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This is completed downloadable of Downloadable Test Bank for Maternity And Womens Health Care 10th Edition Lowdermilk

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ISBN-10 ‏ : ‎ 0323074294
ISBN-13 ‏ : ‎ 978-0323074292
Author: Lowdermilk

With comprehensive coverage of maternal, newborn, and women’s health nursing, Maternity & Women’s Health Care, 10th Edition provides evidence-based coverage of everything you need to know about caring for women of childbearing age. It’s the #1 maternity book in the market — and now respected authors Dr. Deitra Leonard Lowdermilk, Dr, Shannon E. Perry, Kitty Cashion, and Kathryn R. Alden have improved readability and provided a more focused approach! Not only does this text emphasize childbearing issues and concerns, including care of the newborn, it addresses wellness promotion and management of common women’s health problems. In describing the continuum of care, it integrates the importance of understanding family, culture, and community-based care. New to this edition is the most current information on care of the late preterm infant and the 2008 updated fetal monitoring standards from the National Institute of Child Health and Human Development.

Table of Content:

Unit One Introduction to Maternity & Women’s Health Care
Interactive Review—Unit 1
Chapter 1 21st Century Maternity and Women’s Health Nursing
Learning Objectives
BOX 1-1 HISTORIC OVERVIEW OF MILESTONES IN THE CARE OF MOTHERS AND INFANTS
Contemporary Issues and Trends
Healthy People 2020 Goals
Millennium Development Goals
BOX 1-2 HEALTHY PEOPLE 2020 PERINATAL PROPOSED OBJECTIVES
Objectives Retained from Healthy People 2010
Objectives Retained but Modified from Healthy People 2010
Objectives New to Healthy People 2020
BOX 1-3 UNITED NATIONS MILLENNIUM DEVELOPMENT GOALS
Integrative Health Care
FIG. 1-1 Healing touch with pregnant woman.
Problems with the U.S. Health Care System
Structure of the Health Care Delivery System
BOX 1-4 NATIONAL QUALITY FORUM “NEVER EVENTS” PERTAINING TO MATERNAL AND CHILD HEALTH
Reducing Medical Errors
High Cost of Health Care
BOX 1-5 SELECTED SAFE PRACTICES FOR BETTER HEALTH CARE
Limited Access to Care
Health Care Reform
Efforts to Reduce Health Disparities
Health Literacy
Trends in Fertility and Birth Rate
Low Birth Weight and Preterm Birth
BOX 1-6 MATERNAL-INFANT BIOSTATISTICAL TERMINOLOGY
Infant Mortality in the United States
International Infant Mortality Trends
Maternal Mortality Trends
Increase in High Risk Pregnancies
Regionalization of Perinatal Health Care Services
High-Technology Care
Community-Based Care
Childbirth Practices
CLINICAL REASONING
Safety and Efficacy of Midwifery Care
FIG. 1-2 Father “catching” newborn son. Mother is reaching down to help birth the baby.
Involving Consumers and Promoting Self-Management
International Concerns
Health of Women
Trends in Nursing Practice
Nursing Interventions Classification
Evidence-Based Practice
Cochrane Pregnancy and Childbirth Database
BOX 1-7 CHILDBEARING CARE INTERVENTIONS
Level 1 Domain: Family
Level 2 Class: Childbearing Care
Level 3: Interventions
EVIDENCE-BASED PRACTICE
Searching for and Evaluating the Evidence
Joanna Briggs Institute
TABLE 1-1 NURSING OUTCOMES CLASSIFICATION
Outcomes-Oriented Practice
A Global Perspective
Standards of Practice and Legal Issues in Delivery of Care
FIG. 1-3 Nurse examining client on a medical mission in China.
LEGAL TIP
Standard of Care
Risk Management
BOX 1-8 STANDARDS OF CARE FOR WOMEN AND NEWBORNS
Standards that Define the Nurse’s Responsibility to the Client
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
Standards of Professional Performance that Delineate Roles and Behaviors for Which the Professional Nurse is Accountable
Quality of Care
Performance Appraisal
Education
Collegiality
Ethics
Collaboration
Research
Resource Utilization
Practice Environment
Accountability
Sentinel Events
TABLE 1-2 THE JOINT COMMISSION “DO NOT USE” LIST
Failure to Rescue
Quality and Safety Education for Nurses
Teamwork and Communication
Situation, Background, Assessment, Recommendation
TeamSTEPPS
BOX 1-9 INSTITUTE OF MEDICINE COMPETENCIES FOR NURSING
Ethical Issues in Perinatal Nursing and Women’s Health Care
Research in Perinatal Nursing and Women’s Health Care
BOX 1-10 SAMPLE SBAR REPORT TO PHYSICIAN OR MIDWIFE ABOUT A CRITICAL SITUATION
Ethical Guidelines for Nursing Research
KEY POINTS
References
Chapter 2 Community Care: The Family and Culture
Learning Objectives
Introduction to Family, Culture, Community, and Home Care
COMMUNITY ACTIVITY
The Family in Cultural and Community Context
Defining Family
FIG. 2-1 Nuclear family.
Family Organization and Structure
FIG. 2-2 Extended family.
The Family in Society
Theoretic Approaches to Understanding Families
Family Nursing
Family Assessment
Family Theories
NURSING CARE PLAN
Incorporating the Infant into the Family
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
TABLE 2-1 THEORIES AND MODELS RELEVANT TO FAMILY NURSING PRACTICE
Graphic Representations of Families
The Family in a Cultural Context
Cultural Factors Related to Family Health
Implications for Nursing
FIG. 2-3 The Friedman Family Assessment Model (short form).
FIG. 2-4 Example of a family genogram.
CLINICAL REASONING
Providing Culturally Appropriate Care
FIG. 2-5 Example of an ecomap. An ecomap describes social relationships and depicts available supports.
Childbearing Beliefs and Practices
BOX 2-1 WORKING WITH AN INTERPRETER
Remember
Personal Space
Time Orientation
Family Roles
BOX 2-2 STRATEGIES FOR CARE DELIVERY AND PROVIDING CULTURALLY APPROPRIATE CARE
Strategies for Care Delivery
Providing Appropriate Care
TABLE 2-2 TRADITIONAL∗ CULTURAL BELIEFS AND PRACTICES: CHILDBEARING AND PARENTING
CULTURAL CONSIDERATIONS
Questions to Ask to Elicit Cultural Expectations About Childbearing
Developing Cultural Competence
Community Health Promotion
Levels of Preventive Care
Promoting Family Health
Assessing the Community
Data Collection and Sources of Community Health Data
FIG. 2-6 Community health assessment wheel.
BOX 2-3 COMMUNITY WALK-THROUGH
Vulnerable Populations in the Community
Women
Racial and Ethnic Minorities
Adolescent Girls
Older Women
Incarcerated Women
Refugee and Migrant Women
Rural Versus Urban Community Settings
Homeless Women
Low Literacy
Implications for Nursing
Home Care in the Community
Communication and Technology Applications
FIG. 2-7 Perinatal continuum of care.
Guidelines for Nursing Practice
Perinatal Services
Client Selection and Referral
Care Management
Preparing for the Home Visit
First Home Care Visit
Assessment and Nursing Diagnoses
BOX 2-4 PROTOCOL FOR PERINATAL HOME VISITS
Previsit Interventions
In-Home Interventions: Establishing a Relationship
In-Home Interventions: Working with the Family
FIG. 2-8 Home care nurse visits with a woman in preterm labor at home on bed rest.
In-Home Interventions: Ending the Visit
Postvisit Interventions
Nursing Considerations
BOX 2-5 PSYCHOSOCIAL ASSESSMENT
Language
Community Resources/Access to Care
Social Support
Interpersonal Relationships
Caregiver
Stress and Coping
Safety Issues for the Home Care Nurse
NURSING CARE PLAN
Community and Home Care
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Personal Safety
Woman’s Home
Infection Control
SAFETY ALERT
KEY POINTS
References
Chapter 3 Clinical Genetics
Learning Objectives
Nursing Expertise in Genetics and Genomics
Essential Competencies in Genetics and Genomics for All Nurses
Expanded Roles for Maternity and Women’s Health Nurses
Human Genome Project and Implications for Clinical Practice
Importance of Family History
Gene Identification and Testing
Pharmacogenomics
Gene Therapy
Ethical, Legal, and Social Implications
Factors Influencing the Decision to Undergo Genetic Testing
Clinical Genetics
Genetic Transmission
Genes and Chromosomes
FIG. 3-1 Chromosomes during cell division. A, Example of photomicrograph. B, Chromosomes arranged in karyotype; female and male sex-determining chromosomes.
Chromosomal Abnormalities
Autosomal Abnormalities
Abnormalities of Chromosome Number
FIG. 3-2 Infant with Down syndrome. Note upward slant to eyes, flat nasal bridge, slightly protruding tongue, and mottled skin.
NURSING CARE PLAN
The Family Living with a Child with Down Syndrome
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Abnormalities of Chromosome Structure
Sex Chromosome Abnormalities
Patterns of Genetic Transmission
Multifactorial Inheritance
Unifactorial Inheritance
Autosomal Dominant Inheritance
FIG. 3-3 Possible offspring in three types of matings. A, Homozygous-dominant parent and homozygous-recessive parent: children all heterozygous, displaying dominant trait. B, Heterozygous parent and homozygous recessive parent: children 50% heterozygous, displaying dominant trait; 50% homozygous, displaying recessive trait. C, Both parents heterozygous: children 25% homozygous, displaying dominant trait; 25% homozygous, displaying recessive trait; 50% heterozygous, displaying dominant trait.
Autosomal Recessive Inheritance
Inborn Errors of Metabolism
X-linked Dominant Inheritance
X-linked Recessive Inheritance
Cancer Genomics
Gene Mutations That Can Lead to Cancer
Hereditary Breast and Ovarian Cancer
Colon Cancer
Genetic Counseling
Definition of Genetic Counseling
Access and Referral to Genetic Counseling
Estimation of Risk
Interpretation of Risk
Multiple Roles for Nurses in Genetics
CLINICAL REASONING
Counseling About Genetic Risk
Future Promise of Genetics
COMMUNITY ACTIVITY
KEY POINTS
References
Unit Two Women’s Health
Interactive Review—Unit 2
Chapter 4 Assessment and Health Promotion
Learning Objectives
Female Reproductive System
FIG. 4-1 External female genitalia.
External Structures
Internal Structures
FIG. 4-2 Midsagittal view of female pelvic organs with woman lying supine.
FIG. 4-3 Schematic arrangement of directions of muscle fibers. Note that uterine muscle fibers are continuous with supportive ligaments of uterus.
FIG. 4-4 Adult female pelvis. A, Anterior view. B, External view of innominate bone (fused).
The Bony Pelvis
FIG. 4-5 Female pelvis. A, Cavity of false pelvis is shallow. B, Cavity of true pelvis is an irregularly curved canal (arrows).
Breasts
FIG. 4-6 Anatomy of the breast, showing position and major structures.
TEACHING FOR SELF-MANAGEMENT
Breast Self-Examination
EVIDENCE-BASED PRACTICE
Teaching Women Breast Self-Examination: Is It Worthwhile?
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
TABLE 4-1 FEMALE REPRODUCTIVE PHYSICAL ASSESSMENT ACROSS THE LIFE CYCLE
Menstruation And Menopause
Menarche and Puberty
Menstrual Cycle
Hypothalamic-Pituitary Cycle
Ovarian Cycle
Endometrial Cycle
FIG. 4-7 Menstrual cycle: hypothalamic-pituitary, ovarian, and endometrial.
Other Cyclic Changes
Prostaglandins
Climacteric and Menopause
Sexual Response
Reasons for Entering the Health Care System
TABLE 4-2 FOUR PHASES OF SEXUAL RESPONSE
Preconception Counseling and Care
BOX 4-1 COMPONENTS OF PRECONCEPTION CARE
Health Promotion: General Teaching
Risk Factor Assessment
Interventions
Pregnancy
Well-Woman Care
BOX 4-2 MAJOR GOALS OF PRENATAL CARE
Fertility Control and Infertility
BOX 4-3 CONTRACEPTIVE HEALTH PROMOTION
Menstrual Problems
Perimenopause
Barriers to Seeking Health Care
Financial Issues
Cultural Issues
Gender Issues
CULTURAL CONSIDERATIONS
Female Genital Mutilation
Health Risks in the Childbearing Years
Age
Adolescence
Teenage Pregnancy
Young and Middle Adulthood
Parenthood After Age 35
Late Reproductive Age
Socioeconomic Status
Substance Use and Abuse
Smoking
COMMUNITY ACTIVITY
Alcohol
Prescription Drugs
Illicit Drugs
Nutrition
Nutritional Deficiencies
Obesity
Other Considerations
Anorexia Nervosa
BOX 4-4 SCREENING FOR EATING DISORDERS
Scoff Questions
Bulimia Nervosa
Binge Eating Disorder
Physical Fitness and Exercise
SAFETY ALERT
Stress
BOX 4-5 STRESS SYMPTOMS
Physical
Behavior
Psychologic
Sexual Practices
NURSING ALERT
Medical Conditions
Gynecologic Conditions
BOX 4-6 TOP 10 LEADING CAUSES OF DEATH IN WOMEN IN THE UNITED STATES
Environmental and Workplace Hazards
Violence Against Women
Health Assessment
FIG. 4-8 Nurse interviews woman as part of history taking prior to physical examination.
Interview
CULTURAL CONSIDERATIONS
Communication Variations
Cultural Considerations
Women with Special Needs
Women with Disabilities
Abused Women
FIG. 4-9 Lithotomy and variable positions for women who have a disability.
FIG. 4-10 Abuse assessment screen.
Adolescents (Ages 13 to 19 Years)
Midlife and Older Women (Ages 50 Years and Older)
BOX 4-7 SPIRITUAL WELLNESS SELF-ASSESSMENT
Healthy Aging
History
Physical Examination
BOX 4-8 HEALTH HISTORY AND REVIEW OF SYSTEMS
Pelvic Examination
FIG. 4-11 External examination. Separation of the labia.
External Inspection
External Palpation
Vulvar Self-Examination
Internal Examination
FIG. 4-12 Insertion of speculum for vaginal examination. A, Opening of the introitus. B, Oblique insertion of the speculum. C, Final insertion of the speculum. D, Opening of the speculum blades.
PROCEDURE
Assisting with Pelvic Examination
Collection of Specimens
Papanicolaou (Pap) Test
Vaginal Examination
Bimanual Palpation
Rectovaginal Palpation
Pelvic Examination During Pregnancy
PROCEDURE
Papanicolaou Test
A, Collecting cells from endocervix using a Cytobrush. B, Obtaining cells from the transformation zone using a wooden spatula.
FIG. 4-13 Bimanual palpation of the uterus.
Pelvic Examination After Hysterectomy
Laboratory and Diagnostic Procedures
Anticipatory Guidance for Health Promotion and Illness Prevention
FIG. 4-14 Rectovaginal examination.
Nutrition
TABLE 4-3 HEALTH SCREENING GUIDELINES AND IMMUNIZATION RECOMMENDATIONS FOR WOMEN AGES 18 YEARS AND OLDER
CLINICAL REASONING
Cardiovascular Disease—the Leading Cause of Death in Women
FIG. 4-15 Exercise should be a part of one’s regular health routine. A cycle class is fun and provides moderate to vigorous exercise.
Exercise
Kegel Exercises
TEACHING FOR SELF-MANAGEMENT
Kegel Exercises
Description and Rationale
Technique
Specific Instructions
Other Suggestions for Implementation
Stress Management
Substance Use Cessation
Sexual Practices That Reduce Risk
Health Screening Schedule
BOX 4-9 INTERVENTIONS FOR SMOKING CESSATION: THE FIVE A’S
Ask
Assess
Advise
Assist
ARrange Follow-Up
Health Risk Prevention
Health Protection
KEY POINTS
Female External Genitalia (read text)
Female Reproductive Ducts (read text)
Ovaries (read text)
Ovulation (read text)
Breasts (read text)
Menstrual Cycle: Uterine (read text)
Ovarian Cycle (read text)
References
Chapter 5 Violence Against Women
Learning Objectives
CLINICAL REASONING
Intimate Partner Violence
Historical Perspective
Conceptual and Theoretic Perspectives
Biologic Factors
Psychologic Perspective
BOX 5-1 CHARACTERISTICS OF A POTENTIAL MALE BATTERER
Sociologic Perspective
Feminist Perspective
FIG. 5-1 Model of how power and control issues perpetuate battering.
Ecological Model
FIG. 5-2 Ecological framework for intimate partner violence.
Women Experiencing Intimate Partner Violence
Characteristics of Women in Abusive Relationships
TABLE 5-1 COMPARISON OF CHARACTERISTICS OF POSTTRAUMATIC STRESS SYNDROME, BATTERED WOMAN SYNDROME, AND RAPE-TRAUMA SYNDROME
Cultural Considerations
TABLE 5-2 MYTHS AND FACTS ABOUT INTIMATE PARTNER VIOLENCE
African-American Culture
Hispanic (and Latino) Cultures
Native American Culture
Asian Women
Intimate Partner Violence During Pregnancy
Care Management
LEGAL TIP
Mandatory Reporting of Domestic Violence
EVIDENCE-BASED PRACTICE
Interventions for Intimate Partner Violence
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Nursing Interventions
NURSING PROCESS
Intimate Partner Violence
Assessment
Nursing Diagnoses
Hopelessness related to
Powerlessness related to
Fear related to
Risk for Post-trauma Syndrome related to
Social Isolation related to
Ineffective Family Coping related to
Injury related to
Situational Low Self-esteem related to
Deficient Knowledge related to
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
BOX 5-2 DOCUMENTING ABUSE
NURSING CARE PLAN
The Woman Experiencing Intimate Partner Violence
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
FIG. 5-3 Danger assessment tool.
Prevention
Sexual Violence
Why Do Some Men Rape?
Mental Health Consequences of Sexual Assault
Rape-Trauma
Acute Phase: Disorganization
Outward Adjustment Phase
Long-Term Process: Reorganization Phase
Collaborative Care
Psychologic First Aid
BOX 5-3 ADULT SEXUAL ASSAULT PROTOCOL: EMERGENCY DEPARTMENT
Purpose
Assessment
Safety
Care
Client/Significant Other (SO) Teaching
Documentation
The Sexual Assault Examination
LEGAL TIP
Collector of Evidence
History
LEGAL TIP
Documentation
Physical Examination and Laboratory Tests
Immediate Care
BOX 5-4 NURSING DIAGNOSES FOR THE RAPE VICTIM DURING THE IMMEDIATE AND LATER POSTTRAUMA PERIODS
Immediate Posttrauma Period
Later Posttrauma Period
Discharge
After Discharge
COMMUNITY ACTIVITY
KEY POINTS
References
Chapter 6 Reproductive System Concerns
Learning Objectives
Common Menstrual Disorders
Amenorrhea
Management
Cyclic Perimenstrual Pain and Discomfort
Dysmenorrhea
Primary Dysmenorrhea
Management
CLINICAL REASONING
Relief for Menstrual Discomfort
NURSING ALERT
TABLE 6-1 NONSTEROIDAL ANTIINFLAMMATORY AGENTS USED TO TREAT DYSMENORRHEA
NURSING ALERT
Secondary Dysmenorrhea
Premenstrual Syndrome and Premenstrual Dysphoric Disorder
TABLE 6-2 HERBAL THERAPIES FOR MENSTRUAL DISORDERS
Management
NURSING CARE PLAN
Premenstrual Syndrome
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Endometriosis
FIG. 6-1 Common sites of endometriosis.
Management
Alterations in Cyclic Bleeding
NURSING CARE PLAN
Endometriosis
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Oligomenorrhea/Hypomenorrhea
Metrorrhagia
EVIDENCE-BASED PRACTICE
Heavy Menstrual Bleeding: Treatments to Improve Quality of Life
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
TABLE 6-3 CAUSES OF INTERMENSTRUAL BLEEDING
Menorrhagia
NURSING ALERT
Dysfunctional Uterine Bleeding
BOX 6-1 POSSIBLE CAUSES OF ABNORMAL UTERINE BLEEDING
Anovulation
Pregnancy-Related Conditions
Lower Reproductive Tract Infections
Neoplasms
Trauma
Systemic Diseases
Iatrogenic Causes
Care Management
Menopause
NURSING PROCESS
Menstrual Disorders
Assessment
Nursing Diagnoses
Risk for Ineffective Individual Coping related to:
Deficient Knowledge related to:
Risk for Disturbed Body Image related to:
Risk for Situational Low Self-Esteem related to:
Acute or Chronic Pain related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Physiologic Characteristics
Physical Changes During the Perimenopausal Period
Bleeding
Genital Changes
Vasomotor Instability
Mood and Behavioral Responses
Health Risks of Perimenopausal Women
Osteoporosis
FIG. 6-2 Skeletal changes secondary to osteoporosis assessed by height and body shape at A, age 55 years; B, age 65 years; and C, age 75 years.
COMMUNITY ACTIVITY
Coronary Heart Disease
Menopausal Hormonal Therapy
Decision to Use Hormone Therapy
Side Effects
Treatment Guidelines
TABLE 6-4 HORMONE MEDICATIONS FOR MENOPAUSAL SYMPTOMS
Bioidentical and Custom-Compounded Hormones
Alternative Therapies
SAFETY ALERT
TEACHING FOR SELF-MANAGEMENT
Comfort Measures for Menopausal Symptoms
Hot Flashes/Flushes
During the Day
At Night
Insomnia
Headaches
Urogenital Symptoms
Nervousness, Irritability
Care Management
Sexual Counseling
NURSING PROCESS
The Perimenopausal Woman
Assessment
Nursing Diagnoses
Deficient Knowledge related to:
Readiness for Enhanced Family Coping related to:
Risk for Injury related to:
Sexual Dysfunction related to:
Risk for Situational Low Self-Esteem related to:
Expected Outcomes of Care
Pland of Care and Interventions
Evaluation
Nutrition
Exercise
Medications for Osteoporosis
FIG. 6-3 Posture exercises. A, Wall standing and pelvic tilt. B, Isometric posture correction. C, Standing back bend. D, The bridge. E, The elbow prop. F, Prone press-ups with deep breathing.
BOX 6-2 PREVENTION OF OSTEOPOROSIS
NURSING ALERT
Midlife Support Groups
FIG. 6-4 Midlife women can develop a supportive network.
KEY POINTS
References
Chapter 7 Sexually Transmitted and Other Infections
Learning Objectives
Prevention
BOX 7-1 SEXUALLY TRANSMITTED INFECTIONS
Bacteria
Viruses
Protozoa
Parasites
BOX 7-2 ASSESSING STI AND HIV RISK BEHAVIORS
Sexual Risk
Drug Use—Related Risk
Blood-Related Risks
Other
Risk Reduction Measures
TABLE 7-1 RISK-REDUCTION PRACTICES
Sexually Transmitted Bacterial Infections
Chlamydia
Screening and Diagnosis
CLINICAL REASONING
STI Counseling in Pregnancy
Management
Gonorrhea
Screening and Diagnosis
Management
TABLE 7-2 SEXUALLY TRANSMITTED INFECTIONS AND DRUG THERAPIES FOR WOMEN∗
LEGAL TIP
Reporting Communicable Diseases
Syphilis
FIG. 7-1 Syphilis. A, Primary stage: chancre with inguinal adenopathy. B, Secondary stage: condylomata lata.
Screening and Diagnosis
Management
NURSING ALERT
Pelvic Inflammatory Disease
Screening and Diagnosis
Management
TABLE 7-3 TREATMENT OF PELVIC INFLAMMATORY DISEASE
Sexually Transmitted Viral Infections
Human Papillomavirus
FIG. 7-2 Human papillomavirus infection. Genital warts or condylomata acuminata.
Screening and Diagnosis
Management
Prevention
Genital Herpes Simplex Virus
Screening and Diagnosis
FIG. 7-3 Herpes genitalis.
Management
Viral Hepatitis
Hepatitis A
Hepatitis B
Screening and Diagnosis
Management
Hepatitis C
Human Immunodeficiency Virus
Screening and Diagnosis
Counseling for HIV Testing
NURSING ALERT
LEGAL TIP
HIV Testing
Management
HIV and Pregnancy
EVIDENCE-BASED PRACTICE
Venus and Mars and HIV/STD Prevention Interventions
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
COMMUNITY ACTIVITY
Vaginal Infections
Bacterial Vaginosis
Screening and Diagnosis
TABLE 7-4 WET SMEAR TESTS FOR VAGINAL INFECTIONS
Management
Candidiasis
TABLE 7-5 VAGINAL INFECTIONS AND DRUG THERAPIES FOR WOMEN
Screening and Diagnosis
Management
TEACHING FOR SELF-MANAGEMENT
Prevention of Genital Tract Infections
Trichomoniasis
Screening and Diagnosis
Management
Group B Streptococci
Effects of Sexually Transmitted Infections on Pregnancy and the Fetus
TORCH Infections
TABLE 7-6 PREGNANCY AND FETAL EFFECTS OF COMMON SEXUALLY TRANSMITTED INFECTIONS
Toxoplasmosis
TABLE 7-7 TORCH INFECTION: MATERNAL AND FETAL
Other Infections
Rubella
Cytomegalovirus
NURSING ALERT
Herpes Simplex Virus
Care Management
TEACHING FOR SELF-MANAGEMENT
Sexually Transmitted Infections
NURSING PROCESS
The Woman with a Sexually Transmitted Infection
Assessment
Nursing Diagnoses
Anxiety/Situational Low Self-Esteem/Disturbed Body Image related to:
Deficient Knowledge related to:
Acute Pain/Impaired Tissue Integrity related to:
Sexual Dysfunction related to:
Social Isolation and Impaired Social Interaction related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
LEGAL TIP
STI Reporting
Infection Control
BOX 7-3 STANDARD PRECAUTIONS
KEY POINTS
Pelvic Inflammatory Disease (read text)
References
Chapter 8 Contraception and Abortion
Learning Objectives
Contraception
Care Management
NURSING PROCESS
Contraception
Assessment
Nursing Diagnoses
Decisional Conflict related to:
Fear related to:
Risk for Infection related to:
Ineffective Sexuality Patterns related to:
Acute Pain related to:
Risk for Spiritual Distress related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
LEGAL TIP
Informed Consent
NURSING ALERT
Methods of Contraception
FIG. 8-1 Nurse counseling woman about contraceptive methods.
BOX 8-1 FACTORS AFFECTING METHOD CONTRACEPTIVE EFFECTIVENESS
Coitus Interruptus
Fertility Awareness Methods (Natural Family Planning)
NURSING CARE PLAN
Sexual Activity and Contraception
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Calendar-Based Methods
Calendar Rhythm Method
FIG. 8-2 CycleBeads. Red bead marks the first day of the menstrual cycle. White beads mark days that are likely to be fertile days; therefore, unprotected intercourse should be avoided. Brown beads are days when pregnancy is unlikely and unprotected intercourse is permitted.
BOX 8-2 POTENTIAL PITFALLS OF USING FERTILITY AWARENESS METHODS OF CONTRACEPTION
Standard Days Method
TEACHING FOR SELF-MANAGEMENT
Cervical Mucus Characteristics
Setting the Stage
Content Related to Cervical Mucus
Assessment Technique
Symptoms-Based Methods
TwoDay Method
Ovulation Method
FIG. 8-3 A, Special thermometer for recording basal body temperature, marked in tenths to enable person to read more easily. B, Basal temperature record shows drop and sharp rise at time of ovulation. Biphasic curve indicates ovulatory cycle.
Basal Body Temperature Method
Symptothermal Method
Biologic Marker Methods
Home Predictor Test Kits for Ovulation
FIG. 8-4 Example of a completed symptothermal chart.
FIG. 8-5 Examples of ovulation prediction tests.
The Marquette Model
Spermicides and Barrier Methods
Spermicides
Condoms
FIG. 8-6 Spermicides.
NURSING ALERT
FIG. 8-7 A, Mechanical barriers. From the top left corner, clockwise: female condom, male condom, cervical cap, diaphragm. B, Contraceptive sponge.
BOX 8-3 MALE CONDOMS
Mechanism of Action
Failure Rate
Advantages
Disadvantages
STI Protection
Nursing Considerations
Diaphragms
TEACHING FOR SELF-MANAGEMENT
Use and Care of the Diaphragm
Inspection of the Diaphragm
Preparation of the Diaphragm
Positions for Insertion of the Diaphragm
Insertion of the Diaphragm
General Information
Removal of the Diaphragm
Care of the Diaphragm
NURSING ALERT
Cervical Caps
TEACHING FOR SELF-MANAGEMENT
Insertion and Removal of the Cervical Cap
TABLE 8-1 HORMONAL CONTRACEPTION
Contraceptive Sponge
Hormonal Methods
Combined Estrogen-Progestin Contraceptives
Oral Contraceptives
Advantages
Disadvantages and Side Effects
NURSING ALERT
Nursing Considerations
Oral Contraceptive 91-Day Regimen
FIG. 8-8 Flowchart for missed active contraceptive pills, 2010.
SIGNS OF POTENTIAL COMPLICATIONS
Oral Contraceptives
Transdermal Contraceptive System
FIG. 8-9 Hormonal contraceptive transdermal patch and vaginal ring.
Vaginal Contraceptive Ring
Progestin-Only Contraceptives
Oral Progestins (Minipill)
Injectable Progestins
CLINICAL REASONING
Vaginal Bleeding on Depo-Provera
NURSING ALERT
Implantable Progestins
NURSING ALERT
Emergency Contraception
TABLE 8-2 ORAL EMERGENCY CONTRACEPTIVES
NURSING ALERT
FIG. 8-10 Intrauterine devices (IUDs). A, Copper T 380A. B, Levonorgestrel-releasing IUD.
Intrauterine Devices
EVIDENCE-BASED PRACTICE
An Ideal Solution: The Intrauterine Device
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Nursing Considerations
Sterilization
SIGNS OF POTENTIAL COMPLICATIONS
Intrauterine Devices (IUDs)
FIG. 8-11 Sterilization. A, Uterine tubes severed and ligated (tubal ligation). B, Sperm duct severed and ligated (vasectomy).
Female Sterilization
Tubal Occlusion
FIG. 8-12 Use of minilaparotomy to gain access to uterine tubes for occlusion procedures. Tenaculum is used to lift uterus (arrow) toward incision.
TEACHING FOR SELF-MANAGEMENT
What to Expect After Tubal Ligation
Transcervical Sterilization
Tubal Reconstruction
Male Sterilization
Tubal Reconstruction
Laws and Regulations
LEGAL TIP
Sterilization
Nursing Considerations
Breastfeeding: Lactational Amenorrhea Method
Future Trends
Induced Abortion
LEGAL TIP
Induced Abortion
Incidence
The Decision to Have an Abortion
LEGAL TIP
Institutional Policies for Nurses’ Rights and Responsibilities Related to Abortion
Care Management
BOX 8-4 SELECTED NURSING DIAGNOSES FOR WOMEN HAVING ELECTIVE ABORTION
CLINICAL REASONING
Abortion
First-Trimester Abortion
Aspiration
SAFETY ALERT
Medical Abortion
Methotrexate and Misoprostol
Mifepristone and Misoprostol
Second-Trimester Abortion
Dilation and Evacuation
Nursing Considerations
COMMUNITY ACTIVITY
KEY POINTS
References
Chapter 9 Infertility
Learning Objectives
Incidence
CLINICAL REASONING
Infertility Counseling
Factors Associated with Infertility
Female Infertility
Congenital or Developmental Factors
Hormonal and Ovulatory Factors
BOX 9-1 FACTORS AFFECTING FEMALE FERTILITY
Ovarian Factors
Uterine, Tubal, and Peritoneal Factors
Other Factors
BOX 9-2 FACTORS AFFECTING MALE FERTILITY
Structural or Hormonal Disorders
Other Factors
Age-Related Infertility
Tubal/Peritoneal Factors
EVIDENCE-BASED PRACTICE
Endometriosis Treatments for Infertility
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
FIG. 9-1 Abnormal uterus. A, Complete bicornuate uterus with vagina divided by a septum. B, Complete bicornuate uterus with normal vagina. C, Partial bicornuate uterus with normal vagina. D, Unicornuate uterus.
Uterine Factors
Vaginal-Cervical Factors
Male Infertility
Care Management
BOX 9-3 RELIGIOUS AND CULTURAL CONSIDERATIONS OF FERTILITY
Religious Considerations
Cultural Considerations
Assessment of Female Infertility
Diagnostic Tests for Female Infertility
BOX 9-4 INSURANCE COVERAGE FOR INFERTILITY
Detection of Ovulation
NURSING PROCESS
Infertility
Assessment
Assessment of female infertility
Assessment of male infertility
Nursing Diagnoses
Anxiety related to
Disturbed Body Image or Situational Low Self-esteem related to
Risk for Ineffective Individual Coping related to
Interrupted Family Processes related to
Acute Pain related to
Ineffective Sexuality Patterns related to
Deficient Knowledge related to
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
TABLE 9-1 Tests for Impaired Fertility Revised
BOX 9-5 SUMMARY OF FINDINGS FAVORABLE TO FERTILITY
Hormone Analysis
Ultrasonography
Hysterosalpingography
FIG. 9-2 Vaginal ultrasonography. Major scanning planes of transducer. H, Horizontal; V, vertical.
FIG. 9-3 Hysterosalpingography. Note that contrast medium flows through intrauterine cannula and out through the uterine tubes.
Hysteroscopy
Timed Endometrial Biopsy
Laparoscopy
FIG. 9-4 Laparoscopy.
BOX 9-6 SEMEN ANALYSIS
Assessment of Male Infertility
Semen Analysis
Ultrasonography
Assessment of the Couple
Postcoital Test
Interventions
Psychosocial
NURSING CARE PLAN
Infertility
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
TABLE 9-2 Nursing Actions in Response to Behavior Associated with Impaired Fertility
Nonmedical
Herbal Alternative Measures
Medical
MEDICATION GUIDE
Infertility Medications
Surgical
BOX 9-7 ISSUES TO BE ADDRESSED BY INFERTILE COUPLES BEFORE TREATMENT
Assisted Reproductive Therapies
In Vitro Fertilization–Embryo Transfer
TABLE 9-3 Assisted Reproductive Therapies
LEGAL TIP
Cryopreservation of Human Embryos
Gamete Intrafallopian Transfer
FIG. 9-5 Gamete intrafallopian transfer. A, Through laparoscopy, a ripe follicle is located and fluid containing the egg is removed. B, The sperm and egg are placed separately in the uterine tube, where fertilization occurs.
Zygote Intrafallopian Transfer
Complications
Oocyte Donation
Embryo Donation
Surrogate Mothers/Embryo Hosts
Therapeutic Donor Insemination
Adoption
COMMUNITY ACTIVITY
KEY POINTS
References
Chapter 10 Problems of the Breast
Learning Objectives
Benign Conditions of the Breast
Fibrocystic Changes
Etiology
Clinical Manifestations and Diagnosis
Therapeutic Management
Fibroadenomas
Nipple Discharge
Mammary Duct Ectasia
Intraductal Papilloma
Macromastia and Micromastia
Collaborative Care
TABLE 10-1 COMPARISON OF COMMON MANIFESTATIONS OF BENIGN BREAST MASSES
Malignant Conditions of the Breast
Incidence
Etiologic Factors
FIG. 10-1 Female breast cancer incidence and mortality rates by race and ethnicity, U.S. 2002-2006
Determining a Woman’s Risk of Genetically Related Breast Cancer
EVIDENCE-BASED PRACTICE
Genetic Risk Assessment for Breast Cancer
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Chemoprevention
Pathophysiology
BOX 10-1 RISK FACTORS INCLUDED IN THE BREAST CANCER RISK ASSESSMENT TOOL
Clinical Manifestations and Diagnosis
TABLE 10-2 STAGING FOR BREAST CANCER∗
FIG. 10-2 Relative location of malignant lesions of the breast.
FIG. 10-3 Mammography.
CULTURAL CONSIDERATIONS
Breast Screening Practices
TABLE 10-3 SCREENING GUIDELINES FOR EARLY BREAST CANCER DETECTION
BOX 10-2 SCREENING FOR BREAST CANCER
FIG. 10-4 Diagnosis. A, Needle aspiration. B, Open biopsy.
Prognosis
FIG. 10-5 Lymphatic spread of breast cancer.
Care Management
BOX 10-3 DECISION-MAKING QUESTIONS TO ASK
CLINICAL REASONING
Breast Cancer Treatment Options
Surgery
FIG. 10-6 Surgical alternatives for breast cancer. A, Lumpectomy. B, Partial mastectomy. C, Total (simple) mastectomy. D, Radical mastectomy.
Breast Reconstruction
TABLE 10-4 RECONSTRUCTIVE BREAST SURGERY OPTIONS
Radiation
Adjuvant Systemic Therapy
Hormonal therapy
MEDICATION GUIDE
Tamoxifen (Nolvadex)
Action
Indication
Dosage and Route
Adverse Reactions
Nursing Considerations
Chemotherapy
MEDICATION GUIDE
Raloxifene Hydrochloride (Evista)
Action
Indications
Dosage
Adverse Reactions
Nursing Considerations
MEDICATION GUIDE
Letrozole (Femara)
Action
Indication
Dosage and Route
Adverse Reactions
Nursing Considerations
BOX 10-4 COMMON CHEMOTHERAPY REGIMENS FOR ADJUVANT TREATMENT OF BREAST CANCER
Care Management
Nursing Considerations
Emotional Support After Diagnosis
Preoperative Care
Immediate Postoperative Care
NURSING PROCESS
The Woman with Breast Cancer
Assessment
Nursing Diagnoses
Fear/Anxiety related to:
Decisional Conflict related to:
Sexual Dysfunction related to:
Compromised/Disabled Family Coping related to:
Anticipatory Grieving related to:
Fatigue related to:
Acute Pain related to:
Impaired Skin Integrity related to:
Disturbed Body Image related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
NURSING ALERT
NURSING CARE PLAN
The Woman Having Breast-Conserving Surgery and Axillary Node Dissection
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
BOX 10-5 ARM EXERCISES AFTER LYMPH NODE DISSECTION
Exercises After Breast Surgery
Exercises in Lying Position
Wand Exercise
Elbow Winging
Exercises in Sitting Position
Shoulder Blade Stretch
Shoulder Blade Squeeze
Side Bending
Exercises in Standing Position
Chest Wall Stretch
Shoulder Stretch
Discharge Planning and Follow-up Care
Teaching Needs for the Client and Family Undergoing Adjuvant Therapies
COMMUNITY ACTIVITY
TEACHING FOR SELF-MANAGEMENT
After a Mastectomy Without Reconstruction
Additional Nursing Care for Women Undergoing Mastectomy with Reconstruction
KEY POINTS
References
Chapter 11 Structural Disorders and Neoplasms of the Reproductive System
Learning Objectives
Structural Disorders of the Uterus and Vagina
Alterations in Pelvic Support
Uterine Displacement and Prolapse
FIG. 11-1 Types of uterine displacement. A, Anterior displacement. B, Retroversion (backward displacement of the uterus).
FIG. 11-2 Prolapse of uterus.
FIG. 11-3 A, Cystocele. B, Rectocele.
Clinical Manifestations
Cystocele and Rectocele
Clinical Manifestations
Urinary Incontinence
Clinical Manifestations
FIG. 11-4 Urethrovesical angle. A, Normal angle. B, Widening (absence) of angle.
Genital Fistulas
Clinical Manifestations
Collaborative Care
FIG. 11-5 Types of fistulas that may develop in the vagina, uterus, or rectum.
FIG. 11-6 Examples of pessaries. A, Smith. B, Hodge without support. C, Incontinence dish without support. D, Ring without support. E, Cube. F, Gellhorn.
Benign Neoplasms
Ovarian Cysts
Follicular Cysts
FIG. 11-7 Ovarian cyst.
Corpus Luteum Cysts
Theca-Lutein Cysts
Polycystic Ovary Syndrome
Collaborative Care
Other Benign Ovarian Cysts and Neoplasms
FIG. 11-8 Endometrial polyps.
Uterine Polyps
Collaborative Care
Leiomyomas
CLINICAL REASONING
Informed Decision Making for Treatment of Leiomyoma
Clinical Manifestations and Diagnosis
FIG. 11-9 Types of leiomyomas. A, Subserous. B, Intramural. C, Submucosal. D, Cervical. E, Pedunculated.
Care Management
Medical Management
Medications
NURSING PROCESS
The Woman with a Leiomyoma
Assessment
Nursing Diagnoses
Anxiety related to:
Acute or Chronic Pain related to:
Sexual Dysfunction related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Uterine Artery Embolization
Surgical Management
TEACHING FOR SELF-MANAGEMENT
Care After Uterine Artery Embolization
Laser Surgery
Myomectomy
FIG. 11-10 Hysterectomy. A, Vaginal. B, Abdominal.
Hysterectomy
Preoperative Care
BOX 11-1 QUESTIONS FOR A WOMAN TO ASK TO ENSURE INFORMED CONSENT
BOX 11-2 PREOPERATIVE PROCEDURES FOR HYSTERECTOMY
BOX 11-3 POSTOPERATIVE CARE AFTER HYSTERECTOMY
Postoperative Care
Discharge Planning and Teaching
TEACHING FOR SELF-MANAGEMENT
Care After Myomectomy or Hysterectomy
Vulvar Problems
Bartholin Cysts
Collaborative Care
Vulvodynia
Collaborative Care
Malignant Neoplasms
Cancer of the Endometrium
Incidence and Etiology
Care Management
Assessment and Nursing Diagnoses
NURSING ALERT
TABLE 11-1 FIGO CLASSIFICATION OF ENDOMETRIAL CARCINOMA∗
TABLE 11-2 Common Side Effects of Chemotherapy Agents Used for Gynecologic Cancers∗
Expected Outcomes of Care
Plan of Care and Interventions
Therapeutic Management
Nursing Management
CULTURAL CONSIDERATIONS
Meaning of Cancer
Preoperative Care
Postoperative Care
Discharge Planning and Teaching
Evaluation
Cancer of the Ovary
Incidence and Etiology
NURSING CARE PLAN
Hysterectomy for Endometrial Cancer
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Clinical Manifestations and Diagnosis
BOX 11-4 NUTRITIONAL MANAGEMENT FOR COMMON PROBLEMS RELATED TO GYNECOLOGIC CANCER OR TREATMENT
Altered Taste
Anorexia
Nausea and Vomiting
Stomatitis
Constipation
Diarrhea
Postoperative Recovery
Therapeutic Management
Nursing Implications
LEGAL TIP
Advance Directives
Cancer of the Cervix
Incidence and Etiology
FIG. 11-11 Diagram of cervical epithelium showing progressive changes and various terminology.
FIG. 11-12 Location of squamocolumnar junction according to age. The location where the endocervical glands meet the squamous epithelium becomes progressively higher with age. A, Puberty. B, Reproductive years. C, Postmenopausal.
TABLE 11-3 FIGO Classification of Cervical Carcinoma
Clinical Manifestations and Diagnosis
BOX 11-5 2001 BETHESDA SYSTEM FOR REPORTING CERVICAL CYTOLOGY RESULTS
Results/Interpretations
Negative for Intraepithelial Malignancy
Epithelial Cell Abnormalities
Glandular Cell
FIG. 11-13 A, Cone biopsy for endocervical disease. Limits of lesion were not seen colposcopically. B, Cone biopsy for cervical intraepithelial neoplasia of the exocervix. Limits of lesion were identified colposcopically.
Care Management
Medical and Surgical Management
NURSING PROCESS
The Woman Having Radiation Therapy
Assessment
Nursing Diagnoses
Deficient Knowledge related to:
Fear/Anxiety related to:
Disturbed Sensory Perception related to:
Risk for Impaired Skin Integrity related to:
Risk for Injury related to:
Acute Pain related to:
Sexual Dysfunction related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Cryosurgery
EVIDENCE-BASED PRACTICE
Cervical Cancer Treatment Options: Conventional and Complementary
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
FIG. 11-14 Electrosurgical excision. The electric loop vaporizes quickly and removes cone of tissue.
Laser Ablation
Electrosurgical Excision
Radical Hysterectomy
Nursing Management
Radiation Therapy
FIG. 11-15 Intracavitary implant. Applicator in place in uterus is loaded with radium source.
Nursing Management
External Therapy
FIG. 11-16 Interstitial-intracavitary implant.
TEACHING FOR SELF-MANAGEMENT
Care After External Radiation Therapy
Internal Therapy
SAFETY ALERT
TEACHING FOR SELF-MANAGEMENT
Care After Internal Radiation Therapy
Complications of Radiation Therapy
Recurrent and Advanced Cancer of the Cervix
Pelvic Exenteration
Nursing Management
FIG. 11-17 Pelvic exenteration procedures. A, Anterior exenteration. B, Posterior exenteration. C, Total exenteration.
Chemotherapy
Cancer of the Vulva
Incidence and Etiology
Clinical Manifestations and Diagnosis
Collaborative Care
Therapeutic Management
FIG. 11-18 Radical vulvectomy. Note dotted lines denoting vulvectomy incision and inguinal groin incisions.
Nursing Management
TEACHING FOR SELF-MANAGEMENT
Care After Radical Vulvectomy
Cancer of the Vagina
Cancer of the Uterine Tubes
Cancer and Pregnancy
Cancer of the Breast
Cancer of the Cervix
Leukemia
Hodgkin’s Disease
Melanoma
Thyroid Cancer
NURSING ALERT
Colon Cancer
Other Gynecologic Cancers
Cancer of the Vulva
Cancer of the Vagina
Cancer of the Uterus
Cancer of the Uterine Tube
Cancer of the Ovary
Cancer Therapy and Pregnancy
Ethical Considerations
Timing of Therapy
Pregnancy After Cancer Treatment
Gestational Trophoblastic Disease
BOX 11-6 CLASSIFICATION OF GESTATIONAL TROPHOBLASTIC NEOPLASIA
COMMUNITY ACTIVITY
KEY POINTS
References
Unit Three Pregnancy
Interactive Review—Unit 3
Chapter 12 Conception and Fetal Development
Learning Objectives
Conception
Cell Division
Gametogenesis
FIG. 12-1 Gametogenesis. A, Oogenesis. Gametogenesis in the female produces one mature ovum and three polar bodies. Note the relative difference in overall size between the ovum and sperm. B, Spermatogenesis. Gametogenesis of the male produces four mature gametes, the sperm. C, Fertilization results in the single-cell zygote and the restoration of the diploid number of chromosomes.
Ovum
FIG. 12-2 Abnormal gametogenesis: nondisjunction. A, When nondisjunction occurs during the first meiotic division of spermatogenesis, one secondary spermatocyte contains 22 autosomes plus an X and a Y chromosome, whereas the other one contains 22 autosomes and no sex chromosomes. B, Nondisjunction during oogenesis may give rise to an oocyte with 22 autosomes and two X chromosomes (as shown) or one with 22 autosomes and no sex chromosome.
FIG. 12-3 Sperm and ovum.
Sperm
Fertilization
FIG. 12-4 Fertilization. A, Ovum fertilized by X-bearing sperm to form female zygote. B, Ovum fertilized by Y-bearing sperm to form male zygote.
Implantation
Embryo and Fetus
FIG. 12-5 First weeks of human development. A, Follicular development in the ovary, ovulation, fertilization, and transport of the early embryo down the uterine tube and into the uterus, where implantation occurs. B, Blastocyst embedded in endometrium. Germ layers forming.
Primary Germ Layers
Development of the Embryo
Membranes
FIG. 12-6 Extravillous trophoblasts are found outside the villus and can be subdivided into endovascular and interstitial categories. Endovascular trophoblasts invade and transform spiral arteries during pregnancy to create low-resistance blood flow that is characteristic of the placenta. Interstitial trophoblasts invade the decidua and surround spiral arteries.
FIG. 12-7 Development of the fetal membranes. Note gradual obliteration of intrauterine cavity as decidua capsularis and decidua vera meet. Also note thinning of uterine wall. Chorionic and amniotic membranes are in apposition to each other but may be peeled apart.
Amniotic Fluid
FIG. 12-8 Sensitive or critical periods in human development. During the first 2 weeks of development the embryo usually is not susceptible to teratogens. At that time a teratogen damages all or most of the cells, resulting in death of the embryo, or damages only a few cells, allowing the conceptus to recover and the embryo to develop without birth defects. The dark color denotes highly sensitive periods; the light color indicates stages that are less sensitive to teratogens.
Yolk Sac
Umbilical Cord
FIG. 12-9 Term placenta. A, Maternal (or uterine) surface, showing cotyledons and grooves. B, Fetal (or amniotic) surface, showing blood vessels running under amnion and converging to form umbilical vessels at attachment of umbilical cord. C, Amnion and smooth chorion are arranged to show that they are (1) fused and (2) continuous with margins of placenta.
FIG. 12-10 Schematic drawing of the placenta illustrating how it supplies oxygen and nutrition to the embryo and removes its waste products. Deoxygenated blood leaves the fetus through the umbilical arteries and enters the placenta, where it is oxygenated. Oxygenated blood leaves the placenta through the umbilical vein, which enters the fetus via the umbilical cord.
Placenta
Structure
FIG. 12-11 Distinct profile for the concentrations of human chorionic gonadotropin (hCG) and human chorionic somatomammotropin (hcs) in serum of women through normal pregnancy. IU, International units.
Functions
FIG. 12.12 Plasma level of progesterone, estradiol, estrone, and estriol in women during the course of gestation.
BOX 12-1 DEVELOPMENTALLY TOXIC EXPOSURES IN HUMANS
Fetal Maturation
Fetal Circulatory System
FIG. 12-13 Schematic illustration of the fetal circulation. The colors indicate the oxygen saturation of the blood, and the arrows show the course of the blood from the placenta to the heart. The organs are not drawn to scale. Observe that three shunts permit most of the blood to bypass the liver and lungs: (1) ductus venosus, (2) foramen ovale, and (3) ductus arteriosus. A small amount of highly oxygenated blood from the inferior vena cava remains in the right atrium and mixes with poorly oxygenated blood from the superior vena cava. This medium oxygenated blood then passes into the right ventricle. The poorly oxygenated blood returns to the placenta for oxygen and nutrients through the umbilical arteries.
Hematopoietic System
Gastrointestinal System
Hepatic System
Respiratory System
Pulmonary Surfactants
Renal System
Neurologic System
Sensory Awareness
Endocrine System
Reproductive System
Musculoskeletal System
CLINICAL REASONING
Ultrasound Examination During Pregnancy
Integumentary System
Immunologic System
FIG. 12-14 Formation of dizygotic twins, with fertilization of two ova, two implantations, two placentas, two chorions, and two amnions.
TABLE 12-1 MILESTONES IN HUMAN DEVELOPMENT BEFORE BIRTH SINCE LAST MENSTRUAL PERIOD
Multifetal Pregnancy
Twins
Dizygotic Twins
FIG. 12-15 Diamniotic dichorionic (separate) twin placenta.
Monozygotic Twins
Conjoined Twins
FIG. 12-16 Formation of monozygotic twins. A, One fertilization: blastomeres separate, resulting in two implantations, two placentas, and two sets of membranes. B, One blastomere with two inner cell masses, one fused placenta, one chorion, and separate amnions. C, One blastomere with incomplete separation of cell mass, resulting in conjoined twins.
Other Multifetal Pregnancies
Nongenetic Factors Influencing Development
KEY POINTS
Oogenesis and Meiosis (read text)
Spermatogenesis (read text)
Testes (read text)
Male Accessory Sex Glands (read text)
Male External Genitalia (read text)
Male Reproductive Ducts (read text)
Pathway of Ovum (read text)
Pathway of Sperm (read text)
Fertilization and Implantation (read text)
Maternal and Fetal Circulation (read text)
First Trimester, Fetal Development (read text)
Second Trimester, Fetal Development (read text)
Third Trimester, Fetal Development (read text)
References
Chapter 13 Anatomy and Physiology of Pregnancy
Learning Objectives
Gravidity and Parity
TABLE 13-1 OBSTETRIC HISTORY USING FIVE-DIGIT SYSTEM AND TWO-DIGIT SYSTEM
NURSING ALERT
Pregnancy Tests
FIG. 13-1 Many pregnancy test products are available over the counter.
TEACHING FOR SELF-MANAGEMENT
Home Pregnancy Testing
CLINICAL REASONING
Pregnancy Testing
Adaptations to Pregnancy
TABLE 13-2 SIGNS OF PREGNANCY
Signs of Pregnancy
Reproductive System and Breasts
Uterus
Changes in Size, Shape, and Position
FIG. 13-2 Comparison of abdomen, vulva, and cervix in nullipara (A), and multipara (B), at the same stage of pregnancy.
Changes in Contractility
Uteroplacental Blood Flow
FIG. 13-3 Height of fundus by weeks of normal gestation with a single fetus. Dashed line, height after lightening.
Cervical Changes
FIG. 13-4 Displacement of internal abdominal structures and diaphragm by the enlarging uterus at 4, 6, and 9 months of gestation.
Changes Related to the Presence of the Fetus
FIG. 13-5 Hegar sign. Bimanual examination for assessing compressibility and softening of the isthmus (lower uterine segment) while the cervix is still firm.
FIG. 13-6 Internal ballottement (18 weeks).
Vagina and Vulva
FIG. 13-7 A, Cervix in nonpregnant woman. B, Cervix during pregnancy.
Breasts
General Body Systems
Cardiovascular System
FIG. 13-9 Changes in position of heart, lungs, and thoracic cage in pregnancy. Broken line, nonpregnant; solid line, change that occurs in pregnancy.
BOX 13-1 BLOOD PRESSURE MEASUREMENT
Blood Pressure
BOX 13-2 CALCULATION OF MEAN ARTERIAL PRESSURE
Blood Volume and Composition
FIG. 13-10 Hemorrhoids.
Cardiac Output
Circulation and Coagulation Times
Respiratory System
Pulmonary Function
Basal Metabolic Rate
TABLE 13-3 LABORATORY VALUES FOR PREGNANT AND NONPREGNANT WOMEN
TABLE 13-4 CARDIOVASCULAR CHANGES IN PREGNANCY
Acid-Base Balance
Renal System
Anatomic Changes
TABLE 13-5 RESPIRATORY CHANGES IN PREGNANCY
Functional Changes
Fluid and Electrolyte Balance
Integumentary System
FIG. 13-11 Striae gravidarum and linea nigra in a dark-skinned woman.
NURSING ALERT
Musculoskeletal System
FIG. 13-12 Postural changes during pregnancy. A, Nonpregnant posture. B, Incorrect posture during pregnancy. C, Correct posture during pregnancy.
Neurologic System
FIG. 13-13 Possible change in rectus abdominis muscles during pregnancy. A, Normal position in nonpregnant woman. B, Diastasis recti abdominis in pregnant woman.
Gastrointestinal System
Appetite
Mouth
Esophagus, Stomach, and Intestines
Gallbladder and Liver
Abdominal Discomfort
Endocrine System
Pituitary and Placental Hormones
FIG. 13-14 Change in position of appendix in pregnancy. Note McBurney’s point.
Thyroid Gland
Parathyroid Gland
Pancreas
Adrenal Glands
KEY POINTS
References
Chapter 14 Maternal and Fetal Nutrition
Learning Objectives
Nutrient Needs Before Conception
FIG. 14-1 Factors that affect the outcome of pregnancy.
Nutrient Needs During Pregnancy
Energy Needs
BOX 14-1 FOOD SOURCES OF FOLATE
Foods Providing 500 Micrograms or More Per Serving
Foods Providing 200 Micrograms or More Per Serving
Foods Providing 100 Micrograms or More Per Serving
Foods Providing 50 Micrograms or More Per Serving
Foods Providing 20 Micrograms or More Per Serving
Weight Gain
FIG. 14-2 Prenatal weight-gain chart for plotting weight gain of normal-weight women.
TABLE 14-1 RECOMMENDATIONS FOR DAILY INTAKES OF SELECTED NUTRIENTS DURING PREGNANCY AND LACTATION
Pattern of Weight Gain
BOX 14-2 WEIGHT GAIN DURING PREGNANCY
Hazards of Restricting Adequate Weight Gain
CLINICAL REASONING
Imbalanced Nutrition
Excessive Weight Gain
TABLE 14-2 TISSUES CONTRIBUTING TO MATERNAL WEIGHT GAIN AT 40 WEEKS OF GESTATION
BOX 14-3 BARIATRIC OBSTETRIC CARE
Protein
TABLE 14-3 DAILY FOOD GUIDE FOR PREGNANCY AND LACTATION
SAFETY ALERT
Fluids
Minerals and Vitamins
TABLE 14-4 CAFFEINE CONTENT OF COMMON BEVERAGES AND FOODS
Iron
BOX 14-4 USE OF ARTIFICIAL SWEETENERS DURING PREGNANCY
Calcium
BOX 14-5 INDICATORS OF NUTRITIONAL RISK IN PREGNANCY
EVIDENCE-BASED PRACTICE
What Else Should We Tell Our Pregnant Clients to Take, Besides Folic Acid?
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Evidence
Implications for Practice
References
Other Minerals and Electrolytes
Magnesium
Sodium
BOX 14-6 CALCIUM SOURCES FOR WOMEN WHO DO NOT DRINK MILK
Fish
Beans and Legumes
Greens
Baked Products
Fruits
Sauces
Potassium
Zinc
Fluoride
Fat-Soluble Vitamins
Water-Soluble Vitamins
Folate/Folic Acid
Pyridoxine
Vitamin C
FIG. 14-3 Nonfood substances consumed in pica: red clay from Georgia, Nzu from East Nigeria, baking powder, cornstarch, baking soda, laundry starch, and ice. Some individuals practice poly-pica, consuming more than one of these or other nonfood substances.
Other Nutritional Issues During Pregnancy
Pica and Food Cravings
Adolescent Pregnancy Needs
Preeclampsia
Physical Activity During Pregnancy
Nutrient Needs During Lactation
Care Management
Diet History
Obstetric and Gynecologic Effects on Nutrition
NURSING PROCESS
Excessive Gestational Weight Gain
Assessment
Nursing Diagnoses
Imbalanced Nutrition: More than Body Requirements related to:
Deficient Knowledge related to:
Risk for Injury (to the Fetus) related to:
Ineffective Health Maintenance related to:
Disturbed Body Image related to:
Expected Outcomes of Care
Plan of Care and Interventions
Home Care
Evaluation
Health History
Usual Maternal Diet
SAFETY ALERT
Physical Examination
Laboratory Testing
Client Education
BOX 14-7 FOOD INTAKE QUESTIONNAIRE
Adequate Dietary Intake
TABLE 14-5 PHYSICAL ASSESSMENT OF NUTRITIONAL STATUS
COMMUNITY ACTIVITY
Pregnancy
Postpartum
NURSING CARE PLAN
Nutrition During Pregnancy
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Daily Food Guide and Menu Planning
Medical Nutrition Therapy
Counseling About Iron Supplementation
Coping with Nutrition-Related Discomforts of Pregnancy
Nausea and Vomiting
TEACHING FOR SELF-MANAGEMENT
Iron Supplementation
Constipation
Pyrosis
Cultural Influences
BOX 14-8 SUGGESTIONS FOR MANAGING NAUSEA AND VOMITING DURING PREGNANCY
Vegetarian Diets
TABLE 14-6 POPULAR FOODS OF VARIOUS CULTURAL AND ETHNIC GROUPS AND THEIR PLACE IN MYPYRAMID
KEY POINTS
References
Chapter 15 Nursing Care of the Family During Pregnancy
Learning Objectives
Diagnosis of Pregnancy
Signs and Symptoms
Estimating Date of Birth
BOX 15-1 USE OF NÄGELE’S RULE
Adaptation to Pregnancy
Maternal Adaptation
Accepting the Pregnancy
Identifying with the Mother Role
Reordering Personal Relationships
FIG. 15-1 A pregnant woman and her mother enjoying their walk together.
Establishing a Relationship with the Fetus
Preparing for Childbirth
FIG. 15-2 Four-year-old likes to examine the pregnant abdomen of his mother.
Paternal Adaptation
Accepting the Pregnancy
Identifying with the Father Role
FIG. 15-3 A prospective mother and father walk together. Women respond positively to their partner’s interest and concern.
Reordering Personal Relationships
Establishing a Relationship with the Fetus
Preparing for Childbirth
Sibling Adaptation
FIG. 15-4 A sibling class of preschoolers learns infant care using dolls.
BOX 15-2 SIBLING ADAPTATION
Tips for Sibling Preparation
Prenatal
During the Hospital Stay
Going Home
Adjustment After the Baby Is Home
Grandparent Adaptation
Care Management
FIG. 15-5 A grandfather getting to know his grandson.
BOX 15-3 PRENATAL VISIT SCHEDULE
Initial Visit
Prenatal Interview
NURSING PROCESS
Nursing Care During Pregnancy
Assessment
Nursing Diagnoses
Anxiety related to
Interrupted Family Processes related to
Deficient Knowledge related to
Disturbed Sleep Pattern related to
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Reason for Seeking Care
Current Pregnancy
Childbearing and Female Reproductive System History
Health History
Nutritional History
History of Drug and Herbal Preparations Use
Family History
Social, Experiential, and Occupational History
History of Physical Abuse
Review of Systems
Physical Examination
TABLE 15-1 LABORATORY TESTS IN PRENATAL PERIOD
Laboratory Tests
BOX 15-4 HIV SCREENING
Follow-up Visits
FIG. 15-6 A prenatal interview.
Interview
Physical Examination
EMERGENCY
Supine Hypotension
Signs and Symptoms
Interventions
Fetal Assessment
Listening for Fetal Heart Tones
Measuring Fundal Height
SIGNS OF POTENTIAL COMPLICATIONS
First, Second, and Third Trimesters
FIG. 15-7 Measurement of fundal height from symphysis that (A), includes the upper curve of the fundus and (B), does not include the upper curve of the fundus. Note position of hands and measuring tape.
Gestational Age
FIG. 15-8 Detecting fetal heart rate. A, Father listens to the fetal heart (first detectable around 18 to 20 weeks) with a fetoscope. B, Doppler ultrasound stethoscope (fetal heartbeat detectable at 12 weeks). C, Pinard fetoscope. Note: Hands should not touch fetoscope while listening.
Health Status
Laboratory Tests
Collaborative Care
Education About Maternal and Fetal Changes
Education for Self-Management
Nutrition
Personal Hygiene
Prevention of Urinary Tract Infections
Kegel Exercises
Preparation for Breastfeeding
FIG. 15-9 A, Normal nipple everts with gentle pressure. B, Inverted nipple inverts with gentle pressure.
FIG. 15-10 Breast shell in place inside bra to evert nipple.
Dental Care
Physical Activity
Posture and Body Mechanics
TEACHING FOR SELF-MANAGEMENT
Exercise Tips for Pregnant Women
Riding a recumbent bicycle provides exercise while supplying back support.
FIG. 15-11 Exercises. A-C, Pelvic rocking relieves low backache (excellent for relief of menstrual cramps as well). D, Abdominal breathing aids relaxation and lifts abdominal wall off uterus.
FIG. 15-12 Correct body mechanics. A, Squatting. B, Lifting.
TEACHING FOR SELF-MANAGEMENT
Posture and Body Mechanics
To Prevent or Relieve Backache
To Restrict the Lumbar Curve
To Prevent Round Ligament Pain and Strain on Abdominal Muscles
Rest and Relaxation
FIG. 15-13 Side-lying position for rest and relaxation. Some women prefer to support upper part of leg with pillows.
FIG. 15-14 Squatting for muscle relaxation and strengthening and for keeping leg and hip joints flexible.
Employment
BOX 15-5 CONSCIOUS RELAXATION TIPS
TEACHING FOR SELF-MANAGEMENT
Safety During Pregnancy
FIG. 15-15 Position for resting legs and for reducing edema and varicosities. Encourage woman with vulvar varicosities to include pillow under her hips.
Clothing
Travel
FIG. 15-16 Relief of muscle spasm (leg cramps). A, Another person dorsiflexes foot with knee extended. B, Woman stands and leans forward, thereby dorsiflexing foot of affected leg.
FIG. 15-17 Proper use of seat belt and headrest.
Medications and Herbal Preparations
NURSING ALERT
Immunizations
SAFETY ALERT
Alcohol, Cigarette Smoke, Caffeine, and Drugs
EVIDENCE-BASED PRACTICE
Perinatal Smoking Cessation
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Normal Discomforts
CLINICAL REASONING
Nausea in pregnancy
BOX 15-6 COMPLEMENTARY AND ALTERNATIVE THERAPIES USED IN PREGNANCY
Morning Sickness and Hyperemesis
Relaxation and Muscle-Ache Relief
Recognizing Potential Complications
FIG. 15-18 Pericardium 6 (p6) acupressure point for nausea.
TEACHING FOR SELF-MANAGEMENT
Sexuality in Pregnancy
TABLE 15-2 DISCOMFORTS RELATED TO PREGNANCY
NURSING CARE PLAN
Discomforts of Pregnancy and Warning Signs
First Trimester
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Second Trimester
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Third Trimester
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Recognizing Preterm Labor
Sexual Counseling
Using the History
Countering Misinformation
Suggesting Alternative Behaviors
FIG. 15-19 Positions for sexual intercourse during pregnancy. A, Female superior. B, Side by side. C, Rear entry. D, Side-lying, facing each other.
Psychosocial Support
Variations in Prenatal Care
Cultural Influences
Emotional Response
Clothing
Physical Activity and Rest
FIG. 15-20 A young woman from Honduras wearing a muñeco given to her by her mother to ensure a safe birth.
Sexual Activity
Diet
Age Differences
Adolescents
Women Older Than 35 Years
Multiparous Women
FIG. 15-21 Pregnant adolescents reviewing fetal development.
NURSING CARE PLAN
Adolescent Pregnancy
NURSING DIAGNOSIS
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Primiparous Women
Multifetal Pregnancy
Childbirth and Perinatal Education
Childbirth Education Programs
FIG. 15-22 Learning relaxation exercises with the whole family.
Current Practices in Childbirth Education
Pain Management
Perinatal Care Choices
Physicians
Nurse-Midwives
Direct-Entry Midwives
Doulas
COMMUNITY ACTIVITY
Birth Plans
Birth Setting Choices
BOX 15-7 QUESTIONS TO ASK WHEN CHOOSING A DOULA
Labor, Delivery, Recovery, Postpartum (Birthing) Rooms
Birth Centers
FIG. 15-23 A, Labor, delivery, and recovery (LDR) unit. B, Labor, delivery, recovery, and postpartum (LDRP) unit. Note sofa in background that converts to a bed.
FIG. 15-24 Birth center. A, Note double bed, baby crib, and birthing stool. B, Lounge and kitchen.
Home Birth
KEY POINTS
Abdomen / Fundal Height (read text)
References
Unit Four Childbirth
Interactive Review—Unit 4
Chapter 16 Labor and Birth Processes
Learning Objectives
Factors Affecting Labor
Passenger
Size of the Fetal Head
FIG. 16-1 Fetal head at term. A, Bones.B, Sutures and fontanels.
Fetal Presentation
Fetal Lie
Fetal Attitude
Fetal Position
FIG. 16-2 Examples of fetal vertex (occiput) presentations in relation to front, back, or side of maternal pelvis.
Passageway
FIG. 16-3 Fetal presentations. A through C, Breech (sacral) presentations. D, Shoulder presentation.
FIG. 16-4 Diameters of the fetal head at term. A, Cephalic presentations: occiput, vertex, and sinciput; and cephalic diameters: suboccipitobregmatic, occipitofrontal, and occipitomental. B, Biparietal diameter.
Bony Pelvis
FIG. 16-5 Head entering pelvis. Biparietal diameter is indicated with shading (9.25 cm). A, Suboccipitobregmatic diameter: complete flexion of head on chest so that smallest diameter enters. B, Occipitofrontal diameter: moderate extension (military attitude) so that large diameter enters. C, Occipitomental diameter: marked extension (deflection), so that the largest diameter, which is too large to permit head to enter pelvis, is presenting.
FIG. 16-7 Female pelvis. A, Pelvic brim from above. B, Pelvic outlet from below.
FIG. 16-8 Pelvic cavity. A, Inlet and midplane. Outlet not shown. B, Cavity of true pelvis. C, Note curve of sacrum and axis of birth canal.
FIG. 16-9 Estimation of angle of subpubic arch. With both thumbs, examiner externally traces descending rami down to tuberosities.
Soft Tissues
Powers
Primary Powers
FIG. 16-10 A, Uterus in normal labor in early first stage, and B, in second stage. Passive segment is derived from lower uterine segment (isthmus) and cervix, and physiologic retraction ring is derived from anatomic internal os. C, Uterus in abnormal labor in second-stage dystocia. Pathologic retraction (Bandl) ring that forms under abnormal conditions develops from the physiologic ring.
TABLE 16-1 OBSTETRIC MEASUREMENTS
TABLE 16-2 COMPARISON OF PELVIC TYPES
FIG. 16-11 Cervical effacement and dilation. Note how cervix is drawn up around presenting part (internal os). Membranes are intact, and head is not well applied to cervix. A, Before labor. B, Early effacement. C, Complete effacement (100%). Head is well applied to cervix. D, Complete dilation (10 cm). Cranial bones overlap somewhat, and membranes are still intact.
Secondary Powers
Position of the Laboring Woman
Process of Labor
Signs Preceding Labor
FIG. 16-12 Positions for labor and birth. A, Positions for labor. B, Positions for birth.
Onset of Labor
BOX 16-1 SIGNS PRECEDING LABOR
Stages of Labor
CLINICAL REASONING
Second Stage Labor in a Woman with an Epidural
Mechanism of Labor
FIG. 16-13 Cardinal movements of the mechanism of labor. Left occipitoanterior (LOA) position. Pelvic figures show the position of the fetal head as seen by the birth attendant. A, Engagement and descent. B, Flexion. C, Internal rotation to occipitoanterior position (OA). D, Extension. E, External rotation beginning (restitution). F, External rotation.
Engagement
Asynclitism
Descent
FIG. 16-14 Synclitism and asynclitism. A, Anterior asynclitism. B, Normal synclitism. C, Posterior asynclitism.
Flexion
Internal Rotation
Extension
Restitution and External Rotation
Expulsion
Physiologic Adaptation to Labor
Fetal Adaptation
Fetal Heart Rate
Fetal Circulation
Fetal Respiration
Maternal Adaptation
Cardiovascular Changes
BOX 16-2 MATERNAL PHYSIOLOGIC CHANGES DURING LABOR
Respiratory Changes
Renal Changes
Integumentary Changes
Musculoskeletal Changes
Neurologic Changes
Gastrointestinal Changes
Endocrine Changes
KEY POINTS
Presentation (read text)
Fetal Lie (read text)
Position (read text)
References
Chapter 17 Pain Management
Learning Objectives
Pain During Labor and Birth
Neurologic Origins
Perception of Pain
Expression of Pain
FIG. 17-1 Discomfort during labor. A, Distribution of labor pain during first stage. B, Distribution of labor pain during transition and early phase of second stage. C, Distribution of pain during late second stage and actual birth.
Factors Influencing Pain Response
Physiologic Factors
Culture
CULTURAL CONSIDERATIONS
Some Cultural Beliefs About Pain
Anxiety
Previous Experience
Gate-Control Theory of Pain
Comfort
Support
BOX 17-1 SUGGESTED MEASURES FOR SUPPORTING A WOMAN IN LABOR
Environment
Nonpharmacologic Pain Management
EVIDENCE-BASED PRACTICE
Complementary and Alternative Pain Management in Labor
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
CLINICAL REASONING
Making Decisions Regarding Pain Management for Labor
Childbirth Preparation Methods
BOX 17-2 NONPHARMACOLOGIC STRATEGIES TO ENCOURAGE RELAXATION AND RELIEVE PAIN
Cutaneous Stimulation Strategies
Sensory Stimulation Strategies
Cognitive Strategies
COMMUNITY ACTIVITY
Relaxation and Breathing Techniques
Focusing and Relaxation Techniques
FIG. 17-2 A laboring woman using focusing and breathing techniques during a uterine contraction with coaching from her partner.
Breathing Techniques
FIG. 17-3 Expectant parents learning relaxation techniques.
BOX 17-3 PACED BREATHING TECHNIQUES
Cleansing Breath
Slow-Paced Breathing (Approximately 6 to 8 Breaths per Minute)
Modified-Paced Breathing (Approximately 32 to 40 Breaths per Minute)
Patterned-Paced or Pant-Blow Breathing (Same Rate as Modified)
Effleurage and Counterpressure
Music
FIG. 17-4 Water therapy during labor. A, Use of shower during labor. B, Woman experiencing back labor relaxes as partner sprays warm water on her back. C, Laboring woman relaxes in Jacuzzi. Note that fetal monitoring can continue during time in the Jacuzzi.
Water Therapy (Hydrotherapy)
SAFETY ALERT
Transcutaneous Electrical Nerve Stimulation
Acupressure and Acupuncture
FIG. 17-5 Placement of transcutaneous electrical nerve stimulation (TENS) electrodes on back for relief of labor pain.
FIG. 17-6 Ho-Ku acupressure point (back of hand where thumb and index finger come together) used to enhance uterine contractions without increasing pain.
Application of Heat and Cold
Touch and Massage
Hypnosis
Biofeedback
Aromatherapy
FIG. 17-7 Intradermal injections of 0.1 ml of sterile water in the treatment of women with back pain during labor. Sterile water is injected into four locations on the lower back, two over each posterior superior iliac spine (PSIS) and two 3 cm below and 1 cm medial to the PSIS. The injections should raise a bleb on the skin. Simultaneous injections administered by two clinicians will decrease the pain of the injections.
Intradermal Water Block
Pharmacologic Pain Management
Sedatives
Analgesia and Anesthesia
BOX 17-4 PHARMACOLOGIC CONTROL OF DISCOMFORT BY STAGE OF LABOR AND METHOD OF BIRTH
First Stage
Second Stage
Vaginal Birth
Cesarean Birth
Systemic Analgesia
Opioid Agonist Analgesics
SAFETY ALERT
Opioid (Narcotic) Agonist-Antagonist Analgesics
MEDICATION GUIDE
Opioid Agonist Analgesics
Action
Indication
Dosage and Route
Adverse Effects
Nursing Considerations
MEDICATION GUIDE
Opioid Agonist-Antagonist Analgesics
Action
Indication
Dosage and Route
Adverse Effects
Nursing Considerations
SIGNS OF POTENTIAL COMPLICATIONS
Maternal Opioid Abstinence Syndrome (Opioid/Narcotic Withdrawal)
Opioid (Narcotic) Antagonists
NURSING ALERT
MEDICATION GUIDE
Opioid Antagonist
Action
Indication
Dosage and Route
Adult
Newborn
Adverse Effects
Nursing Considerations
Nerve Block Analgesia and Anesthesia
Local Perineal Infiltration Anesthesia
FIG. 17-8 Pain pathways and sites of pharmacologic nerve blocks. A, Pudendal nerve block: suitable during second and third stages of labor and for repair of episiotomy or lacerations. B, Epidural block: suitable for all stages of labor and types of birth, and for repair of episiotomy and lacerations.
Pudendal Nerve Block
Spinal Anesthesia
FIG. 17-9 Pudendal nerve block. Use of needle guide (Iowa trumpet) and Luer-Lok syringe to inject medication.
SAFETY ALERT
FIG. 17-10 A, Membranes and spaces of spinal cord and levels of sacral, lumbar, and thoracic nerves. B, Cross section of vertebra and spinal cord. C, Level of anesthesia necessary for cesarean birth and for vaginal births.
FIG. 17-11 Positioning for spinal and epidural blocks. A, Lateral position. B, Upright position. C, Catheter for epidural is taped to woman’s back with port segment located near her shoulder.
EMERGENCY
Maternal Hypotension with Decreased Placental Perfusion
Signs and Symptoms
Interventions
FIG. 17-12 Blood-patch therapy for spinal headache.
Epidural Anesthesia or Analgesia (Block)
NURSING ALERT
BOX 17-5 SIDE EFFECTS OF EPIDURAL AND SPINAL ANESTHESIA
Combined Spinal-Epidural (CSE) Analgesia
Epidural and Intrathecal (Spinal) Opioids
Contraindications to Subarachnoid and Epidural Blocks
Epidural Block Effects on Newborn
Nitrous Oxide for Analgesia
General Anesthesia
FIG. 17-13 Technique of applying pressure on cricoid cartilage to occlude esophagus to prevent pulmonary aspiration of gastric contents during induction of general anesthesia.
Care Management
Nonpharmacologic Interventions
Pharmacologic Interventions
Informed Consent
LEGAL TIP:
Informed Consent for Anesthesia
Timing of Administration
Preparation for Procedures
NURSING PROCESS
Pain Management
Assessment
Nursing Diagnoses
Acute Pain related to:
Risk for Ineffective Tissue Perfusion related to:
Situational Low Self-esteem related to:
Anxiety or Fear related to:
Risk for Fetal Injury related to:
Risk for Maternal Injury related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
NURSING CARE PLAN
Nonpharmacologic Pain Management
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Administration of Medication
Intravenous Route
Intramuscular Route
BOX 17-6 NURSING INTERVENTIONS FOR THE WOMAN RECEIVING EPIDURAL OR SPINAL ANESTHESIA
Prior to the Block
During Initiation of the Block
While the Block is in Effect
While the Block is Wearing off After Birth
Regional (Epidural or Spinal) Anesthesia
NURSING ALERT
FIG. 17-14 Modified throne position for labor.
SAFETY ALERT
Safety and General Care
KEY POINTS
References
Chapter 18 Fetal Assessment During Labor
Learning Objectives
Basis for Monitoring
Fetal Response
BOX 18-1 THREE-TIER FETAL HEART RATE CLASSIFICATION SYSTEM
Category I
Category II
Category III
Uterine Activity
Fetal Compromise
TABLE 18-1 NORMAL UTERINE ACTIVITY DURING LABOR
Monitoring Techniques
Intermittent Auscultation
EVIDENCE-BASED PRACTICE
Fetal Monitoring and the Machine That Goes “Beep”
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Evidence
Implications for Practice
References
FIG. 18-1 A, Ultrasound fetoscope. B, Ultrasound stethoscope. C, DeLee-Hillis fetoscope.
BOX 18-2 PROCEDURE FOR INTERMITTENT AUSCULTATION OF THE FETAL HEART RATE
NURSING ALERT
Electronic Fetal Monitoring
External Monitoring
Internal Monitoring
TABLE 18-2 EXTERNAL AND INTERNAL MODES OF MONITORING
FIG. 18-2 A, External noninvasive fetal monitoring with tocotransducer and ultrasound transducer. B, Ultrasound transducer is placed below umbilicus, over the area where fetal heart rate is best heard, and tocotransducer is placed on uterine fundus.
FIG. 18-3 Diagrammatic representation of internal invasive fetal monitoring with intrauterine pressure catheter and spiral electrode in place (membranes ruptured and cervix dilated).
Display
FIG. 18-4 Display of fetal heart rate and uterine activity on monitor paper. A, External mode with ultrasound and tocotransducer as signal source. B, Internal mode with spiral electrode and intrauterine catheter as signal source. Frequency of contractions is measured from the beginning of one contraction to the beginning of the next.
Fetal Heart Rate Patterns
Baseline Fetal Heart Rate
Variability
FIG. 18-5 Fetal heart rate variability. A, Absent variability; amplitude range undetectable. B, Minimal variability; amplitude range detectable up to and including 5 beats/min. C, Moderate variability; amplitude range 6 to 25 beats/min. D, Marked variability; amplitude range >25 beats/min.
FIG. 18-6 Sinusoidal FHR pattern.
Tachycardia
FIG. 18-7 Fetal tachycardia.
TABLE 18-3 TACHYCARDIA AND BRADYCARDIA
Bradycardia
FIG. 18-8 Fetal bradycardia.
Periodic and Episodic Changes in Fetal Heart Rate
Accelerations
FIG. 18-9 Fetal accelerations.
BOX 18-3 ACCELERATIONS
Causes
Clinical Significance
Nursing Interventions
Decelerations
Early Decelerations
FIG. 18-10 Early decelerations.
BOX 18-4 EARLY DECELERATIONS
Cause
Clinical Significance
Nursing Interventions
Late Decelerations
FIG. 18-11 Late decelerations.
BOX 18-5 LATE DECELERATIONS
Cause
Clinical Significance
Nursing Interventions
Variable Decelerations
FIG. 18-12 Variable decelerations.
CLINICAL REASONING
Admission of an Emergency Client to Labor and Delivery
BOX 18-6 VARIABLE DECELERATIONS
Cause
Clinical Significance
Nursing Interventions
Prolonged Decelerations
FIG. 18-13 Prolonged decelerations.
NURSING ALERT
Care Management
Electronic Fetal Monitoring Pattern Recognition and Interpretation
Categorizing FHR Tracings
BOX 18-7 CHECKLIST FOR FETAL MONITORING EQUIPMENT
Preparation of Monitor
Ultrasound Transducer
Tocotransducer
Spiral Electrode
Internal Catheter or Strain Gauge
NURSING PROCESS
Electronic Fetal Heart Rate Monitoring
Assessment
Nursing Diagnoses
Decreased Maternal Cardiac Output related to:
Anxiety related to:
Impaired Fetal Gas Exchange related to:
Risk for Fetal Injury related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
LEGAL TIP
Fetal Monitoring Standards
Nursing Management of Abnormal Patterns
BOX 18-8 MANAGEMENT OF ABNORMAL FETAL HEART RATE PATTERNS
Basic Interventions
Interventions for Specific Problems
Other Methods of Assessment and Intervention
Assessment Techniques
Fetal Scalp Stimulation and Vibroacoustic Stimulation
Umbilical Cord Acid-Base Determination
TABLE 18-4 APPROXIMATE NORMAL VALUES FOR CORD BLOOD
TABLE 18-5 TYPES OF ACIDEMIA
Fetal Scalp Blood Sampling
Fetal Pulse Oximetry
Interventions
Amnioinfusion
Tocolytic Therapy
FIG. 18-14 A nurse explains electronic fetal monitoring as ultrasound transducer monitors the fetal heart rate.
Client and Family Teaching
BOX 18-9 CLIENT AND FAMILY TEACHING WHEN ELECTRONIC FETAL MONITOR IS USED
Documentation
BOX 18-10 CHECKLIST FOR FETAL HEART RATE AND UTERINE ACTIVITY ASSESSMENT WITH ELECTRONIC FETAL MONITORING
KEY POINTS
Fetal Heart Rate (read text)
References
Chapter 19 Nursing Care of the Family During Labor and Birth
Learning Objectives
First Stage of Labor
Care Management
Assessment
TEACHING FOR SELF-MANAGEMENT
How to Distinguish True Labor from False Labor
True Labor
False Labor
FIG. 19-1 Woman being assessed for admission to the labor and birth unit.
COMMUNITY ACTIVITY
Prenatal Data
FIG. 19-2 Admission screens in an electronic medical record. A, General admission screen. B, Current admission screen.
Interview
PROCEDURE
Tests for Rupture of Membranes
Nitrazine Test for pH
Procedure
Read Results
Document Results
Test for Ferning or Fern Pattern
Document Results
BOX 19-1 THE BIRTH PLAN
Psychosocial Factors
Women with a History of Sexual Abuse
Stress in Labor
TABLE 19-1 EXPECTED MATERNAL PROGRESS IN FIRST STAGE OF LABOR
BOX 19-2 PSYCHOSOCIAL ASSESSMENT OF THE LABORING WOMAN
Verbal Interactions
Body Language
Perceptual Ability
Discomfort Level
Cultural Factors
FIG. 19-3 Birthing room specific to a Native-American population. Note the arrow pointing east, the rug on the wall, and the rope or sash belt hanging from the ceiling.
Culture and Father Participation
The Non–English-Speaking Woman in Labor
Physical Examination
BOX 19-3 STANDARD PRECAUTIONS DURING CHILDBIRTH
General Systems Assessment
Vital Signs
Leopold Maneuvers (Abdominal Palpation)
Assessment of Fetal Heart Rate and Pattern
Assessment of Uterine Contractions
FIG. 19-4 Portion of the labor flowsheet screen in an electronic medical record.
FIG. 19-6 Location of the fetal heart tones (FHTs). A, FHTs with fetus in right occipitoanterior (ROA) position. B, Changes in location of point of maximal intensity of FHTs as fetus undergoes internal rotation from ROA to OA and descent for birth. C, FHTs with fetus in left sacrum posterior position.
LEGAL TIP
Obstetric Triage and EMTALA
CULTURAL CONSIDERATIONS
Birth Practices in Different Cultures
South Korea
Japan
China
India
Iran
Mexico
Laos
NURSING PROCESS
First Stage of Labor
Assessment
Nursing Diagnoses
Acute Pain related to
Anxiety related to
Impaired Urinary Elimination related to
Impaired Gas Exchange (Fetal) related to
Situational Low Self-esteem (Maternal) related to
Situational Low Self-esteem (father or partner) related to
Expected Outcomes of Care
Plan of Care and Interventions
Latent phase
Active and transition phase
Evaluation
PROCEDURE
Leopold Maneuvers
NURSING ALERT
NURSING ALERT
Vaginal Examination
PROCEDURE
Vaginal Examination of the Laboring Woman
Laboratory and Diagnostic Tests
Analysis of Urine Specimen
Blood Tests
FIG. 19-7 Assessment of uterine contractions. A, Abdominal contour before and during uterine contraction. B, Wavelike pattern of contractile activity.
FIG. 19-8 Partograms for assessment of patterns of cervical dilation and descent. Individual woman’s labor patterns (colored) are superimposed on prepared labor graph (black) for comparison. A, Labor of a nulliparous woman. B, Labor of a multiparous woman. The rate of cervical dilation is plotted with the circled plot points. A line drawn through these symbols depicts the slope of the curve. Station is plotted with Xs. A line drawn through the Xs reveals the pattern of descent.
Other Tests
Assessment of Amniotic Membranes and Fluid
NURSING ALERT
Infection
Nursing Care
SIGNS OF POTENTIAL COMPLICATIONS
Labor
BOX 19-4 EVIDENCE-BASED CARE PRACTICES DESIGNED TO PROMOTE, PROTECT, AND SUPPORT NORMAL LABOR AND BIRTH
General Hygiene
NURSING CARE PLAN
Labor and Birth
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
TABLE 19-2 PHYSICAL NURSING CARE DURING LABOR
Nutrient and Fluid Intake
Oral Intake
Intravenous Intake
NURSING ALERT
Elimination
Voiding
Catheterization
Bowel Elimination
FIG. 19-10 Woman preparing to walk with partner.
Ambulation and Positioning
SAFETY ALERT
FIG. 19-13 Woman laboring using birth ball.
EVIDENCE-BASED PRACTICE
Benefits of Continuous Labor Support
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Evidence
Implications for Practice
References
Supportive Care During Labor and Birth
CLINICAL REASONING
Encouraging Evidence-Based Birth Practices
BOX 19-5 COMMON MATERNAL POSITIONS∗ DURING LABOR AND BIRTH
Semirecumbent Position (See Figs. 19-15, B; Fig. 19-16, B)
Lateral Position (See Figs. 19-12, B, and 19-15, A)
Upright Position
Hands-and-Knees Position—Position for Posterior Positions of the Presenting Part (See Figs. 19-11, B; Fig. 19-13)
Labor Support by the Nurse
FIG. 19-14 Partner providing comfort measures.
Labor Support by the Father or Partner
BOX 19-6 GUIDELINES FOR SUPPORTING THE FATHER∗
Labor Support by Doulas
Labor Support by Grandparents
Siblings During Labor and Birth
Emergency Interventions
Second Stage of Labor
Care Management
EMERGENCY
Interventions for Emergencies During Labor
TABLE 19-3 EXPECTED MATERNAL PROGRESS IN THE SECOND STAGE OF LABOR
Preparing for Birth
Maternal Position
NURSING PROCESS
Second Stage of Labor
Assessment
Nursing Diagnoses
Risk for Injury (to Mother and Fetus) related to
Acute Pain related to
Anxiety related to
Risk for Infection related to
Situational Low Self-Esteem (maternal) related to
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
FIG. 19-15 A, Pushing, side-lying position. Perineal bulging can be seen. B, Pushing, semisitting position. Midwife assists mother to feel top of fetal head.
BOX 19-7 GUIDELINES FOR ASSISTANCE AT THE EMERGENCY BIRTH OF A FETUS IN THE VERTEX PRESENTATION
FIG. 19-16 The versatility of today’s birthing bed makes it practical in a variety of settings. NOTE: OB table used for lithotomy position. A, Labor bed. B, Birth chair. C, Birth bed. D, OB table. E, Squatting or birth bar.
Bearing-Down Efforts
FIG. 19-17 Birth bed.
Fetal Heart Rate and Pattern
Support of the Father or Partner
Supplies, Instruments, and Equipment
FIG. 19-18 Instrument table.
FIG. 19-19 Radiant warmer for newborn.
Birth in a Delivery Room or Birthing Room
FIG. 19-20 Delivery room.
Mechanism of Birth: Vertex Presentation
FIG. 19-21 Beginning birth with vertex presenting. A, Anteroposterior slit. B, Oval opening. C, Circular shape. D, Crowning.
FIG. 19-22 Birth of head with modified Ritgen maneuver. Note control to prevent too-rapid birth of head.
Fundal Pressure
Immediate Assessments and Care of the Newborn
LEGAL TIP
Documentation
BOX 19-8 NORMAL VAGINAL CHILDBIRTH
First Stage
Anteroposterior slit. Vertex visible during contraction.
Oval opening. Vertex presenting. NOTE: Nurse (on left) is wearing gloves, but support person (on right) is not.
Second Stage
Crowning.
Nurse-midwife using Ritgen maneuver as head is born by extension.
After nurse-midwife checks for nuchal cord, she supports head during external rotation and restitution.
Use of bulb syringe to suction mucus.
Birth of posterior shoulder.
Birth of newborn by slow expulsion.
Second stage complete. Note that newborn is not completely pink yet.
Third Stage
Newborn placed on mother’s abdomen while cord is clamped and cut.
Note increased bleeding as placenta separates.
Expulsion of placenta.
Expulsion is complete, marking the end of the third stage.
The Newborn
Newborn awaiting assessment. Note that color is almost completely pink.
Newborn assessment under radiant warmer.
Parents admiring their newborn.
Perineal Trauma Related to Childbirth
Perineal Lacerations
Vaginal and Urethral Lacerations
Cervical Injuries
Episiotomy
FIG. 19-23 Types of episiotomies.
Third Stage of Labor
Placental Separation and Expulsion
NURSING PROCESS
Third Stage of Labor
Assessment
Nursing Diagnoses
Risk for Deficient Fluid Volume related to
Risk for Infection related to
Anxiety related to
Fatigue related to
Compromised Family Coping related to
Situational low self-esteem (maternal and paternal) related to
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
FIG. 19-24 Third stage of labor. A, Placenta begins to separate in central portion, accompanied by retroplacental bleeding. Uterus changes from discoid to globular shape. B, Placenta completes separation and enters lower uterine segment. Uterus has globular shape. C, Placenta enters vagina, cord is seen to lengthen, and there may be an increase in bleeding. D, Expulsion (delivery) of placenta and completion of third stage.
FIG. 19-25 Examination of the placenta.
Fourth Stage of Labor
Care Management
Assessment
FIG. 19-26 Big brother becomes acquainted with new baby sister.
BOX 19-9 ASSESSMENT DURING THE FOURTH STAGE OF LABOR
Blood Pressure
Pulse
Temperature
Fundus
Bladder
Lochia
Perineum
Postanesthesia Recovery
NURSING ALERT
Care of the New Mother
Care of the Family
Family-Newborn Relationships
KEY POINTS
Leopold’s Maneuvers (First) (read text)
Leopold’s Maneuvers (Second) (read text)
Leopold’s Maneuvers (Third) (read text)
Leopold’s Maneuvers (Fourth) (read text)
Normal Delivery (read text)
References
Unit Five Postpartum
Interactive Review—Unit 5
Chapter 20 Postpartum Physiology
Learning Objectives
Reproductive System and Associated Structures
Uterus
Involution Process
Contractions
FIG. 20-1 Assessment of involution of uterus after childbirth. A, Normal progress, days 1 through 9. B, Size and position of uterus 2 hours after childbirth. C, Two days after childbirth. D, Four days after childbirth.
Afterpains
Placental Site
Lochia
TABLE 20-1 LOCHIAL AND NONLOCHIAL BLEEDING
Cervix
Vagina and Perineum
CLINICAL REASONING
Assessment of Postpartum Bleeding
Pelvic Muscular Support
Endocrine System
Placental Hormones
Pituitary Hormones and Ovarian Function
FIG. 20-2 Abdominal wall 6 weeks after vaginal birth is almost back to prepregnancy appearance. Note that the linea nigra is still visible.
Abdomen
Urinary System
Urine Components
Postpartal Diuresis
Urethra and Bladder
Gastrointestinal System
Appetite
Bowel Evacuation
Breasts
Breastfeeding Mothers
Nonbreastfeeding Mothers
TABLE 20-2 VITAL SIGNS AFTER CHILDBIRTH
Cardiovascular System
Blood Volume
Cardiac Output
Vital Signs
Blood Components
Hematocrit and Hemoglobin
White Blood Cell Count
Coagulation Factors
FIG. 20-3 Varicosities in legs.
Varicosities
Neurologic System
Musculoskeletal System
Integumentary System
Immune System
KEY POINTS
References
Chapter 21 Nursing Care of the Family During the Postpartum Period
Learning Objectives
Transfer from the Recovery Area
FIG. 21-1 Portion of a vaginal birth recovery screen in an electronic record.
Planning for Discharge
Laws Relating to Discharge
TABLE 21-1 RECOVERY NURSE’S REPORT
BOX 21-1 CRITERIA FOR EARLY DISCHARGE
Mother
Infant
General
Criteria for Discharge
TABLE 21-2 POSTPARTUM ASSESSMENT AND SIGNS OF POTENTIAL COMPLICATIONS
LEGAL TIP
Early Discharge
Care Management: Physical Needs
Ongoing Physical Assessment
NURSING PROCESS
Postpartum Physical Concerns
Assessment
Initial assessment
Ongoing assessment
Nursing Diagnoses
Risk for Constipation related to:
Acute Pain related to:
Ineffective Breastfeeding related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Routine Laboratory Tests
Nursing Interventions
NURSING CARE PLAN
Postpartum Care—Vaginal Birth
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationale
Prevention of Infection
BOX 21-2 INTERVENTIONS FOR EPISIOTOMY, LACERATIONS, AND HEMORRHOIDS
Cleansing
Ice Pack
Squeeze Bottle
Sitz Bath
Built-in Type
Disposable Type
Topical Applications
Prevention of Excessive Bleeding
NURSING ALERT
NURSING ALERT
Maintenance of Uterine Tone
FIG. 21-2 Blood loss after birth is assessed by the extent of perineal pad saturation as (from left to right) scant (<2.5 cm), light (<10 cm), moderate (>10 cm), or heavy (one pad saturated within 2 hours).
FIG. 21-3 Palpating fundus of uterus during the postpartum period. Note that upper hand is cupped over fundus; lower hand dips in above symphysis pubis and supports uterus while it is massaged gently.
EMERGENCY
Hypovolemic Shock
Signs and Symptoms
Interventions
Prevention of Bladder Distention
Promotion of Comfort, Rest, Ambulation, and Exercise
Comfort
Nonpharmacologic Interventions
Pharmacologic Interventions
NURSING ALERT
Rest
Ambulation
SAFETY ALERT
Exercise
Promotion of Nutrition
FIG. 21-4 Postpartum exercise should begin as soon as possible. The woman should start with simple exercises and gradually progress to more strenuous ones.
EVIDENCE-BASED PRACTICE
Kegel, Kegel, Kegel!
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Promotion of Normal Bladder and Bowel Patterns
Bladder Function
Bowel Function
NURSING ALERT
Breastfeeding Promotion and Lactation Suppression
Breastfeeding Promotion
Lactation Suppression
Health Promotion for Future Pregnancies and Children
Rubella Vaccination
Varicella Vaccination
Tetanus-Diphtheria-Acellular Pertussis Vaccine
MEDICATION GUIDE
Rh Immune Globulin, RhoGAM, Gamulin Rh, HypRho-D, Rhophylac
Action
Indications
Dosage and Route
Adverse Effects
Nursing Considerations
LEGAL TIP
Rubella and Varicella Vaccination
Prevention of Rh Isoimmunization
NURSING ALERT
Care Management: Psychosocial Needs
Effect of the Birth Experience
Maternal Self-Image
NURSING PROCESS
Postpartum Psychosocial Concerns
Assessment
Nursing Diagnoses
Readiness for Enhanced Family Processes related to:
Risk for Impaired Parenting related to:
Risk for Situational Low Self-esteem related to:
Risk for Caregiver Role Strain related to:
Risk for Ineffective Coping related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
SIGNS OF POTENTIAL COMPLICATIONS
Postpartum Psychosocial Concerns
Adaptation to Parenthood and Parent-Infant Interactions
Family Structure and Functioning
FIG. 21-5 A mother’s adjustment is eased with acceptance of infant by other children. Smile indicates acceptance of the baby.
Effect of Cultural Diversity
Discharge Teaching
Self-Management and Signs of Complications
CULTURAL CONSIDERATIONS
Postpartum Period and Family Planning
Postpartum Care
Family Planning
NURSING ALERT
Sexual Activity and Contraception
TEACHING FOR SELF-MANAGEMENT
Resumption of Sexual Activity
CLINICAL REASONING
Family Planning and Contraceptive Use
Prescribed Medications
Follow-Up After Discharge
Routine Mother and Baby Follow-up Care
Home Visits
Telephone Follow-up
Warm Lines
Support Groups
Referral to Community Resources
COMMUNITY ACTIVITY
KEY POINTS
References
Chapter 22 Transition to Parenthood
Learning Objectives
Parental Attachment, Bonding, and Acquaintance
FIG. 22-1 Hands.
TABLE 22-1 INFANT BEHAVIORS AFFECTING PARENTAL ATTACHMENT
TABLE 22-2 PARENTAL BEHAVIORS AFFECTING INFANT ATTACHMENT
FIG. 22-2 Early acquaintance between parents and newborn as mother holds infant in en face position.
FIG. 22-3 Father looks for resemblance between newborns and older daughter.
TABLE 22-3 EXAMPLES OF PARENT-INFANT ATTACHMENT INTERVENTIONS
CULTURAL CONSIDERATIONS
Fostering Bonding in Women of Varying Ethnic and Cultural Groups
Assessment of Attachment Behaviors
BOX 22-1 ASSESSING ATTACHMENT BEHAVIOR
Parent-Infant Contact
Early Contact
Extended Contact
Communication Between Parent and Infant
The Senses
Touch
Eye Contact
FIG. 22-4 Father interacts with his newborn son.
Voice
Odor
Entrainment
FIG. 22-5 Infant in alert state.
Biorhythmicity
Reciprocity and Synchrony
FIG. 22-6 Sharing a smile: an example of synchrony.
Parental Role After Birth
Transition to Parenthood
Parental Tasks and Responsibilities
NURSING CARE PLAN
Home Care Follow-up: Transition to Parenthood
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Becoming a Mother
TABLE 22-4 PHASES OF MATERNAL POSTPARTUM ADJUSTMENT
Postpartum “Blues”
TEACHING FOR SELF-MANAGEMENT
Coping with Postpartum Blues
Becoming a Father
TABLE 22-5 EARLY DEVELOPMENT OF THE INVOLVED FATHER ROLE
FIG. 22-7 Engrossment. Father is absorbed in looking at his newborn.
Adjustment for the Couple
Resuming Sexual Intimacy
Infant-Parent Adjustment
Rhythm
FIG. 22-8 Holding newborn in en face position, mother interacts with her daughter, six hours old. A, Infant is quiet and alert. B, Mother begins talking to daughter. C, Infant responds, opens mouth like her mother. D, Infant gazes at her mother. E, Infant waves hand. F, Infant glances away, resting; hands relax.
EVIDENCE-BASED PRACTICE
Education for Family Planning
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Behavioral Repertoires
Responsivity
Diversity in Transitions to Parenthood
Age
The Adolescent Mother
CLINICAL REASONING
Transition to Parenthood for the Adolescent Couple
The Adolescent Father
Maternal Age Older Than 35 Years
Paternal Age Older Than 35 Years
Parenting in the Lesbian Couple
Social Support
Culture
Socioeconomic Conditions
Personal Aspirations
Parental Sensory Impairment
Visually Impaired Parent
Hearing-Impaired Parent
BOX 22-2 NURSING APPROACHES FOR WORKING WITH VISUALLY IMPAIRED PARENTS
Sibling Adaptation
FIG. 22-9 First meeting. Sister with mother during first meeting with new sibling. A, First tentative touch with fingertip. B, Relationship is more secure; touching with whole hand is now okay. C, Smiles indicate acceptance.
BOX 22-3 NURSING APPROACHES FOR WORKING WITH HEARING-IMPAIRED PARENTS
BOX 22-4 STRATEGIES FOR FACILITATING SIBLING ACCEPTANCE OF A NEW BABY
Grandparent Adaptation
FIG. 22-10 Father, grandfather, and new grandson get acquainted.
NURSING PROCESS
Transition to Parenthood
Assessment
Nursing Diagnoses
Readiness for Enhanced Family Coping related to:
Risk for Impaired Parenting related to:
Parental Role Conflict related to:
Risk for Impaired Parent/Child Attachment related to:
Readlines for Enhanced Family Processes related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Care Management
COMMUNITY ACTIVITY
KEY POINTS
References
Unit Six The Newborn
Interactive Review—Unit 6
Chapter 23 Physiologic and Behavioral Adaptations of the Newborn
Learning Objectives
Transition to Extrauterine Life
Physiologic Adaptations
Respiratory System
Initiation of Breathing
Chemical Factors
Mechanical Factors
Thermal Factors
Sensory Factors
NURSING ALERT
Signs of Respiratory Distress
TABLE 23-1 CHARACTERISTICS OF THE RESPIRATORY SYSTEM OF THE NEONATE
Cardiovascular System
TABLE 23-2 CARDIOVASCULAR CHANGES AT BIRTH
Heart Rate and Sounds
Blood Pressure
Blood Volume
Signs of Risk for Cardiovascular Problems
Hematopoietic System
Red Blood Cells
Leukocytes
Platelets
Blood groups
Thermogenic System
Heat Loss
FIG. 23-1 Infant in skin-to-skin contact with mother.
Thermogenesis
FIG. 23-2 Effects of cold stress. When an infant is stressed by cold, oxygen consumption increases, and pulmonary and peripheral vasoconstriction occurs, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and the PO2 and pH decrease, leading to metabolic acidosis.
Cold Stress
Hyperthermia
Renal System
NURSING ALERT
Fluid and Electrolyte Balance
Signs of Risk for Renal System Problems
Gastrointestinal System
Digestion
Stools
BOX 23-1 CHANGE IN STOOLING PATTERNS OF NEWBORNS
Meconium
Transitional Stools
Milk Stool
Feeding Behaviors
Signs of Risk for Gastrointestinal Problems
Hepatic System
Iron Storage
Carbohydrate Metabolism
Conjugation of Bilirubin and Newborn Jaundice
FIG. 23-3 Formation and excretion of bilirubin.
Physiologic Jaundice
NURSING ALERT
Pathologic Jaundice
TABLE 23-3 CAUSES OF NEONATAL UNCONJUGATED (INDIRECT) HYPERBILIRUBINEMIA
Jaundice Related to Breastfeeding
Coagulation
Signs of Risk for Hepatic System Problems
Immune System
Risk for Infection
Integumentary System
Sweat Glands
Desquamation
Mongolian Spots
Nevi
FIG. 23-4 Mongolian spot.
Erythema Toxicum
Signs of Risk for Integumentary Problems
FIG. 23-5 A, Telangiectatic nevi (stork bite). B, Erythema toxicum (flea bite dermatitis).
Reproductive System
Female
Male
Swelling of Breast Tissue
Signs of Risk for Reproductive System Problems
FIG. 23-6 External genitalia. A, Genitals in female term infant. Note mucoid vaginal discharge. B, Genitals in male infant. Uncircumcised penis. Rugae cover scrotum, indicating term gestation. Cord has been swabbed with ethylene blue to prevent infection.
Skeletal System
FIG. 23-7 Swelling of the genitals and bruising of the buttocks after a breech birth.
FIG. 23-8 Molding. A, Significant molding, soon after birth. B, Schematic of bones of skull when molding is present.
FIG. 23-9 Differences between caput succedaneum, cephalhematoma, and subgaleal hemorrhage. A, Caput succedaneum: edema of scalp noted at birth; crosses suture lines. B, Cephalhematoma: bleeding between periosteum and skull bone appearing within first 2 days; does not cross suture lines. C, Subgaleal hemorrhage: bleeding into the subgaleal compartment; bleeding extends beyond bone, often posteriorly into the neck and continuous after birth.
FIG. 23-10 Position of infant’s legs after breech birth.
SAFETY ALERT
Signs of Risk for Skeletal Problems
FIG. 23-11 Signs of developmental dysplasia of the hip. A, Asymmetry of gluteal and thigh folds with shortening of the thigh (Galeazzi sign). B, Limited hip abduction, as seen in flexion (Ortolani maneuver). C, Apparent shortening of the femur, as indicated by the level of the knees in flexion (Allis sign). D, Ortolani maneuver with femoral head moving in and out of acetabulum (in infants 1 to 2 months of age).
Neuromuscular System
Newborn Reflexes
Signs of Risk for Neuromuscular Problems
Behavioral Characteristics
BOX 23-2 CLUSTERS OF NEONATAL BEHAVIORS IN THE BRAZELTON NEONATAL BEHAVIORAL ASSESSMENT SCALE (BNBAS)
TABLE 23-4 ASSESSMENT OF NEWBORN’S REFLEXES∗
Classic pose in spontaneous tonic neck reflex.
Moro reflex.
Stepping reflex.
Crossed extension reflex.
Babinski reflex.
Trunk incurvation reflex.
Magnet reflex.
Sleep-Wake States
FIG. 23-12 Summary of newborn sleep-wake states. States of consciousness: A, Deep sleep. B, Light sleep. C, Drowsy. D, Quiet alert. E, Active alert. F, Crying.
Other Factors Influencing Newborn Behavior
Gestational Age
Time
Stimuli
Medication
Sensory Behaviors
Vision
Hearing
Smell
Taste
Touch
Response to Environmental Stimuli
Temperament
Habituation
Consolability
Cuddliness
Irritability
Crying
KEY POINTS
Rooting and Sucking (read text)
Plantar Grasp (read text)
Moro Reflex (read text)
Babinski Reflex, Male Infant (read text)
References
Chapter 24 Nursing Care of the Newborn and Family
Learning Objectives
Care Management: Birth Through the First 2 Hours
Assessment
Initial Assessment and Apgar Scoring
BOX 24-1 ASSESSMENT OF PRECONCEPTION, PRENATAL, AND INTRAPARTUM RISK FACTORS
Preconception
Prenatal
Intrapartum
Apgar Score
TABLE 24-1 APGAR SCORE
BOX 24-2 INITIAL PHYSICAL ASSESSMENT OF THE NEWBORN
Initial Physical Assessment
Physical Assessment
TABLE 24-2 PHYSICAL ASSESSMENT OF NEWBORN
Weighing the infant. The nurse never leaves the infant alone on a scale. The scale is covered to protect against cross-infection.
Measuring length crown to heel. To determine total length, include length of legs. If measurements are taken before the infant’s initial bath, wear gloves.
Measuring circumference of head.
Measuring circumference of chest.
Eyes. In pseudostrabismus, inner epicanthal folds cause the eyes to appear misaligned; however, corneal light reflexes are perfectly symmetric. Eyes are symmetric in size and shape and are well placed.
Placement of ears on the head in relation to a line drawn from the inner to the outer canthus of the eye. A, Normal position. B, Abnormally angled ear. C, True low-set ear.
BOX 24-3 SIGNIFICANCE OF THE APGAR SCORE
BOX 24-4 PERFORMING A PHYSICAL EXAMINATION OF THE NEWBORN
General Appearance
Vital Signs
Baseline Measurements of Physical Growth
Weight
Head Circumference and Body Length
NURSING CARE PLAN
The Normal Newborn
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Neurologic Assessment
Gestational Age Assessment
FIG. 24-1 Estimation of gestational age. A, New Ballard Score for newborn maturity rating. Expanded scale includes extremely premature infants and has been refined to improve accuracy in more mature infants. (From Ballard, J., Khoury, J., Wang, L., Eilers-Walsman, B., & Lipp, R. [1991]. New Ballard score, expanded to include extremely premature infants, Journal of Pediatrics, 119[3], 424.) B, Intrauterine growth: birth weight percentiles based on live single births at gestational ages 20 to 44 weeks.
Classification of Newborns by Gestational Age and Birth Weight
BOX 24-5 MANEUVERS USED IN ASSESSING GESTATIONAL AGE
Posture
Square Window
Arm Recoil
Popliteal Angle
Scarf Sign
Heel to Ear
Late Preterm Infant
NURSING PROCESS
Care of the Newborn and Family
Assessment
Nursing Diagnoses
Ineffective Airway Clearance related to:
Impaired Gas Exchange related to:
Risk for Imbalanced Body Temperature related to:
Acute Pain related to:
Readiness for Enhanced Parenting related to:
Readiness for Enhanced Family Coping related to:
Risk for Impaired Parent-Infant Attachment related to:
Situational Low Self-Esteem related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Interventions
Airway Maintenance
PROCEDURE
Suctioning with a Bulb Syringe
FIG. 24-2 Bulb syringe. Bulb must be compressed before insertion.
Maintaining an Adequate Oxygen Supply
PROCEDURE
Suctioning with a Nasopharyngeal Catheter with Mechanical Suction Apparatus
SIGNS OF POTENTIAL COMPLICATIONS
Abnormal Newborn Breathing
Maintaining Body Temperature
EVIDENCE-BASED PRACTICE
Hypothermia Prevention and Skin-to-Skin Contact
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Immediate Interventions
Eye Prophylaxis
FIG. 24-3 Instillation of medication into eye of newborn. Thumb and forefinger are used to open the eye; medication is placed in the lower conjunctiva from the inner to the outer canthus.
MEDICATION GUIDE
Eye Prophylaxis: Erythromycin Ophthalmic Ointment, 0.5%, and Tetracycline Ophthalmic Ointment, 1%
Action
Indication
Neonatal Dosage
Adverse Reactions
Nursing Considerations
Vitamin K Prophylaxis
MEDICATION GUIDE
Vitamin K: Phytonadione (AquaMEPHYTON, Konakion)
Action
Indication
Neonatal Dosage
Adverse Reactions
Nursing Considerations
SAFETY ALERT
Umbilical Cord Care
FIG. 24-4 With special tool, remove clamp after cord dries (approximately 24 hours).
FIG. 24-5 Cord separation. A, Cord separated with some dried blood still in the umbilicus. B, Umbilicus cleansed and beginning to heal.
Promoting Parent-Infant Interaction
Care Management: from 2 Hours After Birth Until Discharge
Common Newborn Problems
Birth Injuries
Soft Tissue Injuries
FIG. 24-6 Marked bruising on the entire face of an infant born vaginally after face presentation. Less severe ecchymoses were present on the extremities. Phototherapy was required for treatment of jaundice resulting from the breakdown of accumulated blood.
Physiologic Problems
Jaundice
Physiologic Jaundice
FIG. 24-7 Transcutaneous monitoring of bilirubin with a transcutaneous bilirubinometry (TcB) monitor.
FIG. 24-8 Nomogram for designation of risk in 2840 well newborns at 36 or more weeks of gestational age with birth weight of 2000 g or more or 35 or more weeks of gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values. (This nomogram should not be used to represent the natural history of neonatal hyperbilirubinemia.)
Hypoglycemia
NURSING ALERT
Hypocalcemia
Laboratory and Diagnostic Tests
BOX 24-6 STANDARD LABORATORY VALUES IN THE NEONATAL PERIOD
Newborn Hearing Screening
TABLE 24-3 NEWBORN SCREENING SUMMARY
Collection of Specimens
Heelstick
Venipuncture
FIG. 24-9 Newborn hearing screening. A, Evoked otoacoustic emissions (EOAE) test. B, Auditory brain response (ABR)) test.
FIG. 24-10 Heelstick sites (shaded areas) on infant’s foot for obtaining samples of capillary blood.
NURSING ALERT
FIG. 24-11 Venipuncture using a butterfly needle.
Obtaining a Urine Specimen
FIG. 24-12 Application of mummy restraint (swaddling). A, Infant is placed on folded corner of blanket. B, One corner of blanket is brought across body and secured beneath the body. C, Lower corner is folded and tucked and second corner is brought across body and secured. D, Modified mummy restraint with one hand uncovered.
FIG. 24-13 Alternate methods of infant restraint. A, Restraining infant for femoral vein puncture. B, Modified side-lying position for lumbar puncture.
FIG. 24-14 Collection of urine specimen. A, Protective paper is removed from the adhesive surface. B, Applied to female infant. C, Applied to male infant.
Restraining the Infant
Restraint Without Appliance
Interventions
Protective Environment
Environmental Factors
Infection Control Factors
NURSING ALERT
FIG. 24-15 Neonatal safety device.
Safety Factors
Therapeutic and Surgical Procedures
Intramuscular Injection
MEDICATION GUIDE
Hepatitis B Vaccine (Recombivax HB, Engerix-B)
Action
Indication
Neonatal Dosage
Adverse Reactions
Nursing Considerations
MEDICATION GUIDE
Hepatitis B Immune Globulin
Action
Indication
Neonatal Dosage
Adverse Reactions
Nursing Considerations
Therapy for Hyperbilirubinemia
Phototherapy
FIG. 24-16 Intramuscular injection. A, Acceptable intramuscular injection site for newborn infant. X, Injection site. B, Infant’s leg stabilized for intramuscular injection. Nurse is wearing gloves to give injection.
FIG. 24-17 Infant under phototherapy lights while in incubator
FIG. 24-18 Infant with eyes covered while receiving phototherapy.
Parent Education
Home Phototherapy
Circumcision
FIG. 24-19 Proper positioning of infant for circumcision.
FIG. 24-20 Circumcision with Yellen clamp. After hemostasis occurs, the prepuce (over cone) will be cut away.
FIG. 24-21 Circumcision using Hollister PlastiBell. A, Suture around rim of PlastiBell controls bleeding. B, Plastic rim and suture drop off in 7 to 10 days.
Procedural Pain Management
Care of the Newly Circumcised Infant
Neonatal Pain
BOX 24-7 CARE OF THE CIRCUMCISED NEWBORN AT HOME
Check For Bleeding
Observe for Urination
Keep Area Clean
Check for Infection
Provide Comfort
Neonatal Responses to Pain
FIG. 24-22 Signs of discomfort: note eye squeeze, brow bulge, nasolabial furrow, and wide-spread mouth
Assessment of Neonatal Pain
Management of Neonatal Pain
Nonpharmacologic Management
Pharmacologic Management
Promoting Parent-Infant Interaction
FIG. 24-23 Baby swaddled snugly with one hand near face and other held close to body
TABLE 24-4 CRIES NEONATAL POSTOPERATIVE PAIN SCALE∗
CULTURAL CONSIDERATIONS
Cultural Beliefs and Practices Related to Infant Care
FIG. 24-24 Great-grandmother and infant enjoying social interaction.
Discharge Planning and Teaching
FIG. 24-25 Mother supervising contact of older sibling with newborn.
Temperature
Respirations
BOX 24-8
Infant Safety
Feeding Patterns
Elimination
Positioning and Holding
FIG. 24-26 Holding baby securely with support for head. A, Holding infant while moving infant from one place to another. Baby is undressed to show posture. B, Holding baby upright in “burping” position. C, “Football” (under the arm) hold. D, Cradling hold.
Rashes
Diaper Rash
Other Rashes
Clothing
FIG. 24-27 Sunglasses protect the infant’s eyes.
Car Seat Safety
SAFETY ALERT
FIG. 24-28 Rear-facing car seat in rear seat of car. Infant is placed in seat when going home from the hospital.
Nonnutritive Sucking
Bathing, Cord Care, and Skin Care
Bathing
FIG. 24-29 Safe pacifiers for term and preterm infants. Note one-piece construction, easily grasped handle, and large shield with ventilation holes.
FIG. 24-30 Mother giving newborn a sponge bath at home.
Cord Care
BOX 24-9 BATHING, CORD CARE, SKIN CARE, AND NAIL CARE
Fit Baths into the Family’s Schedule
Prevent Heat Loss
Gather Supplies and Clothing Before Starting
Bathe the Baby
Wash hair with baby wrapped to limit heat loss.
Skin Care
Cord Care
Nail Care
Clean Genitals
Infant Follow-up Care
Immunizations
Cardiopulmonary Resuscitation
Practical Suggestions for the First Weeks at Home
BOX 24-10 NEWBORN PROGRESS AFTER EARLY DISCHARGE
Activities of Daily Living
TABLE 24-5 IMMUNIZATION SCHEDULE—2010∗
Visitors
Activity and Rest
EMERGENCY
Relieving Airway Obstruction
Back blows and chest thrust in infant to clear airway obstruction. A, Back blow. B, Chest thrust.
Back Blows
Turn the Infant
Chest Thrusts
Open the Airway
Development of Day-Night Routines
EMERGENCY
Cardiopulmonary Resuscitation (CPR) for Infants
Assess Responsiveness
Position Infant
Airway
A, Opening airway with head tilt–chin lift method. B, Checking pulse of brachial artery. C, Side-by-side thumb placement for chest compression in newborn.
Breathing
Circulation
Interpretation of Crying and Use of Quieting Techniques
Developmental Milestones
BOX 24-11 INFANT QUIETING TECHNIQUES
Infant Stimulation
TABLE 24-6 GROWTH AND DEVELOPMENT DURING INFANCY
Recognizing Signs of Illness
TABLE 24-7 PLAY DURING INFANCY: SUGGESTED ACTIVITIES FOR BIRTH THROUGH 3 MONTHS
BOX 24-12 TEACHING YOUR NEWBORN
BOX 24-13 TEACHING YOUR 1-MONTH-OLD
BOX 24-14 SIGNS OF ILLNESS
COMMUNITY ACTIVITY
KEY POINTS
Neck, posterior (read text)
Male Breasts (supine position) (read text)
Cremasteric Reflex (read text)
Upper Extremities (read text)
Legs: Symmetry, length (read text)
Buttocks (read text)
Circumcision (read text)
References
Chapter 25 Newborn Nutrition and Feeding
Learning Objectives
Recommended Infant Nutrition
Breastfeeding Rates
Benefits of Breastfeeding
Choosing an Infant Feeding Method
TABLE 25-1 BENEFITS OF BREASTFEEDING
Supporting Breastfeeding Mothers
FIG. 25-1 Breastfeeding mothers support group with lactation consultant.
Cultural Influences on Infant Feeding
BOX 25-1 TEN STEPS TO SUCCESSFUL BREASTFEEDING FOR HOSPITALS
Nutrient Needs
Fluids
Energy
Carbohydrate
Fat
Protein
Vitamins
Minerals
Anatomy and Physiology of Lactation
Anatomy of the Lactating Breast
FIG. 25-2 Anatomy of the lactating breast.
FIG. 25-3 Enhanced view of milk glands and milk ducts.
Lactogenesis
FIG. 25-4 Maternal breastfeeding reflexes. A, Milk production. B, Milk ejection (let-down).
NURSING ALERT
Uniqueness of Human Milk
Care Management: the Breastfeeding Mother and Infant
Positioning
NURSING PROCESS
Breastfeeding Mother-Infant Pair
Assessment
Nursing Diagnoses
Effective Breastfeeding related to:
Risk for Ineffective Breastfeeding related to:
Risk for Imbalanced Nutrition: Less than Body Requirements related to:
Risk for Deficient Fluid Volume related to:
Expected Outcomes of Care
Infant
Mother
Plan of Care and Interventions
Evaluation
FIG. 25-5 Breastfeeding positions. A, Football or clutch (under the arm) hold. B, Across the lap (modified cradle). C, Cradling. D, Lying down.
NURSING ALERT
Latch
FIG. 25-6 Latch. A, The mother tickles baby’s lower lip with the nipple until he or she opens wide. B, Once baby’s mouth is opened wide, she quickly “hugs” the baby to the breast. C, Baby should have as much areola (dark area around nipple) in his or her mouth as possible, not just the nipple.
FIG. 25-7 Removing infant from the breast.
NURSING CARE PLAN
Breastfeeding and Infant Nutrition
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Milk Ejection or Let-Down
Frequency of Feedings
Duration of Feedings
Indicators of Effective Breastfeeding
BOX 25-2 SIGNS OF EFFECTIVE BREASTFEEDING
Mother
Infant
Supplements, Bottles, and Pacifiers
EVIDENCE-BASED PRACTICE
Supplemental Feeding
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Special Considerations
Sleepy Baby
Fussy Baby
BOX 25-3 WAKING THE SLEEPY NEWBORN
Slow Weight Gain
BOX 25-4 CALMING THE FUSSY BABY
BOX 25-5 WARNING SIGNS OF INEFFECTIVE BREASTFEEDING
FIG. 25-8 Supplemental nursing system.
Jaundice
Preterm Infants
FIG. 25-9 Hospital-grade electric breast pump.
Late Preterm Infants
Breastfeeding Multiple Infants
Expressing and Storing Breast Milk
FIG. 25-10 Breastfeeding twins.
Hand Expression
Mechanical Expression (Pumping)
Types of Pumps
FIG. 25-11 Bilateral breast pumping.
Storage of Breast Milk
FIG. 25-12 Manual breast pumps.
SAFETY ALERT
Being Away from the Baby
Maternal Employment
TEACHING FOR SELF-MANAGEMENT
Breast Milk Storage Guidelines for Home Use for Full-Term Infants
Human Milk Storage Guidelines for Full-Term Infants
Weaning
FIG. 25-13 Lactation room. Note the breast pump, rocking chair, nursing foot stool, changing table, books, and supplies.
Milk Banking
Care of the Mother
Diet
Weight Loss
Rest
Breast Care
Sexual Sensations
FIG. 25-14 Breast shells.
Breastfeeding and Contraception
Breastfeeding During Pregnancy
Breastfeeding After Breast Surgery
Medications and Breastfeeding
Environmental Contaminants
Common Concerns of the Breastfeeding Mother
Engorgement
CLINICAL REASONING
Breastfeeding: Engorgement and Nipple Soreness
FIG. 25-15 Cabbage leaves to treat engorgement.
Sore Nipples
Candidiasis
Plugged Milk Ducts
Mastitis
Follow-up After Hospital Discharge
Formula Feeding
Parent Education
Readiness for Feeding
Feeding Patterns
Feeding Technique
FIG. 25-16 Father bottle feeding infant son. Note angled bottle that ensures that milk covers nipple area.
SAFETY ALERT
Common Concerns
Bottles and Nipples
FIG. 25-17 Positions for burping an infant. A, Sitting. B, On the shoulder. C, Across the lap.
Infant Formulas
Commercial Formulas
SAFETY ALERT
Formula Preparation
SAFETY ALERT
Vitamin and Mineral Supplementation
Weaning
Complementary Feeding: Introducing Solid Foods
TEACHING FOR SELF-MANAGEMENT
Formula Preparation and Feeding
Formula Preparation
Feeding Techniques and Tips
Safety Tips
COMMUNITY ACTIVITY
KEY POINTS
References
Unit Seven Complications of Pregnancy
Interactive Review—Unit 7
Chapter 26 Assessment for Risk Factors in Pregnancy
Learning Objectives
Assessment of Risk Factors
BOX 26-1 CATEGORIES OF HIGH RISK FACTORS
BIOPHYSICAL FACTORS
PSYCHOSOCIAL FACTORS
SOCIODEMOGRAPHIC FACTORS
ENVIRONMENTAL FACTORS
BOX 26-2 SPECIFIC PREGNANCY PROBLEMS AND RELATED RISK FACTORS
POLYHYDRAMNIOS
INTRAUTERINE GROWTH RESTRICTION
OLIGOHYDRAMNIOS
CHROMOSOMAL ABNORMALITIES
Psychologic Considerations Related to High Risk Pregnancy
Antepartum Testing
BOX 26-3 COMMON INDICATIONS FOR ANTEPARTUM TESTING
OBSTETRIC INDICATIONS
MEDICAL INDICATIONS
Biophysical Assessment
Daily Fetal Movement Count
NURSING ALERT
Ultrasonography
FIG. 26-1 Fetus seen on three-dimensional ultrasound. A, Full body view of fetus at 11 weeks and 6 days of gestation. B, Close-up view of fetal face later in pregnancy.
TABLE 26-1 MAJOR USES OF ULTRASONOGRAPHY DURING PREGNANCY
Levels of Ultrasonography
Indications For Use
FIG. 26-2 Appropriate planes of sections (dotted lines) for head circumference (HC) and abdominal circumference (AC).
Fetal Heart Activity
Gestational Age
Fetal Growth
Fetal Anatomy
Fetal Genetic Disorders and Physical Anomalies
Placental Position and Function
FIG. 26-3 Fetal nuchal translucency. A, Nuchal lucency (calipers) and nasal bone (arrow) in 12-week fetus. B, Increased nuchal translucency. Transvaginal ultrasound performed at 12 weeks demonstrates a sonolucent area (asterisk) over the posterior neck and upper thorax.
Adjunct to Other Invasive Tests
Fetal Well-being
FIG. 26-4 Umbilical artery velocity waveform.
Doppler Blood Flow Analysis
Amniotic Fluid Volume
TABLE 26-2 BIOPHYSICAL PROFILE SCORING
Biophysical Profile
TABLE 26-3 BIOPHYSICAL PROFILE MANAGEMENT
EVIDENCE-BASED PRACTICE
“How’s My Baby Doing?”
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Nursing Role
CLINICAL REASONING
Fetal Assessment Using the Biophysical Profile
Magnetic Resonance Imaging
Biochemical Assessment
Amniocentesis
NURSING ALERT
Indications for Use
Genetic Concerns
FIG. 26-5 A, Amniocentesis and laboratory use of amniotic fluid aspirant. B, Transabdominal amniocentesis.
TABLE 26-4 SUMMARY OF BIOCHEMICAL MONITORING TECHNIQUES
BOX 26-4 FETAL RIGHTS
BOX 26-5 ELIMINATION OF MATERNAL AGE AS AN INDICATION FOR INVASIVE PRENATAL DIAGNOSIS
Fetal Maturity
Fetal Hemolytic Disease
Chorionic Villus Sampling
FIG. 26-6 Transcervical chorionic villus sampling.
FIG. 26-7 Transabdominal chorionic villus sampling.
NURSING ALERT
Percutaneous Umbilical Blood Sampling
FIG. 26-8 Technique for percutaneous umbilical blood sampling guided by ultrasound.
Maternal Assays
Alpha-Fetoprotein
FIG. 26-9 Umbilical cord as seen on ultrasound at 26 weeks of gestation.
Multiple Marker Screens
Coombs Test
Antepartal Assessment Using Electronic Fetal Monitoring
Indications
BOX 26-6 INDICATIONS FOR ELECTRONIC FETAL MONITORING ASSESSMENT USING THE NONSTRESS TEST AND THE CONTRACTION STRESS TEST
Nonstress Test
Procedure
Interpretation
FIG. 26-10 Reactive nonstress test.
FIG. 26-11 Nonnreactive nonstress test.
Vibroacoustic Stimulation
Contraction Stress Test
BOX 26-7 INTERPRETATION OF THE NONSTRESS TEST
NURSING ALERT
Procedure
Nipple-Stimulated Contraction Test
FIG. 26-12 Reactive nonstress test after vibroacoustic stimulation. The stimulus was applied at the point marked by the musical notes. A sustained fetal heart rate acceleration was produced.
FIG. 26-13 Contraction stress test (CST). A, Negative CST. B, Positive CST.
Oxytocin-Stimulated Contraction Test
Interpretation
BOX 26-8 INTERPRETATION OF THE CONTRACTION STRESS TEST
Nurses’ Role in Assessment of the High Risk Pregnancy
KEY POINTS
References
Chapter 27 Hypertensive Disorders in Pregnancy
Learning Objectives
Significance and Incidence
Morbidity and Mortality
Classification
TABLE 27-1 CLASSIFICATION OF HYPERTENSIVE STATES OF PREGNANCY
Gestational Hypertension
TABLE 27-2 DIFFERENTIATION BETWEEN MILD AND SEVERE PREECLAMPSIA
TABLE 27-3 COMMON LABORATORY CHANGES IN PREECLAMPSIA
Preeclampsia
Eclampsia
COMMUNITY ACTIVITY
Chronic Hypertension
Chronic Hypertension with Superimposed Preeclampsia
Preeclampsia
Etiology
BOX 27-1 RISK FACTORS FOR PREECLAMPSIA
Pathophysiology
FIG. 27-1 Etiology of preeclampsia: disruptions in placental perfusion and endothelial cell dysfunction
FIG. 27-2 Consequences of endothelial cell dysfunction. DIC, Disseminated vascular coagulation; IUGR, intrauterine growth restriction, N/V, nausea/vomiting; RUQ, right upper quadrant.
HELLP Syndrome
CLINICAL REASONING
Severe Complications of Preeclampsia
NURSING ALERT
Care Management
Identifying and Preventing Preeclampsia
EVIDENCE-BASED PRACTICE
Preeclampsia Risk Factors and Prevention
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Health Assessment and Screening
Interview
NURSING PROCESS
Mild Preeclampsia
Assessment
Nursing Diagnoses
Anxiety related to:
Ineffective Individual and Family Coping related to:
Powerlessness related to:
Ineffective Tissue Perfusion related to:
Risk for Injury (to fetus) related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Physical Examination
FIG. 27-3 Assessment of pitting edema of lower extremities. A, +1; B, +2; C, +3; D, +4.
FIG. 27-4 Location of tendons for evaluation of deep tendon reflexes. A, Biceps. B, Brachioradial. C, Triceps. D, Patellar. E, Achilles, F, Evaluation of ankle clonus.
TABLE 27-4 ASSESSING DEEP TENDON REFLEXES
Mild Gestational Hypertension and Mild Preeclampsia
Home Care
Maternal and Fetal Assessment
TEACHING FOR SELF-MANAGEMENT
Assessing and Reporting Clinical Signs of Preeclampsia
Activity Restriction
Diet
Severe Gestational Hypertension and Severe Preeclampsia
TEACHING FOR SELF-MANAGEMENT
Coping with Activity Restriction
At Home
In the Hospital
TEACHING FOR SELF-MANAGEMENT
Diet for Preeclampsia
Intrapartum Care
NURSING CARE PLAN
Severe Preeclampsia
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Other Possible Nursing Diagnoses
Expected Outcomes
Nursing Interventions/Rationales
Pharmacologic Therapy
Magnesium Sulfate
BOX 27-2 HOSPITAL PRECAUTIONARY MEASURES
NURSING ALERT
NURSING ALERT
BOX 27-3 CARE OF THE WOMAN WITH PREECLAMPSIA RECEIVING MAGNESIUM SULFATE
Client and Family Teaching
Administration
Maternal and Fetal Assessments
Reportable Conditions
Emergency Measures
Documentation
SAFETY ALERT
Antihypertensive Medications
Postpartum Care
TABLE 27-5 PHARMACOLOGIC CONTROL OF HYPERTENSION IN PREGNANCY
Future Health Care
Eclampsia
EMERGENCY
Eclampsia
Tonic-Clonic Convulsion Signs
Intervention
After Convulsion
Immediate Care
NURSING ALERT
Chronic Hypertension
KEY POINTS
References
Chapter 28 Antepartum Hemorrhagic Disorders
Learning Objectives
Early Pregnancy Bleeding
Miscarriage (Spontaneous Abortion)
Incidence and Etiology
FIG. 28-1 Miscarriage. A, Threatened. B, Inevitable. C, Incomplete. D, Complete. E, Missed.
Types
Clinical Manifestations
TABLE 28-1 ASSESSING MISCARRIAGE AND THE USUAL MANAGEMENT
Management
Initial Care
NURSING PROCESS
Miscarriage
Assessment
Nursing Diagnoses
Anxiety or Fear related to:
Deficient Fluid Volume related to:
Acute Pain related to:
Anticipatory Grieving related to:
Situational Low Self-Esteem related to:
Risk for Infection related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
EVIDENCE-BASED PRACTICE
The Precarious First Trimester
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Follow-up Care at Home
NURSING ALERT
TEACHING FOR SELF-MANAGEMENT
Discharge Teaching for the Woman After Early Miscarriage
COMMUNITY ACTIVITY
Recurrent Premature Dilation of the Cervix (Incompetent Cervix)
Etiology
Diagnosis
Management
FIG. 28-2 A, Cerclage correction of premature dilation of the cervical os. B, Cross-sectional view of closed internal os.
Follow-up Care at Home
FIG. 28-3 Sites of implantation of ectopic pregnancies. Order of frequency of occurrence is ampulla, isthmus, interstitium, fimbria, tuboovarian ligament, ovary, abdominal cavity, and cervix (external os).
Ectopic Pregnancy
Incidence and Etiology
FIG. 28-4 Ectopic pregnancy, abdominal.
Clinical Manifestations
Tubal Pregnancy Management
Initial Care
Medical Management
NURSING ALERT
BOX 28-1 NURSING CONSIDERATIONS FOR WOMEN UNDERGOING METHOTREXATE TREATMENT FOR ECTOPIC PREGNANCY
ADMINISTRATION
CLIENT AND FAMILY TEACHING
FOLLOW-UP
Surgical Management
Follow-up Care
Hydatidiform Mole (Molar Pregnancy)
Incidence and Etiology
Types
FIG. 28-5 A, Chromosomal origin of complete mole. Single sperm (color) fertilizes an “empty” ovum. Reduplication of sperm’s 23, X set gives completely homozygous diploid 46,XX. B, Uterine rupture with hydatidiform mole. 1, Vaginal expulsion of mole through cervix. 2, Rupture of uterus and spillage of mole into peritoneal cavity (rare).
Clinical Manifestations
FIG. 28-6 Gross specimen in a woman treated for complete hydatidiform mole with primary hysterectomy.
FIG. 28-7 Chromosomal origin of triploid partial mole. Normal ovum with 23,X haploid set is fertilized by two sperms to give total of 69 chromosomes. Sex configuration of XXY, XXX, or XYY is possible.
Diagnosis
Management
NURSING ALERT
Follow-up Care
Late Pregnancy Bleeding
Placenta Previa
Incidence and Etiology
Clinical Manifestations
FIG. 28-8 Types of placenta previa. A, Complete. B, Marginal.
TABLE 28-2 SUMMARY OF FINDINGS: ABRUPTIO PLACENTAE AND PLACENTA PREVIA
Maternal and Fetal Outcomes
Diagnosis
Management
Expectant Management
NURSING PROCESS
Placenta Previa
Assessment
Nursing Diagnoses
Decreased Cardiac Output related to:
Deficient Fluid Volume related to:
Ineffective Peripheral Tissue Perfusion related to:
Anxiety or Fear related to:
Grieving related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Home Care
Active Management
Premature Separation of Placenta (Abruptio Placentae [Placental Abruption])
Incidence and Etiology
FIG. 28-9 Abruptio placentae. Premature separation of normally implanted placenta. A large retroplacental clot is present.
CLINICAL REASONING
Third-Trimester Vaginal Bleeding
Classification
Clinical Manifestations
FIG. 28-10 Abruptio placentae, showing partial and complete placental separation.
Maternal and Fetal Outcomes
Diagnosis
Management
Expectant Management
Active management
Cord Insertion and Placental Variations
Clotting Disorders in Pregnancy
Normal Clotting
Clotting Problems
Disseminated Intravascular Coagulation
FIG. 28-11 Vasa previa (velamentous insertion of cord). Arrow shows velamentous cord insertion in the placenta.
FIG. 28-12 Cord insertion and placental variations A, Battledore placenta. B, Placenta succenturiate.
Management
BOX 28-2 CLINICAL MANIFESTATIONS AND LABORATORY SCREENING RESULTS FOR WOMEN WITH DISSEMINATED INTRAVASCULAR COAGULATION
POSSIBLE PHYSICAL EXAMINATION FINDINGS
LABORATORY COAGULATION SCREENING TEST RESULTS
KEY POINTS
References
Chapter 29 Endocrine and Metabolic Disorders in Pregnancy
Learning Objectives
Diabetes Mellitus
Pathogenesis
Classification
White’s Classification of Diabetes in Pregnancy
Metabolic Changes Associated with Pregnancy
TABLE 29-1 WHITE’S CLASSIFICATION OF DIABETES IN PREGNANCY (MODIFIED)
FIG. 29-1 Changing insulin needs during pregnancy. A, First trimester: Insulin need is reduced because of increased insulin production by pancreas and increased peripheral sensitivity to insulin; nausea, vomiting, and decreased food intake by mother and glucose transfer to embryo or fetus contribute to hypoglycemia. B, Second trimester: Insulin needs begin to increase as placental hormones, cortisol, and insulinase act as insulin antagonists, decreasing insulin’s effectiveness. C, Third trimester: Insulin needs may double or even quadruple but usually level off after 36 weeks of gestation. D, Day of birth: Maternal insulin requirements decrease drastically to approach prepregnancy levels. E, Breastfeeding mother maintains lower insulin requirements, as much as 25% less than those of prepregnancy; insulin needs of nonbreastfeeding mother return to prepregnancy levels in 7 to 10 days. F, Weaning of breastfeeding infant causes mother’s insulin needs to return to prepregnancy levels.
Pregestational Diabetes Mellitus
Preconception Counseling
COMMUNITY ACTIVITY
Maternal Risks and Complications
TABLE 29-2 DIFFERENTIATION OF HYPOGLYCEMIA (INSULIN SHOCK) AND HYPERGLYCEMIA (DIABETIC KETOACIDOSIS)
Fetal and Neonatal Risks and Complications
Care Management
Antepartum
NURSING PROCESS
Pregestational Diabetes
Assessment
History
Interview
Physical Examination
Laboratory Tests
Nursing Diagnoses
Deficient Knowledge related to:
Anxiety, Fear, Dysfunctional Grieving, Powerlessness, Disturbed Body Image, Situational Low Self-esteem, Spiritual Distress, Ineffective Role Performance, and Interrupted Family Processes related to:
Risk for Injury (to Fetus) related to:
Risk for Injury (to Mother) related to:
Expected Outcomes of Care
Plan of Care and Interventions
Antepartum
Intrapartum
Postpartum
Evaluation
FIG. 29-2 A, Clinic nurse collects blood to determine glucose level. B, Nurse interprets glucose value displayed by monitor.
TABLE 29-3 TARGET BLOOD GLUCOSE LEVELS DURING PREGNANCY
Diet
TEACHING FOR SELF-MANAGEMENT
Dietary Management of Diabetic Pregnancy
Exercise
NURSING ALERT
Insulin Therapy
TEACHING FOR SELF-MANAGEMENT
Self-Administration of Insulin
Procedure for Mixing Nph (Intermediate-Acting) and Regular (Short-Acting) Insulin
Procedure for Self-Injection of Insulin
BOX 29-1 HELPFUL HINTS FOR USING INSULIN
TABLE 29-4 COMMON INSULIN PREPARATIONS
FIG. 29-3 Insulin pump shows basal rate for pregnant women with diabetes.
Monitoring Blood Glucose Levels
SAFETY ALERT
NURSING ALERT
TEACHING FOR SELF-MANAGEMENT
Self-Testing of Blood Glucose Level
TEACHING FOR SELF-MANAGEMENT
Treatment for Hypoglycemia
TEACHING FOR SELF-MANAGEMENT
What to Do When Illness Occurs
Urine Testing
Complications Requiring Hospitalization
Fetal Surveillance
Determination of Birth Date and Mode of Birth
Intrapartum
Postpartum
Gestational Diabetes Mellitus
Fetal Risks
Screening for Gestational Diabetes Mellitus
Care Management
Antepartum
Diet
Exercise
EVIDENCE-BASED PRACTICE
Stricter Glucose Tolerance Test in Pregnancy Will Mean Increased Diagnoses of Gestational Diabetes
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
Monitoring Blood Glucose Levels
Medications for Controlling Blood Glucose Levels
NURSING CARE PLAN
The Pregnant Woman with Gestational Diabetes
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
FIG. 29-4 Screening and diagnosis for gestational diabetes.
CLINICAL REASONING
Causes of Hyperglycemia in a Woman with Gestational Diabetes Mellitus (GDM)
Fetal Surveillance
Intrapartum
Postpartum
Hyperemesis Gravidarum
Etiology
Clinical Manifestations
Care Management
Assessment
Initial Care
Follow-up Care
TEACHING FOR SELF-MANAGEMENT
Diet for Hyperemesis
Thyroid Disorders
Hyperthyroidism
NURSING ALERT
Hypothyroidism
NURSING ALERT
Nursing Care
Maternal Phenylketonuria
KEY POINTS
References
Chapter 30 Medical-Surgical Problems in Pregnancy
Learning Objectives
Cardiovascular Disorders
BOX 30-1 MATERNAL CARDIAC DISEASE RISK GROUPS
Group I (Low Risk)
Group II (Moderate Risk)
Group III (High Risk)
Congenital Cardiac Disease
Septal Defects
Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
Acyanotic Lesions
Coarctation of the Aorta
Cyanotic Lesions
Tetralogy of Fallot
Acquired Cardiac Disease
Mitral Valve Stenosis
BOX 30-2 PROPHYLAXIS FOR BACTERIAL ENDOCARDITIS DURING LABOR AND BIRTH
High Risk Clients
Penicillin-Allergic Clients
Moderate Risk Clients
Penicillin-Allergic Clients
Mitral Valve Prolapse
Aortic Stenosis
Ischemic Heart Disease
Myocardial Infarction
Other Cardiac Diseases and Conditions
Primary Pulmonary Hypertension
Marfan Syndrome
Infective Endocarditis
Eisenmenger Syndrome
Peripartum Cardiomyopathy
Valve Replacement
Heart Transplantation
Care Management
Antepartum
SIGNS OF POTENTIAL COMPLICATIONS
Cardiac Decompensation
Pregnant Woman: Subjective Symptoms
Nurse: Objective Signs
NURSING PROCESS
Cardiac Disease
Assessment
Interview
Physical Examination
Laboratory and Diagnostic Tests
Nursing Diagnoses
Prenatal Period
Fear related to
Deficient Knowledge related to
Activity Intolerance related to
Risk for Self-care Deficit (bathing, grooming, and dressing) related to
Impaired Home Maintenance related to
Intrapartum Period
Anxiety related to
Fear related to
Risk for Impaired Gas Exchange related to
Postpartum Period
Risk for Impaired Gas Exchange related to
Risk for Excess Fluid Volume related to
Ineffective Breastfeeding related to
Expected Outcomes of Care
Plan of Care and Interventions
The woman with class I or II heart disease
The woman with class II cardiac disease
The woman with class III cardiac disease
Other considerations
Evaluation
TABLE 30-1 SELECTED DRUGS USED IN TREATMENT OF CARDIAC DISORDERS IN THE PREGNANT WOMAN
Heart Surgery During Pregnancy
Intrapartum
NURSING CARE PLAN
The Pregnant Woman with Heart Disease
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
NURSING ALERT
LEGAL TIP
Cardiac and Metabolic Emergencies
Postpartum
NURSING ALERT
Cardiopulmonary Resuscitation of the Pregnant Woman
EMERGENCY
Cardiopulmonary Resuscitation for the Pregnant Woman
Airway
Breathing
Circulation
Defibrillation
Relief of Foreign Body Airway Obstruction
FIG. 30-1 Abdominal thrust maneuver (formerly known as the Heimlich maneuver). Clearing airway obstruction in woman in late stage of pregnancy (can also be used in markedly obese victim). A, Standing behind victim, place your arms under woman’s armpits and across chest. Place thumb side of your clenched fist against middle of sternum, and place other hand over fist. B, Perform backward chest thrusts until foreign body is expelled or woman becomes unconscious. If pregnant woman becomes unconscious because of foreign body airway obstruction, place her on her back and kneel close to her side. (Be sure uterus is displaced laterally by using, for example, a rolled blanket under her hip.) Open mouth with tongue-jaw lift, perform finger sweep, and attempt rescue breathing. If unable to ventilate, position hands as for chest compression. Deliver five chest thrusts firmly to remove obstruction. Repeat this sequence of abdominal thrust maneuver, finger sweep, and attempt to ventilate. Continue sequence until pregnant woman’s airway is clear of obstruction or help has arrived to relieve you. If the woman is unconscious, give chest compressions as for the woman without pulse
Other Medical Disorders in Pregnancy
Anemia
Iron Deficiency Anemia
Folate Deficiency Anemia
Sickle Cell Hemoglobinopathy
COMMUNITY ACTIVITY
SAFETY ALERT
Thalassemia
Pulmonary Disorders
Asthma
Cystic Fibrosis
EVIDENCE-BASED PRACTICE
The 2009 Influenza A (H1N1) Pandemic and Pregnancy
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
NURSING PROCESS
Asthma
Assessment
History
Physical examination
Laboratory tests
Nursing Diagnoses
Risk for Injury (to the fetus) related to
Anxiety related to
Ineffective Airway Clearance related to
Deficient Knowledge related to
Expected Outcomes of Care
Plan of Care and Interventions
Home care
Evaluation
TABLE 30-2 MEDICATIONS USED IN PREGNANCY IN WOMEN WITH ASTHMA
Acute Respiratory Distress Syndrome
NURSING ALERT
Integumentary Disorders
SAFETY ALERT
FIG. 30-2 Woman with pruritic urticarial papules and plaques of pregnancy. Lesions also are present on her arms, back, abdomen, and buttocks.
Neurologic Disorders
Epilepsy
SAFETY ALERT
Multiple Sclerosis
Bell Palsy
Autoimmune Disorders
Systemic Lupus Erythematosus
Myasthenia Gravis
Gastrointestinal Disorders
Cholelithiasis and Cholecystitis
TEACHING FOR SELF-MANAGEMENT
Nutritional Counseling for the Pregnant Woman with Cholecystitis or Cholelithiasis
Inflammatory Bowel Disease
Urinary Tract Infections
Asymptomatic Bacteriuria
Cystitis
CLINICAL REASONING
Asymptomatic Bacteriuria
Pyelonephritis
Client Education
TEACHING FOR SELF-MANAGEMENT
Prevention of Urinary Tract Infections
Surgery During Pregnancy
Appendicitis
Care Management
Hospital Care
Home Care
BOX 30-3 DISCHARGE TEACHING FOR HOME CARE AFTER SURGERY
KEY POINTS
References
Chapter 31 Obstetric Critical Care
Learning Objectives
Obstetric Intensive Care Unit
LEGAL TIP
Nursing Assignments
LEGAL TIP
Client Care Standards
Equipment and Expertise
LEGAL TIP
Legal Review
BOX 31-1 COMPLICATIONS OF PREGNANCY THAT INDICATE THE NEED FOR CRITICAL CARE
Physiologic Changes in Pregnancy
Cardiovascular Changes
TABLE 31-1 CARDIOVASCULAR CHANGES DURING PREGNANCY
Colloid Osmotic Pressure
TABLE 31-2 COLLOID OSMOTIC (ONCOTIC) PRESSURE VALUES
Respiratory Changes
Hematologic Changes
Systemic Vascular Resistance
TABLE 31-3 CARDIAC OUTPUT IN RELATION TO MATERNAL POSITION
Hemodynamic Monitoring
Anatomic and Physiologic Characteristics of Circulation
FIG. 31-1 Diagram of heart with position of pulmonary artery catheter.
Cardiac Output
Positional Changes
NURSING ALERT
Cardiac Output Determinants
FIG. 31-2 Relation of preload to cardiac output. Ventricular function (Starling) curve for heart, showing both normal function and during failure.
SAFETY ALERT
FIG. 31-3 Relation of afterload to cardiac output when preload is maintained constant. As afterload increases, cardiac output decreases.
Invasive Hemodynamic Monitoring
Pulmonary Artery Catheter
FIG. 31-4 Standard triple-lumen flow-directed pulmonary artery catheter.
Venous Access
PROCEDURE
How to Set Up, Calibrate, and Zero-Reference Pressure Lines
Waveforms and Pressure Readings
FIG. 31-5 Location of phlebostatic axis and zeroing.
BOX 31-2 PULMONARY ARTERY CATHETER (PAC) PROTOCOL
Setup
Client Preparation for Insertion
Nursing Management During Insertion
Nursing Assessments
Nursing Management for Catheter Removal
Documentation
FIG. 31-6 Components of hemodynamic monitoring system: pressurized tubing, pressure transducer, and hemodynamic monitor.
Arterial Pressure Catheter
FIG 31-7 Pressure waveform in relation to catheter position from right atrium (RA), to right ventricle (RV), to pulmonary artery (PA), to pulmonary capillary wedge pressure (PCWP).
PROCEDURE
Obtaining a Pulmonary Capillary Wedge Pressure Reading
BOX 31-3 TROUBLESHOOTING PULMONARY ARTERY CATHETER PROBLEMS
Spontaneous Wedging: Pcwp Waveform Appears on Monitor Screen
Migration of Catheter Backward: Right Ventricular Waveform on Screen
Suspected Balloon Rupture: Absence of Resistance Felt When Inflating Balloon or Inability to Obtain Pcwp Reading
BOX 31-4 ALLEN’S TEST PROCEDURE
FIG. 31-8 Arterial waveform.
Pressure Lines
Data Collection
PROCEDURE
Making and Recording Hemodynamic Assessments
Oxygenation
SaO2 Monitoring
PROCEDURE
Thermodilution Procedure for Measuring Cardiac Output
SvO2 Monitoring
NURSING ALERT
Central Venous Pressure Lines
Interpretation of Hemodynamic Data
TABLE 31-4 NORMAL HEMODYNAMIC VALUES IN PREGNANCY
TABLE 31-5 CENTRAL HEMODYNAMIC NORMAL VALUES
BOX 31-5 CASE STUDIES
Case 1
Evaluation
Case 2
Evaluation
Case 3
Evaluation
Pulmonary Edema
CLINICAL REASONING
Nursing Care of the Critically Ill Pregnant Woman
Case I
Case II
Trauma During Pregnancy
Significance
Maternal Physiologic Characteristics
NURSING ALERT
TABLE 31-6 MATERNAL ADAPTATIONS DURING PREGNANCY AND RELATION TO TRAUMA
Fetal Physiologic Characteristics
Mechanisms of Trauma
Blunt Abdominal Trauma
NURSING ALERT
Penetrating Abdominal Trauma
Thoracic Trauma
Immediate Stabilization
NURSING ALERT
Primary Survey
NURSING ALERT
Secondary Survey
BOX 31-6 GLASGOW COMA SCALE
BOX 31-7 PHYSICAL EXAMINATION OF THE PREGNANT TRAUMA VICTIM
Head
Neck
Chest
Abdomen
Lower Back
Extremities
Vagina
Urinary Tract
Electronic Fetal Monitoring
LEGAL TIP
Care of the Pregnant Woman Involved in a Minor Trauma Situation
Fetal-Maternal Hemorrhage
Ultrasound
Radiation Exposure
Perimortem Cesarean Birth
Family-centered Obstetric Critical Care
Maternal Death
KEY POINTS
References
Chapter 32 Mental Health Disorders and Substance Abuse in Pregnancy
Learning Objectives
Mental Health Disorders During Pregnancy
Mood Disorders
NURSING ALERT
COMMUNITY ACTIVITY
Collaborative Care
Antidepressant Medications
TABLE 32-1 ANTIDEPRESSANT MEDICATIONS
Anxiety Disorders
Collaborative Care
TABLE 32-2 ANTIANXIETY MEDICATIONS
Special Considerations for Medications During Pregnancy
TABLE 32-3 MOOD STABILIZERS
Substance Abuse During Pregnancy
Prevalence
Risk Factors
Barriers to Treatment
Legal Considerations
LEGAL TIP
Drug Testing During Pregnancy
Commonly Abused Drugs
Nicotine and Caffeine
Alcohol
Marijuana
Cocaine and Methamphetamine
Opiates
BOX 32-1 CAGE QUESTIONNAIRE
Care Management
Screening
BOX 32-2 SCREENING WITH THE 4P’s PLUS
Assessment
Collaborative Care
NURSING PROCESS
Substance Abuse
Assessment
Nursing Diagnoses
Risk for Imbalanced Nutrition: Less than Body Requirements related to:
Risk for injury (to self, fetus, or newborn) related to:
Risk for infection related to:
Self-care deficit (bathing or hygiene) related to:
Ineffective coping related to:
Risk for Impaired Parent-infant Attachment related to:
Hopelessness related to:
Powerlessness related to:
Risk for suicide related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Intrapartum and Postpartum Care Considerations
Postpartum Psychologic Complications
Mood Disorders
Etiology and Risk Factors
BOX 32-3 RISK FACTORS FOR POSTPARTUM DEPRESSION
Postpartum Depression Without Psychotic Features
Medical Management
Postpartum Depression with Psychotic Features
NURSING ALERT
Medical Management
TABLE 32-4 ANTIPSYCHOTIC MEDICATIONS
Care Management
SAFETY ALERT
Postpartum Depression Screening Tools
NURSING CARE PLAN
Postpartum Depression (PPD)
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Care on the Postpartum Unit
TEACHING FOR SELF-MANAGEMENT
Activities to Prevent Postpartum Depression
NURSING PROCESS
Postpartum Depression
Assessment
Nursing Diagnoses
Situational Low Self- esteem (in the mother) related to:
Disabled Family Coping related to:
Risk for Impaired Parenting related to:
Risk for Injury (to the newborn) related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
NURSING ALERT
Nursing Care in the Home and Community
Referral
EVIDENCE-BASED PRACTICE
Assessing for Postpartum Depression
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Evidence
Implications for Practice
References
Providing Safety
Psychiatric Hospitalization
NURSING ALERT
SAFETY ALERT
Psychotropic Medications
LEGAL TIP
Commitment for Psychiatric Care
Psychotropic Medications and Lactation
CLINICAL REASONING
Postpartum Depression
Other Treatments for PPD
NURSING ALERT
Postpartum Onset of Anxiety Disorders
Medical Management
Nursing Considerations
KEY POINTS
References
Chapter 33 Labor and Birth Complications
Learning Objectives
Preterm Labor and Birth
Preterm Birth Versus Low Birth Weight
BOX 33-1 RISK FACTORS FOR SPONTANEOUS PRETERM LABOR
BOX 33-2 COMMON CAUSES OF INDICATED PRETERM BIRTH
Predicting Spontaneous Preterm Labor and Birth
Biochemical Marker
Cervical Length
Causes of Preterm Labor and Birth
NURSING CARE PLAN
Preterm Labor
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Care Management
Prevention
Early Recognition and Diagnosis
BOX 33-3 SIGNS AND SYMPTOMS OF PRETERM LABOR
Uterine Activity
Discomfort
Vaginal Discharge
TEACHING FOR SELF-MANAGEMENT
What to Do If Symptoms of Preterm Labor Occur
FIG. 33-1 A nurse teaching a couple signs and symptoms of preterm labor.
COMMUNITY ACTIVITY
Lifestyle Modifications
Activity Restriction
Restriction of Sexual Activity
BOX 33-4 ADVERSE EFFECTS OF BED REST
Maternal Effects (Physical)
Maternal Effects (Psychosocial)
Effects on Support System
Home Care
EVIDENCE-BASED PRACTICE
Preterm Labor: Is Bed Rest (Especially in the Hospital) Really Best?
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
FIG. 33-2 Woman at home on restricted activity for preterm labor prevention. Note how she has arranged her daytime resting area so that needed items are close at hand.
TEACHING FOR SELF-MANAGEMENT
Activities for Children of Women on Activity Restriction
BOX 33-5 CONTRAINDICATIONS TO TOCOLYSIS
Maternal
Fetal
Suppression of Uterine Activity
SAFETY ALERT
BOX 33-6 NURSING CARE FOR THE WOMAN RECEIVING TOCOLYTIC THERAPY
MEDICATION GUIDE
Tocolytic Therapy for Preterm Labor
SAFETY ALERT
Promotion of Fetal Lung Maturity
MEDICATION GUIDE
Antenatal Glucocorticoid Therapy with Betamethasone or Dexamethasone
Action
Indication
Dosage and Route
Adverse Effects
Nursing Considerations
NURSING ALERT
Management of Inevitable Preterm Birth
Fetal and Early Neonatal Loss
Premature Rupture of Membranes
Care Management
TEACHING FOR SELF-MANAGEMENT
Home Care Instructions for the Woman with Preterm Premature Rupture of Membranes
Chorioamnionitis
Dysfunctional Labor (Dystocia)
Abnormal Uterine Activity
Hypertonic Uterine Dysfunction
Hypotonic Uterine Dysfunction
TABLE 33-1 DYSFUNCTIONAL LABOR: PRIMARY AND SECONDARY POWERS
Secondary Powers
Abnormal Labor Patterns
TABLE 33-2 ABNORMAL LABOR PATTERNS
Precipitous Labor
Alterations in Pelvic Structure
Pelvic Dystocia
Soft-Tissue Dystocia
Fetal Causes
Anomalies
Cephalopelvic Disproportion
Malposition
BOX 33-7 MEASURES TO REDUCE BACK PAIN AND FACILITATE ROTATION OF FETAL HEAD DURING BACK LABOR-OCCIPUT POSTERIOR POSITION
Measures to Reduce Back Pain During a Contraction
Measures to Facilitate the Rotation of the Fetal Head (may also Reduce Back Pain)
Malpresentation
FIG. 33-3 Breech presentation. A, Frank breech. B, Complete breech. C, Single footling breech.
FIG. 33-4 Mechanism of labor in breech presentation. A, Breech before onset of labor. B, Engagement and internal rotation. C, Lateral flexion. D, External rotation or restitution. E, Internal rotation of shoulders and head. F, Face rotates to sacrum when occiput is anterior. G, Head is born by gradual flexion during elevation of fetal body.
Multifetal Pregnancy
Position of the Woman
Psychologic Responses
Care Management
LEGAL TIP
Standard of Care—Labor and Birth Complications
Obesity
Care Management
NURSING PROCESS
Dysfunctional Labor
Assessment
Past History
Physical
Psychologic
Nursing Diagnoses
Risk for Injury (maternal or fetal) related to
Powerlessness related to
Risk for Infection related to
Ineffective Individual Coping related to
EXPECTED OUTCOMES OF CARE
Plan of Care and Interventions
Evaluation
FIG. 33-5 Room specifically designed to accommodate obese pregnant clients. Note lift attached to ceiling for use in transferring women from the bed to chairs or stretchers.
FIG. 33-6 External version of fetus from breech to vertex presentation. This must be achieved without force. A, Breech is pushed up out of pelvic inlet while head is pulled toward inlet. B, Head is pushed toward inlet while breech is pulled upward.
Obstetric Procedures
Version
External Cephalic Version
Internal Version
Induction of Labor
BOX 33-8 INDICATIONS AND CONTRAINDICATIONS FOR LABOR INDUCTION
Indications
Contraindications
Relative Contraindications
TABLE 33-3 BISHOP SCORE
Cervical Ripening Methods
Chemical Agents
Mechanical and Physical Methods
MEDICATION GUIDE
Prostaglandin E1 (PGE1): Misoprostol (Cytotec)
Action
Indications
Dosage and Administration
Adverse Effects
Nursing Considerations
Alternative Methods
MEDICATION GUIDE
Prostaglandin E2 (PGE2): Dinoprostone (Cervidil Insert; Prepidil Gel)
Action
Indications
Dosage and Route
Adverse Effects
Nursing Considerations
Amniotomy
PROCEDURE
Assisting with Amniotomy
Procedure
Documentation
NURSNG ALERT
LEGAL TIP: Performing Amniotomy
Oxytocin
SAFETY ALERT
MEDICATION GUIDE
Oxytocin (Pitocin)
Action
Indications
Dosage
Adverse effects
Nursing Considerations
Nursing Considerations.
FIG. 33-7 Woman in side-lying position receiving oxytocin.
EMERGENCY
Uterine Tachysystole with Oxytocin
Signs
Interventions (With Normal [Reassuring] Fhr)
Interventions (Wth Abnormal [Nonreassuring] FHR)
Resumption of Oxytocin After Resolution of Tachysystole
NURSING ALERT
Augmentation of Labor
Operative vaginal birth
Forceps-Assisted Birth
Management
NURSING ALERT
Nursing Considerations
FIG. 33-8 Types of forceps. Piper forceps are used to assist delivery of the head in a breech birth.
FIG. 33-9 Outlet forceps-assisted extraction of the head.
TABLE 33-4 DEFINITIONS FOR FORCEPS- AND VACUUM-ASSISTED BIRTHS
Vacuum-Assisted Birth
FIG. 33-10 Use of vacuum extraction to rotate fetal head and assist with descent. A, Arrow indicates direction of traction on the vacuum cup. B, Caput succedaneum formed by the vacuum cup.
Management
BOX 33-9 ASSISTING WITH BIRTH BY VACUUM EXTRACTION
Nursing Considerations
Cesarean Birth
BOX 33-10 SELECTED MEASURES TO REDUCE THE CESAREAN BIRTH RATE AND INCREASE THE RATE OF VAGINAL BIRTH AFTER CESAREAN
Educate Women Regarding
Establish Admission Criteria for Women in Labor that
Use Appropriate Assessment Techniques to
Initiate a Doula Program that
Develop a Philosophy of Labor Management that
Indications
BOX 33-11 INDICATIONS FOR CESAREAN BIRTH
Maternal
Fetal
Maternal-fetal
Elective Cesarean Birth
CLINICAL REASONING
The Woman Seeking Elective Cesarean Birth
Forced Cesarean Birth
Surgical Techniques
FIG. 33-11 Skin incisions for cesarean birth. A, Vertical. B, Horizontal (Pfannenstiel).
FIG. 33-12 Uterine incisions for cesarean birth. A, Low transverse incision. B, Low vertical incision. C, Classic incision
Complications and Risks
Anesthesia
Scheduled Cesarean Birth
Unplanned Cesarean Birth
Prenatal Preparation
Preoperative Care
FIG. 33-13 Cesarean birth. A, “Bikini” incision has been made, the muscle layer is separated, the abdomen is entered, and the uterus has been exposed and incised; suctioning of amniotic fluid continues as head is brought up through the incision. Note small amount of bleeding. B, The neonate’s birth through the uterine incision is nearly complete. C, A quick assessment is performed; note extreme molding of head resulting from cephalopelvic disproportion.
Intraoperative Care
LEGAL TIP
Disclosure of Client Information
Immediate Postoperative Care
FIG. 33-14 A, Parents and their newborn. The physician manually removes the placenta, suctions the remaining amniotic fluid and blood from the uterine cavity, and closes the uterine incision, peritoneum, muscle layer, fatty tissue, and finally the skin, while the new family shares some time together. B, Parents become better acquainted with their newborn while mother rests after surgery.
Postoperative or Postpartum Care
TEACHING FOR SELF-MANAGEMENT
Postpartum Pain Relief After Cesarean Birth
Incisional
Gas
SAFETY ALERT
SAFETY ALERT
TEACHING FOR SELF-MANAGEMENT
Signs of Postoperative Complications After Discharge Following Cesarean Birth
Trial of Labor
BOX 33-12 SELECTION CRITERIA FOR VAGINAL BIRTH AFTER CESAREAN
Vaginal Birth After Cesarean
Postterm Pregnancy, Labor, and Birth
Maternal and Fetal Risks
Care Management
TEACHING FOR SELF-MANAGEMENT
Postterm Pregnancy
Obstetric Emergencies
Meconium Stained Amniotic Fluid
Care Management
EMERGENCY
Immediate Management of the Newborn with Meconium-Stained Amniotic Fluid
Prior to Birth
Immediately after Birth
NURSING ALERT
Shoulder Dystocia
FIG. 33-15 Application of suprapubic pressure
FIG. 33-16 McRoberts maneuver.
Care Management
Prolapsed Umbilical Cord
Care Management
FIG. 33-17 Prolapse of umbilical cord. Note pressure of presenting part on umbilical cord, which endangers fetal circulation. A, Occult (hidden) prolapse of cord. B, Complete prolapse of cord. Note that membranes are intact. C, Cord presenting in front of the fetal head may be seen in vagina. D, Frank breech presentation with prolapsed cord.
FIG. 33-18 Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord. Pressure exerted by examiner’s fingers in A, vertex presentation, and B, breech presentation. C, Gravity relieves pressure when woman is in modified Sims position with hips elevated as high as possible with pillows. D, Knee-chest position.
Rupture of the Uterus
EMERGENCY
Prolapsed Umbilical Cord
Signs
Interventions
Care Management
Anaphylactoid Syndrome of Pregnancy
EMERGENCY
Anaphylactoid Syndrome of Pregnancy
Signs
Respiratory Distress
Circulatory Collapse
Hemorrhage
Interventions
Oxygenate
Maintain Cardiac Output and Replace Fluid Losses
Care Management
KEY POINTS
Breech Presentation Examination (read text)
Breech Birth, Face (read text)
Cesarean Delivery (read text)
Shoulder Dystocia (read text)
Umbilical Cord Prolapse (read text)
References
Chapter 34 Postpartum Complications
Learning Objectives
Postpartum Hemorrhage
Definition and Incidence
Etiology and Risk Factors
CLINICAL REASONING
Postpartum Hemorrhage
Uterine Atony
Lacerations of the Genital Tract
BOX 34-1 RISK FACTORS AND CAUSES OF POSTPARTUM HEMORRHAGE
Retained Placenta
Nonadherent Retained Placenta
Adherent Retained Placenta
Inversion of the Uterus
Subinvolution of the Uterus
Care Management
Medical Management
Hypotonic Uterus
NURSING ALERT
MEDICATION GUIDE
Drugs Used to Manage Postpartum Hemorrhage
Bleeding with a Contracted Uterus
Uterine Inversion
BOX 34-2 HERBAL REMEDIES FOR POSTPARTUM HEMORRHAGE∗
Subinvolution
Herbal Remedies
Nursing Interventions
FIG. 34-1 Nursing assessments for postpartum bleeding. CBC, Complete blood count; IV, intravenous; uterotonics, medications to contract the uterus.
BOX 34-3 NONINVASIVE ASSESSMENTS OF CARDIAC OUTPUT IN POSTPARTUM WOMEN WHO ARE BLEEDING
Palpation Of Pulses (Rate, Quality, Equality)
Auscultation
Inspection
Observation
Measurement
NURSING PROCESS
Postpartum Hemorrhage
Assessment
Nursing Diagnoses
Deficient Fluid Volume related to:
Risk for Imbalanced Fluid Volume related to:
Risk for Infection related to:
Risk for Injury related to:
Fear or Anxiety related to:
Risk for Impaired Parenting related to:
Ineffective (Peripheral) Tissue Perfusion related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
NURSING ALERT
Hemorrhagic (Hypovolemic) Shock
NURSING CARE PLAN
Postpartum Hemorrhage
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
EMERGENCY
Hemorrhagic Shock
Intervention
Medical Management
Nursing Interventions
Fluid or Blood Replacement Therapy
LEGAL TIP
Standard of Care for Bleeding Emergencies
Coagulopathies
Idiopathic Thrombocytopenic Purpura
von Willebrand Disease
Thromboembolic Disease
Incidence and Etiology
Clinical Manifestations
FIG. 34-2 Deep venous thrombophlebitis.
Medical Management
Nursing Interventions
NURSING ALERT
Postpartum Infections
BOX 34-4 PREDISPOSING FACTORS FOR POSTPARTUM INFECTION
Preconception or Antepartal Factors
Intrapartal Factors
Endometritis
Wound Infections
Urinary Tract Infections
FIG. 34-3 Postpartum infection—endometritis.
FIG. 34-4 Mastitis.
Mastitis
BOX 34-5 NURSING DIAGNOSES FOR WOMEN EXPERIENCING POSTPARTUM INFECTION
Deficient Knowledge related to:
Impaired Tissue Integrity related to:
Acute Pain related to:
Interrupted Family Processes related to:
Risk for Impaired Parenting related to:
Care Management
KEY POINTS
References
Unit Eight Newborn Complications
Interactive Review—Unit 8
Chapter 35 Acquired Problems of the Newborn
Learning Objectives
Birth Trauma
Soft-Tissue Injuries
TABLE 35-1 ANATOMIC CLASSIFICATION OF BIRTH INJURIES
FIG. 35-1 Marked bruising on the entire face of an infant born vaginally after face presentation. Less severe ecchymoses were present on the extremities. Phototherapy was required for treatment of jaundice resulting from the breakdown of accumulated blood.
FIG. 35-2 Swelling of the genitals and bruising of the buttocks after a breech birth. Note the position of the infant’s legs.
FIG. 35-3 Fractured clavicle after shoulder dystocia.
Skeletal Injuries
FIG. 35-4 Erb-Duchenne palsy in newborn infant. The Moro reflex was absent in right upper extremity. Recovery was complete.
Peripheral Nervous System Injuries
FIG. 35-5 Facial paralysis 15 minutes after forceps birth. Absence of movement on affected side is especially noticeable when infant cries.
Central Nervous System Injuries
Infants of Mothers With Diabetes
Pathophysiology
NURSING PROCESS
Birth Injury
Assessment
Nursing Diagnoses
Infant
Impaired Physical Mobility related to:
Impaired Gas Exchange related to:
Acute Pain related to:
Injury related to:
Parents and Family
Anxiety related to Deficient Knowledge Regarding:
Grieving related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Congenital Anomalies
FIG. 35-6 Macrosomia.
Macrosomia
Birth Trauma and Perinatal Hypoxia
Respiratory Distress Syndrome
Hypoglycemia
Hypocalcemia and Hypomagnesemia
Cardiomyopathy
Hyperbilirubinemia and Polycythemia
Nursing Care
TABLE 35-2 RISK FACTORS FOR NEONATAL SEPSIS
Neonatal Infections
Sepsis
NURSING CARE PLAN
The Infant of the Mother with Pregestational or Gestational Diabetes
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Care Management
NURSING PROCESS
The Infant with Suspected Sepsis
Assessment
Nursing Diagnoses
Risk for Infection related to:
Ineffective Thermoregulation related to:
Impaired Tissue Integrity related to:
Acute Pain related to:
Parents and Family
Anxiety, Fear, or Grieving related to:
Risk for Impaired Parenting related to:
Expected Outcomes of Care
Newborn
Parents
Plan of Care and Interventions
Evaluation
TABLE 35-3 SIGNS OF SEPSIS∗
Preventive Measures
Curative Measures
NURSING ALERT
Transplacental Infections
Toxoplasmosis
BOX 35-1 TRANSPLACENTAL (TORCH) INFECTIONS AFFECTING NEWBORNS
Gonorrhea
Syphilis
FIG. 35-7 Neonatal syphilis lesions on hands and feet.
Medical Management
Prognosis
Varicella-Zoster
Hepatitis B Virus
NURSING ALERT
Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
Rubella Infection
SAFETY ALERT
Cytomegalovirus Infection
FIG. 35-8 Neonatal cytomegalovirus infection. Typical rash seen in a severely affected infant.
Herpes Simplex Virus
FIG. 35-9 Neonatal herpes simplex virus oral lesions.
Parvovirus B19
Enterovirus
Bacterial Infections
Group B Streptococci
FIG. 35-10 Sample algorithm for management of a newborn whose mother received intrapartum antimicrobial agents for prevention (IAP) of early-onset group B streptococcal disease or suspected chorioamnionitis. This algorithm is not an exclusive course of management. Variations that incorporate individual circumstances or institutional preferences may be appropriate.
Escherichia coli
Staphylococcus aureus
Listeriosis
Chlamydia Trachomatis
Fungal Infections
Candidiasis
COMMUNITY ACTIVITY
Substance Abuse
TABLE 35-4 SUMMARY OF NEONATAL EFFECTS OF COMMONLY ABUSED SUBSTANCES
TABLE 35-5 SIGNS OF NEONATAL ABSTINENCE SYNDROME
Tobacco
Alcohol
FIG. 35-11 Critical periods in human embryogenesis. Infant with fetal alcohol syndrome.
BOX 35-2 DIAGNOSTIC CRITERIA FOR FETAL ALCOHOL SYNDROME AND ALCOHOL-RELATED EFFECTS
FIG. 35-12 Infant with fetal alcohol syndrome.
Heroin
NURSING ALERT
SAFETY ALERT
Methadone
Marijuana
Cocaine
BOX 35-3 FETAL AND NEONATAL EFFECTS OF MATERNAL COCAINE USE DURING PREGNANCY
Methamphetamine
MDMA/Ecstasy
Other Drugs of Concern
Caffeine
Selective Serotonin Reuptake Inhibitors
Care Management
Nursing Care
FIG. 35-13 Neonatal Abstinence Scoring System.
BOX 35-4 CARE OF THE INFANT EXPERIENCING WITHDRAWAL (NEONATAL ABSTINENCE SYNDROME)
NURSING CARE PLAN
The Infant Experiencing Drug Withdrawal (Neonatal Abstinence Syndrome)
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
CLINICAL REASONING
Narcotic Exposure in a Newborn
KEY POINTS
References
Chapter 36 Hemolytic Disorders and Congenital Anomalies
Learning Objectives
Hyperbilirubinemia
Physiologic Jaundice
Pathologic Jaundice
BOX 36-1 MONITORING FOR JAUNDICE AFTER EARLY DISCHARGE
BOX 36-2 POTENTIAL CAUSES OF PATHOLOGIC HYPERBILIRUBINEMIA IN NEONATES
Maternal Factors
Fetal/Newborn Factors
Hemolytic Disease of the Newborn
Rh Incompatibility
ABO Incompatibility
Other Causes of Hemolytic Jaundice
Acute Bilirubin Encephalopathy
Care Management
BOX 36-3 INDICATIONS FOR AMOUNT OF RHO(D) IMMUNOGLOBULIN TO BE ADMINISTERED
50 mcg
300 mcg
More Than 300 mcg
NURSING CARE PLAN
The Infant with Hyperbilirubinemia
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Congenital Anomalies
Cardiovascular System Anomalies
TABLE 36-1 PHYSIOLOGIC CLASSIFICATION OF CARDIAC DEFECTS
FIG. 36-1 Congenital heart abnormalities.
Central Nervous System Anomalies
Encephalocele and Anencephaly
Spina Bifida
FIG. 36-2 A, Myelomeningocele. Note absence of vertebral arches. B, Myelomeningocele (spina bifida).
NURSING ALERT
Hydrocephalus
FIG. 36-3 Mother providing kangaroo care to preterm twins; the one on the right has hydrocephalus. The characteristic appearance is an enlarged head, thinning of the scalp, distended scalp veins, and a full fontanel.
Microcephaly
Respiratory System Anomalies
Laryngeal Web and Choanal Atresia
Congenital Diaphragmatic Hernia
FIG. 36-4 Choanal atresia. Posterior nares are obstructed by membrane or bone either bilaterally or unilaterally. Infant becomes cyanotic at rest. With crying, newborn’s color improves. Nasal discharge is present. Snorting respirations often are observed with increased respiratory effort. Newborn may be unable to breathe and eat at the same time. Diagnosis is made by noting inability to pass small feeding tube through one or both nares.
FIG. 36-5 A, Normal diaphragm separating the abdominal and thoracic cavities. B, Diaphragmatic hernia with a small lung and abdominal contents in the thoracic cavity.
Gastrointestinal System Anomalies
Cleft Lip and Palate
FIG. 36-6 Variations in clefts of lip and palate at birth. A, Notch in vermilion border. B, Unilateral cleft lip and cleft palate. C, Bilateral cleft lip and cleft palate. D, Cleft palate. E, Infant with complete unilateral cleft lip. Note the feeding tube.
Esophageal Atresia and Tracheoesophageal Fistula
FIG. 36-7 Aids in feeding infants with cleft lip and palate 1, Mead Johnson bottle and nipple for cleft palate. Cleft palate nipple system (2a) with valve (2b) to regulate flow. Haberman feeder (3a) with disk (3b) to control flow of milk. 4, Ross cleft palate assembly. Nipple can be trimmed to accommodate palate size.
NURSING ALERT
FIG. 36-8 Congenital atresia of esophagus and tracheoesophageal fistula. A, Upper and lower segments of esophagus end in blind sac, occurring in 5% to 8% of such infants. B, Upper segment of esophagus ends in atresia and connects to trachea by fistulous tract, occurring rarely. C, Upper segment of esophagus ends in blind pouch; lower segment connects with trachea by small fistulous tract, occurring in 80% to 95% of such infants. D, Both segments of esophagus connect by fistulous tracts to trachea, occurring in less than 1% of such infants. Infant may aspirate with first feeding. E, Esophagus is continuous but connects by fistulous tract to trachea; known as H-type.
Omphalocele and Gastroschisis
Gastrointestinal Obstruction
FIG. 36-9 A, Omphalocele. B, Gastroschisis of bowel and stomach.
Imperforate Anus
FIG. 36-10 Types of imperforate anus. Anal sphincter muscle may be present and intact. A, High lesion opening onto perineum through narrow fistulous tract. B, High lesion ending in fistulous tract to urinary tract. C, Low lesion in bowel passes through puborectal muscle. D, High lesion ending in fistulous tract to vagina.
FIG. 36-11 Imperforate anus.
Musculoskeletal System Anomalies
Developmental Dysplasia of the Hip
FIG. 36-12 Configuration and relationship of structures in developmental dysplasia of the hip.
NURSING ALERT
NURSING ALERT
CLINICAL REASONING
Developmental Dysplasia of the Hip (DDH)
Clubfoot
Polydactyly
Genitourinary System Anomalies
Hypospadias and Epispadias
FIG. 36-13 Classification of hypospadias by position of the urethral meatus.
FIG. 36-14 Hypospadias.
Exstrophy of the Bladder
FIG. 36-15 Exstrophy of bladder.
FIG. 36-16 Ambiguous external genitals (i.e., structure can be enlarged clitoral hood and clitoris or malformed penis).
Ambiguous Genitalia
Care Management
Prenatal Diagnosis
Perinatal Diagnosis
Postnatal Diagnosis
Genetic Diagnosis
Newborn Screening
FIG. 36-17 A, Clinical features of Down syndrome. B, Simian crease.
NURSING ALERT
Cytogenetic Studies
Dermatoglyphics
Newborn Care
NURSING PROCESS
The Newborn with a Congenital Anomaly
Assessment
Newborn
Parents
Nursing Diagnoses
Newborn
Risk for Injury related to
Risk for Infection related to
Impaired Gas Exchange related to
Imbalanced Nutrition: Less than Body Requirements related to
Delayed Growth and Development related to
Parents and Family
Grieving or Spiritual Distress related to
Compromised Family Coping related to
Deficient Knowledge related to
Anxiety related to
Risk for Impaired Parenting related to
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
Parents and Family Support
COMMUNITY ACTIVITY
KEY POINTS
References
Chapter 37 Nursing Care of the High Risk Newborn
Learning Objectives
Preterm Infants
BOX 37-1 CLASSIFICATION OF HIGH RISK INFANTS
Classification According to Size
Classification According to Gestational Age
Classification According to Mortality
Late Preterm Infants
Physiologic Functions
Respiratory Function
NURSING ALERT
Cardiovascular Function
Maintaining Body Temperature
BOX 37-2 SIGNS OF HYPOTHERMIA AND HYPERTHERMIA
Hypothermia
Hyperthermia
Central Nervous System Function
Maintaining Adequate Nutrition
Maintaining Renal Function
Maintaining Hematologic Status
Resisting Infection
Growth and Development Potential
BOX 37-3 SIGNS AND SYMPTOMS OF INFECTION
Care Management
NURSING PROCESS
Late Preterm and Preterm Infant Care
Assessment
Nursing Diagnoses
Ineffective Breathing Pattern related to:
Ineffective Thermoregulation related to:
Risk for Infection related to:
Anxiety (parental) related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
NURSING CARE PLAN
The High Risk Preterm Newborn
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Physical Care
Maintaining Body Temperature
Care of the Hypothermic Infant
FIG. 37-1 Preterm infant in polyethylene bag to protect against heat loss.
Oxygen Therapy
NURSING ALERT
Hood Therapy
Nasal Cannula
FIG. 37-2 A, Infant under hood. B, Infant with nasal cannula.
Continuous Positive Airway Pressure Therapy
Mechanical Ventilation
FIG. 37-3 Infant receiving ventilatory assistance with nasal continuous positive airway pressure (CPAP).
FIG. 37-4 Infant intubated and on ventilator.
Neonatal Resuscitation
TABLE 37-1 COMMON METHODS FOR ASSISTED VENTILATION IN NEONATAL RESPIRATORY DISTRESSlowast;
NURSING ALERT
FIG. 37-5 Neonatal resuscitation flow algorithm.
Surfactant Administration
High-Frequency Ventilation.
Additional Therapies
Nitric Oxide Therapy.
Extracorporeal Membrane Oxygenation (ECMO).
MEDICATION GUIDE
Surfactant Replacement
Drug/Source
Action
Indications
Dosage and Route
Adverse Reactions
Nursing Considerations
Partial Liquid Ventilation (PLV).
Weaning from Respiratory Assistance.
Nutritional Care
Type of Nourishment
SAFETY ALERT
Weight and Fluid Loss or Gain
BOX 37-4 CALCULATION OF A WEIGHT LOSS OR GAIN
Example 1
Example 2
Elimination Patterns
Oral Feeding
Gavage Feeding
Gastrostomy Feedings
FIG. 37-6 Gavage feeding. A, Measurement of gavage feeding tube from tip of nose to earlobe and to midpoint between end of xiphoid process and umbilicus. Tape may be used to mark correct length on tube. For accurate measure, the infant should be facing up. B, Insertion of gavage tube using orogastric route. C, Indwelling gavage tube, nasogastric route. After feeding by orogastric or nasogastric tube, infant is propped on right side or placed prone (preterm infant) for 1 hour to facilitate emptying of stomach into small intestine.
PROCEDURE
Inserting a Gavage Feeding Tube
Parenteral Nutrition
Advancing Infant Feedings
FIG. 37-7 Nonnutritive sucking.
Nonnutritive Sucking
Skin Care
FIG. 37-8 Although necessary, neonatal intensive care unit equipment can contribute to significant environmental stimulation. Note bed, wall oxygen attachments, monitor, ventilator, incubator, and pumps, all of which have alarm systems.
Environmental Concerns
NURSING ALERT
Developmental Care
Positioning
FIG. 37-9 Developmental care: positioning of preterm infant using containment while undergoing phototherapy.
Reducing Inappropriate Stimuli
Infant Communication
Infant Stimulation
Kangaroo Care
FIG. 37-10 Father holding infant in kangaroo care
Parental Adaptation to Preterm Infant
Parental Tasks
Parental Responses
Parental Support
Fig. 37-11 A, Mother and father touch preterm infant. B, Mother caresses preterm infant.
Parental Maladaptation
FIG. 37-12 Sibling visits newborn in the neonatal intensive care unit. A, Father prepares older child for visit. B, Sibling observes neonate at a safe distance. C, He reaches out to touch the infant.
Parent Education
Complications in High Risk Infants
Respiratory Distress Syndrome
FIG. 37-13 Pathogenesis of respiratory distress syndrome (RDS).
TABLE 37-2 NORMAL ARTERIAL BLOOD GAS VALUES FOR NEONATES
NURSING ALERT
Complications Associated with Oxygen Therapy
Retinopathy of Prematurity
Bronchopulmonary Dysplasia
Patent Ductus Arteriosus
Germinal Matrix Hemorrhage–Intraventricular Hemorrhage
Necrotizing Enterocolitis
BOX 37-5 PROPOSED RISK FACTORS FOR NECROTIZING ENTEROCOLITIS
Infant Pain Responses
Pain Assessment
NURSING ALERT
BOX 37-6 MANIFESTATIONS OF ACUTE PAIN IN THE NEONATE
Physiologic Responses
Vital Signs
Oxygenation
Skin
Other Observations
Behavioral Responses
Vocalizations: Observe Quality, Timing, and Duration
Facial Expression
Body Movements and Posture
Change in State
Memory of Pain
Consequences of Untreated Pain in Infants
Pain Management
EVIDENCE-BASED PRACTICE
Non-Pharmacologic Pain Relief Measures for Newborns
Ask the Question
Search for Evidence
Search Strategies
Databases Searched
Critically Analyze the Data
Implications for Practice
References
TABLE 37-3 LATE PRETERM INFANT ASSESSMENT AND INTERVENTIONS
Late Preterm Infants
Respiratory Distress
Thermoregulation
Nutrition
Hypoglycemia
Hyperbilirubinemia
Infection
Postmature Infants
CLINICAL REASONING
The Late Preterm Infant
Meconium Aspiration Syndrome
FIG. 37-14 Infant being resuscitated at birth. Meconium was present on the abdomen, and umbilical cord. Infant was not breathing, and heart rate was 65 beats/min at birth. Respirations and heart rate were normal at 2 minutes.
Persistent Pulmonary Hypertension of the Newborn
Other Problems Related to Gestation
Small for Gestational Age and Intrauterine Growth Restriction
Perinatal Asphyxia.
Hypoglycemia
Hyperglycemia
Polycythemia
Heat Loss
Large for Gestational Age Infants
Discharge Planning
Transport to and from a Regional Center
FIG. 37-15 Total life support system for transport of high risk newborns
BOX 37-7 S.T.A.B.L.E. PROGRAM ON POST-RESUSCITATION AND POST-TRANSPORT STABILIZATION CARE OF SICK INFANTS
Anticipatory Grief
Loss of an Infant
COMMUNITY ACTIVITY
KEY POINTS
References
Chapter 38 Perinatal Loss and Grief
Learning Objectives
Perinatal Loss
Grief Responses
Acute Distress
BOX 38-1 CONCEPTUAL MODEL OF PARENTAL GRIEF
Phase of Acute Distress
Phase of Intense Grief
Reorganization
Intense Grief
Reorganization
Family Aspects of Grief
Grandparents and Siblings
Care Management
NURSING PROCESS
Perinatal Grief
Assessment
Nursing Diagnoses
Anxiety related to:
Ineffective Coping related to:
Powerlessness related to:
Interrupted Family Processes related to:
Ineffective Sexuality Pattern (between the mother and father) related to:
Fatigue and Disturbed Sleep Pattern related to:
Complicated Grieving related to:
Situational Low Self-esteem related to:
Spiritual Distress related to:
Expected Outcomes of Care
Plan of Care and Interventions
Evaluation
FIG. 38-1 Sample checklist for assisting parents experiencing miscarriage/ectopic pregnancy.
FIG. 38-2 Sample checklist for assisting parents experiencing stillbirth or newborn death.
Help the Mother, the Father, and Other Family Members Actualize the Loss
CLINICAL REASONING
The Bereaved Couple
NURSING ALERT
FIG. 38-3 Laura.
FIG. 38-4 Laura’s family members say a special good-bye.
FIG. 38-5 Door card for room of mother who has had a perinatal loss.
Help the Parents with Decision Making
LEGAL TIP
Laws Regarding Live Birth
Help the Bereaved Parents Acknowledge and Express Their Feelings
BOX 38-2 WHAT TO SAY AND WHAT NOT TO SAY TO BEREAVED PARENTS
What to Say
What not to Say
Normalize the Grief Process and Facilitate Positive Coping
Meet the Physical Needs of the Postpartum Bereaved Mother
Assist the Bereaved in Communicating with, Supporting, and Getting Support from Family
FIG. 38-6 A memory kit assembled at John C. Lincoln Hospital, Phoenix, AZ. Memory kits may include pictures of the infant, clothing, death certificate, footprints, identification bands, fetal monitor printout, and ultrasound picture.
Create Memories for Parents to Take Home
Communicate Using a Caring Framework
Be Concerned About Cultural and Spiritual Needs of Parents
Provide Sensitive Care At and After Discharge
FIG. 38-7 Burial cradle.
Provide Postmortem Care
Special Losses
Prenatal Diagnoses with Negative Outcome
NURSING CARE PLAN
Fetal Death: 24 Weeks of Gestation
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcomes
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Nursing Diagnosis
Expected Outcome
Nursing Interventions/Rationales
Loss of One in a Multiple Birth
Adolescent Grief
Complicated Grief
COMMUNITY ACTIVITY
KEY POINTS
References
Glossary
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Index
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z

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