Case Scenario #1: The Nursing

Role in Reproductive and Sexual

Health

Retita, Elinor faith

Abdulmalik, Hanimah,
Anlites, Jan Clarenze
Case Scenario

 AN ADOLESCENT IN NEED OF SAFER SEX COUNSELING

Andrea is a 20-year-old student you see at a college health clinic.
 CHIEF CONCERN:
“I can’t stand up; I have such terrible cramps every month. I don’t do anything I’m
not supposed to do like eat sour things. Either give me something that works for
pain or I’ll have to get pregnant so I don’t have periods. Maybe hope for early
menopause. And while we’re talking, my sex life isn’t great. I don’t have orgasms.
Do you think my boyfriend needs Viagra?”
HISTORY OF CHIEF CONCERN:

 Andrea misses at least 1 day of school every month from menstrual period pain.
Menarche was at 16 years of age. Her usual pattern is 30 days interval with 7
days duration of menses. Cramping begins at start of menses and lasts at least 24
hours. Her last menstrual period was 2 weeks ago. She takes an over-the-counter
combination (acetylsalicylic acid, acetaminophen, and caffeine) 10 g every 4
hours for pain.
 The client has been sexually active for 4 months with a monogamous 18-year-old
partner. She states she knows safer sex practices. Her boyfriend uses condoms for
both safer sex and their reproductive life planning method.
 FAMILY PROFILE:
She lives with parents and one male sibling, 12 years old, in a suburban community.
Her father works as garage mechanic; her mother as a receptionist at a real estate
firm. She works part-time as a member of a “garage band.” She describes family
finances as, “We’re not rich, but okay.”
 PAST MEDICAL ILLNESSES:
She had a surgery for appendectomy at 6 years of age. She had no complications.
She had chickenpox about age 7 years. She has “bad acne” since eighth grade. She
has a “sensitive stomach” or develops nausea easily.
 HISTORY OF FAMILY ILLNESSES:
Her father had a left lung lobe removed for lung cancer followed by
chemotherapy 2 years ago. There is no apparent reoccurrence to date. A
maternal aunt has valvular heart disease. A paternal aunt had severe
pelvic inflammatory disease with arthritis and is now undergoing
fertility studies for fallopian tube strictures
DAY HISTORY

Nutrition: 24-hour dietary recall:

Breakfast: 1 cup of coffee; 2 pieces pan de sal
Lunch: Fried chicken and rice; 1 glass cola

Dinner: 2 slices bread; 1 glass milk

Snacks: 1 bowl corn chips

Sleep: The patient sleeps 8 hours per night.

Recreation: She does not participate in any organized sports or club programs; she “does the mall” with best girlfriend
two to three times per week after school.
Growth and development: She is a college sophomore. She feels her development is “normal” except “my breasts
are so small, my boyfriend has bigger ones. So big, my mother says he’s a transvestite. Do you think I’m too small to be able
to breastfeed?” She is asking if she should be on “the pill.” She states, “My boyfriend had a urinary tract infection last
month; maybe he’s sterile now so it doesn’t matter.”
REVIEW OF SYSTEMS:

Negative but for chief concern; she wears contact

lenses to correct 20/70 vision. She has no recent
hearing examination or immunizations. She has not
had HPV vaccine.
PHYSICAL EXAMINATION:

Height: 5 ft 5 in. (50%)

Weight: 120 lb (50%)
BMI: 20
General appearance: Tall, slim, pale-appearing young adult
Head: Normocephalic; numerous black comedones on erythematous bases present on forehead
Eyes: Red reflex present; pupils equal in size; react to light and accommodate
Ears: Normal alignment; tympanic membranes pink; landmarks present; responds to whispered words
Nose: Midline septum; nares patent
Mouth and throat: Palate intact; lower third molars partially erupted; areas tender to touch; midline uvula; gag reflex intact; tonsil issue
not reddened
PHYSICAL EXAMINATION:

Neck: Full range of motion; one node palpable in left anterior chain; midline trachea: thyroid not
enlarged
Chest: Tanner 4; one supernumerary nipple present, 3 cm below right nipple; lung sounds normal; respiratory rate: 22
breath/min

Heart: Rate: 72 beat/min; no murmurs

Abdomen: Bowel sounds heard in all 4 quadrants; no masses; neither spleen nor liver palpable
Genitalia: Normal female
Extremities: Full range of motion; ecchymotic area 2 cm × 2 cm on left knee
Neuro: Deep tendon reflexes 2+; sensory and motor responses grossly intact; normal gait and responses to questions
Pelvic examination: Uterus slightly anteflexed; mild cystocele present
LABORATORY REPORTS:

 Hemoglobin: 8.3 g/dl

Andrea is diagnosed as having iron-deficiency anemia and dysmenorrhea. She is

prescribed an oral iron supplement and advised to use ibuprofen (Motrin or Advil)
for pain relief. She was also counseled about safer sex practices, sexual response,
and the symptoms of sexually transmitted diseases.
 STUDY QUESTIONS:

1.Andrea was advised to use a new analgesic. She was also found to have iron-
deficiency anemia and was asked to revisit in 1 month. Based on this, which
would be the priority nursing diagnosis for Andrea?
A. Ineffective health maintenance related to abnormal endothelial tissue
B. Pain related to uterine cramping from menstruation
C. Fear related to possible pregnancy
D. Anxiety related to lack of knowledge about menses
 Rationale:

Answer: B. Pain related to uterine cramping from menstruation

; Pain related to uterine cramping from menstruation is a
common nursing diagnosis with regards to reproductive
health concerns especially given that the patient have iron-
deficiency anemia which increases the risk of menstrual
cramps(Page 78)
2. Andrea’s menstrual cycle is 30 days duration with menses for 7 days. Based
on this, you should teach Andrea which of the following?
A. Her pattern is normal for a late adolescent or young adult female.
B. Her cycle is abnormally long and this is what is causing the pain.
C. Her cycle is shorter than usual so normal endometrium cannot form.
D. Seven days is a long menses so, of course, she will have some pain.
 Rationale:

Answer: A.Her pattern is normal for a late adolescent or young

adult female.

Menstrual cycle has an average of 28 days and range of 23-

35 days still considered normal. Menstrual flow duration
has an average of 4-6 days with range of 2-9 days still
considered normal. So, Andrea’s menstrual cycle is normal.
(Page 93 TABLE 5.1)
3. Andrea has a normal amount of menstrual flow.
Excessive menstrual bleeding is termed:
a. Menorrhagia.
b. Dysmenorrhea.
c. Dysfunctional bleeding.
d. Metrorrhagia.
Rationale:

Answer: A.Menorrhagia.
Menorrhagia is a heavy menstrual flow related
to endometriosis and myoma and is risk for
anemia (Page 1330)
4. Why is ibuprofen usually an effective drug to relieve menstrual
pain?
A. It shortens the length of menstrual periods.
B. It does not cause painful stomach irritation.
C. It reduces inflammation as well as reducing pain.
D. It is effective and is associated with a modest risk of developing
dependence
Rationale:

Answer: C. It reduces inflammation as well as reducing pain.

Dysmenorrhea (menstrual pain) is cause by the release of
prostaglandins in response to tissue destruction during menstrual
cycle and ibuprofen is an anti-inflammatory drug that
reduce/inhibit the production of prostaglandins to stop menstrual
pain. (PAGE 1329 Dysmenorrhea)
5.Andrea tells you she might not be ovulating. Which of the
following could you tell her is the manifestation of ovulation?
A. Cervical mucus becomes thin and can be stretched
B. Negative ferning pattern
C. Decrease in the basal body temperature
D. Cervical mucus is stick and pasty
Rationale:

Answer: A. Cervical mucus becomes thin and can be stretched

The cervical mucus method is used to predict the ovulation during
the changes in cervical mucus that occur naturally during peak day
of ovulation, the mucus secretion becomes copious, thin, watery and
transparent and it feels slippery and stretches at least 1inch before
the strand breaks. (PAGE 108, cervical mucus method)
6. Andrea asked you when will be her ovulation if her menstrual cycle is 30
days. What will be your best response?
A. You will have your ovulation on the 14th day prior to your next menstrual cycle.
B. You will have your ovulation on the 15th day prior to your next menstrual cycle.
C. You will have your ovulation on the 16th day prior to your next menstrual cycle.
D. You will have your ovulation on the 17th day prior to your next menstrual cycle.
Rationale:

Answer: Answer: C. You will have your ovulation on the 16 th

day prior to your next menstrual cycle.
to be exact, ovulation occurs 14 days before the end of every
menstrual cycle. If Andrea’s menstrual cycle is 30 days,
minus 14 days to determine the date of ovulation and that
would be the 16th day prior to her next menstrual cycle.
(PAGE 93)
7. Andrea was diagnosed as having a mild cystocele. This is:
A. An outpouching of the bladder into the vagina.
B. A displaced or tilted uterus that causes pain.
C. An abnormality of the ureters near fallopian tubes.
D. A cervical lesion that leads to spotting or bleeding.
Rationale:

Answer: A. An outpouching of the bladder into the vagina.

Mild cystocele is when the bladder droops only a short way
into the vagina and this is a risk for causing frequent
urinary infection from status of urine. (PAGE 89)
8. Andrea asked if her boyfriend needs sildenafil (Viagra). This drug
is prescribed for what health problem?
A. A low sperm count
B. Erectile dysfunction
C. Urethral irritation
D. Premature ejaculation
 Rationale:

Answer: B. Erectile dysfunction

Sildenafil (Viagra) is used for Erectile dysfunction (page 139) which is
the inability to get and keep an erection firm enough for sex. and
many factors contribute to achieve orgasm (Page 96). it could be the
size of the penis, the performance by not being stimulated enough, or
disease on either the woman's part or man's part. So giving Viagra to
the boyfriend is not yet an option until further assessment for both
part.
9. Andrea is diagnosed as having an anteflexed uterus. You should
recognize what implication of this diagnosis?
A. Her uterine cervix is smaller than normally.
B. Her entire uterus is tipped forward.
C. The body of her uterus bends sharply forward.
D. Her uterus is positioned in front of the bladder.
 Rationale:

Answer: C.The body of her uterus bends sharply forward.

Anteflexed uterus in which the body of the uterus is bent
sharply forward (page.90) is a uterine deviation which can
interfere with fertility or pregnancy. this malformation may
decrease the ability to conceive or to carry a pregnancy to
term.
10. Andrea’s aunt was diagnosed as having arthritis. This will
interfere with:
A. Sexual relations.
B. Menses.
C. Orgasm
D. Self-esteem
Rationale:

Answer: A. Sexual relations.

People with chronic pain such as arthritis may be too
uncomfortable to enjoy sexual relations. (PAGE 97)
11. Andrea said her boyfriend has somewhat enlarged breasts. His
health record would note the presence of:
A. Gynecomastia.
B. Paraphilia.
C. Adrenophilia.
D. Estrogenic suppression.
Rationale:

Answer: A.Gynecomastia.
Boys especially those who are obese may notice a
temporary increase in their breast size at puberty, termed
gynecomastia and is considered a normal change in
puberty. (Page 92)
12. To obtain a sexual history on Andrea, what is the best question
you should begin with?
A. Are you sexually active?
B. Are you worried you have AIDS?
C. Have you ever been pregnant?
D. How many boyfriends have you had?
Rationale:

Answer: A. Are you sexually active?

A specific question that help assessing and meeting

reproductive concern. (Page 79-80)
13. Andrea is worried she won’t be able to breastfeed because her breasts are
small. Your best advice to her would be:
A. “You probably won’t be able to breastfeed, but there may be hope.”
B. “The size of breasts does not greatly affect breastfeeding success.”
C. “Women with small breasts are actually best at breastfeeding.”
D. “You might want to think about implants to enlarge your breasts.”
Rationale:

Answer: B.“The size of breasts does not greatly affect breastfeeding

success.”
The milk glands are the structures important for breastfeeding and
the size of the breast is associated with fat deposits, the size of the
breast has no effect on whether a woman can successfully
breastfeed. (P.92)
14. Suppose Andrea asks you which are her fertile days during a
menstrual cycle. You would explain to her that ovulation generally
occurs at what time?
A. Fourteen days from the beginning of her cycle
B. The midpoint of her menstrual cycle
C. Five days after the menstrual flow
D. Fourteen days before the end of the cycle
Rationale:

Answer: D. Fourteen days before the end of the cycle

Ovulation does not necessarily occur on the 14th day of
their cycle it occurs 14 days before the end of their cycle.
(P.93)
15. You try to locate Andrea’s uterus by abdominal
palpation. The uterus is normally shaped like:
A. A pear
B. An almond
C. An orange
D. A mango
Rationale:

Answer: A. A pear

The uterus is a hollow,muscular,pear-shaped organ located in the

lower pelvis, posterior to the bladder and anterior to the rectum.
(P.87)
16. Andrea’s boyfriend recently had a bladder infection. She asked
you if this could have interfered with sperm production. You would
explain sperm are produced in the:
A. Epididymis coronal cells.
B. Testes seminiferous cells.
C. Van deferens prostate cells.
D. Seminal vesicles cells.
Rationale:

Answer: B. Testes seminiferous cells.

Testest are two ovoid glands, 2 to 3 cm wide, that rest in the scrotum. Each
testis is encased by a protective white fibrous capsule and is composed of a
number of lobules. Each lobole contains interstitial cells(leydig cells) that
produce testosterone and a seminiferous tubule that produces spermatozoa. So
the bladder infection doesn’t affect the production of sperm (P83). Yes there is a
possibility that the infection will spread because the bladder is near the testes
and may cause interfility.
17. Andrea said that she did experience any orgasm. What physiologic changes
will occur during an orgasm?
A. Arterial dilation and venous constriction in the genital area
B. Clitoris drawn forward and retracts under prepuce and penile distension
C. Vigorous contractions of muscles in the female pelvic area and ejaculatory
contractions for the male
D. External and internal genital organs return to an unaroused state
Rationale

Answer: C.Vigorous contractions of muscles in the female pelvic area and

ejaculatory contractions for the male

orgasm occurs when stimulation proceeds through the plateau stage to a point
at which a vigorous contraction of muscle in the pelvic area expels or dissipates
blood and fluid from the are of congestion.(P.96)
18. Andrea states she hopes she’ll have early menopause. What will happen to
the ovarian function during menopause?
A. The time when a woman no longer has menstrual cycles and the production of
ova stops.
B. The time when only 1000 ova are believed to be left undeveloped
C. The point at which ovaries become fibrotic and scarred
D. The point when the fimbria becomes thinned and nonfunctional
 Rationale:

Answer: A. The time when a woman no longer has menstrual cycles and the
production of ova stops.

FSH and LH are called gonoadotropic hormones because they cause

growth(trophy) in the gonads(ovaries). Every month during the fertile period of
a woman’s life(from menarche to menopause) one of the ovary’s oocytes is
activated by FSH to begin to grow and mature.(P.93)
19. Order the usual stages of a sexual response.
A. Plateau
B. Excitement
C. Resolution
D. Orgasm
 Rationale:

Answer:BADC
B. Excitement
A. Plateau
D. Orgasm
C. Resolution
They described the sexual response as a cycle with four discrete
stages;excitement,plateau, orgasm and resolution. Whether stages are felt as
separate steps this way or blended into one smooth process of desire, arousal
and orgasm is individualized.