Summative Cases

Summative Case #7

Colleen Burgoyne, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I am here for my 24-week OB check-up.”

Patient Profile

Name: Brett Ashley

Age: 37 years old

Gender: female

History of Present Illness

B.A. is a 37-year-old woman who reports that she has been feeling well over the past month since her last OB appointment. The nausea she had been experiencing earlier in her pregnancy has improved. She reports that she occasionally experiences some aching in the lumbar spine. This usually occurs on days when she has been on her feet for long periods. She has been taking acetaminophen 650 mg occasionally to alleviate this pain and it works quite well. She reports that she has been feeling the baby move more and more as the pregnancy progresses. She notices that the baby is most active at night when she is trying to go to sleep. She has found it harder to fall asleep than usual and wakes up to use the bathroom at least once every night. She denies any vaginal bleeding or unusual discharge. She denies any contractions.

As noted in her medical history, Brett’s pregnancy has been complicated by a fracture of the distal aspect of the left ulna. This occurred about three weeks ago. The left wrist is in a cast. Brett reports minimal pain in this area and denies any numbness or tingling of the distal digits. She has a follow-up appointment scheduled with orthopedic surgery in about three weeks to assess healing.

Brett shares that she has been feeling extremely anxious about her pregnancy. She finds herself ruminating on her memories of losing a pregnancy due to a placental abruption about five years ago. Recalling this experience brings up profound sadness for her as well as fear related to the current pregnancy. She shares that her husband is becoming frustrated with her level of anxiety about this and her fixation on the topic. This makes her more anxious because their relationship suffered considerably after the pregnancy loss with a period of separation for about a year. She denies any thoughts of harming herself or others. She is considering re-establishing care with a therapist.

Of note, this is only Brett’s second OB appointment this pregnancy. A physical exam was not possible at her first visit at 22 weeks because she was running late for work and needed to leave before it could be completed. She was late to engage in prenatal care which she attributes to recently moving to a new apartment. This pregnancy was not planned. Brett had been using oral contraception but states that she had run out of pills a couple of months before becoming pregnant. With all of the recent stressors, she had not been able to make it to any healthcare appointments.

Obstetrical History

G3P0 (TPAL:0020)

Allergies

None

Medical History

  • Infertility
  • Pregnancy loss due placental abruption
  • Ulnar fracture, left distal

Surgical History

None

Medications

Prenatal vitamin

Social History

  • Occupation: Brett works part-time as a clerk in a craft supply store
  • Smoking: Never smoked
  • Alcohol: No alcohol use since three months prior to the start of her pregnancy. Prior to that, alcohol consumption was about one to two glasses of wine per week.
  • Cannabis: No use during pregnancy. Prior to pregnancy, she reports two to three instances of smoking marijuana.
  • Illicit Substances: She has never used illicit substances.
  • Family/Living Situation: Brett lives with her husband, Jake, in an apartment in a nearby suburb. Jake works full-time as a machinist. Neither of their parents nor their extended families live in the area.

Family History

  • Mother: Hypertension, systemic lupus erythematosus.
  • Father: Coronary artery disease, hypertension, obesity, recently suffered a myocardial infarction.
  • Maternal grandmother: Deceased at age 82. Breast cancer, diagnosed at age 70, hypertension.
  • Sister: 35 years old, in good health.

Review of Systems

  • General: Denies fevers, chills, fatigue, night sweats, and weight loss. She reports weight gain with pregnancy.
  • Skin: Reports vertical “stretch marks” on the abdomen. Denies any other lesions, rash, or wounds.
  • Head, Eyes, Ears, Nose, Throat (HEENT)
    • Head: Denies headache and trauma.
    • Eyes: Denies pain, double vision, blurred vision, excessive tearing, drainage, and changes in visual acuity.
    • Ears: Denies changes in hearing acuity, tinnitus, vertigo, pain, and drainage.
    • Nose: Denies nasal drainage, epistaxis, and sinus pain.
    • Mouth and Throat: Denies throat pain, difficulty swallowing, and hoarse voice. Denies any active tooth pain. She sees a dentist regularly, last visit was two months ago.
    • Neck: Denies pain, stiffness, enlarged lymph nodes.
  • Breasts: Denies pain, lumps, nipple discharge, and change in size.
  • Respiratory: Denies cough, shortness of breath, hemoptysis, and chest pain.
  • Cardiovascular: Denies chest pain, palpitations, and shortness of breath. She reports slight swelling of the lower legs bilaterally.
  • Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal pain, constipation, bloody or black tarry stools. Denies epigastric pain.
  • Peripheral Vascular: Denies leg pain, varicose veins, swelling in the extremities, and changes in temperature or color of the extremities.
  • Urinary: Denies dysuria, hematuria, incontinence, and suprapubic pain. She reports increased urinary frequency, which is more bothersome at night.
  • Genital: Denies vaginal discharge, vaginal bleeding, pain with intercourse.
  • Musculoskeletal: Reports occasional lumbar back pain, which bothers her at the end of long days on her feet. Denies any other joint pain, swelling, or redness. Reports pain in the right elbow which has been present for two to three months. Denies any recent falls or trauma.
  • Psychiatric: Reports feeling stressed and depressed recently as described in HPI. Denies memory changes or hallucinations. Denies suicidal and homicidal ideation.
  • Neurological: Denies confusion, syncope, numbness in any extremity, weakness in any extremity, tremors, seizures, and visual changes.
  • Hematologic: Denies easy bruising or bleeding.
  • Endocrine: Denies heat or cold intolerance, excessive sweating, excessive thirst, excessive hunger, or increased urine output.

Physical Exam

Vital Signs

  • Heart rate: 84 bpm
  • Respiratory rate: 18 bpm
  • Blood pressure: 145/94 mm Hg
  • Oxygen saturation: 99% on room air
  • Temperature: 98.4°F
  • Height: 5 ft 6 in (168.9 cm)
  • Weight: 165 lbs
  • BMI: 26.6

General Survey

Well-appearing pregnant woman. She appears well-groomed and is dressed in clean-appearing clothes, which are appropriate for the weather. No unusual or foul odors detected.

  • HEENT
    • Head: Head is normocephalic/atraumatic. Scalp is without lesions. Hair is of normal texture and distribution.
    • Nose: Mucosa is pink, septum is midline. No sinus tenderness.
    • Oral: Dentition appears to be in good repair with no obvious areas of decay or broken teeth. Gingival tissue is pink and without swelling. Tongue is midline. Pharynx is without exudate.
  • Cardiovascular: S1/S2 with grade 1 systolic ejection murmur with a soft pitch and a crescendo-decrescendo pattern, heart best at the second intercostal space at the left sternal border. There is also a venous hum, which is heard best at the sternal border of the third intercostal space bilaterally, and is present throughout systole and diastole. No rub. Trace edema in bilateral lower extremities.
  • Breasts: Breasts are symmetrical with everted nipples, several prominent Montgomery glands noted bilaterally. Breasts are slightly tender with palpation bilaterally. No areas of erythema or dimpling of the skin. Small amount of colostrum expressed from nipples with compression.
  • Abdomen: Gravid abdomen with purple striae on the lateral aspects bilaterally, no scars. Fundal height is 23 cm. Fetal heart rate of 130 bpm detected with doppler. Fetus is vertex presentation and not engaged in pelvis by Leopold’s maneuvers.
  • Genital: There is a small labial varicosity on the lateral aspect of the right external labia. On internal exam, vaginal walls are intact with no lesions. The vaginal walls are bluish in color and have deep rugae. There is a moderate amount of milky white discharge within the vaginal canal. Cervix is closed with ectropion visible, no lesions, mildly friable. Cervix is estimated to be 4 cm in length on bimanual exam. No adnexal tenderness or cervical motion tenderness with bimanual exam.
  • Neurological: Alert, oriented to person, place, time, and situation. Speech is fluent and coherent. Affect appropriate. +3 deep tendon reflexes elicited in the patellar and Achilles locations bilaterally.

Checkpoint

Review the patient’s presentation with particular attention to her vital signs. Select the statement that is the most accurate assessment of Brett’s blood pressure.

  1. This is a normal blood pressure during pregnancy. The blood pressure commonly becomes elevated above the patient’s baseline as a physiological adaptation to the demands of pregnancy.
  2. Her blood pressure is diagnostic of eclampsia and urgent intervention is needed.
  3. Her blood pressure is diagnostic of preeclampsia and urgent evaluation and intervention is needed to detect and prevent progression to eclampsia.
  4. Her blood pressure is elevated above the normal range. Based on this, she may have gestational hypertension, but more evaluation is needed.

Review the physical examination findings of the cardiovascular system. What is the most likely cause of the heart murmur?

  1. Hypertrophic cardiomyopathy
  2. Aortic stenosis
  3. Pulmonic stenosis
  4. Physiologic murmur of pregnancy
  5. Aortic regurgitation

Case Study, Continued

You recognize Brett’s blood pressure as being consistent with hypertension. Through review of her chart and further detailed interview, you are able to determine that all of her prior blood pressure readings during her prenatal care have been normal and that she has never been diagnosed or had evidence of hypertension outside of pregnancy. You send her home to rest for a few hours before returning in the afternoon for another blood pressure check. She remains hypertensive on the return visit with a BP of 148/88 mm Hg.

Diagnosis

Gestational hypertension

Plan

  • Referral to maternal-fetal medicine based on high-risk nature of pregnancy.
  • Start labetalol 100 mg twice daily by mouth

Checkpoint

Brett is distraught at the news of the diagnosis. Her road to pregnancy has been a long and difficult one. She has been scrupulous about following all of the recommended pregnancy precautions. She asks if it is possible that she did something to cause the development of hypertension. After reviewing Brett’s case, what risk factors for gestational hypertension does she have? (list all that apply)

  1. Preexisting diabetes
  2. Chronic kidney disease
  3. Pre-pregnancy overweight or obesity
  4. Nulliparity
  5. Adolescent age
  6. Advanced maternal age
  7. Multifetal pregnancy
  8. Systemic lupus erythematous
  9. Prior pregnancy complications associated with placental insufficiency

Obstetrical History Nomenclature

Her past obstetrical history is documented in the case using a standard, shorthand nomenclature. The “G” in this system denotes gravidity and indicates the number of times the patient has been pregnant. In this case, we are informed that Brett has been pregnant 3 times. The next data point is “P,” which stands for parity, and specifies the number of times the patient has given birth to a fetus of greater than or equal to 24 weeks gestational age, regardless of whether it was a live birth or a stillbirth. In Brett’s case, she has never given birth to a fetus of greater than or equal to 24 weeks gestational age. This stipulates that her pregnancy losses have occurred prior to 24 weeks gestation. The next section of the nomenclature provides a further level of detail about parity. A standard format with the mnemonic of TPAL is where “T” refers to number of term deliveries, “P” refers to the number of preterm deliveries, “A” refers to the number of abortions (inclusive of spontaneous abortions and terminated pregnancies), and “L” refers to the number of living children (Bickley, 2023). In our case study, the notation of TPAL:0020 in Brett’s obstetrical history tells us that she has never had a term or preterm delivery, she has no living children, and she has had two abortions. The fact that the total of the numbers in TPAL for Brett, which is 2, is less than her gravidity of 3 tells us that she is currently pregnant as well. Based on the information gleaned from the TPAL documentation alone, we do not know whether the abortions that Brett experienced were spontaneous or terminated pregnancies. However, reviewing her past medical history and HPI provides the additional context that she had 1 terminated pregnancy in late adolescence and then had a spontaneous abortion related to complications of placental abruption about 5 years ago.

You have now diagnosed Brett with gestational hypertension and started her on treatment with labetalol. You have also referred her to maternal-fetal medicine given the high-risk nature of her pregnancy.

It is also important to evaluate whether she meets the criteria for preeclampsia.

Checkpoint

Which of the following laboratory tests helps to distinguish gestational hypertension from preeclampsia?

  1. 24-hour urine to measure protein excretion
  2. Complete blood count to ascertain the degree of dilutional anemia
  3. Serum cortisol level
  4. A lipid panel to evaluate for elevated triglycerides

Options for evaluating proteinuria include a 24-hour urine collection or a protein-to-creatinine ratio on a random urine sample. Using a urine dipstick test to test for proteinuria is not recommended, unless the other methods are not available because of the risk of false negatives and false positives (Melvin & Funai, 2025).

Table 1. Normal Values of Urine Tests During Pregnancy
Laboratory Test Normal Values during pregnancy
24-hour urine collection < 300 mg of protein excreted/24 hours
Protein-to-creatine ratio (random urine sample) < 0.3
Urine dipstick < 2+ (this test is not recommended for evaluating for preeclampsia)

Brett completed the 24-hour urine test that you ordered to evaluate for proteinuria. The results demonstrate <300 mg of protein excretion in the 24-hour period. While this is reassuring that she does not have preeclampsia at this time, it does not definitively rule it out. Further laboratory evaluation for evidence of end-organ damage, which can occur with preeclampsia but not gestational hypertension, is also needed. This evaluation consists of platelet count, alanine transaminase (ALT), and aspartate transaminase (AST).

Table 2 shows Brett’s results for the additional lab work.

Table 2. Lab Test Results for Brett Ashley
Laboratory Test Brett’s Results Reference Range
Platelet count 210,000/ μL 150,000-450,000/ μL
Alanine transaminase (ALT) 22 U/L 19-25 U/L (normal range of females)
Aspartate transaminase (AST) 15 U/L 0-35 U/L

The additional laboratory results for Brett are reassuring. The maternal-fetal medicine consult includes a plan to monitor closely with weekly office visits for clinical assessment and blood pressure monitoring, as well as weekly lab work consisting of urine protein-to-creatinine ratio, platelet count, serum creatinine, ALT, and AST. As mentioned above, the patient has been started on labetolol 100 mg twice daily and aspirin 81 mg daily. Brett is transferred to the obstetrician in the practice for further prenatal care. On the labetalol and aspirin treatment, her blood pressures return to the normal range and she has no further symptoms.

A few weeks later, Brett arrives for her 28-week visit with the obstetrician in the practice, but the obstetrician is called out for a delivery. You see Brett for this appointment to make sure that she is evaluated and find that her blood pressure is 162/88 mm Hg. She appears tired and more disheveled than usual. She seems to have trouble sitting still during the interview, frequently changing positions and fidgeting with her sweatshirt or the pens on the desk. She tells you that she has not been feeling well over the past few days. She wonders if she might have the flu and expresses frustration with herself for not getting vaccinated against the flu earlier in the season. She denies fevers or chills but reports fatigue and malaise. She reports nausea, anorexia, and abdominal pain, which is localized to the right upper quadrant. She denies any vomiting or diarrhea.

You are aware that Brett has a history of experiencing frequent headaches that predates her pregnancy. The headaches continued when she became pregnant with a slight increase in frequency but otherwise unchanged presentation. Acetaminophen has been effective in relieving her headaches throughout the pregnancy. During the current encounter, you ask about her headaches over the past few days. She responds that she has had more frequent headaches than usual over the past days. She has been taking acetaminophen, which helps reduce the severity, but does not fully resolve the headache. She states: “I am so tired that I can hardly read! I have been trying to distract myself by rereading one of my favorite books, but it feels like there is a smudge in the corner of my vision and the words are blurry in that area.”

Activity: Exam Review

Reread the text of Brett’s symptoms below and select the portions of the text that indicate that she has progressed to preeclampsia with alarm features.

Her blood pressure is 162/88 mm Hg. She appears tired and more disheveled than usual when you enter the room. She seems to have trouble sitting still during the interview, frequently changing positions and fidgeting with her sweatshirt or the pens on the desk. She tells you that she has not been feeling well over the past few days. She wonders if she might have the flu and expresses frustration with herself for not getting vaccinated against the flu earlier in the season. She denies fevers or chills but reports fatigue and malaise. She reports nausea, anorexia, and abdominal pain, which is localized to the right upper quadrant. She denies any vomiting or diarrhea.

You are aware that Brett has a history of experiencing frequent headaches that predate her pregnancy. The headaches have continued during pregnancy with a slight increase in frequency but otherwise unchanged presentation. Acetaminophen has been effective in relieving her headaches throughout the pregnancy. During the current encounter, you ask about her headaches over the past few days. She responds that she has had more frequent headaches than usual over the past days. She has been taking acetaminophen, which helps reduce the severity, but does not fully resolve the headache. She states: “I am so tired that I can hardly read! I have been trying to distract myself by rereading one of my favorite books, but it feels like there is a smudge in the corner of my vision and the words are blurry in that area.”

Preeclampsia with Severe Features

Table 3. Preeclampsia Symptoms
Symptom Presentation
Severe hypertension Systolic pressure ≥ 160 mm Hg and/or diastolic pressure ≥ 110 mm Hg
Symptoms of central nervous system dysfunction New onset cerebral or visual disturbance

Photopsia, scotomata, cortical blindness, retinal vasospasm

And/or

Severe headache or headache that persists and progress despite analgesic therapy with acetaminophen and not accounted for by alternative diagnoses

And/or

Altered mental status

Confusion

Altered behavior such as agitation
Hepatic abnormality Impaired liver function not accounted for by another diagnosis and characterized by serum transaminase concentration >2 times the upper limit of the normal range

And/or

Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis
Thrombocytopenia Platelet count < 100,000 platelets/μL
Kidney function impairment Serum creatine > 1.1 mg/dL

And/or

Doubling of the serum creatinine concentration in the absence of other kidney disease
Pulmonary edema New dyspnea

Orthopnea

Case Conclusion

Based on her presentation, you arrange for emergency medical services (EMS) to transfer Brett via ambulance to the OB triage at the medical center associated with the clinic where you practice. You make this decision because you recognize that her blood pressure needs to be urgently reduced, seizure precautions taken, and close fetal and maternal monitoring implemented, including an urgent evaluation for HELLP syndrome, a severe sequela of preeclampsia.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. Preeclampsia is a common risk factor for maternal and fetal morbidity and mortality. There is no curative treatment other than delivery. For these reasons, prevention and early detection are of paramount importance. Which of the following would have been the most effective preeclampsia preventative intervention for Brett if initiated earlier in the pregnancy?
    1. Fish oil supplementation
    2. Dietary modification to limit salt intake
    3. Increasing antioxidant intake with vitamin C and E supplementation
    4. Folic acid supplementation
    5. Low-dose aspirin
Answer:

E. Low-dose aspirin
Feedback:

The United States Preventative Services Task Force (USPTF) and the American College of Obstetricians and Gynecologists (ACOG) recommend low-dose aspirin starting at 12 or more weeks gestation and ideally initiated before 16 weeks gestation for patients at high-risk of developing preeclampsia.

Fish oil is a source of omega-3 acids. Although ACOG recommends that women of childbearing age consume at least 250 mg/d of docosahexaenoic acid and eicosatetraenoic acid from diet or supplements and in pregnancy an additional intake of >100 to 200 mg/d of docosahexaenoic acid, the rationale for this is based on strong evidence that this intervention reduces the risk of preterm labor (Cetin et al., 2024). There is no evidence that supplementation of omega-3 acids reduces the risk of developing preeclampsia (August, 2024).

Similarly, although eating a healthy diet is associated with many long-term health benefits, there is no evidence that dietary modifications including salt-restricted diets are effective for preventing preeclampsia in patients at moderate or high risk for the condition (August, 2024).

Vitamin C and E supplementation does not effectively prevent preeclampsia and may even be associated with a slightly increased risk of gestational hypertension and prelabor rupture of membranes (August, 2024; Basaran et al., 2010; Conde-Agudelo et al., 2011).

Folic acid supplementation is recommended for all women during the periconceptual period because it effectively reduces the occurrence of neural tube defects. However, folic acid supplementation does not impact the risk of developing preeclampsia (August, 2024).

High-risk and moderate-risk factors for developing preeclampsia
Patients are considered at increased risk for developing preeclampsia when >1 high-risk factors or >2 moderate-risk factors are identified.
High-risk factors Previous pregnancy with preeclampsia, especially early onset and with an adverse outcome
Type 1 or 2 diabetes mellitus
Chronic hypertension
Multifetal gestation
Kidney disease
Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematous
Combinations of multiple moderate risk factors
Moderate-risk factors Nulliparity
First degree relative with preeclampsia
>10-year pregnancy interval
BMI >30 kg/m2
Age ≥ 35 years
Black race (as a proxy for underlying structural racism)
Lower income
In-vitro fertilization
Personal history factors (e.g, low birth weight or small for gestational age, previous adverse pregnancy outcome)
Abruption, stillbirth, or fetal growth restriction in a previous pregnancy
  1. Which of the following statements best describes the appropriate approach to intimate partner violence (IPV) screening in this case?
    1. IPV is rare during pregnancy, so screening is not needed.
    2. To avoid re-traumatizing the patient, the provider should only discuss this issue if the patient initiates the conversation.
    3. Screening for IPV does not improve outcomes. Therefore, it is not recommended.
    4. Screening for IPV is recommended at the first prenatal visit, at least once per trimester during pregnancy, and at the post-partum visit.
Answer:

D. Screening for IPV is recommended at the first prenatal visit, at least once per trimester during pregnancy, and at the post-partum visit.

Feedback:

Pregnancy is a time of heightened vulnerability to IPV. The relationship between pregnancy and IPV is partially contoured by reproductive coercion, which is often a factor in relationships affected by IPV. Reproductive coercion is characterized by a perpetrator limiting their partner’s ability to obtain or use contraceptive methods, potentially resulting in more pregnancies in relationships affected by IPV (Weil, 2024).

Although there have been reports of discomfort with IPV screening expressed by clinicians and patients, screening is recommended as a part of prenatal care at the initial prenatal visit, at least once per trimester, and at that post-partum visit. This recommendation is supported by evidence that screening for IPV improves health outcomes in pregnancy (Kiely et al., 2010; Nelson et al., 2012).

Laws requiring mandatory reporting of suspected IPV vary between states. You should be familiar with the laws in the state where you practice.

  1. Initiating a conversation about IPV with a patient can be uncomfortable. From the choices below, select the best question to ask as a way to start this conversation.
    1. Have you ever been beaten or hit by your husband?
    2. Please let me know if you would like to speak to the social worker about resources for battered women.
    3. Pregnancy can be a challenging time in people’s relationships. I ask all my patients about the safety of their relationships so that we can work together to keep everyone safe and healthy. I would like to ask you a few questions about your relationship. Is that ok with you?
    4. You have a history of pregnancy loss which is suspicious for IPV. Is your partner currently abusing you?
Answer:

C. Pregnancy can be a challenging time in people’s relationships. I ask all my patients about the safety of their relationships so that we can work together to keep everyone safe and healthy. I would like to ask you a few questions about your relationship. Is that ok with you?

Feedback:

Screening for IPV should be done during a private interaction with the patient. Framing the IPV inquiry as being a routine part of practice and within the purview of the NP, who is invested in caring for the safety and health of the patient, can help to normalize the conversation. This is done in choice “C” by informing the patient why the NP is pursuing this line of questioning. Additionally, choice “C” allows the patient to maintain autonomy of whether or not to engage in the conversation. IPV can be a disempowering experience. Language that recognizes and respects the autonomy of the person expresses an affirmation of their dignity (Marshall et al., 2024). ACOG recommends avoiding stigmatizing language such as “battered,” “abuse,” or “violence” (ACOG, 2022).

References

American College of Obstetrics and Gynecology (2022). Intimate partner violence. Committee Opinion, 518. https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2012/02/intimate-partner-violence.pdf

Ananth, C. V., & Kinzler, W. L. (2024). Acute placental abruption: Pathophysiology, clinical features, diagnosis and consequences. UpToDate. Retrieved May 1, 2025 from https://www.uptodate.com/contents/acute-placental-abruption-pathophysiology-clinical-features-diagnosis-and-consequences

August, P. (2025). Preeclampsia: Clinical features and diagnosis. UpToDate. Retrieved May 16, 2025, from https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis

Bauer, K. A. (2024). Maternal adaptations to pregnancy: Hematologic changes. UpToDate. Retrieved May 1, 2025 from https://www.uptodate.com/contents/acute-placental-abruption-pathophysiology-clinical-features-diagnosis-and-consequences

Bickley, L. S. (2024). Bates’ Guide to Physical Examination (13th ed.). Wolters Kluwer.

Cetin, I., Carlson, S. E., Burden, C., da Fonseca, E. B., di Renzo, G. C., Hadjipanayis, A., Harris, W. S., Kumar, K. R., Frodi Olsen, S., Mader, S., McAuliffe, F. M., Muhlhausler, B., Oken, E., Poon, L. C., Poston, L., Ramakrishnan, U., Roehr, C. C., Savona-Ventura, C., Smuts, C. M.,…Koletzko, B. (2024). Omega-3 fatty acid supply in pregnancy for risk reduction of preterm and early preterm birth. American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine, 6(2), 101251. http://doi.org/10.1016/j.ajogmf.2023.101251

Jeyabalan, A. (2024). Chronic hypertension in pregnancy: Prenatal and postpartum care. UpToDate. Retrieved May 8, 2025, from https://www.uptodate.com/contents/chronic-hypertension-in-pregnancy-prenatal-and-postpartum-care

Marshall, L. H., Vargas, L., Eltantawy, N. & Cruz, G. (2024). Do you feel safe at home? A critical discourse analysis of tools used in medical settings to screen for intimate partner violence. Journal of Family Violence, 39, 783-795. http://doi.org/10.1007/s10896-023-00527-5

Melvin, L. M. (2025). Gestational hypertension. UpToDate. Retrieved May 3, 2025, from https://www.uptodate.com/contents/gestational-hypertension

Powe, C.E. (2024). Preexisting (pregestational) diabetes mellitus: Obstetric issues and pregnancy management. UpToDate. Retrieved May 3, 2025, from https://www.uptodate.com/contents/preexisting-pregestational-diabetes-mellitus-obstetric-issues-and-pregnancy-management

Valente, A.M., & Economy, K. (2024). Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes. UpToDate. Retrieved June 3, 2025 from https://www.uptodate.com/contents/maternal-adaptations-to-pregnancy-cardiovascular-and-hemodynamic-changes

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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