of the opposite sex • Transvestite: A person who adopts the dress and often the behavior typical of the opposite sex, especially for purposes of emotional or sexual gratification Sexual activities and factors that influence them include: • Sexual activity: Any voluntary sexual behavior, which can be done alone or with other people • Most common sexual activities: Masturbation, kissing, massage, intimate touching, intercourse (vaginal or anal), oral sex, utilization of sex toys, watching and/or reading erotica • Factors affecting sexual activity or behavior: Sexual modesty, religiousigns and symptomspiritual beliefs, reproductive choices • Culture and families: These shape a person’s idea of what is sexually acceptable (may lead to a fear of discussing or learning about or doing it) • Age: Frequency of sex declines with age due to physical health, financial concerns, and sexual dissatisfaction (especially among women) 1.5 Gender Development • Gender norm: The set of rules for what is appropriate masculine and feminine behavior in a given culture • Gender identity: The way in which being feminine or masculine, a woman or a male, becomes

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N209: Reproductive Health Study Guide an internalized part of the way we think about ourselves • Gender socialization: The process through which individuals learn the gender norms of their society and come to develop an internal gender identity Gender and Developmental Changes • Gender identity develops between 18 months and three years of age. • A child observes and imitates role models to learn gender typical behaviors (gender typing). • Families plan an important role in gender role socialization by how they organize the environment for the child (boys and girls are dressed differently, given different types of toys to play with, and have a decorated environment according to gender). • There is no evidence of differences in the gender roles of boys and girls raised in gay or lesbian families. • Parental power has a great impact on sex typing in boys, but not in girls. • Parental characteristics influence gender typing in terms of the role models that are available for the child to imitate. • Girls and boys are viewed and treated differently by their parents, particularly their fathers. Paternal Influence in Gender Absence of the father has been related to disruptions in gender typing in preadolescent boys. The absence of the father for girls has been related to problems in relationships with peers of the opposite sex for adolescent females; studies have shown that these effects can be long-lasting, extending to marital choices. 1.6 Sexual Response The sexual response cycle refers to the sequence of physical and emotional changes that occur as a person becomes sexually aroused and participates in sexually stimulating activity. Sexual Response Cycle Phases Phase 1: Excitement • Can last from a few minutes to several hours • Increase in muscle tension • Heart rate increases, breathing is accelerated, and the skin is flushed • Nipples harden and become erect • Increase in blood flow to the genitals (swelling of the clitoris and penile erection) • Vaginal lubrication begins, the vaginal walls begin to swell, and breasts become fuller • Testes swell, scrotum tightens, and the male begins secreting a lubricating liquid

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Phase 2: Plateau •

Extends to the brink of orgasm Intensified phase one changes

• • Increased blood flow and swelling of the vagina; vaginal walls turn purple • Increased sensitivity of the clitoris with retraction under the clitoral hood to avoid direct penile stimulation • Testes withdraw up into the scrotum • Increase in respiratory rate, heart rate, and blood pressure • Muscle tension increases Phase 3: Orgasm • The phase where the climax of the sexual response cycle occurs • Shortest phase, which lasts only seconds • Involuntary muscle spasms begin; foot muscles spasm • Highest point of respiratory rate, heart rate, and blood pressure with increased oxygen intake • Sudden release of sexual tension • Vaginal muscles contract; rhythmic contractions in the uterus • Rhythmic contractions of muscles in the penile base; semen is ejaculated • Sexual rash or flush may occur Phase 4: Resolution • Body returns to normal functioning and body parts return to previous size and color • General sense of well-being, intimacy, and fatigue • Women are capable of returning to orgasmic state with further stimulation; can have multiple orgasms • Men experience refractory period or recovery time where they cannot reach orgasm again 1.7 Sexual Dysfunction Sexual dysfunction refers to a problem during any phase in the sexual response cycle that interferes with achieving satisfaction from the sexual activity. Causes of sexual dysfunction include: • Physical and/or medical: Causes such as heart disease, diabetes, menopause, chronic disease, decreased mobility, and certain medications • Psychological: Stress and anxiety, depression, relationship issues, and history of sexual abuse/trauma

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Sexual Dysfunction in Women • Lack of desire or interest: Can be a result of hormonal changes (menopause or pregnancy), stress, medical complications and/or treatment, and fatigue • Inability to become aroused: Resulting from insufficient lubrication, inadequate stimulation, or anxiety • Lack of orgasm: Caused by health problems such as endometriosis, pelvic mass, ovarian cysts, vaginitis, or sexually transmitted disease • Treatment: Education, enhanced stimulation with erotic materials, masturbation, and changes to sexual routine Sexual Dysfunction in Men • Ejaculation disorders: o Premature or inhibited ejaculation (occurring too soon or not at all); this is the most common form of sexual dysfunction in men o Often caused by performance anxiety or psychological factors, such as religion or lack of attraction o Retrograde ejaculation: Ejaculation is forced back into the bladder; most common in diabetes related to nerve problems • Erectile dysfunction: o Also known as impotence and is defined as the inability to attain and/or maintain an erection o Can be a result of stress, anxiety, depression, medications, or relationship issues • Decreased libido: o Can be related to low testosterone, medical illness (such as diabetes or hypertension), medications, and relationship issues • Treatment: o Medications: Viagra, Cialis, or hormone replacement therapy o Medical treatment for underlying cause o Psychological therapy o Mechanical aids (penis pump or penile implant) o Education 1.8 Sexually Transmitted Diseases Sexually transmitted diseases are infections that are spread by sexual contact with an infected partner through oral, anal, or vaginal sex. They are also referred to as STIs (sexually transmitted infections) and often have no signs or symptoms. If left untreated, there is an increased risk of acquiring another STI such as HIV.

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Types of Sexually Transmitted Diseases • Chlamydia: Bacterial infection of the genital tract; easily cured but often has no signs or symptoms; the most commonly reported STD in the United States o Symptoms: Usually appear 1-3 weeks after exposure; includes painful urination, lower abdominal pain, vaginal/penile discharge, painful intercourse for women, testicular pain for men, and bleeding between periods • Gonorrhea: Caused by Neisseria Gonorrhoeae, it is bacteria that can also grow in the nose, mouth, throat, eyes, or anus; a common infection, especially in ages 15-24 o Symptoms: Usually appear ten days after exposure, but some people can be infected for months before signs and symptoms occur; characterized by thick/cloudy/bloody discharge from penis or vagina, painful urination, painful testicles, painful bowel movements, anal itching, and vaginal bleeding between periods • Trichomoniasis: Caused by a microscopic, one-celled parasite called trichomonas vaginalis; usually infects the urinary tract in men; often has no signs; infects the vagina in women o Symptoms: If symptoms occur, they will appear 5-28 days from exposure and can range from mild irritation to severe inflammation; thin, greenish-yellow, frothy or foamy vaginal discharge for women with strong vaginal odor and vaginal itching; slight discharge from the penis with burning after urination or ejaculation for men • Bacterial Vaginosis: Infection caused from overgrowth of one of several types of bacteria normally present in the vagina, upsetting the natural balance of vaginal bacteria; most common vaginal infection in women ages 15-44; not considered an STD, but can increase risk for getting an STD; can also affect women who have never had sex; no known best way to prevent it, but can lower risk by abstinence, limiting partners, and avoiding douching o Symptoms: Vaginal discharge that’s thin and grayish-white, foul-smelling “fishy” vaginal odor (especially after sexual intercourse), vaginal itching, and burning during urination • Genital Herpes: Common in the U.S. with one in six people ages 14-49 with genital herpes; caused by two virus types: herpes simplex I and simplex II; fluids found in herpes lesion carry the virus; can also be spread with no visible sore because the virus can be released through the skin; outbreaks can occur in areas not fully covered by a condom, so condoms do not provide full protection; can lie dormant for decades before becoming active again o Symptoms: Can have no or mild symptoms, but they usually appear as one or more blisters on or around the genitals, rectum, or mouth; first time outbreak can also exhibit flu-like symptoms; repeat outbreaks are common, especially in first year after infection; usually shorter and less severe than the first outbreak; the infection can remain in the body for life and there is no cure; medications can prevent or shorten outbreaks; touching the sores or fluids can transfer herpes to other body parts (from mouth to genitals through oral sex) • Syphilis: Bacterial infection usually spread by sexual contact; caused by the bacteria treponema pallidium; early syphilis can be treated with penicillin, but treatment is only capable of killing the bacteria and preventing further damage, it cannot repair damage already done to organs or prevent reinfection if exposed again; can lie dormant for decades before becoming active again; without treatment, syphilis can severely damage the heart, brain, and other organs and can be life-threatening o Stages of syphilis:

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N209: Reproductive Health Study Guide Primary: Small chancre sore at the spot where the bacteria entered the body (most people develop only one chancre, but some develop several) ; usually painless and may go unnoticed depending upon location ; heals within six weeks  Secondary: Spreads through the body to the skin, liver, joints, lymph nodes, muscles and brain; a rash frequently appears about six weeks to three months after the chancre has healed; during this time, the disease is highly contagious because the bacteria are present in lesion secretions; may also form in mucous membranes of the mouth and throat and on the bones and internal organs  Latent: With no treatment, the disease moves into the latent phase with no symptoms; may last for years; symptoms may never return or may progress to tertiary stage  Tertiary (late): Occurs in 15-30 percent of people infected who don’t get treatment; damage can occur to the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints • Human Papillomavirus (HPV): The most common sexually transmitted infection; nearly all sexually active men and women get it at some point in their lives; about 70 million Americans are currently infected and about 14 million people become newly infected each year; there are many different types of HPV; can cause genital warts and certain cancers.; a vaccine is available, boys and girls age 11 or 12 should receive vaccine; catch-up vaccines are recommended for males through age 21 and females through age 26 if they did not receive the vaccine when younger; vaccine recommended for gay and bisexual men through age 26 o Symptoms: Most people do not know they are infected and never develop symptoms or health problems; sometimes diagnosed when genital warts develop; others discover they have HPV when a pap smear is abnormal; may not be discovered until a serious health problem (cancer) occurs; there is no test to check for HPV status; HPV tests can be used to screen for cervical cancer for women 30 and over, but they are not recommended to screen men, adolescents, or women under age 30 HIV/AIDS and STDs • If an STD is present, the person should be tested for HIV. • If a person has an STD and HIV, they are more likely to spread HIV to their partner. • Hepatitis B is also considered an STD because it can be transmitted via blood and body fluids through sexual contact. Pregnancy and STDs • Chlamydia: If left untreated, it has been linked to preterm labor, premature rupture of membranes, and low birth weight. It can pass from a woman to her baby during delivery. • Syphilis: It has been linked to premature birth, stillbirth, and death after birth. It can pass from the mother to her baby during pregnancy. Untreated infants are at risk for multiple organ problems. • Gonorrhea: During pregnancy, it has been linked to miscarriage, preterm birth, premature rupture of membranes, and low birth weight. It can be passed from mother to baby during delivery. 

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N209: Reproductive Health Study Guide • HPV: It can cause genital warts or abnormal cervical cell changes. Women should receive routine cervical cancer screenings. • Genital herpes: It can lead to miscarriage or premature delivery. It can be passed from the mother to her baby if symptoms are present at the time of delivery, causing neonatal herpes, which can be fatal. o Most often occurs with primary episode of HSV in third trimester with no seroconversion by the onset of labor; 33% chance of transmission o Often asymptomatic shedding o HSV I: Orofacial lesions o HSV II: Genital tract o Both can infect oral and genital tract • Congenital HSV (4% of all neonatal infections) o Can result in microcephaly, hydrocephalus, chorioretinitis, and vesicular skin lesions o Causes seizures, psychomotor retardation, spasticity, blindness, learning disabilities, and death Methods of STD Prevention The only reliable way to avoid infection is abstinence. However, the following are additional ways to prevent STDs: • Vaccines: HPV and Hepatitis B • Mutual monogamy with uninfected partner • Reducing the number of partners • Condom use for anal, vaginal, and oral sex o Use of dental dams o Use protection consistently and correctly o Condoms reduce the risk of exposure but are not 100% effective in prevention • Avoid excessive alcohol and drug use • Educate children/teens on risks and transmission • Consider male circumcision; there is evidence that male circumcision can help reduce the risks of acquiring HIV in heterosexual transmission by as much as 60 percent; it may also help reduce transmission of HPV and genital herpes Condom: Collects ejaculate and keeps sperm from entering the vagina • Hormonal: Implant, patch, pills, or injections (increases cervical mucous and prevents egg 1.9 Birth Control Methods •

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N209: Reproductive Health Study Guide from leaving the ovaries) • Sponge/cervical cap: Releases spermicide; covers cervix and blocks sperm from entering the uterus • Diaphragm: Blocks opening to the uterus to prevent sperm from entering; must be used with spermicide to be effective • Fertility awareness: Keeping sperm out of the vagina near the time of ovulation through abstinence, withdrawal, barrier methods, or utilizing alternative sexual activity • IUD (intrauterine device): Affects mobility of sperm to avoid joining with the egg o Can be copper or hormonal o Hormonal may prevent the egg from leaving the ovary and thickens cervical mucous • Sterilization: Tubal ligation or vasectomy; meant to be permanent o Can be done in women by tying and cutting fallopian tubes (tubal ligation) o Can also be sealed using electrical current, closed with clips, clamps or rings, or removal of part of tube o Can also be done via insert directly into the tubes (ESSURE); tissue grows around inserts and blocks tubes • Morning after pill: Emergency contraception; prevents the egg release for longer than normal (can be used up to 5 days after unprotected sex) • Withdrawal: Coitus interruptus or pull-out method 1.10 Medications and Sexual Dysfunction Medications can cause sexual dysfunction in both men and women. Some prescription medications and even over-the-counter medications can impact sexual functioning, while other meds can affect libido. Some medications affect the ability to become aroused or achieve orgasm. Medications that Contribute to Sexual Dysfunction • Proscar: Used to treat BPH; can decrease libido by lowering testosterone; in lower doses, medication is Propecia (used for baldness) • Antihistamines: Benadryl and Chlor-Trimeton (libido) • Marijuana: Can impact both libido and ability to perform • Anti-seizure medications: Tegretol prevents impulses from traveling along the nerve cells (similar path as orgasm) • Pain control/opioids: Can lower testosterone (libido) • Oral contraceptives: Can lower levels of sex hormones (libido) • Beta blockers: Reduce testosterone levels; interfere with impulses associated with arousal; cause sedation and depression • Blood pressure medications: Used to lower pressure inside of vessels

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N209: Reproductive Health Study Guide o Decreased blood flow can reduce desire and interfere with erectile and ejaculation function in men o In women, it can lead to vaginal dryness and difficulty achieving orgasm o Highest incidence is with diuretics and beta and alpha blockers • Statins and fibrates: Used for high cholesterol; interferes with production of testosterone, estrogen, and other sex hormones • H2 Blockers: Used to treat GI disorders; Tagamet; wide range of sex-related side effects (decreased libido, decreased sperm count, and erectile dysfunction) • Antidepressants: Cause problems in all areas of sexual function o Blocks the action of three brain chemicals that relay signals to nerve cells: acetylcholine, serotonin, and norepinephrine o Anafranil (Clomipramine): Causes ejaculation failure, impotence, and decreased libido; SSRIs like Prozac and tricyclic antidepressants (Elavil) decrease libido • Antipsychotics: Block dopamine, which helps regulate the brain’s pleasure centers; also increase prolactin, which leads to erectile dysfunction and decreased libido Medications that Improve Sexual Function • Viagra, Levitra, Cialis o Used for men who have trouble getting or keeping an erection o Reverse dysfunction by increasing nitric oxide, which opens and relaxes the blood vessels in the penis o These medications do not increase sex drive, they only cause erections when a person is sexually stimulated 1.11 Age-Related Changes to Sexuality Changes for Women • Enjoyment: Some enjoy sex more as they grow older, due to no longer having the concern of unwanted pregnancy. For others, age-related changes may make sex less enjoyable. • Appearance: Some women feel age-related physical changes make them less attractive, which may decrease enjoyment or participation in sexual activity. • Menopause: Loss of estrogen and testosterone following menopause can lead to a decrease in tactile stimulation and sensation. o The decrease in estrogen can also decrease blood supply to the vagina, affecting lubrication. o Vaginal walls become thinner and stiffer, causing discomfort during intercourse. Changes for Men • As men age, impotence becomes more common. o By age 65, 15-25% of men may experience impotence one out of every four times

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they have sex.

o It can occur due to hypertension, heart disease, diabetes, or the medications used to treat chronic illnesses. • Men may also require increased time to obtain an erection, firmness and amount of ejaculate may decrease, they may lose an erection more rapidly after an orgasm, or it may take longer to achieve an erection again. 1.12 The Nursing Process Assessment: • Obtain health history: Illness/medication history, reproductive history, sexual activity, self- care behaviors (BSE, TSE, pap smear, mammogram, contraception, and STD prevention) • Assess cultural beliefs: Socioeconomic status, education level, and religious beliefs as they relate to patient’s views on sexuality and activity • Review objective data: Results related to reproductive assessment, such as pap smear results, STD testing, mammogram results, and hormone levels Analysis/Diagnosis: • Collaboration with health team and patient to identify actual and potential health problems • Identify nursing diagnosis (ineffective sexuality pattern, anxiety, acute pain, ineffective health maintenance, etc.) Planning: • Establish expected outcomes; plan nursing interventions to meet goals for health promotion (education related to STD prevention, birth control, availability of HRT, medication side effects, etc.) • Consider patient’s ability to follow the plan of care based on resources, religion, lifestyle, and mobility • Use standards of care and protocols per AWHONN, ACOG, and ANA; utilize evidence-based practice for teaching prevention and health maintenance Implementation • Set forth nursing interventions and a plan of care to achieve expected outcomes utilizing therapeutic communication and identification of cultural and religious beliefs • Implement teaching per assessment needs (STD prevention, hygiene, family planning, etc.) Evaluation • Assess and document patient’s response to nursing interventions and revise plan of care as

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N209: Reproductive Health Study Guide needed in order to achieve patient-centered goals Nursing Diagnosis Pertinent to Human Sexuality • Deficient knowledge related to safe sex practices, birth control, medication side effects, and age-related sexual disorders • Anxiety related to sexual dysfunction and STD diagnosis • Altered oral mucous membranes related to HSV • Risk for latex allergy response related to STD prevention barrier methods • Impaired tissue integrity related to menopausal changes • Dysfunctional family processes and ineffective sexuality patterns related to religious/cultural beliefs, sexual dysfunction, and sexual identity issues

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6. The only form of STD prevention that is 100% effective is: a. Condom use b. Mutual monogamy c. Proper use of hormonal birth control d. None of the above 7. All of the following are barrier methods of birth control except: a. Condoms b. IUD c. Diaphragm d. Cervical cap 8. Certain medications can cause sexual dysfunction by: a. Affecting libido b. Decreasing arousal c. Achieving orgasm d. All of the above 9. Estrogen and progesterone are produced as a result of hormone release in the: a. Medulla b. Pituitary gland c. Cerebellum d. All of the above 10. When formulating patient goals related to human sexuality, it is important to consider which of the following: a. Cultural and religious beliefs b. Sexual and reproductive history c. Current medications d. All of the above The answer key is found on page 109.

Chapter One Practice Exam 1. Any male or female body structure directly related to reproduction is considered to be a: a. Gender identity b. Primary sex characteristic c. Gender norm d. Secondary sex characteristic 2. Examples of how gender norms are learned include all of the following EXCEPT: a. How a child is dressed b. Sexual orientation of parents c. Toys provided for a child d. Environmental surroundings and decoration 3. What can cause sexual dysfunction? a. Physical conditions, such as diabetes or hypertension b. Medications c. History of sexual abuse d. All of the above 4. What is the most common form of sexual dysfunction in men? a. Erectile dysfunction b. Premature ejaculation c. Retrograde ejaculation d. Decreased libido related to low testosterone levels 5. What is the most commonly reported STD in the United States? a. Syphilis b.

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N209: Reproductive Health Study Guide

Chapter Two: Preconception Period

2.1 Preconception Preconception care as defined by the CDC is “a set of interventions aimed at identifying and modifying biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management.” The goal is to ensure that the woman is as healthy as possible before conception to promote her health and the health of her unborn child. Preconception care is an important part of primary care for women who are in their reproductive years. It does not consist of one well visit for pregnancy counseling, but should be incorporated into every medical decision and treatment plan recommended during the reproductive years. For this reason, a woman’s primary care physician plays an important role in reproductive planning and preparation. Preconception Assessment Preconception planning begins with a thorough health history, including the following: • Age at onset of menses; cycle pattern • Family medical history • General medical history including any acute or chronic conditions, medication, toxic habits, obesity, age, stress, and socioeconomic factors • Sexual history: Includes use of contraception, risk behaviors, and sexual dysfunction • Sexual health history (STDs) • Pregnancy history: Birth history (vaginal vs. C-section), miscarriages, abortions, term vs. preterm, complications with pregnancy and/or delivery, and infertility • Contraception and pregnancy plans: o Contraception for pregnancy prevention o What age they plan to begin having children o Number of years planned between children o Health goals prior to pregnancy (weight loss, smoking cessation, chronic illness control) o Partner’s health history Preconception Health Education Education should be related to risks associated with the patient’s lifestyle and current health status: • Encourage smoking cessation: Smoking makes it harder to get pregnant and increases the risk for miscarriage. It interferes with placental circulation and can lead to placental abruption, preterm delivery, and low birth weight. Smoking during and after pregnancy increases the risk for SIDS (Sudden Infant Death Syndrome).

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N209: Reproductive Health Study Guide • Discourage alcohol use: There is no safe amount of alcohol use during pregnancy or while trying to get pregnant. All types of alcohol are equally harmful. Alcohol passes through to the fetus via the umbilical cord and can cause miscarriage or stillbirth. It can also cause lifelong disabilities known as Fetal Alcohol Syndrome, which includes physical and learning disabilities and vision, hearing, heart, kidney and bone problems. • Counseling and treatment for STDs: STDs can interfere with the ability to conceive. The nurse should encourage testing and treatment prior to conception. Inform the patient of risks, such as preterm delivery, birth defects, and infant death. • Encourage medication reviewwith physician: This should be done prior to conception as some medications can cause birth defects. • Encourage 400 mcg of folic acid daily: Folic acid can help to prevent neural tube defects (spina bifida and anecephaly). • Avoid toxic substances: Toxic substances can lead to infertility, miscarriage, and birth defects. Review with patient the potential exposure at home and at work. • Obtain and update vaccinations: Recommend Varicella, Hepatitis B, and Rubella, preferably one month prior to trying to conceive. • Review family history: Review family history for the patient and partner and refer for genetic counseling for preconception assessment. • Discuss socioeconomic factors: Check access to adequate prenatal care, healthy and safe environment, and good nutrition (all socioeconomic factors affect both mom and baby). • Review age-related risk factors: Patients older than 35 are at an increased risk for infertility, miscarriage, and chromosomal abnormalities. Adolescents have an increased risk for stillbirth, preterm delivery, and low birthweight. • Discuss healthy weight management: Being overweight can increase the risk for gestational diabetes, preeclampsia (high blood pressure with signs of damage to another organ systems, often kidneys), infections (UTIs and postpartum infection), post-date pregnancy, labor problems (interference with pain medications and a higher incidence of need for labor induction), and puts the patients at an increased risk for C-section, macrosomia, and miscarriage. • Review pregnancy history: Look for complications, such as hypertension, gestational diabetes, preterm labor or delivery, and birth defects. • Address current medical conditions: Encourage the patient to seek treatment for any conditions prior to conception (thyroid disease, diabetes, seizure disorders, high blood pressure, eating disorders, etc.). 2.2 Infertility Infertility is the inability to conceive after 12 months of attempting to conceive with unprotected intercourse. It also refers to the inability to carry a pregnancy to term. For women over age 35, the time of trying to conceive is reduced to six months. Infertility affects approximately ten percent of the population (or one in eight couples) and is recognized as a disease by the WHO, ACOG, and ASRM

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