a nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy This is a topic that many people are looking for. star-trek-voyager.net is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, star-trek-voyager.net would like to introduce to you Antenatal Care – Obstetrics | Lecturio. Following along are instructions in the video below:
Everybody rebus here welcoming you back to a stardew valley tier list. So today. We were going to do the girls of stardew valley.
Which ones the hottest ones the best you know what this is gonna be a lot shorter. So first of all lets go ahead. Lets do whats her name jazz yep.
Im just gonna say too young yeah. Lets just get that over with pam all right abusive mom. I i dont like her she like its too lazy to work until you fix the bus generally seems like crappy all around to you it keeps you out of the house when youre helping penny.
Im gonna put you in trash. Dear. I think shes just like complete character evelyn her name.
I think its that one i think thats who she is so shes the grandma no she lives with george alex. Her sprite is like completely out of touch with like everybody elses like all the are character sprites look like fine and hers looks like really off. I do like the fact that she like actually cares for the community.
Shes kind of the driving force that keeps like george and alex like okay. She also stepped up to really like help out when it would ever happen with alexs parents like i mean. Shes good all around.
She is older. Im going to say she is a be not as like hottest in the sense like attractive just like shes a good overall person yeah you know whats see putting her any higher than c. Just feels like dirty and wrong to me.
Yeah. Marnie has animals raising a shane and jess generally kind of a nice person. She is getting freaky with lois which i can respect like i thought she was ten times.
Younger than lois so i was kind of like oh thats interesting overall. I mean i think like design wise. Shes actually not bad like i love the hairstyle.
I love the look of her i love like everything i hate her spray. I do hate her sprite. But the actual portrait.
Im not about the hope. Toby thats a good portrait thats a good look. Shes a good looking woman.
Oh all right lets see lets see lets see lets see lets see who do i go with next. Im going to say sandy sandy. I dont you really dont know anything about her other than shes out in the oasis.
Shes got like this weird like it looks like weird ass tentacles like on her like thats what her portrait looks like is a dress. Um. Tells you a lot of cool.
Also has like an illegal like casino in the back office. Which is like pretty cool too. Im a bit of a bad girl.
Well go with the beat well worth. It hey i have a thing for pink haired girls. I dont know i really think shes like these look like tentacles.
But thats just me alright. Lets go with robin robin ah. The builder.
Build you stuff. Married to demetrios definitely a. But this girl is like honestly.
When i saw her in the lake initial intro where they bring her in and like she like messes with lewis. And everything i really hoped she was a bachelorette like i absolutely was like man that girl is like like shes kind of got that mature look to her but man is she awesome and i was like really disappointed when she was like married has like a kid everything like that but like oh. My god like everything with her was just like such a cool like interaction.
I really i mean like she does right by her family and she never like knocks like maru like for not being like im actually not sure if maru is like technically. I think shes technically her daughter. Yeah.
I think she is her daughter its demetrius isnt sebastians father thats right i like her i do i thought i was wishing she was a bachelorette she is an s. She is definitely in it she is yeah. Yeah.
I cant say more than that uh jodi. I like jodi. Im just noticing all the like women with this hairstyle kind of look alike like theyre very similar like he took like the same look and just slightly altered like the portrait huh merida cant takes good care of sam takes good care of vincent.
Shes a good wife she talks she goes through sugah. She uh goes to church. I believe as well i like her i think shes fun.
Shes nice she keeps fit you get an a youre good youre good girl. I like her. I like a lot of the women in this game.
Uh caroline hate. Her husband looks. Very like only like not in like a bad way.
But like shes just normal like the green hair is the only thing that like theyre off. She gets a knockdown because i still believe she like cheated on her husband. With the wizard.
Ah man. You know what youre getting addy. I i dont i dont know i just dont like her that much its it sucks because their interactions with theyre so nice oh my gosh okay mario about maru works in a hospital.
The clinic has a nurses outfit is one of her costumes. So yeah um overall an adventure. I mean shes shes what could small you know so thats good ah.
But she just doesnt have anything thats like beauty. You know what i mean like shes not like a pretty like theres nothing pretty about her character like the sprite for it sucks ah man. Its like tough because like i think.
Shes cool you get a c for cool youre in front of but you get to go there. Just yeah youre not that i dont know just not that great okay all right so im gonna ah penny penny is like weird to me like she would be the best mother like she would be the best character like you know she has like a rough life like she lives with her mom in a trailer. You know like shes one of those girls that when you like meet in the game.
Youre just like man. I just want to give her a better life like you just want to like marry her just to like get her away from this shitty. Person.
And that might be like a white knight thing to say but like i like her she doesnt really have like i dont know i feel like she could be like man you know what im like adding like this whole extra backstory to or like shed be like reserved. But kind of freaky like im like going like doing penny like i had penny like when i play like down here. Like i never go after her shes like man now thinking about shes like kind of growing on me like you know shed be down to earth you know she like takes care of the kids she like teaches them she like your ass.
You know what your ass you are an s. Just for being like a really attractive awesome. You know what i like her you know what im going with that thats fine.
I wasnt going to but now i am and youre up here. Uh. Emily uh kind of a hippie chick.
She wasnt one of the original or bachelorettes. Which is okay a lot of her stuff was weird as hell. She works at the bar.
I dont know nothing about her ever made me like go wow. Shes awesome.
Im glad she was added as a bachelorette that was a completely awesome thing. Yeah. She doesnt leave any mark on me.
I dont think ive ever gone for her just cuz like i dont know its like all hippy and she makes you wear like people were stupid costumes. Shes going first see as well all right um haley. He at least kind of one of those girls like everything about her is boring like from it like highbrow like perspective.
When you first meet her shes like like everything about her comes off its like she is the biggest like pain like shes the worst person like theres nothing redeeming in like it sucks cuz. Im sitting here going like i like actually i like hey leah. I think haley is like one of the best characters in the game.
And its just because like i like that blue eyed like blond girl look. Shes also got like a fantastic rack. But like her main hobby is like photography and she really doesnt have anything else like i dont really remember anything else with her story being interesting and theres just nothing like like every other girl has something thats like oh.
My gosh like i get you like maru is like an inventor pennies like the trailer park girl that like wants a better life. Emilys like a hippie trick. And haleys just kind of dare.
Im gonna put her at b. Just because i like the look of her. I think she is very attractive robin no no leah.
I get them confused because i think theyre the exact same person because if you put them over each other they pretty much look exactly the same yeah leah art girl lives in the cabin. I think shes cool i like her you get artwork if you marry her she has that kind of rugged outdoor look to her you can like beat her boyfriend. So she has some baggage shes basically robin if robin was a bachelorette yeah.
I like her too mm hmm and they do look. Oh. My gosh.
They like almost completely match up. Anyway leah s. Yeah oh.
Abigail abigail. Abigail bad girl um man she is like the girl that hangs out like the slightly chubby girl that hangs out at like hot topic like you know what im talking about like youre walking a hot topic and this girls like standing. There.
Shes got kind of the alt. The alt look where shes like partially there. But hasnt committed to it yet like shes like i could see her wearing like a band t shirt from like some band that like nobodys heard of hanging out in there with like buying like some jack skellington stuff maybe.
Some invader zim. And shes kind of got that look and then i think its partially the purple hair. Shes also the wizards daughter so that pushes her up.
I think the big thing. Though is with her like shes she plays video games. She wants to actually like be kind of more helpful like she knows about the mind.
She knows about the monsters and shes like i should be able to fight and i i do respect that i feel like shes a character thats like supposed to be in an rpg like its a recruitable character like she wants to fight. She knows like theres a great evil coming and she should be fighting against it you know what shes gonna get esther and shes gonna be upfront. Because she makes that one joke after you play video games with her about knowing your way around a joystick.
And i was like oh sexuality window. Thats hilarious so this is my tier list. Im kind of curious if you guys agree or disagree with this if you do or want to like throw out some suggestions leave a like leave a comment.
Leave a subscribe let me know what you think until next time guys. This is reba sayin. Ill catch you later you you First is rubella now most women are rubella immune because they did receive vaccinations as children.
However sometimes even with the vaccines. We do not build up the immunity to rubella and to contract rubella during pregnancy can mean some adverse outcomes for the fetus. So it is recommended we screen to determine if a patient is rubella immune or non immune in the first trimester.
Unfortunately. If theyre non immune. Were still not able to give the vaccine until after the delivery for.
Hiv the cdc says that 50000. People will be infected by hiv every year. So it is recommended that all pregnant women get screened as part of their initial prenatal visit.
If theyre an erisa an area thats high risk for hiv or if they participate in behaviors that will increase their risk of contracting hiv. It is recommended that they also get screened in the third trimester because of the effects. It can have on the fetus moving on from there is recommend that recommended that all women get screened for syphilis through the rp our vdrl in the first trimester.
If that if theyre in a high risk area for contracting syphilis. Its recommended they get screened in the second and third trimester as well and for hepatitis b. Because of the risk of transmission to the fetus.
It is recommended that pregnant women get screened for hepatitis b. At their initial prenatal visit. Now also as part of the initial prenatal visit screening.
If a patient has not had a pap smear in the last three years and they are over 21 years old. And is recommended. They get a pap smear for their baseline labs.
And as well as cultures for gonorrhea and chlamydia. Women should also be screened for hemoglobinopathies and genetic diseases in particular for african american women they should be screened for sickle cell trait for ashkenazi jews they should be screened for connivance disease and for tay sachs and for caucasian women. They should be screened for cystic fibrosis.
So back to our question. A 23 year old g1p zero intrauterine pregnancy. At eight weeks and five days.
Presents for her initial prenatal visit. Which of the following labs would you not order as part of her routine initial prenatal labs. A with complete blood cell count or cbc b.
Maternal. Serum. Alpha fetoprotein.
See the blood type in the rh factor. Rd. Hiv status.
The answer is b. Maternal. Serum.
Alpha fetoprotein. This is not part of the routine screening labs. Now lets move on for screening for down syndrome.
Were going to discuss this in great detail in another lecture. But its important to note that while women of advanced maternal age are at increased risk for having an infant with down syndrome. All women should be offered screening in the first trimester.
So there are other routine screening tests that are done through pregnancy. One is the anatomy ultrasound. This is done between 18 weeks and 22 weeks gestation and at this anatomy ultrasound.
We look at all structures of the fetus to make sure theyre within normal limits. We look at the brain. Well look at the heart the intestines again looking to see if there any structural abnormalities screening for gestational diabetes.
Now we have a whole lecture thats devoted to gestational diabetes. But in to keep with our theme and discuss about how we screen for it this is done between 24 and 28 weeks of pregnancy in the states. We do the 50 gram glucose test.
And if a patient has a random glucose level of 140 milligrams per deciliter. They are considered to have a positive screen for gestational diabetes.
And then either confirmation test. Which is a three hour test in this test. They come in get a fasting blood sugar.
Drink. A 100 gram gluto cola test. And then they kept a blood sugar at one hour two hours and three hours if they have two values out of those four lab values that are abnormal they have gestational diabetes.
Now for women that are rh negative. Again. We discussed the ill effects that can happen in a pregnancy.
When a patient is rh negative. And some of the preventive measures that we do we give rhogam. At 28 weeks to again help bind those antigens says antibodies dont form against an rh positive fetus in the next pregnancy so this is not a screening test but this is something thats also recommended for pregnant women thats the pertussis vaccination.
Because theres been a resurgence of whooping cough. The cdc recommends all women get vaccinated for pertussis in the third trimester and theyre able to pass some of that immunity on to the baby now lastly. We screen for group b.
Beta. Streptococcus or gbs. At 35 to 37 weeks.
Now. Gbs is a bacteria thats part of the normal vaginal flora. However if its not treated during delivery time especially a vaginal delivery.
Then the infant can contract this disease and can lead to meningitis or pneumonia. So its very important to know if a patient is positive for dbs so they can receive the appropriate treatment hi. Now were going to discuss screening for downs syndrome.
So this foot three ways that we screen for down syndrome and pregnancy. Were going to discuss those methods and talk about why we would choose one over the other so. The first is the free fetal dna test basically we have found that theres free fetal dna circulating in moms blood so moms blood is drawn usually after ten weeks of gestation and youre able to see the actual carrier type of the fetus.
So you know without with a 99 accuracy. If the fetus has down syndrome. Youre also able to find out the sex of the baby at that time.
So the next option for screening is the integrated sequential or contingency screening. These are all grouped the same way. But theyre performed just a little bit differently.
And it can be confusing. So lets go over that so this test is performed between 11 weeks and 13 weeks and 6 days has a detection rate of 96. Now the test involves performing a test called the nuchal translucency.
Thats an ultrasound that measures the skin fold behind the babys neck. That is done with along with blood work pappa and beta hcg. Now the difference in the tests.
So. The integrated screening takes. The results of that first trimester test.
Again. The nuchal translucency and those two hormones paplu and beta hcg and looks at the blood work in the second trimester. Which is that essentially the quad screen integrates them together to give a patients risk of having a fetus with down syndrome.
Now this is done as probability. So there is no value thats higher or lower correct or incorrect. Because its done as probability sequential screening means that you take the results of the first trimester you get a result you take the results of the second trimester getter and get a result and overall.
Youre given a result thats a little bit different than the integrate it where with integrated. You dont get a result until the second trimester. The contingency screen is done in the first trimester and if the risk of having down syndrome is low the second trimester test is not done.
Only in alpha fetoprotein. Is done the second trimester to determine if theres a risk of nuchal translucency. Together.
These each have a detection rate of about 95 to 96 percent. The third test is the quad screen. This is performed between 15 weeks in 22 weeks and 6 days of gestation moms blood is drawn looking for 4 different hormone levels.
Thats hcg estrella all inhibin a and alpha fetoprotein. This has the lowest detection rate. Its 81 percent and again this is done as probabilities.
So it looks at a mother of that ethnicity at that gestational age with those. 4. Home hormone levels to tell the probability of the baby having down syndrome.
So you can see amongst the 3 tests. The free fetal dna is the most accurate however because it is a little bit newer. It is the most expensive test of the 3.
We do recommend this test for our women that are over 35 years old as they have an increased risk for down syndrome. The quad screen can be used if a patient interests pregnancy. After 13 weeks and 6 days.
And is not able to get the integrated sequential or contingency screen now these previous discussed tests are meant for screening purposes. Only so if theyre abnormal. Then invasive testing is recommended.
So. What are our options for invasive testing. Well theres two chorionic villus.
Sampling and amniocentesis. So chorionic villi sampling is performed between 10 to 14 weeks of gestational age. And as you can see here in the picture.
A needle is inserted into moms belly and theres blood thats drawn from the chorionic villi karyotype is performed to see if the fetus. Indeed has down syndrome. The risk of this procedure is pregnancy loss.
But we are able to do it at an early gestation the next invasive test is amniocentesis now with this test in a similar manner as you can see here in the picture. A needle is play since inside moms belly amniotic fluid is drawn and again a karyotype is performed this test is usually done around 15. We gestational age and again it is confirmation to determine if a patient has a fetus with down syndrome.
The risks that go along with this procedure are bleeding infection. Placental. Abruption and again fetal loss.
It was previously thought that with corral villi sampling that there was an increased risk of fetal loss compared to amniocentesis. But we now know that risk is about the same so lets go through a study here a 24 year old gravity one pair of zero female at eight weeks and three days of gestation prevents for an antenatal visit. She has a sister was down syndrome.
And is concerned that the baby may be at increased risk the best non invasive screening option for this patient is a free fetal dna. Be integrated. Screening c.
Quad. Screen. Or d.
Amniocentesis. Well. Lets think about these options.
The free fetal dna. Weve already said has a 99 detection rate for down syndrome. Integrated screening has about a 95 percent and then quad screen has about an 81 percent.
Amniocentesis is the most accurate because it is looking at the karyotype and it is the test for diagnosing down syndrome. But we have to go back to the stem of our question amniocentesis is not a non invasive tests. So based on our options.
The answer is a the free fetal dna test music you .
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