Chapter 19: Alterations in Women's Health

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You know, usually when we talk about a medical diagnosis, there's this expectation of absolute precision.

Right, like engineering or something.

Yeah, exactly.

Like you break your arm, the x -ray shows that jagged white line, and the doctor just points and says, there it is, broken.

It's visible, it's categorized, and honestly, it's kind of comforting.

It is comforting because it's binary.

It's either broken or it's not.

But as you step into the world of women's reproductive health, well, you quickly realize that hypothetical x -ray machine just doesn't work the same way.

Not at all.

The diagnostic landscape here is incredibly murky.

Conditions overlap, you know, hormones are pulling strings from behind a curtain,

and systemic issues often disguise themselves as localized pain.

And if you are listening to this, you're likely a nursing student staring down a major exam or like a clinical rotation on alterations in women's health.

Which is a huge topic.

Huge.

So today, our mission for this deep dive is to give you the map to navigate those muddy waters.

We are mastering Chapter 19 of David's Advantage for Maternal Newborn Nursing.

And we're going to tackle this exactly how you'll see it in clinical practice.

Right.

We're not just reading you a textbook, we're starting with the baseline normal anatomy and physiology, then moving into expected changes and complications, and finally arriving at your nursing clinical judgment and safe interventions.

Because if you understand the underlying why behind these physiological processes,

memorizing the what for your exams becomes, well, it just becomes second nature.

Definitely.

So we have to start with the baseline normal.

Right.

Specifically, the hypothalamic pituitary ovarian axis or, you know, the HPO axis.

This is essentially the command center for the menstrual cycle.

I've always pictured the HPO axis like the heating system in a house.

Oh, I like that.

How so?

Well, the hypothalamus is the thermostat on the wall.

It reads the room.

When it senses hormone levels are low, it releases GnRH.

That's like the electrical signal traveling down to the pituitary gland, which is the furnace in the basement.

Right.

The furnace gets the signal.

Exactly.

The pituitary gets the signal and pumps out FSH and LH.

That heat travels to the ovaries, telling them it's time to release estrogen and progesterone.

That analogy perfectly captures the feedback loop.

And understanding that loop is so crucial because when that communication breaks down, you see menstrual disorders.

Like amenorrhea.

Yes.

The absence of a period.

Primary amenorrhea is when a young woman hasn't had her first period by age 16.

So sticking with your analogy, the thermostat or the furnace is fundamentally offline, often due to like a genetic anomaly or congenital pituitary issue.

But secondary amenorrhea is different, right?

Very different.

The system was working perfectly, but it suddenly shut down for three months or more.

I imagine the body shuts down the reproductive system when it's under extreme stress,

like severe nutritional deficits, extreme athletic training, or obviously pregnancy.

Precisely.

The body is essentially saying now is not a safe time to support a fetus.

It prioritizes survival over reproduction.

Makes sense.

But alongside missing periods, you'll also encounter abnormal uterine bleeding, or AUB, and severe pain, known as dysmenorrhea.

And as a nurse, you need to differentiate between primary and secondary dysmenorrhea.

Right, because primary dysmenorrhea is entirely chemical, isn't it?

Yes, it is.

Some women produce up to 10 times the normal amount of prostaglandins during their cycle.

Let's pause on prostaglandins for a second, because I know they play a huge role in inflammation.

What are they actually doing inside the uterus to cause such intense cramping?

Well, prostaglandins are really powerful myometrial stimulants and vasoconstrictors.

So they aren't just making the uterine muscle contract violently.

They're cutting off the blood supply.

Exactly.

They are actually squeezing the blood vessels supplying the uterus.

That causes temporary ischemia, which is a lack of oxygen to the tissue.

Wow.

So the pain these women feel is essentially ischemic muscle pain.

Yes.

It's very similar to the mechanism of chest pain during a heart attack, just on a localized reproductive scale.

That paints a completely different picture than just bad cramps.

It really does, and that's primary.

Secondary dysmenorrhea, on the other hand, is anatomical.

There's a physical pathology causing the pain, like pelvic adhesions or endometriosis.

Which naturally brings us to the broader category of chronic pelvic pain.

By clinical definition, this is pain lasting six months or longer.

But the vital piece of clinical judgment here is that chronic pelvic pain is not always a reproductive issue.

Right.

When your patient reports this, you really have to broaden your assessment because the pelvis is a crowded neighborhood.

It's very crowded.

If a patient comes in with pelvic pain, it could be urological,

like chronic smoldering It could be UTIs or interstitial cystitis.

It could be GI, like Crohn's disease, or irritable bowel syndrome.

I've even read it can be musculoskeletal, radiating from a herniated disc.

This is exactly why your nursing assessment has to look at the whole patient.

You cannot get tunnel vision on the reproductive organs.

You have to look at the systemic picture.

Right.

And that systemic perspective is the perfect bridge to understanding our next major clinical focus – polycystic ovary syndrome or PCOS.

PCOS is fascinating because it starts with the ovaries but cascades into a total body metabolic crisis.

It really does.

It's fundamentally a hyperandrogenic disorder.

Meaning there's an excess of male hormones like testosterone.

Yes, which leads to an ovulation.

The ovaries fail to release an egg, and the failure to release that egg creates the characteristic cysts.

But the cysts aren't even the most dangerous part, are they?

No.

The true danger of PCOS is that it acts as a siren for systemic disease.

A significant portion of women with PCOS will develop metabolic syndrome.

And there's a critical clinical judgment box for this in Chapter 19.

It's a huge area for nursing intervention because metabolic syndrome drastically increases a patient's risk for heart disease, stroke, and type 2 diabetes.

Exactly.

As a nurse taking vitals and pulling lab results, you are looking for a patient meeting three of five very specific criteria.

Okay.

Let's break those down.

First is abdominal obesity, right?

Yes, which is a waist circumference of 35 inches or greater in women.

Second, elevated triglycerides at 150 or higher.

Got it.

Third is depressed HDL, so the good cholesterol falls below 50.

Perfect.

Fourth is a blood pressure reading over 130 over 85.

And fifth, an elevated fasting blood glucose of 110 or higher.

So if I have like a 28 -year -old patient with PCOS, I'm not just treating her irregular periods, I'm aggressively monitoring her waistline, her blood pressure, and her fasting glucose to prevent a heart attack at age 45.

That is exactly the critical thinking your exams and your future patients demand.

And what about the physical symptoms of the excess testosterone?

Right.

You're also going to be managing things like hirsutism, which is unwanted facial and body hair.

Providers frequently prescribe a topical cream called a flournathine HCL or Vanica.

How does a cream actually stop hair growth?

Does it just destroy the follicle?

No, it doesn't destroy the follicle, which is why it's not a permanent cure.

Instead, it inhibits a specific enzyme in the skin that's necessary for cell division and hair shaft production.

Oh, so it just slows it way down.

Exactly.

By blocking that enzyme, hair growth slows to a crawl.

But your patient education here is critical for safety and efficacy.

Because of the application timing, right?

Yes.

They need to wait a full eight hours between their twice -daily doses, and they absolutely cannot wash their face for four hours after applying it, or they'll just wash away the active ingredient.

OK, so PCOS shows us how a hormonal imbalance ripples outward into a systemic metabolic issue.

Let's contrast that with a condition where hormones cause severe localized structural damage, endometriosis.

This is when tissue that resembles the uterine lining starts growing outside the uterus.

The pathophysiology here is driven by what we call retrograde menstruation.

Meaning it goes backward.

Yes.

Instead of the shed uterine lining exiting entirely through the vagina, some of it travels backward through the fallopian tubes and spills into the pelvic cavity.

It acts almost like seeds, adhering to the outside of the ovaries, the bowel, or the bladder.

But wait.

If this tissue is fundamentally the same as the uterine lining, doesn't it respond to the HPO -axis thermostat we talked about earlier?

When the ovaries release estrogen, does this rogue tissue thicken?

That is the crux of the pathology.

It is entirely estrogen -dependent.

So every month, the hormones signal the uterus to thicken its lining, and these misplaced lesions stick in too.

And when the hormones drop, signaling the uterus to shed and bleed, these lesions also break down and bleed.

Except that blood has absolutely nowhere to go.

It's bleeding freely into the closed pelvic cavity.

The inflammatory response to that free -floating blood must be massive.

The inflammation is agonizing, and over time, that chronic inflammation forms dense scar tissue and adhesions, physically binding organs together.

Which causes the infertility.

Right.

It's a leading cause of severe pain and infertility.

To treat it, we have to cut the fuel source.

We have to stop the estrogen.

So how do we do that?

We often use a synthetic GnRH analog called nepharalin, or cineral.

That's administered as a nasal spray, right?

Like one spray and one nostril in the morning and one the other nostril at night?

Exactly.

But wait, if GnRH normally stimulates the whole reproductive cascade,

why are we giving more of it to stop endometriosis?

It seems totally counterintuitive, right?

But it's about receptor downregulation.

By providing a constant, potent flood of synthetic GnRH, you overwhelm the pituitary glands.

It just gives up.

Basically.

It eventually just shuts down production of FSH and LH.

The ovaries go dormant, estrogen levels plummet, and the endometrial lesions are starved into shrinking.

But dropping a woman's estrogen to near zero means you are medically inducing menopause.

You are.

So your nursing education has to prepare like a 25 or 30 -year -old woman for hot flashes,

vaginal dryness, and bone density loss.

You're trading the agony of internal bleeding for the disruptive symptoms of menopause.

It is a profound trade -off, and your empathy and education are vital there.

Now, moving from these internal hormonal disruptions, we must address external pathogenic invaders.

Right, infections.

The reproductive tract is highly susceptible to infections, categorized broadly into STIs, vaginitis, and UTIs.

Let's start with sexually transmitted infections, things like chlamydia and gonorrhea.

Aside from the immediate discomfort, why are these considered such a high nursing priority in women's health?

Because the female reproductive anatomy is an open pathway to the peritoneal cavity.

Exactly.

If chlamydia or gonorrhea goes untreated in the vagina or cervix, the bacteria ascend into the uterus and the fallopian tubes, causing pelvic inflammatory disease or PID.

And the resulting infection damages the delicate cilia in the fallopian tubes and leaves behind scar tissue.

And that scar tissue creates a roadblock.

So later on, an egg might get fertilized by a sperm, but the embryo gets trapped by the scar tissue in the tube instead of making it to the uterus.

And that is the mechanism behind an ectopic pregnancy.

Which is a surgical emergency.

Precisely.

PID is a primary driver of ectopic pregnancies.

This is why you must educate patients that both partners must be treated simultaneously.

Otherwise, they engage in a ping -pong effect, just passing the pathogen back and forth.

Let's talk about treatment safety, specifically for infections like trichomoniasis or bacterial vaginosis.

Providers rely heavily on metronidazole, brand name flagell.

I know this medication comes with a massive bold print warning label.

Oh,

absolutely.

If you take away only one thing about flagell, let it be this.

Strict, absolute zero alcohol tolerance.

Zero.

Zero.

And that includes hidden alcohol in mouthwash or cough syrup.

What actually happens if they mix the two?

Is it just liver toxicity?

No, it's an acute disulfiram -like reaction.

The medication stops the body from fully breaking down alcohol, causing a toxic buildup of acetaldehyde.

That sounds bad.

It's terrifying.

Within minutes of drinking, the patient will experience intense nausea, violent vomiting, severe facial flushing, tachycardia, and shortness of breath.

It is a potentially dangerous cardiovascular event.

Okay, zero alcohol.

Understood.

Now, you mentioned bacterial vaginosis, or BV.

This is a form of vaginitis caused not by a foreign pathogen, but by a disruption of the normal flora, right?

Right.

The healthy lactobacilli drop and opportunistic bacteria take over, causing a distinct fishy odor.

I often hear BV dismissed as just a nuisance, but it's much more serious if the patient is pregnant, isn't it?

It is a major pregnancy complication risk.

The bacteria associated with BV produce enzymes that weaken the amniotic sac, and the localized inflammation triggers the release of, guess what, prostaglandins.

When we established earlier, the prostaglandins stimulate the myometrium, so BV can literally trigger the uterus to start contracting prematurely.

Exactly.

Pregnant women with BV are at a significantly higher risk for preterm labor and postpartum endometritis.

You never dismiss BV in an obstetric setting.

Wow.

Good to know.

We see a similar risk profile with urinary tract infections, which are typically ascending infections caused by E.

coli.

But I want to pivot your clinical judgment to how UTIs present in an older demographic.

Okay, so picture yourself on a medsurg floor.

Your 80 -year -old patient suddenly doesn't know what year it is.

She's agitated, pulling at her 5e, and she just had an unexplained fall.

Your first instinct might be a stroke or dementia progression.

Right, but your clinical judgment should immediately make you think, I need to check her urine.

Because of immune senescence, the aging of the immune system, older women rarely mount a fever or complain of classic burning during urination.

The symptoms are totally different.

Completely.

The first and only sign of a severe UTI might be profound encephalopathy, sudden confusion, delirium, or hallucinations.

When treating these UTIs, you'll frequently administer trimethoprimsulfamethoxazole, that are known as Bactrim.

The nursing actions here are straightforward but critical.

Force fluids to physically flush the bacteria from the bladder and reinforce wiping from front to back to keep rectal E.

coli away from the urethra.

Perfect.

Let's shift our focus from microscopic bacterial invaders to macroscopic structural roadblocks.

We're talking about benign tumors of the reproductive organs, specifically laemiomas and ovarian cysts.

Laemiomas are commonly known as uterine fibroids.

They are benign, rubbery tumors growing within the muscle wall of the uterus.

And just like the endometriosis lesions, they are highly sensitive to estrogen and progesterone.

They feed on the hormones of the reproductive cycle.

Which means your patient education can offer a light at the end of the tunnel.

While these fibroids can cause heavy bleeding and pelvic pressure in a woman's 30s and 40s, they predictably shrink and calcify after menopause when the estrogen supply dries up.

And then we have ovarian cysts.

Most are just physiological hiccups, right?

Like a follicular cyst, where the follicle gears up to release an egg but just fails to rupture, filling with fluid instead.

Or a corpus lydium cyst that doesn't dissolve properly, they usually resolve on their own.

But when a provider finds a complex mass on an ovary, they often order a CA125 blood test.

CA125 is a tumor marker, right?

Yes.

It measures a specific protein antigen in the blood that is often highly elevated in ovarian cancer.

However, your clinical judgment must recognize its limitations.

Because it can elevate for other reasons.

Exactly.

It is not a perfect screening tool because CA125 can also elevate in the presence of severe endometriosis, massive fibroids or pelvic inflammatory disease.

It's a puzzle piece, not a definitive diagnosis.

Let's think about the physics of the pelvis for a second.

If a patient has heavy fibroids, enlarged cysts, or has endured multiple vaginal childbirths, that puts immense physical strain on the pelvic floor muscles.

Those muscles are like a hammock supporting the bladder, uterus, and rectum.

And when the hammock frays,

the organs drop.

This is pelvic organ prolapse.

You have to understand the specific directional anatomy here.

A cystosil is when the anterior vaginal wall weakens and the bladder bulges backward into the vagina.

Okay, so anterior is bladder.

A rectosil is when the posterior vaginal wall weakens and the rectum bulges forward into the vagina.

And a uterine prolapse is when the structural ligaments fail entirely, allowing the cervix and uterus to descend down the vaginal canal.

Beyond preparing them for potential surgical repair, what can we do as nurses to manage prolapse conservatively?

We empower them with behavioral and structural support.

We teach Kegel exercises to actively rebuild the pubicocygous muscle.

And diet is important too, right?

Rigorously educate on diet high fiber and high fluid intake because straining against a hard bowel movement will physically force a prolapse where they're down.

And we manage the use of pessaries, which are flexible silicone rings inserted into the vagina to act like an internal shelf holding the organs in place.

And it makes perfect anatomical sense that if the bladder has dropped out of its normal position, the patient is going to suffer from urinary incontinence.

Specifically,

stress incontinence.

Where the mechanical pressure of coughing, sneezing, or laughing physically forces urine past the sphincter.

To manage the urgency and frequency associated with bladder dysfunction, providers use anti -cholinergic medications like tolduridine or D -Trol.

It inhibits the bladder's smooth muscle contractions.

But whenever you administer an anti -cholinergic, you must anticipate systemic drying effects.

Right, the classic anti -cholinergic rhyme.

Can't see, can't pee, can't spit, can't… well, you get the idea.

Yeah, you have to monitor for blurred vision, severe dry mouth,

and constatation, which as we just established is terrible for a prolapse.

It's a delicate balancing act.

Also in this realm of structural damage are vaginal fistulas.

These are abnormal, hollow pathways connecting two organs that shouldn't be connected.

Like from a severe childbirth tear.

Yes, or radiation therapy.

It can cause the tissue wall between the rectum and vagina to break down, allowing stool to directly out of the vagina.

Nursing care here is intensely focused on aggressive hygiene, preventing overwhelming infection and using warm sitz baths to promote tissue healing and comfort.

Moving systematically upward from the pelvis, we arrive at the breasts.

And once again, hormones are the driving force behind both benign and malignant changes.

Benign changes include fibrocystic breasts characterized by bilateral, cyclic lumpiness and pain that tracks perfectly with the rise and fall of estrogen during the menstrual cycle.

But when changes become malignant, we are dealing with breast cancer, the second most common cancer in women.

Risk assessment is your first line of defense.

The National Cancer Institute developed a breast cancer risk assessment tool that is vital for clinical planning.

I've seen this tool.

It doesn't just give a generic risk percentage.

No, it calculates a woman's specific probability of developing invasive breast cancer over the next five years, and then extends that projection up to age 90.

That's incredibly thorough.

It really is.

It factors in her current age, the age she started menstruating, family history, and importantly, the number of previous benign breast biopsies she's had.

It tells providers who needs MRIs instead of just standard mammograms.

And if a malignancy is found, the diagnostic landscape has evolved beautifully with genomic testing.

The Oncotype DX assay is a prime example.

We take a sample of the tumor tissue and analyze the expression of 21 specific genes.

Why those 21 genes?

What is the assay actually looking for?

It looks at the tumor's biological aggression.

The assay calculates a recurrence score.

It tells the provider exactly how likely this specific tumor is to return, and crucially, whether the patient will actually see a survival benefit from systemic chemotherapy.

Wow, so we are sparing thousands of women the toxicity of chemo because their genomic profile proves it won't help them.

That is the definition of precision medicine.

Now, if the tumor is estrogen receptor positive, meaning it uses estrogen as fuel to grow, we often turn to tamoxifen.

Tamoxifen is a selective estrogen receptor modulator, or CIRM.

Think of it like a bouncer at a nightclub.

A bouncer?

Yeah.

In the breast tissue, it blocks the door.

It binds to the estrogen receptor, stopping the actual estrogen from getting in, effectively starving the breast tumor.

But because it's selective, it acts differently depending on the tissue.

While it's blocking the door in the breast, it's actually holding the door wide open in the uterus.

It stimulates the endometrial lining.

Which leads to its most severe safety risks.

As a nurse, you are monitoring tamoxifen patients for deep vein thromboses, pulmonary embolisms, stroke, and endometrial cancer.

Any abnormal vaginal bleeding in a patient on tamoxifen is an immediate red flag.

And for patients undergoing traditional chemo or radiation, your nursing interventions are all about maintaining the quality of life.

For radiation to the breast or pelvis, we teach avoiding tight clothing,

avoiding harsh soaps, and using sitz baths.

For chemotherapy, it's managing the profound nausea and the alteration in taste.

A simple, brilliant nursing intervention.

If the chemotherapy is causing a metallic taste in the patient's mouth, making them lose their appetite, advise them to use plastic utensils instead of silverware.

That is such a smart, practical tip.

Pair that with small, frequent, high -protein meals to maintain their strength.

Let's shift from the breast back down to mignancies of the reproductive organs.

Gynecological cancers generally fall into three major categories.

Cervical, uterine, and ovarian.

Cervical cancer is a triumph of preventative medicine.

It is almost entirely driven by high -risk strains of the human papillomavirus, or HPV.

And because it's a very slow -growing cancer, routine pap smears allow us to identify and pre -cancerous cervical dysplasia years before it becomes invasive.

Next is uterine, or endometrial cancer.

And there is a cardinal flash and red light symptom here that will absolutely be on your NCLE -X.

Any post -menopausal bleeding.

Yes.

Let's think about the mechanism.

After menopause, the ovaries stop producing the estrogen that thickens the uterine lining.

The lining should be thin and dormant.

So if a post -menopausal woman suddenly experiences vaginal bleeding, it means something is abnormally forcing that tissue to proliferate and shed.

You must assume endometrial cancer until proven otherwise.

Finally, ovarian cancer, which carries a grim reputation as the silent killer.

It earns that name because of its location.

The ovaries are suspended deep in the pelvic cavity.

A tumor can grow to the size of a grapefruit before it pushes against anything that causes sharp pain.

So what are the early symptoms?

Instead of sharp pain, the early symptoms mimic everyday GI annoyances.

Little bloating, feeling full quickly, mild indigestion.

By the time the patient seeks help, the cancer has typically metastasized throughout the abdomen.

Okay, taking a step back from the cellular level.

As holistic nurses, evaluating a woman's health isn't just about screening her internal organs.

We have a mandate to evaluate her physical safety within her environment.

We have to discuss intimate partner violence, or IPV.

The American Nurses Association is clear.

Universal screening is required.

Every patient, every setting, every time.

IPV crosses all socioeconomic, educational, and ethnic boundaries.

You cannot assume someone is safe just because they are wealthy or well -educated.

Recognizing the signs requires a high degree of situational awareness.

Let's say you have a patient and her partner is glued to her side.

He answers every question you ask her, corrects her medical history, and refuses to go to the waiting room while you do an exam.

On the surface, you might think, wow, he's a real helicopter partner.

He's just incredibly concerned.

But you have to view that through the lens of coercive control.

Overly solicitous behavior, isolating the patient from the healthcare team, and speaking for her are major red flags for an abusive dynamic.

What other clues should we look for?

You also look for physical clues.

Injuries in various stages of healing, a significant time lag between when an injury occurred and when they sought care,

and vague, non -specific somatic complaints.

If you identify IPV, your immediate nursing intervention is assessing urgent safety needs.

Are they safe to go home today?

You must know your local mandatory reporting laws, provide information on safe shelters, and assist the patient in developing a rapid escape safety plan.

To conclude our clinical journey, we look at the ultimate surgical intervention that treats so many of the severe pathologies we've discussed today.

Fibroids, endometriosis, prolapse, and malignancies.

The hysterectomy.

Depending on the pathology, the surgeon has a few approaches.

Abdominal, where they make an incision through the belly.

Vaginal, where the uterus is detached and removed entirely through the vaginal canal, leaving no visible scars.

LAVH, which uses a laparoscope to assist a vaginal removal.

And robotic -assisted surgeries for extreme precision.

But the surgery's success begins long before the incision.

We utilize the Strong for Surgery Bundle, a public health initiative by the American College of Surgeons.

It is a preoperative checklist designed to optimize the patient's physiology to prevent complications like surgical site infections.

It's basically training the body for the trauma of surgery.

The bundle focuses on optimizing nutritional status and ensuring tight glycemic control because high blood sugar paralyzes the immune system's wound healing cells.

It also mandates smoking cessation to improve tissue oxygenation and prehabilitation, getting the patient physically active to build cardiopulmonary reserve.

And postoperatively, your priorities on the floor are clear.

Monitor for hemorrhage by rigorously assessing the perineal pad count and the abdominal dressing.

Prevent atelectasis by teaching the patient to firmly split their abdomen with a pillow when they cough or deep breathe.

And most importantly, get them out of bed.

Early ambulation is the absolute best defense against deep vein thrombosis, and it physically stimulates intestinal peristalsis to relieve agonizing postoperative gas pains.

We've covered the cycle, the systemic hormonal cascades, the infections, the structural failures, the malignancies and the surgical recoveries.

We covered a lot of ground today.

We really did.

And as we wrap up, I want to leave you with a thought about the history of this field.

For centuries, when women presented with the complex systemic symptoms we've discussed today, the chronic pelvic pain, the severe fatigue of endometriosis,

they were dismissed.

Completely ignored.

The medical establishment labeled it hysteria, literally derived from the Greek word for uterus, the wandering womb.

They blamed the patient's mind.

Look at where we are now.

We've moved from dismissing a woman's pain as psychological to taking a sample of a tumor, mapping the expression of 21 specific genes with Oncotype DX and tailoring a molecular defense.

We've replaced the myth of the wandering womb with the undeniable proof of genomic science.

Exactly.

When you advocate for your patients, you aren't just applying Chapter 19, you are participating in the historic validation of women's health.

The female reproductive system acts as a mirror for systemic health.

A missed period isn't just a local reproductive issue.

As we saw with PCOS, it can be the first warning siren for cardiovascular disease decades down the line.

The X -ray might still be a little blurry in reproductive health, but you now have the clinical judgment to read the systemic clues.

To the nursing student listening to this,

you are going to absolutely crush your exam.

From all of us here at the Deep Dive on the Last Minute Lecture Team, thank you for studying with us.

You've got this!