Mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening.

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is a broad term that denotes the entire transitional stage between childhood and sexual maturity.

Increasing amounts of gonadotropin and estrogen secretion develop into a cyclic pattern at least a year before menarche. In North America, this occurs in most girls at about 13 years of age

Initially, menstrual periods are irregular, unpredictable, painless, and anovulatory (no ovum is released from the ovary). After 1 or more years, a hypothalamic-pituitary rhythm develops and the ovary produces adequate cyclic estrogen to make a mature ovum.

Ovulatory (ovum released from the ovary) periods tend to be regular, with estrogen dominating the first half of the cycle and progesterone dominating the second half of the cycle.

Is the periodic uterine bleeding that begins approximately 14 days after ovulation. 

It is controlled by a feedback system of three cycles: endometrial, hypothalamic-pituitary, and ovarian.

The average length of a menstrual cycle is 28 days, but variations are normal. 

The first day of bleeding is designated as day 1 of the cycle. The average duration of menstrual flow is 5 days and the average blood loss is 50 mL but can vary greatly.

The menstrual cycle is a complex interplay of events that occur simultaneously in the endometrium, the hypothalamus, the pituitary glands, and the ovaries. The menstrual cycle prepares the uterus for pregnancy. When pregnancy does not occur, menstruation follows. A woman’s age, physical and emotional status, and environment influence the regularity of her menstrual cycles.

term which refers to the stringy or stretchy property found to varying degrees in mucus, saliva, albumen and similar viscoelastic fluids.

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Oxygenated fatty acids classified as hormones. Menstrual blood is a potent PG source.

PGs may play a key role in ovulation. If PG levels do not rise along with the surge of LH, the ovum remains trapped within the Graafian follicle. After ovulation, PGs may influence the production of estrogen and progesterone by the corpus luteum.

The introduction of PGs into the vagina or the uterine cavity (from ejaculated semen) increases the motility of uterine musculature, which may assist the transport of sperm through the uterus and into the oviduct.

PGs produced by the woman cause regression of the corpus luteum and regression and sloughing of the endometrium, resulting in menstruation. PGs increase myometrial response to oxytocic stimulation, enhance uterine contractions, and cause cervical dilation. They may be a factor in the initiation of labor, the maintenance of labor, or both. They may also be involved in dysmenorrhea and preeclampsia/eclampsia.

Vasocongestion and myotonia

Sexual stimulation results in an increase in circulation to circumvaginal blood vessels (lubrication in the female), causing engorgement and distention of the genitals. Venous congestion is localized primarily in the genitalia, but it also occurs to a lesser degree in the breasts and other parts of the body. Arousal is characterized by myotonia (increased muscular tension), resulting in voluntary and involuntary rhythmic contractions. Examples of sexually stimulated myotonia are pelvic thrusting, facial grimacing, and spasms of the hands and feet (carpopedal spasms).

MAJOR GOALS OF PRENATAL

CARE

• Define health status of mother and fetus.

• Determine the gestational age of the fetus, and monitor fetal development.

• Identify the woman at risk for complications, and minimize the risk whenever possible.

• Provide appropriate education and counseling.

Ask

• What was her age when she started smoking?

• How many cigarettes does she smoke a day? When was her last cigarette?

• Has she tried to quit?

• Does she want to quit?

Advise

• Give her information about the effects of smoking on pregnancy and her fetus, on her own future health, and on the members of her household.

Assess

• What were her reasons for not being able to quit before, or what made her start again?

• Does she have anyone who can help her?

• Does anyone else smoke at home?

• Does she have friends or family who have quit successfully?

Assist

• Provide support; give self-help materials.

• Encourage her to set a quit date.

• Refer to a smoking cessation program, or provide information about nicotine replacement products (not recommended during pregnancy) if she is interested.

• Teach and encourage use of stress-reduction activities.

• Provide for follow-up with a phone call, letter, or clinic visit.

Arrange Follow-Up

• Arrange to follow the woman to find out about smoking-cessation status.

• Make a phone call around the time of her quit date. Assess her status at every prenatal visit.

• Congratulate her on her success, or provide support for her if she relapses.

• Referral to intensive treatment may be necessary.

Predisposing factors and problems associated with cocaine use in pregnancy are polydrug use; poor nutrition; poverty; STIs; hepatitis B infection; dysfunctional family systems; employment difficulties; stress; anger; poor self-esteem; and previous or present physical, emotional, and sexual abuse. Cocaine use is especially concentrated among poor women of color.

Cocaine affects all of the major body systems. Among other complications, it produces cardiovascular stress (including tachycardia and hypertension) that can lead to heart attack or stroke, liver disease, central nervous system simulation that can cause seizures, and even perforation of the nasal septum. Needle-borne diseases such as hepatitis B and acquired immunodeficiency syndrome (AIDS) are common among cocaine users. If the user is pregnant, there is an increased incidence of miscarriage, preterm labor, small for- gestational age babies, abruption of the placenta, and stillbirth. Anomalies have been reported.

Treat with acupuncture

• Overuse of health services

• Vague, nonspecific complaints

• Missed appointments

• Unexplainable injuries

• Untreated serious injuries

• Injuries not matching the description

• Intimate partner never leaving the patient’s side

• Intimate partner insisting on telling the story of the injury

What Not to Say

1. Do not ask “why.” This question “revictimizes” and blames the victim.

2. Do not talk negatively about the abuser to the victim. She may become defensive and stop talking.

3. Do not talk directly to the abuser about your suspicions of abuse. The abuser will assume the victim old you, and the victim risks retaliation.

What to Say

1. “I’m afraid for your safety (and the safety of your children).”

2. “I believe you.”

3. “It is progressive and will only get worse.”

4. “You deserve better than this. You deserve to be treated with respect.”

5. “You are not alone.”

6. “It is a crime.”

7. “I’m here for you.”

What to Do

1. Empower the victim.

2. Sit down with her.

3. Assure her of total privacy and confidentiality (but only if you can).

4. Use your best listening skills.

5. Call 911 and report any incident of imminent danger.

6. Give the woman the telephone number of the nearest battered women’s shelter.

• Prevention of STIs and HIV is possible only if there is no oral, genital, or rectal exchange of body fluids or if a person is in a long-term, mutually monogamous relationship with an uninfected partner.

• Correct use of latex condoms, although greatly reducing risk, is not exclusively protective.

• Sexual partners should be selected with great care.

• Partners should be asked about history of STIs.

• Preexposure vaccination is one of the most effective methods for preventing transmission of some STIs (hepatitis A and hepatitis B, human papillomavirus).

• A new condom should be used for each act of sexual intercourse.

• Abstinence from sexual intercourse is encouraged for persons who are being treated for an STI or whose partners are being treated.

Each question scores 1 point. A score of 2 or more indicates the person may have anorexia nervosa or bulimia.

1. Do you make yourself Sick (i.e., induce vomiting) because you feel too full?

2. Do you worry about the loss of Control over the amount you eat?

3. Have you recently lost more than One stone (6.4 kg [14 lbs]) in a 3-month period?

4. Do you think you are too Fat even if others think you are too thin?

5. Does Food dominate your life?

BMI 18.5 or less—Underweight

BMI 18.5 to 24.9—Normal weight

BMI 25.0 to 29.9—Overweight

BMI 30.0 to 34.5—Obese

BMI 35.0 to 40—Very obese

The more questions for which you have an answer other than “I don’t know,” the higher the level of spiritual wellness.

1. What is your purpose in life?

2. What activities do you do regularly that bring you joy?

3. Do you believe in a higher power?

4. Who can you count on for encouragement and/or support?

5. To whom do you give encouragement and/or support?

6. Who loves you?

7. Whom do you love or care about?

8. In what areas are you growing?

9. What activities nurture you?

10. Is there something that you do just for yourself every day?

11. How do you go about forgiving yourself?

12. How do you go about forgiving others?

13. To whom do you confide your hopes, dreams, and pain?

14. What do you hope for in the future?

15. What do you do regularly just for fun?

16. When do you reach out to people?

17. What goals do you have for 6 months from now?

18. What goals do you have for 2 years from now?

19. Do you look forward to getting up in the morning?

20. Would you like to live to be 100?

• Facilitation: Using a word or posture that communicates

interest such as leaning forward, making eye contact, or saying “Mm-hmmm” or “Go on”

• Reflection: Repeating a word or phrase that a woman has used

• Clarification: Asking the woman what is meant by a stated word or phrase

• Empathic Responses: Acknowledging the feelings of a

woman by statements such as “That must have been frightening”

• Confrontation: Identifying something about the woman’s behavior or feelings not expressed verbally or apparently inconsistent with her history

• Interpretation: Putting into words what you infer about the woman’s feelings or about the meaning of her symptoms, events, or other matters

• General appearance: age, race, sex, state of health, posture, height, weight, development, dress, hygiene, affect, alertness, orientation, cooperativeness, and communication skills

• Vital signs: temperature, pulse, respiration, blood pressure

• Skin: color; integrity; texture; hydration; temperature; edema; excessive perspiration; unusual odor; presence and description of lesions; hair texture and distribution; nail configuration, color, texture, and condition; presence of nail clubbing

• Head: size, shape, trauma, masses, scars, rashes, or scaling; facial symmetry; presence of edema or puffiness

• Eyes: pupil size, shape, reactivity, conjunctival injection, scleral icterus, fundal papilledema, hemorrhage, lids, extraocular movements, visual fields and acuity

• Ears: shape and symmetry, tenderness, discharge, external canal, and tympanic membranes; hearing—Weber should be midline (loudness of sound equal in both ears) and Rinne negative (no conductive or sensorineural hearing loss); should be able to hear whisper at 3 feet

• Nose: symmetry, tenderness, discharge, mucosa, turbinate inflammation, frontal or maxillary sinus tenderness; discrimination of odors

• Mouth and throat: hygiene; condition of teeth; dentures; appearance of lips, tongue, buccal and oral mucosa; erythema; edema; exudate; tonsillar enlargement; palate; uvula; gag reflex; ulcers

 • Neck: mobility, masses, range of motion, tracheal deviation, thyroid size, carotid bruits

• Lymphatic: cervical, intraclavicular, axillary, trochlear, or inguinal adenopathy; size, shape, tenderness, and consistency

• Breasts: skin changes, dimpling, symmetry, scars, tenderness, discharge, masses; characteristics of nipples and areolae

• Heart: rate, rhythm, murmurs, rubs, gallops, clicks, heaves, or precordial movements

• Peripheral vascular: jugular vein distention, bruits, edema, swelling, vein distention, Homans’ sign, or tenderness of extremities

• Lungs: chest symmetry with respirations, wheezes, crackles, rhonchi, vocal fremitus, whispered pectoriloquy, percussion, and diaphragmatic excursion; breath sounds equal and clear bilaterally

• Abdomen: shape, scars, bowel sounds, consistency, tenderness, rebound, masses, guarding, organomegaly, liver span, percussion (tympany, shifting, dullness), or costovertebral angel tenderness

• Extremities: edema, ulceration, tenderness, varicosities, erythema, tremor, or deformity

• Genitourinary: external genitalia, perineum, vaginal mucosa, cervix; inflammation, tenderness, discharge, bleeding, ulcers, nodules, or masses; internal vaginal support, bimanual and rectovaginal palpation of cervix, uterus, and adnexa

• Rectal: sphincter tone, masses, hemorrhoids, rectal wall contour, tenderness, and stool for occult blood

• Musculoskeletal: posture, symmetry of muscle mass, muscle atrophy, weakness, appearance of joints, tenderness or crepitus, joint range of motion, instability, redness, swelling, or spinal deviation

• Neurologic: mental status, orientation, memory, mood, speech clarity and comprehension, cranial nerves II to XII, sensation, strength, deep tendon and superficial reflexes, gait, balance, and coordination with rapid alternating motions

• Conversational style and pacing: Silence may show respect or acknowledgment that the listener has heard. In cultures in which a direct “no” is considered rude, silence may mean no. Repetition or loudness may mean emphasis or anger.

• Personal space: Cultural conceptions of personal space differ. Based on one’s culture, for example, someone may be perceived as distant for backing off when approached or aggressive for standing too close.

• Eye contact: Eye contact varies among cultures from intense to fleeting. Consistent with the effort to refrain from invading personal space, avoiding direct eye contact may be a sign of respect.

• Touch: The norms about how people should touch each other vary among cultures. In some cultures, physical contact with the same sex (embracing, walking hand in hand) is more appropriate than that with an unrelated person of the opposite sex.

• Time orientation: In some cultures, involvement with people is more valued than being “on time.” In other cultures, life is scheduled and paced according to clock time, which is valued over personal time.

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When she is in the lithotomy position, the woman’s hips and knees are flexed, with buttocks at the edge of the table, and her feet are supported by heel or knee stirrups. Many women find it distressing to attempt to converse in the lithotomy position. While the pregnant woman is in lithotomy position, the nurse must watch for supine hypotension (decrease in blood pressure) caused by the weight of the uterus pressing on the vena cava and aorta. Symptoms of supine hypotension include pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, and sweating. The woman should be positioned on her side until symptoms resolve and vital signs stabilize. The vaginal examination can be done with the woman in lateral position.

1. Wash hands. Assemble equipment (see illustration below).

2. Ask woman to empty her bladder before the examination (obtain cleancatch urine specimen as needed).

3. Assist with relaxation techniques. Have the woman place her hands on her chest at about the level of the diaphragm and breathe deeply and slowly.

4. Encourage the woman to become involved with the examination if she shows interest. For example, a mirror can be placed so that she can see the area being examined.

5. Assess for and treat signs of problems such as supine hypotension.

6. Warm the speculum in warm water if a prewarmed one is not available.

7. Instruct the woman to bear down when the speculum is being inserted.

8. Apply gloves and assist the examiner with collection of specimens for cytologic examination, such as a Pap test. After handling specimens, remove gloves and wash hands.

9. Lubricate the examiner’s fingers with water or water-soluble lubricant before bimanual examination.

10. Assist the woman at completion of the examination to a sitting position and then a standing position.

11. Provide tissues to wipe lubricant from perineum.

12. Provide privacy for the woman while she is dressing.

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• Ulcerations
• Masses
• inflammation
• excessive protrusion into the vaginal vault
• Cockscomb (a protrusion over the cervix that looks like a rooster's comb
• a hooded or collared cervix (seen in diethylstilbestrol [DES] daughters)
• or polyps

To prevent contamination of the rectum from organisms in the vagina (e.g., Neisseria gonorrhoeae), it is necessary to change gloves, add fresh lubricant, and then reinsert the index finger into the vagina and the middle finger into the rectum. Insertion is facilitated if the woman strains down. The maneuvers of the abdominovaginal examination are repeated. The rectovaginal examination permits assessment of the rectovaginal septum, the posterior surface of the uterus, and the region behind the cervix and the adnexa. The vaginal finger is removed and folded into the palm,

leaving the middle finger free to rotate 360 degrees. The rectum is palpated for rectal tenderness and masses.

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• In preparation, make sure the woman has not douched, used vaginal medications, or had sexual intercourse for 24 to 48 hours before the procedure. Reschedule the test if the woman is menstruating. Midcycle is the best time for the test.

• Explain to the woman the purpose of the test and what sensations she will feel as the specimen is obtained (e.g., pressure but not pain).

• The woman is assisted into a lithotomy position. A speculum is inserted into the vagina.

• The cytologic specimen is obtained before any digital examination of the vagina is made or endocervical bacteriologic specimens are taken. A cotton swab may be used to remove excess cervical discharge before the specimen is collected.

• The ThinPrep or SurePath Pap Test is a liquid-based method of preserving cells that reduces blood, mucus, and inflammation. The Pap specimen is obtained in the manner described above except that the cervix is not swabbed before collection of the sample. The collection device (brush, spatula, or broom) is rinsed in a vial of preserving solution that is provided by the laboratory. The sealed vial with solution is sent off to the appropriate laboratory. A special processing device filters the contents, and a thin layer of cervical cells is deposited on a slide, which is then examined microscopically. The AutoPap and Papnet tests are similar to the ThinPrep test. If cytology is abnormal, liquid-based methods allow follow-up testing for human papillomavirus (HPV) DNA with the same sample.

• Label the slides or vial with the woman’s name and site. Include on the form to accompany the specimens the woman’s name, age, parity, and chief complaint or reason for taking the cytologic specimens.

• Send specimens to the pathology laboratory promptly for staining, evaluation, and a written report, with special reference to abnormal elements, including cancer cells.

• Advise the woman that repeated tests may be necessary if the specimen is not adequate.

• Instruct the woman concerning routine checkups for cervical and vaginal cancer. Women vaccinated against HPV should follow the same screening guidelines as unvaccinated women. Current recommendations of the U.S. Preventive Services Task Force (USPSTF) (2012) and the American Cancer

• The specimen is obtained by using an endocervical sampling device (Cytobrush, Cervex-brush, spatula, or broom) (see Figs. A and B). If the twosample method of obtaining cells is used, the Cytobrush is inserted into the canal and rotated 90 to 180 degrees, followed by a gentle smear of the entire transformation zone by using a spatula. Broom devices are inserted and rotated 360 degrees five times. They obtain endocervical and ectocervical samples at the same time. If the patient has had a hysterectomy, the vaginal cuff is sampled. Areas that appear abnormal on visualization will require colposcopy and biopsy. If using a one-slide technique, the spatula sample is smeared first. This is followed by applying the Cytobrush sample (rolling the brush in the opposite direction from which it was obtained), which is less subject to drying artifact; then the slide is sprayed with preservative within 5 seconds. Society (ACS) (2012) for Pap tests are that women ages 21 through 65 be screened every 3 years, or for women ages 30 through 65 every 5 years (if they had a pap test plus HPV test that were both negative). These guidelines recommend no screening in women younger than 21, although if a girl becomes sexually active, the guidelines recommend that she get a Pap test within 3 years of initiating sexual activity or at age 21—whichever comes first. Women with high risk factors such as exposure to diethylstilbestrol (DES) in utero, those treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, cervical cancer, or human immunodeficiency virus (HIV) may need more frequent screening.

• Young women who have been treated with excisional procedures for dysplasia have had an increase in premature births. A large majority of the cervical dysplasias in adolescents caused by HPV resolve on their own without treatment. It is important to avoid unnecessary instrumentation and procedures that negatively affect the cervix. Women who have had a complete hysterectomy for noncancerous reasons who have no history of high-grade CIN may have routine cervical cytology testing discontinued. Women who are older than 65 years who have not had serious cervical precancer or cancer in the past 20 years may discontinue cervical cancer screening (American Cancer Society, 2012).

• Record the examination date on the woman’s record.

• Communicate findings to the woman per agency protocol.