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ISBN-10 ‏ : ‎ 9781455733064
ISBN-13 ‏ : ‎ 978-1455733064
Author: Sharon Smith Murray MSN RN C (Author), Emily Slone McKinney MSN RN C (Author)

With easy-to-read coverage of nursing care for women and newborns, Foundations of Maternal-Newborn & Women’s Health Nursing, 6th Edition shows how to provide safe, competent care in the clinical setting. Evidence-based guidelines and step-by-step instructions for assessments and interventions help you quickly master key skills and techniques. Also emphasized is the importance of understanding family, communication, culture, client teaching, and clinical decision making. Written by specialists in maternity nursing, Sharon Smith Murray and Emily Slone McKinney, this text reflects the latest QSEN competencies, and the accompanying Evolve website includes review questions to prepare you for the NCLEX^® exam!

Table of Content:

Part I Foundations for Nursing Care of Childbearing Families
Interactive Review – Part I
Chapter 1 Maternity and Women’s Health Care Today
Objectives
Historical Perspectives on Childbearing
Granny Midwives
Emergence of Medical Management
Government Involvement in Maternal-Infant Care
TABLE 1-1 FEDERAL PROJECTS FOR MATERNAL CHILD CARE
Effects of Consumer Demands on Health Care
Development of Family-Centered Care
Current Settings for Childbirth
Traditional Hospital Setting
Labor, Delivery, and Recovery Rooms
FIG 1-1 A typical labor, delivery, and recovery room. Homelike furnishings (A) can be adapted quickly to expose the necessary technical equipment (B).
Labor, Delivery, Recovery, and Postpartum Rooms
Birth Centers
Home Births
Check Your Reading
Current Trends in Perinatal and Women’s Health Care
Cost Containment
Diagnosis-Related Groups
Capitated Care
Effects of Cost Containment on Maternity Care
Managed Care.
Case Management.
Outcomes Management.
Clinical Pathways.
Variances.
Students’ Use of Clinical Pathways.
Evidence-Based Nursing Care.
Community-Based Perinatal and Women’s Health Nursing
Common Types of Perinatal Home Care
Antepartum Home Care.
Postpartum and Neonatal Home Care.
Home Care for High-Risk Neonates.
Standards of Practice for Perinatal and Women’s Health Nursing
Agency Standards
Organizational Standards
Legal Standards
Advances in Technology
Complementary and Alternative Medicine
TABLE 1-2 COMPLEMENTARY AND ALTERNATIVE MEDICINE CATEGORIES
Check Your Reading
The Family
Traditional Families
Nontraditional Families
Single-Parent Families
Blended Families
Extended Families
Same-Sex Parent Families
Adoptive Families
Characteristics of a Healthy Family
Factors That Interfere with Family Functioning
High-Risk Families
Check Your Reading
Cultural Perspectives in Childbearing
FIG 1-2 Visible and hidden layers of culture are like the visible and submerged parts of an iceberg. Many cultural differences are hidden below the surface.
Implications of Cultural Diversity for Perinatal Nurses
Western Cultural Beliefs
Communication
Southeast Asians.
Hispanics.
African-Americans.
Native Americans.
Native Hawaiian and Pacific Islanders.
Middle Easterners.
Cross-Cultural Health Beliefs
Traditional Methods to Prevent Illness.
Traditional Practices to Maintain Health.
Traditional Practices to Restore Health.
Cultural Assessment
Check Your Reading
Statistics on Maternal, Infant, and Women’s Health
Maternal and Infant Mortality
Maternal Mortality
Infant Mortality
Disparity across Racial Groups
FIG 1-3 Infant mortality rates from 1960 to 2010 based on deaths before 1 year per 1000 live births.
Infant Mortality across Nations
TABLE 1-3 INFANT MORTALITY RATES FOR SELECTED COUNTRIES (BASED ON 2008 DATA)
Adolescent Pregnancy
Women’s Health
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Nursing Skills
Chapter 2 The Nurse’s Role in Maternity and Women’s Health Care
Objectives
Shortage of Nurses
Advanced Preparation for Maternal-Newborn and Women’s Health Nurses
Certified Nurse-Midwives
Nurse Practitioners
Clinical Nurse Specialists
Changing Roles for Nurses
Therapeutic Communication
Guidelines for Therapeutic Communication
Therapeutic Communication Techniques
Check Your Reading
The Nurse’s Role in Teaching and Learning
Principles of Teaching and Learning
TABLE 2-1 COMMUNICATION TECHNIQUES
FIG 2-1 In the prenatal clinic the nurse teaches a woman in a one-on-one setting.
TABLE 2-2 BEHAVIORS THAT BLOCK COMMUNICATION
Factors That Influence Learning
Developmental Level.
Language.
Culture.
Previous Experiences.
Physical Environment.
Organization and Skill of the Instructor.
Effects of Early Discharge
FIG 2-2 Often, the nurse must condense teaching by using a “check-off” sheet because mothers and infants leave the birth facility within a short time after birth.
The Nurse’s Role as Collaborator
The Nurse’s Role as Researcher
The Nurse’s Role as Advocate
The Nurse’s Role as Manager
Check Your Reading
Critical Thinking
Purpose
Steps
Recognizing Assumptions
Examining Biases
Determining the Need for Closure
Becoming Skillful in Data Management
Collecting Data.
Validating Data.
Organizing and Analyzing Data.
Acknowledging Emotions and Environmental Factors
Check Your Reading
Application of the Nursing ProcessMaternal-Newborn and Women’s Health Nursing
Assessment
Screening Assessment
Focused Assessment
Nursing Diagnosis
TABLE 2-3 EXAMPLES OF ACTUAL, RISK, AND WELLNESS NURSING DIAGNOSES
Planning
Setting Priorities
Establishing Goals and Expected Outcomes
Developing Nursing Interventions
Interventions for Actual Nursing Diagnoses.
Interventions for Risk Nursing Diagnoses.
Interventions for Wellness Nursing Diagnoses.
Implementing Interventions
Evaluation
Individualized Nursing Care Plans
Box 2-1
Developing Individualized Nursing Care Through the Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementing Nursing Interventions
Evaluation
The Nursing Process Related to Critical Thinking
Check Your Reading
Nursing Research
FIG 2-3 Relationship between the nursing process and critical thinking.
Summary Concepts
TABLE 2-4 USE OF CRITICAL THINKING IN THE NURSING PROCESS
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 3 Ethical, Social, and Legal Issues
Objectives
Ethics and Bioethics
Ethical Dilemmas
Ethical Theories
Deontologic Model.
Utilitarian Model.
Box 3-1
Ethical Principles in Health Care
Human Rights Model.
Ethical Principles
Solving Dilemmas in Daily Practice
Critical Thinking Exercise 3-1
Questions
Box 3-2
Applying the Nursing Process to Solve Ethical Dilemmas
Ethical Issues in Reproduction
Check Your Reading
Elective Pregnancy Termination
Conflicting Beliefs about Abortion.
Belief That Abortion Is a Private Choice.
Box 3-3
Supreme Court Decisions on Abortion Since Roe V. Wade
Belief That Abortion Is Taking a Life.
Implications for Nurses.
Personal Values.
Professional Obligations.
Check Your Reading
Mandated Contraception
Fetal Injury
Fetal Therapy
Issues in Infertility
Infertility Treatment.
Surrogate Parenting.
Ethical and Legal Reproductive Issues
Privacy Issues
Government Regulations
Online Communications.
Online Document Exchange.
Check Your Reading
Social Issues
Poverty
FIG 3-1 The cycle of poverty.
Homelessness
Access to Health Care
Prenatal Care in the United States
Box 3-4
Factors Related to Poor Access to Health Care
Government Programs for Health Care
Medicaid.
Shelters and Health Care for the Homeless.
Innovative Programs.
Allocation of Health Care Resources.
Care versus Cure
Late Preterm Infants
Check Your Reading
Legal Issues
Safeguards for Health Care
Nurse Practice Acts
Standards of Care
Agency Policies
Accountability.
Malpractice: Limiting Loss
Critical to Remember
Elements of Negligence
Informed Consent
Critical to Remember
Requirements of Informed Consent
Competence.
Full Disclosure.
Understanding of Information.
Voluntary Consent.
Refusal of Care.
Documentation
Documenting Fetal Monitoring.
Documenting Discharge Teaching.
Documenting Incidents.
The Nurse as Patient Advocate
Maintaining Expertise
Check Your Reading
Cost Containment and Downsizing
Delegation to Unlicensed Assistive Personnel
Early Discharge
Concerns about Early Discharge
Methods to Deal with Short Lengths of Stay
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 4 Reproductive Anatomy and Physiology
Objectives
Sexual Development
Prenatal Development
Childhood
Sexual Maturation
TABLE 4-1 COMPARISON OF SECONDARY SEX CHARACTERISTICS IN FEMALES AND MALES
Initiation of Sexual Maturation
Female Puberty Changes
Breast Changes.
Body Contours.
Body Hair.
Skeletal Growth.
Reproductive Organs.
Menarche.
TABLE 4-2 MAJOR HORMONES IN REPRODUCTION
Male Puberty Changes
Nocturnal Emissions.
Body Hair.
Body Composition.
Skeletal Growth.
Voice Changes.
Decline in Fertility
Check Your Reading
Female Reproductive Anatomy
External Female Reproductive Organs
Mons Pubis
Labia Majora and Minora
FIG 4-1 External female reproductive structures.
TABLE 4-3 FUNCTIONS OF FEMALE REPRODUCTIVE AND ACCESSORY ORGANS
Clitoris
Vestibule
Perineum
Internal Female Reproductive Organs
Vagina
Uterus
Divisions of the Uterus.
Corpus.
Isthmus.
Cervix.
Layers of the Uterus.
Perimetrium.
Myometrium.
FIG 4-2 Internal female reproductive structures, anterior view.
FIG 4-3 Internal female reproductive structures, midsagittal view.
Endometrium.
FIG 4-4 Layers of the myometrium showing the three types of smooth muscle fiber.
Fallopian Tubes
Ovaries
Check Your Reading
Support Structures
Pelvis
Muscles
Ligaments
Lateral Support.
Anterior Support.
FIG 4-5 Structures of the bony pelvis, shown in lateral (A) and anterior (B) views.
FIG 4-6 Muscles of the female pelvic floor.
Posterior Support.
Blood Supply
Nerve Supply
Check Your Reading
Female Reproductive Cycle
Ovarian Cycle
Follicular Phase
Ovulatory Phase
Luteal Phase
Endometrial Cycle
Proliferative Phase
Secretory Phase
FIG 4-7 The Female Reproductive Cycle. This figure illustrates the changes in hormone secretion from the anterior pituitary and interrelated changes in the ovary and uterine endometrium.
Menstrual Phase
Changes in Cervical Mucus
Check Your Reading
The Female Breast
Structure
FIG 4-8 Structures of the female breast.
Function
Check Your Reading
Male Reproductive Anatomy and Physiology
External Male Reproductive Organs
Penis
Scrotum
FIG 4-9 Structures of the male reproductive system, midsagittal view.
Internal Male Reproductive Organs
Testes
TABLE 4-4 FUNCTIONS OF MALE REPRODUCTIVE AND ACCESSORY ORGANS
Accessory Ducts and Glands
Check Your Reading
Summary Concepts
FIG 4-10 Internal Structures of the Testis. Initial production of sperm begins within the tiny, coiled seminiferous tubules. Immature sperm pass from the seminiferous tubules to the epididymis and then to the vas deferens. During their passage through these structures, sperm mature and acquire the ability to propel themselves after ejaculation.
References & Readings
Pageburst Integrated Resource
Animations
Glossary
Key Points
Chapter 5 Hereditary and Environmental Influences on Childbearing
Objectives
Hereditary Influences
Structure of Genes and Chromosomes
Deoxyribonucleic Acid
FIG 5-1 The deoxyribonucleic acid (DNA) helix is the building block of genes and chromosomes.
Genes
Chromosomes
FIG 5-2 Before arrangement in a karyotype, chromosomes appear jumbled. This photo is a spectral karyotype from a normal female.
Box 5-1
Ethical Issues Created by Greater Genetic Knowledge
FIG 5-3 Karyotypes of chromosomes that were stained, creating bands to distinguish each chromosome and identify missing or duplicated chromosome material. A, Normal male karyotype: 46,XY. B, Normal female karyotype: 46,XX.
Check Your Reading
Transmission of Traits by Single Genes
Dominance
Chromosome Location
Patterns of Single Gene Inheritance
Autosomal Dominant Traits
Autosomal Recessive Traits
Critical to Remember
Single Gene Abnormalities
X-Linked Traits
Box 5-2
Single Gene Traits
Genogram (Pedigree) Symbols
Autosomal Recessive
Characteristics
Transmission of Trait from Parent to Child
Examples
Genogram
Autosomal Dominant
Characteristics
Transmission of Trait from Parent to Child
Examples
Genogram
X-Linked Recessive
Characteristics
Transmission of Trait from Parent to Child
Examples
Genogram
Check Your Reading
Chromosomal Abnormalities
Numerical Abnormalities
Trisomy.
FIG 5-4 Karyotype of a male with trisomy 21 (Down syndrome: 47,XY, +21).
FIG 5-5 Newborn with several characteristic features of Down Syndrome, or Trisomy 21. Note that the infant has a flat face and occiput, low-set ears, and a protruding tongue. Also note the single transverse palm crease and a single crease on her fifth finger.
Monosomy.
FIG 5-6 Karyotype of a female with monosomy X (Turner’s syndrome: 45,X).
Critical to Remember
Chromosome Abnormalities
Polyploidy.
Structural Abnormalities
FIG 5-7 Illustration of a translocation of chromosome material between chromosomes 4 and 20.
Check Your Reading
Multifactorial Disorders
Characteristics
Risk for Occurrence
Critical to Remember
Multifactorial Birth Defects
Environmental Influences
Teratogens
Box 5-3
Selected Environmental Substances Known or Thought to Harm the Fetus*
Preventing Fetal Exposure
Infections.
Drugs and Other Substances.
Ionizing Radiation.
Maternal Hyperthermia.
Manipulating the Fetal Environment
Mechanical Disruptions to Fetal Development
Check Your Reading
Genetic Counseling
Availability
Focus on the Family
Process of Genetic Counseling
Box 5-4
Diagnostic Methods That May be Used in Genetic Counseling
Preconception Screening
Prenatal Diagnosis for Fetal Abnormalities
Postnatal Diagnosis for an Infant with a Birth Defect
Supplemental Services
Parents Want to Know
About Birth Defects
Nursing Care of Families Concerned about Birth Defects
Nurses as Part of a Genetic Counseling Team
Nurses in General Practice
Women’s Health Nurses
Antepartum Nurses
Therapeutic Communications
Assisting a Woman Who May Benefit from Genetic Counseling
Identifying Families for Referral.
Box 5-5
Reasons for Referral to a Genetic Counselor
Helping the Family Decide about Genetic Counseling.
Teaching about Lifestyle.
Providing Emotional Support.
Box 5-6
Examples of Problems in Genetic Counseling and Prenatal Diagnosis
Helping the Family Deal with Abnormal Results.
Intrapartum and Neonatal Nurses
Pediatric Nurses
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Part II The Family before Birth
Interactive Review – Part II
Chapter 6 Conception and Prenatal Development
Objectives
The Family before Birth
Gametogenesis
Oogenesis
FIG 6-1 Gametogenesis. A, Formation of the mature ovum. B, Formation of mature sperm.
TABLE 6-1 COMPARISON OF FEMALE AND MALE GAMETOGENESIS
Spermatogenesis
FIG 6-2 Mature sperm.
Check Your Reading
Conception
Preparation for Conception in the Female
Release of the Ovum
Ovum Transport
Preparation for Conception in the Male
Ejaculation
Transport of Sperm in the Female Reproductive Tract
FIG 6-3 Process of fertilization. A, A sperm enters the ovum. B, The 23 chromosomes from the sperm mingle with the 23 chromosomes from the ovum, restoring the diploid number to 46. C, The fertilized ovum is now called a zygote and is ready for the first mitotic cell division.
Preparation of Sperm for Fertilization
Fertilization
Entry of One Spermatozoon into the Ovum
Fusion of the Nuclei of Sperm and Ovum
Check Your Reading
Preembryonic Period
Initiation of Cell Division
Entry of the Zygote into the Uterus
FIG 6-4 Prenatal development from fertilization through implantation of the blastocyst. Implantation gradually occurs from day 6 through day 10. Implantation is complete on day 10.
Implantation in the Decidua
Maintaining the Decidua
Location of Implantation
Mechanism of Implantation
FIG 6-5 Embryonic development from week 3 through week 8 after fertilization. A, Week 3. B, Week 4. C, Week 6. D, Week 8. CRL, Crown–rump length.
Check Your Reading
Embryonic Period
Differentiation of Cells
TABLE 6-2 TIMETABLE OF PRENATAL DEVELOPMENT BASED ON FERTILIZATION AGE*
Weekly Developments
Week 2
Week 3
Week 4
TABLE 6-3 DERIVATIVES OF THE THREE GERM LAYERS
Week 5
Week 6
Week 7
Week 8
FIG 6-6 Fetal development from week 9 through week 38 of fertilization age. The gestational age, measured from the first day of the last menstrual period, is approximately 2 weeks longer than the fertilization age.
Check Your Reading
Fetal Period
Weeks 9 through 12
Weeks 13 through 16
Weeks 17 through 20
Weeks 21 through 24
Weeks 25 through 28
Weeks 29 through 32
Weeks 33 through 38
Check Your Reading
Auxiliary Structures
Placenta
Maternal Component
Development.
FIG 6-7 A, Placental structure showing relationship of placenta, fetal membranes, and uterus. Arrows indicate the direction of blood flow between the fetus and placenta through the umbilical arteries and vein. Blood from the mother bathes the fetal chorionic villi within the intervillous spaces to allow exchange of oxygen, nutrients, and waste products without gross mixing of maternal and fetal blood. B, Structure of a chorionic villus; its fetal capillary network is illustrated.
Circulation on the Maternal Side.
Fetal Component
Development.
FIG 6-8 Placental variations.
Circulation on the Fetal Side.
TABLE 6-4 MECHANISMS OF PLACENTAL TRANSFER
Metabolic Functions
Transfer Functions
Gas Exchange.
Nutrient Transfer.
Waste Removal.
Antibody Transfer.
Transfer of Maternal Hormones.
Endocrine Functions.
Check Your Reading
Fetal Membranes and Amniotic Fluid
Fetal Circulation
Umbilical Cord
Fetal Circulatory Circuit
FIG 6-9 A, Fetal circulation. Three shunts allow most blood from the placenta to bypass the fetal lungs and liver; they are the ductus venosus, ductus arteriosus, and foramen ovale. B, Circulation after birth. Note that the fetal shunts have closed. The umbilical vessels (ductus venosus and ductus arteriosus) will be converted to ligaments.
Changes in Blood Circulation after Birth
Check Your Reading
Multifetal Pregnancy
Monozygotic Twinning
Dizygotic Twinning
High Multifetal Gestations
Check Your Reading
Summary Concepts
FIG 6-10 A, Monozygotic twinning. The single inner cell mass divides into two inner cell masses during the blastocyst stage. These twins have a single placenta and chorion, but each twin develops in its own amnion. B, Dizygotic twinning. Two ova are released during ovulation, and each is fertilized by a separate spermatozoon. The ova may implant near each other in the uterus, or they may be far apart.
References & Readings
Pageburst Integrated Resource
Animations
Glossary
Key Points
Chapter 7 Physiologic Adaptations to Pregnancy
Objectives
Changes in Body Systems
Reproductive System
Uterus
Growth.
Pattern of Uterine Growth.
FIG 7-1 Uterine growth pattern during pregnancy.
Contractility.
Uterine Blood Flow.
FIG 7-2 Cervical changes that occur during pregnancy. Note the thick mucous plug filling the cervical canal.
Cervix
Vagina and Vulva
Ovaries
Breasts
FIG 7-3 Breast changes that occur during pregnancy. The breasts increase in size and become more vascular, the areolae become darker, and the nipples become more erect.
Check Your Reading
Cardiovascular System
Heart
Heart Size and Position.
Heart Sounds.
Blood Volume
Plasma Volume
Red Blood Cell Volume.
FIG 7-4 Supine Hypotensive Syndrome. When the pregnant woman is in the supine position, the weight of the uterus partially occludes the vena cava and the aorta. The side-lying position corrects supine hypotension.
Cardiac Output
Systemic Vascular Resistance
Blood Pressure
Effect of Position.
Supine Hypotension.
Blood Flow
Blood Components
Check Your Reading
Respiratory System
Oxygen Consumption
Hormonal Factors
Progesterone.
Estrogen.
Physical Effects of the Enlarging Uterus
Gastrointestinal System
Appetite
Mouth
Esophagus
Stomach
Large and Small Intestines
Liver and Gallbladder
Urinary System
Bladder
Kidneys and Ureters
Changes in Size and Shape.
Functional Changes of the Kidneys.
Check Your Reading
Integumentary System
Skin
Hyperpigmentation.
FIG 7-5 Linea Nigra. A dark pigmented line from the fundus to the symphysis pubis.
Cutaneous Vascular Changes.
Connective Tissue
Hair and Nails
FIG 7-6 Striae Gravidarum. Lineal tears that may occur in connective tissue.
Musculoskeletal System
Calcium Storage
Postural Changes
Abdominal Wall
Endocrine System
Pituitary Gland
FIG 7-7 Lordosis increases by the third trimester as the uterus grows larger, and the woman must lean backward to maintain her balance.
TABLE 7-1 HORMONES RELATED TO PREGNANCY
Thyroid Gland
Parathyroid Glands
Pancreas
Adrenal Glands
Changes Caused by Placental Hormones
Human Chorionic Gonadotropin.
Estrogen.
Progesterone.
Human Chorionic Somatomammotropin.
Relaxin.
Changes in Metabolism
Weight Gain.
Water Metabolism.
Edema.
Carbohydrate Metabolism.
Sensory Organs
Eye
Ear
Immune System
Check Your Reading
Confirmation of Pregnancy
Presumptive Indications of Pregnancy
Amenorrhea
Nausea and Vomiting
Fatigue
Urinary Frequency
Breast and Skin Changes
Vaginal and Cervical Color Change
Fetal Movement
FIG 7-8 Maternal responses based on the date of the last menstrual period.
TABLE 7-2 INDICATIONS OF PREGNANCY AND OTHER POSSIBLE CAUSES
Probable Indications of Pregnancy
Abdominal Enlargement
Cervical Softening
Changes in Uterine Consistency
Ballottement
FIG 7-9 The Hegar sign demonstrates softening of the isthmus of the cervix.
Braxton Hicks Contractions
FIG 7-10 When the cervix is tapped, the fetus floats upward in the amniotic fluid. A rebound is felt by the examiner when the fetus falls back.
Palpation of the Fetal Outline
Uterine Souffle
Pregnancy Tests
Inaccurate Pregnancy Test Results.
Positive Indications of Pregnancy
Auscultation of Fetal Heart Sounds
Fetal Movements Detected by an Examiner
Visualization of the Embryo or Fetus
Check Your Reading
Antepartum Assessment and Care
Preconception and Interconception Care
Initial Prenatal Visit
History
Obstetric History.
Box 7-1
Calculation of Gravida and Para
Menstrual History and Estimated Date of Delivery.
Case Study 7-1
Introduction*
Critical Thinking Exercise
Gynecologic and Contraceptive History.
Medical and Surgical History.
Family History.
Partner’s Health History.
Psychosocial History.
Physical Examination
Vital Signs
Blood Pressure.
Pulse.
Respirations.
Temperature.
Cardiovascular System
Venous Congestion.
Edema.
Musculoskeletal System
Posture and Gait.
Height and Weight.
Abdomen.
Neurologic System
Carpal Tunnel Syndrome.
Integumentary System
Endocrine System
Gastrointestinal System
Mouth.
Intestine.
Urinary System
Protein.
Glucose.
Ketones.
Bacteria.
Reproductive System
Breasts.
External Reproductive Organs.
Internal Reproductive Organs.
Pelvic Measurements.
Laboratory Data
Risk Assessment
Check Your Reading
Subsequent Assessments
TABLE 7-3 COMMON LABORATORY TESTS
TABLE 7-4 LABORATORY VALUES IN NONPREGNANT AND PREGNANT WOMEN
TABLE 7-5 SUMMARY OF MAJOR RISK FACTORS IN PREGNANCY
Case Study 7-1
Critical Thinking Exercise*
Questions
Vital Signs
Weight
Urine
Fundal Height
Leopold Maneuvers
FIG 7-11 Uterine measurements include the distance between the upper border of the symphysis pubis and the top of the fundus.
Fetal Heart Rate
Fetal Activity
Signs of Labor
Ultrasonographic Screening
Glucose Screening
Isoimmunization
Pelvic Examination
Multifetal Pregnancy
Diagnosis
Maternal Adaptation to Multifetal Pregnancy
Antepartum Care in Multifetal Pregnancy
Check Your Reading
Common Discomforts of Pregnancy
Nausea and Vomiting
Heartburn
Backache
FIG 7-12 Posture during pregnancy may cause or alleviate backache. A, Incorrect posture. The neck is jutting forward, the shoulders are slumping, and the back is sharply curved, creating back pain and discomfort. B, Correct posture. The neck and shoulders are straight, the back is flattened, and the pelvis is tucked under and slightly upward.
FIG 7-13 Techniques for Lifting. Squatting places less strain on the back. A, Incorrect technique. Stooping or bending places a great deal of strain on muscles of the lower back. B, Correct technique. Squatting close to the object permits the stronger muscles of the legs to do the lifting.
Round Ligament Pain
Case Study 7-1
Pregnant Women Want to Know*
Nausea and Vomiting
Heartburn
Backache
Round Ligament Pain
Urinary Frequency and Loss of Urine
Varicosities
Constipation
Hemorrhoids
Leg Cramps
Dependent Edema
Urinary Frequency
Varicosities
Constipation
Hemorrhoids
Leg Cramps
Cultural Considerations
Check Your Reading
Case Study 7-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Outcome Criteria
Interventions
Planning: Expected Outcomes:
Interventions and Rationales
Evaluation:
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Planning: Expected Outcomes:
Interventions and RationaleS
Critical Thinking:
Answer:
Evaluation:
Application of the Nursing ProcessFamily Responses to Physical Changes of Pregnancy
FIG 7-14 Exercises to prevent backache.
Assessment
Box 7-2
Common Nursing Diagnoses
Nursing Diagnosis
Planning: Expected Outcomes
Interventions
Teaching Health Behaviors
Bathing.
Hot Tubs and Saunas.
Douching.
Breast Care.
Clothing.
Exercise.
FIG 7-15 During the third trimester, pillows supporting the abdomen and back provide a comfortable position for rest.
Sleep and Rest.
Sexual Activity.
Nutrition.
Employment.
Maternal Safety.
Exposure to Teratogens.
Travel.
Immunizations.
Teaching Necessary Lifestyle Changes
Prescription and Over-the-Counter Drugs.
Complementary and Alternative Therapies.
Tobacco.
Alcohol.
Illicit Drugs.
Teaching about Signs of Possible Complications
Providing Resources
Evaluation
Critical to Remember
Signs of Possible Pregnancy Complications
Summary Concepts
References & Readings
Pageburst Integrated Resource
Case Studies
Glossary
Key Points
Chapter 8 Psychosocial Adaptations to Pregnancy
Objectives
Maternal Psychological Responses
First Trimester
Uncertainty
Ambivalence
The Self as Primary Focus
Second Trimester
Physical Evidence of Pregnancy
The Fetus as Primary Focus
FIG 8-1 Fetal movement, or quickening, confirms that a separate life is developing.
Narcissism and Introversion
Body Image
Nursing Care Plan
Body Image during Pregnancy
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Changes in Sexuality
Third Trimester
Vulnerability
FIG 8-2 During the third trimester, the mother feels increasingly vulnerable. She cradles her fetus to signify her protectiveness.
Increasing Dependence
Preparation for Birth
TABLE 8-1 PROGRESSIVE CHANGES IN MATERNAL RESPONSES TO PREGNANCY
Check Your Reading
Maternal Role Transition
Transitions Experienced throughout Pregnancy
Steps in Maternal Role Taking
Mimicry
Role Play
Fantasy
The Search for a Role Fit
Grief Work
Maternal Tasks of Pregnancy
Seeking Safe Passage
Securing Acceptance
Learning to Give of Herself
FIG 8-3 The bond between a pregnant woman and her own mother is particularly important to the young mother.
Committing Herself to the Unknown Child
Check Your Reading
Paternal Adaptation
Variations in Paternal Adaptation
Developmental Processes
The Reality of Pregnancy and the Child
FIG 8-4 Reality boosters such as hearing the sounds of the fetal heart make the fetus more real for the father.
The Struggle for Recognition as a Parent
FIG 8-5 The nurse who views the mother, father, and child as one patient provides parents with the greatest opportunity to learn infant care and parenting skills.
Creating the Role of the Involved Father
Parenting Information.
Couvade.
Check Your Reading
Adaptation of Grandparents
Age
Number and Spacing of Other Grandchildren
Perceptions of the Role of Grandparents
Adaptation of Siblings
Toddlers
Older Children
FIG 8-6 A pregnant woman who spends time with an older child can provide affection and a sense of security.
Adolescents
Check Your Reading
Factors Influencing Psychosocial Adaptations
Age
Multiparity
Critical Thinking Exercise 8-1
Questions
Social Support
Absence of a Partner
Abnormal Situations
Socioeconomic Status
The Affluent
The Middle Class
TABLE 8-2 IMPACT OF SOCIOECONOMIC FACTORS ON THE FAMILY’S RESPONSE TO PREGNANCY
The Working Poor and Unemployed
Nursing Care Plan
Socioeconomic Problems during Pregnancy
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Critical Thinking:
Answer:
The New Poor
Barriers to Prenatal Care
Check Your Reading
Cultural Influences on Childbearing
Differences within Cultures
Cultural Differences Causing Conflict
Health Beliefs
Health Maintenance.
Belief in Fate.
Preventing Illness.
Restoring Health.
Modesty.
Female Genital Cutting.
Communication
Language.
Nursing Care Plan
Language Barrier during Pregnancy
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Communication Style.
Decision Making.
Eye Contact.
Touch.
Time Orientation
Culturally Competent Nursing Care
Cultural Assessment
Cultural Negotiation
Check Your Reading
Application of the Nursing ProcessPsychosocial Concerns
Assessment
Nursing Diagnosis
TABLE 8-3 PSYCHOSOCIAL ASSESSMENT
Planning: Expected Outcomes
Interventions
Providing Information
Adapting Nursing Care to Pregnancy Progress
Discussing Resources
Box 8-1
Common Nursing Diagnoses Used in Pregnancy
Helping the Family Prepare for Birth
Modeling Communication Technique
Identifying Conflicting Cultural Factors
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 9 Nutrition for Childbearing
Objectives
Weight Gain during Pregnancy
Critical Thinking Exercise 9-1
Questions
Recommendations for Total Weight Gain
TABLE 9-1 RECOMMENDED WEIGHT GAIN DURING PREGNANCY
Case Study 9-1
Introduction*
Pattern of Weight Gain
Maternal and Fetal Weight Distribution
Factors that Influence Weight Gain
FIG 9-1 Distribution of Weight Gain in Pregnancy for Women of Normal Prepregnancy Weight. The numbers represent a general distribution because variation among women is great. The component with the greatest fluctuation is the weight increase attributed to extravascular fluids (edema) and maternal reserves of fat.
TABLE 9-2 RECOMMENDATIONS FOR DAILY ENERGY, CARBOHYDRATE, AND PROTEIN INTAKES FOR WOMEN AGES 15 TO 50 YEARS
Check Your Reading
Nutritional Requirements
Dietary Reference Intakes
Energy
Carbohydrates
Fats
Calories
TABLE 9-3 EXTRA FOODS NEEDED TO MEET PREGNANCY REQUIREMENTS*
Nutrient Density.
Protein
Vitamins
Fat-Soluble Vitamins
Water-Soluble Vitamins
Folic Acid
Check Your Reading
Minerals
Iron
TABLE 9-4 RECOMMENDATIONS FOR VITAMINS AND MINERALS
TABLE 9-5 FOODS HIGH IN IRON CONTENT*
Calcium
Box 9-1
Calcium Sources Approximately Equivalent to 1 Cup of Milk*
Sodium
Box 9-2
High-Sodium Foods*
Nutritional Supplementation
Purpose
Disadvantages and Dangers
Case Study 9-1
Pregnant Women Want to Know*
Water
Food Plan
Whole Grains
Vegetables and Fruits
Dairy Group
TABLE 9-6 FOOD PLAN FOR PREGNANCY AND LACTATION
Protein Group
Other Elements
Food Precautions
Safety Alert
Food Safety during Pregnancy and Lactation
Check Your Reading
Factors That Influence Nutrition
Age
Nutritional Knowledge
Exercise
Culture
Southeast Asian Dietary Practices
Effect of Culture on Diet during Childbearing.
Increasing Nutrients with Traditional Foods.
Hispanic Dietary Practices
Nutritional Risk Factors
Socioeconomic Status
Poverty
Food Supplement Programs
Check Your Reading
Vegetarianism
Meeting the Nutritional Requirements of the Pregnant Vegetarian
Energy.
Protein.
Calcium.
Iron.
Zinc.
Vitamin B12.
Vitamin A.
Lactose Intolerance
Nausea and Vomiting of Pregnancy
Anemia
Abnormal Prepregnancy Weight
Eating Disorders
Food Cravings and Aversions
Pica
Case Study 9-1
Critical Thinking Exercise*
Questions
Multiparity and Multifetal Pregnancy
Substance Abuse
Smoking
Caffeine
Alcohol
Drugs
Adolescence
Nutrient Needs
Common Problems
Teaching the Adolescent
Case Study 9-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Pregnant Adolescents Want to Know
How Can I Eat Fast Foods and Still Maintain a Good Diet?
Other Risk Factors
TABLE 9-7 NUTRITIOUS CHOICES FROM SNACK MACHINES*
Check Your Reading
Nutrition after Birth
Nutrition for the Lactating Mother
Energy
Protein
Fats
Vitamins and Minerals
Specific Nutritional Concerns
Dieting.
Adolescence.
Vegan Diet.
Avoidance of Dairy Products.
Inadequate Diet.
Alcohol.
Caffeine.
Fluids.
Nutrition for the Nonlactating Mother
Weight Loss
Evidence-Based Practice
Information for Postpartum Women about Weight Loss
Check Your Reading
Application of the Nursing ProcessNutrition for Childbearing
Assessment
Interview
Appetite.
Eating Habits.
Food Preferences.
Potential Problems.
Psychosocial Influences.
Diet History
Food Intake Records.
24-Hour Diet History.
Food Frequency Questionnaires.
Physical Assessment
Weight and Height at Initial Visit.
Weight at Subsequent Visits.
FIG 9-2 Weight Gain Grid for Pregnancy. The normal range for weight gain is 11.5 to 16 kg (25 to 35 lb).
Signs of Nutrient Deficiency.
Laboratory Tests
Ongoing Nutritional Status
Nursing Diagnosis
Planning
FIG 9-3 Women often make changes in their diets for the sakes of their unborn children that they would not consider for themselves alone.
Interventions
Identifying Problems
Explaining Nutrient Needs
Providing Reinforcement
Box 9-3
Common Sources of Dietary Fiber
Evaluating Weight Gain
Encouraging Supplement Intake
Making Referrals
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 10 Antepartum Fetal Assessment
Objectives
Indications for Fetal Diagnostic Tests
Ultrasound
Box 10-1
Indications for Fetal Diagnostic Procedures
Medical Conditions
Demographic Factors
Obstetric Factors
Concurrent Maternal Factors
FIG 10-1 Two-dimensional sonogram showing the fetal body profile and details of the fetal arm, hand, and fingers.
FIG 10-2 Three-dimensional ultrasound image of a fetus in the third trimester, showing details of facial features.
Emotional Responses
Levels of Obstetric Ultrasound
Box 10-2
Indications for Limited Ultrasound Scan
First-Trimester Ultrasonography
Purposes
Procedure
Second- and Third-Trimester Ultrasonography
Purposes
Procedure
Advantages
FIG 10-3 The sonographer provides information while moving an ultrasound transducer over the mother’s abdomen to obtain an image.
Disadvantages
Doppler Ultrasound Blood Flow Assessment
Purpose
FIG 10-4 Color Doppler Imaging of the Umbilical Vein and Two Arteries. Blood flow toward the transducer is typically shown as red while the flow away from the transducer is shown as blue.
Check Your Reading
Alpha-Fetoprotein Screening
Purpose
Box 10-3
Conditions Associated with Abnormal Maternal Serum Alpha-Fetoprotein Levels
Elevated Levels of AFP*
Low Levels of AFP
Procedure
Advantages
Limitations
Multiple-Marker Screening
Check Your Reading
Chorionic Villus Sampling
Purpose
Indications
Procedure
Advantages
Risks
Check Your Reading
Amniocentesis
Purposes
Midtrimester
FIG 10-5 Transcervical Chorionic Villus Sampling. Tissue is aspirated to detect the presence of genetic defects in the fetus. Transabdominal aspiration is an alternative method.
FIG 10-6 In amniocentesis, a needle is inserted through the woman’s abdomen to aspirate fluid from the amniotic sac. The fluid can then be tested to determine fetal maturity, chromosome abnormalities, and other possible problems.
Box 10-4
Common Indications for Second-Trimester Amniocentesis
Third Trimester
Tests to Determine Fetal Lung Maturity.
Test for Fetal Hemolytic Disease.
Procedure
Advantages
Disadvantages
Risks
Check Your Reading
Percutaneous Umbilical Blood Sampling (PUBS)
Procedure
FIG 10-7 In percutaneous umbilical blood sampling (PUBS, or cordocentesis), a needle is inserted through the expectant mother’s abdomen and into an umbilical vessel (vein or artery) to withdraw a sample of fetal blood.
Risks
Antepartum Fetal Surveillance
Therapeutic Communications
Responding to Anxiety Related to Fetal Testing
Nonstress Test
Purpose
Procedure
Interpretation
FIG 10-8 A nonstress test is a noninvasive test that measures the response of the fetal heart to fetal movements. Here, the nurse reassures the parents by pointing to fetal heart accelerations.
FIG 10-9 A, Several accelerations have a duration of at least 15 seconds, reaching a peak of 25 to 30 beats per minute in this example of a reactive nonstress test. Comparable accelerations without fetal movement are also reassuring. B, In this recording of a nonreactive nonstress test, accelerations are absent after fetal movement (FM).
Advantages
Disadvantages
Vibroacoustic (Acoustic) Stimulation
Purpose and Procedure
Fetal Responses
Risks
Check Your Reading
Contraction Stress Test
Purpose
Procedure
Interpretation
FIG 10-10 Interpretation of Contraction Stress Test (CST). UPI, Uteroplacental insufficiency.
Advantages
Disadvantages
Check Your Reading
Biophysical Profile
Purpose
FIG 10-11 Effects of gradual hypoxemia and worsening of fetal acidosis.
Procedure and Interpretation
Modified Biophysical Profile
Advantages
Disadvantages
TABLE 10-1 SCORING THE BIOPHYSICAL PROFILE FOR A TERM FETUS*
Check Your Reading
Maternal Assessment of Fetal Movement
Evidence-Based Practice
Mother’s Perception of Fetal Monitoring
Procedure
Advantages
Disadvantages
Application of the Nursing Process
Diagnostic Testing
Assessment
FIG 10-12 Daily Fetal Movement Record in Use. The mother counts the number of fetal movements (kicks) within a specified period several times per day and indicates each movement on a chart. She reports any abnormality to her health care provider.
Nursing Diagnosis
Planning
Interventions
Providing Information
Providing Support
Helping Women Set Realistic Goals
Supporting the Woman’s Decision
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 11 Perinatal Education
Objectives
Goals of Perinatal Education
Providers of Education
Class Participants
Choices for Childbearing
Health Care Provider
Setting
FIG 11-1 An expectant mother may ask a sister or close female friend to be her labor partner and attend classes with her.
Support Person
Siblings
Education
Check Your Reading
Types of Classes Available
Preconception Classes
Early Pregnancy Classes
FIG 11-2 The nurse teaching this class discusses movement of the fetus through the pelvis.
Box 11-1
Topics Covered in Early Pregnancy Classes
Case Study 11-1
Introduction*
Critical Thinking Exercise
Exercise Classes
Childbirth Preparation Classes
FIG 11-3 The teacher helps each couple, individually and together, practice pushing during a labor rehearsal.
Refresher Courses
Critical Thinking Exercise 11-1
Question
Cesarean Birth Preparation Classes
General Cesarean Classes
Box 11-2
Topics Included in Prepared Childbirth Classes
Box 11-3
Topics Included in Cesarean Birth Classes
Planned Cesarean Birth Classes
Vaginal Birth after Cesarean Birth
Breastfeeding Classes
Parenting and Infant Care Classes
Postpartum Classes
Box 11-4
Topics Included in Breastfeeding Classes
Box 11-5
Topics Included in Parenting and Infant Care Classes
Other Classes
Classes for Family Members
Classes for Fathers
FIG 11-4 During sibling classes, children learn about the new babies coming into their lives.
Siblings
Grandparents
Check Your Reading
Education for Childbirth
Methods of Pain Management
Education
Relaxation
Conditioning
Methods of Childbirth Education
Dick-Read Childbirth Education
Bradley Childbirth Education
Lamaze Childbirth Education
Class Content
Exercises
Relaxation Techniques
Progressive Relaxation.
FIG 11-5 As the woman practices relaxation techniques for labor, the partner massages her hand, and the nurse checks for muscle tension.
Neuromuscular Disassociation.
Touch Relaxation.
Relaxation against Pain.
Cutaneous Stimulation Techniques
FIG 11-6 The woman begins effleurage with the hands at the symphysis and then slowly moves around the sides and down the center toward the symphysis again. As an alternative, she can massage up the center of the abdomen and around the sides.
Effleurage.
Sacral Pressure.
Other Massage.
Thermal Stimulation.
Positioning.
Mental Stimulation Techniques
Focal Point.
Imagery.
Music.
Special Techniques
Breathing Techniques
Check Your Reading
The Labor Partner
Role of the Labor Partner
Case Study 11-1
Nursing Care Plan*
Planning for Childbirth:
Nursing Diagnosis:
Critical Thinking:
Answer:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Support Techniques
Check Your Reading
Application of the Nursing ProcessEducation for Childbirth
Assessment
Nursing Diagnosis
Box 11-6
What to Take to the Hospital
Items to Be Included in the Labor Bag
Items for After Birth
Planning
Interventions
Making a Birth Plan
Case Study 11-1
Parents Want to Know*
Choosing Classes
Suggesting Classes for Special Needs
Adolescents.
Women with High-Risk Pregnancies.
Women Who Must Make Cultural Adaptations.
Women with Other Needs.
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Part III The Family during Birth
Interactive Review – Part III
Chapter 12 Processes of Birth
Objectives
Physiologic Effects of the Birth Process
Maternal Response
Reproductive System
Characteristics of Contractions.
Coordinated.
Involuntary.
Intermittent.
Contraction Cycle.
Uterine Body.
Cervical Changes.
FIG 12-1 Contraction cycle.
FIG 12-2 Opposing characteristics of uterine contraction in the upper and lower segments of the uterus.
Effacement.
Dilation.
Cardiovascular System
Respiratory System
FIG 12-3 Cervical Dilation and Effacement. During labor the multipara’s cervix remains thicker than the nullipara’s cervix.
Gastrointestinal System
Urinary System
Hematopoietic System
Fetal Response
Placental Circulation
Cardiovascular System
Pulmonary System
Check Your Reading
Components of the Birth Process
Powers
Uterine Contractions
Maternal Pushing Efforts
Passage
Passenger
Fetal Head
Bones, Sutures, and Fontanels.
FIG 12-4 Pelvic divisions and measurements.
MIDPELVIS The midpelvis, or pelvic cavity, is the narrowest part of the pelvis through which the fetus must pass during birth. Midpelvic diameters are measured at the level of the ischial spines. The anteroposterior diameter averages 12 cm. The transverse diameter (bispinous or interspinous) averages 10.5 cm. Prominent ischial spines that project into the midpelvis can reduce the bispinous diameter.
OUTLET Three important diameters of the pelvic outlet are (1) the anteroposterior, (2) the transverse (bi-ischial or intertuberous), and (3) the posterior sagittal. The angle of the pubic arch also is an important pelvic outlet measure. The anteroposterior diameter ranges from 9.5 to 11.5 cm, varying with the curve between the sacrococcygeal joint and the tip of the coccyx. The anteroposterior diameter can increase if the coccyx is easily movable. The transverse diameter is the bi-ischial, or intertuberous, diameter. This is the distance between the ischial tuberosities (“sit bones”). It averages 11 cm. The posterior sagittal diameter is normally at least 7.5 cm. It is a measure of the posterior pelvis. The posterior sagittal diameter measures the distance from the sacrococcygeal joint to the middle of the transverse (bi-ischial) diameter. The angle of the pubic arch is important because it must be wide enough for the fetus to pass under it. The angle of the pubic arch should be at least 90 degrees. A narrow pubic arch displaces the fetus posteriorly toward the coccyx as it tries to pass under the arch.
Fetal Head Diameters.
Variations in the Passenger
Fetal Lie.
Attitude.
Presentation.
Cephalic Presentation.
FIG 12-5 A, Bones, sutures, and fontanels of the fetal head. Note that the anterior fontanel has a diamond shape, whereas the posterior fontanel is triangular. B, Lateral view of the fetal head demonstrating that anteroposterior diameters vary with the amount of flexion or extension.
FIG 12-6 Fetal Lie. A, In a longitudinal lie, the long axis of the fetus is parallel to the long axis of the mother. B, In a transverse lie, the long axis of the fetus is at right angles to the long axis of the mother. The woman’s abdomen has a wide, short appearance.
Breech Presentation.
FIG 12-7 Attitude. A, The fetus is in the normal attitude of flexion, with the head, arms, and legs flexed tightly against the trunk. B, The fetus is in an abnormal attitude of extension. The head is extended, and the right arm is extended. A face presentation is illustrated.
FIG 12-8 Four Types of Cephalic Presentation. The vertex presentation is normal. Note positional changes of the anterior and posterior fontanels in relation to the maternal pelvis.
Shoulder Presentation.
Check Your Reading
Position
Right (R) or Left (L).
Occiput (O), Mentum (M), or Sacrum (S).
FIG 12-9 Three Variations of a Breech Presentation. Frank breech is the most common variation. Footling breeches may be single or double.
FIG 12-10 Four quadrants of the maternal pelvis from above, which are used to describe fetal position.
Anterior (A), Posterior (P), or Transverse (T).
Check Your Reading
Psyche
Anxiety
FIG 12-11 Fetal presentations and positions.
Culture and Expectations.
Birth as an Experience
Support
Impact of Technology
Interrelationships of Components
Evidence-Based Practice
Factors Associated with Labor Support Behaviors of Nurses
Normal Labor
Theories of Onset
Premonitory Signs
Braxton Hicks Contractions
Lightening
Increased Vaginal Mucous Secretions
Cervical Ripening and Bloody Show
Energy Spurt
Weight Loss
True Labor and False Labor
Critical Thinking Exercise 12-1
Questions
Pregnant Women Want to Know
How to Know Whether Labor Is “Real”
Labor Mechanisms
Check Your Reading
Stages and Phases of Labor
First Stage
FIG 12-12 Mechanisms (cardinal movements) of labor.
Descent of the fetus is a mechanism of labor that accompanies all the others. Without descent, none of the mechanisms will occur. Station
Station is a measurement of the descent of the fetal presenting part in relation to the level of the ischial spines of the maternal pelvis. The level of the ischial spines is a zero station. Other stations are described with numbers representing the approximate number of centimeters above (negative numbers) or below (positive numbers) the ischial spines. As the fetus descends through the pelvis, the station changes from higher negative numbers (–3, –2, –1) to zero to higher positive numbers (+1, +2, +3, etc.). Sometimes the terms floating or ballotable may describe a fetal presenting part that is so high that it is easily displaced upward during abdominal or vaginal examination, similar to tossing a ball upward. Engagement Engagement occurs when the largest diameter of the fetal presenting part (normally the head) has passed the pelvic inlet and entered the pelvic cavity. Engagement is presumed to have occurred when the station of the presenting part is zero or lower. Engagement often takes place before onset of labor in nulliparous women. In many parous women and in some nulliparas, it does not occur until after labor begins. Flexion As the fetus descends, the fetal head is flexed farther as it meets resistance from the soft tissues of the pelvis. Head flexion presents the smallest anteroposterior diameter (suboccipitobregmatic) to the pelvis. Internal Rotation
The fetus enters the pelvic inlet with the sagittal suture in a transverse or oblique orientation to the maternal pelvis because that is the widest inlet diameter. Internal rotation allows the longest fetal head diameter (the anteroposterior) to conform to the longest diameter of the maternal pelvis. The longest pelvic outlet diameter is the anteroposterior. As the head descends to the level of the ischial spines, it gradually turns so that the fetal occiput is in the anterior of the pelvis (OA position, directly under the maternal symphysis pubis). When internal rotation is complete, the sagittal suture is oriented in the anteroposterior pelvic diameter (OA). Less commonly, the head may turn posteriorly so that the occiput is directed toward the mother’s sacrum (OP). EXTENSION
Because the true pelvis is shaped like a curved cylinder, the fetal face is directed posteriorly toward the rectum as it begins its rotation and descent. To negotiate the curve of the pelvis, the fetal head must change from an attitude of flexion to one of extension. While still in flexion, the fetal head meets resistance from the tissues of the pelvic floor. At the same time, the fetal neck stops under the symphysis, which acts as a pivot. The combination of resistance from the pelvic floor and the pivoting action of the symphysis causes the fetal head to swing anteriorly, or extend, with each maternal pushing effort. The head is born in extension, with the occiput sliding under the symphysis and the face directed toward the rectum. The fetal brow, nose, and chin slide over the perineum as the head is born. EXTERNAL ROTATION
When the head is born with the occiput directed anteriorly, the shoulders must rotate internally so that they align with the anteroposterior diameter of the pelvis. After the head is born, it spontaneously turns to the same side as it was in utero as it realigns with the shoulders and back (through a process called restitution). The head then turns farther to that side in external rotation as the shoulders internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet. External rotation of the head accompanies internal rotation of the shoulders. EXPULSION Expulsion occurs first as the anterior, then the posterior, shoulder passes under the symphysis. After the shoulders are born, the rest of body follows.
TABLE 12-1 CHARACTERISTICS OF NORMAL LABOR
FIG 12-13 A labor curve, often called a Friedman curve, may be used to identify whether a woman’s cervical dilation is progressing at the expected rate. The symbol for station (X) may be added to the labor curve. Typical labor curves for a multiparous woman and a nulliparous woman are illustrated for comparison of patterns.
Latent Phase
Active Phase
Transition Phase
Critical Thinking Exercise 12-2
Questions
Second Stage
FIG 12-14 A, Fetal side of the placenta. B, Maternal side of the placenta. C, Separating membranes. D, Umbilical cord vessels: two arteries and one vein.
Third Stage
Fourth Stage
Check Your Reading
Duration of Labor
Summary Concepts
The Childbirth Story
References & Readings
Pageburst Integrated Resource
Animations
Glossary
Key Points
Chapter 13 Nursing Care during Labor and Birth
Objectives
Issues for New Nurses
Pain Associated with Birth
Inexperience and Negative Experiences
Unpredictability
Intimacy
Admission to the Birth Facility
Pregnant Women Want to Know
When to Go to the Hospital or Birth Center
Therapeutic Communications
Establishing a Therapeutic Relationship
The Decision to Go to the Birth Facility
Nursing Responsibilities during Admission
Establish a Therapeutic Relationship
Make the Family Feel Welcome.
Determine Family Expectations About Birth.
Convey Confidence.
Assign a Primary Nurse.
Use Touch for Comfort.
Respect Cultural Values.
Check Your Reading
Admission Assessments
Focused Assessment
Fetal Heart Rate.
Maternal Vital Signs.
Impending Birth.
TABLE 13-1 INTRAPARTUM ASSESSMENT GUIDE*
Check Your Reading
Database Assessment
Basic Information.
Critical Thinking Exercise 13-1
Questions
Fetal Assessments.
Labor Status.
Physical Examination.
Check Your Reading
Admission Procedures
Notify the Birth Attendant.
Consent Forms.
Laboratory Tests.
Intravenous Access.
Assessments after Admission
Fetal Assessments.
Fetal Heart Rate.
Procedure 13-1
Leopold’s Maneuvers
Procedure 13-2
Palpating Contractions
Critical Thinking Exercise 13-2
Question
Maternal Assessments.
Vital Signs.
Contractions.
Labor Progress.
FIG 13-1 Vaginal examination during labor.
Intake and Output.
Response to Labor.
Support Person’s Response.
Check Your Reading
Application of the Nursing ProcessFalse or Early Labor
Assessment
Analysis
Planning
Interventions
Reassurance
Teaching
Evaluation
Application of the Nursing ProcessTrue Labor
Case Study 13-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Expected Outcomes:
Interventions And Rationales
Evaluation:
Fetal Oxygenation
Assessment
Nursing Diagnosis
Critical To Remember
Conditions Associated with Fetal Compromise
Planning
Interventions
Promote Placental Function
Box 13-1
Assisting with an Emergency Birth
Nursing Priorities for an Emergency Birth in Any Setting
Preparing for an Emergency Birth
During the Birth
After the Birth
Observe for Conditions Associated with Fetal Compromise
Evaluation
Discomfort
Case Study 13-1
Nursing Care PlanNursing Care Plan*
Assessment:
Potential Complication:
Expected Outcomes:
Interventions And Rationales
Evaluation:
Assessment
Analysis
FIG 13-2 Cool, damp washcloths placed where the woman finds them most comforting help her relax during each contraction. Extra cool, damp washcloths should be available.
Planning
Interventions
Provide Comfort Measures
Lighting.
Temperature.
Cleanliness.
Mouth Care.
FIG 13-3 Most laboring women welcome ice chips to ease their dry mouths.
Bladder.
Positioning.
Water.
FIG 13-4 Common Maternal Positions for Labor.
Sitting UprightAdvantagesUses gravity to aid fetal descent.Can be done when sitting on side of bed, in a chair, or on the toilet.Can be used with continuous fetal monitoring. Avoids supine hypotension.DisadvantagesMay increase suprapubic discomfort.Contractions are the most efficient when the woman alternates sitting with other positions.Nursing ImplicationsA rocking chair is soothing.Place a pillow on a chair with a disposable underpad over the pillow to absorb secretions.Use pillows or a footstool to keep a short woman’s legs from dangling.Encourage the woman to alternate positions periodically. For example, she can alternate walking with sitting or sitting with side-lying.
Sitting, Leaning Forward with Support Advantages Same as for sitting. Reduces back pain because fetus falls forward, away from sacral promontory. Partner or nurse can rub back or provide sacral pressure to relieve back pain. Disadvantages Same as for sitting. Nursing Implications Same as for sitting.
SemisittingAdvantagesSame as for sitting. Aligns long axis of uterus with pelvic inlet, which applies contraction force in the most efficient direction through pelvis.DisadvantagesSame as for sitting. Does not reduce pain as well as the forward-leaning positions.Nursing ImplicationsSame as for sitting. Raise bed to about a 30- to 45-degree angle. Encourage the woman to use sitting (leaning forward) or side-lying position if she has back pain so that the caregiver can rub her back or apply sacral pressure.
Side-LyingAdvantagesIt is a restful position. Prevents supine hypotension and promotes placental blood flow. Promotes efficient contractions, although they may be less frequent than with other positions. Can be used with continuous fetal monitoring.DisadvantagesDoes not use gravity to aid fetal descent.Nursing ImplicationsTeach the woman and her partner that although the contractions are less frequent, they are more effective. This position offers a break from more tiring positions. Use pillows for support and to prevent pressure: at her back, under her superior arm, and between her knees. Use disposable underpads to protect the pillow between the woman’s knees from secretions. Some women like to put their superior leg on the bed rail. If the woman wants this variation, pad the bed rail with a blanket to prevent pressure. If she wants to remain recumbent, she should use this position to promote placental blood flow.
Kneeling, Leaning Forward with SupportAdvantagesReduces back pain because fetus falls forward, away from sacral promontory. Adds gravity to force of contractions to promote fetal descent. Can be used with continuous fetal monitoring. Caregivers can rub her back or apply sacral pressure. Promotes normal mechanisms of birth.DisadvantagesKnees may become tired or uncomfortable. Tiring if used for long periods.Nursing ImplicationsRaise the head of the bed, and have the woman face the head of the bed while she is on her knees. Another method is for the partner to sit in a chair, with the woman kneeling in front, facing her partner, and leaning forward on him or her for support. Use pillow under the knees and in front of the woman’s chest, as needed, for comfort. Encourage her to change positions if she becomes tired.
POSITIONS FOR PUSHING IN SECOND STAGEHands and KneesAdvantagesReduces back pain because the fetus falls forward, away from the sacral promontory. Promotes normal mechanisms of birth. The woman can use pelvic rocking to decrease back pain. Caregivers can rub the woman’s back or apply sacral pressure easily.DisadvantagesThe woman’s hands (especially wrists) and knees can become uncomfortable. Tiring when used for a long time. Some women are embarrassed to use this position.Nursing ImplicationsEncourage the woman to change to less tiring positions occasionally. Ensure privacy when encouraging the reluctant woman to try this position if she has back pain. A second hospital gown with the opening in front covers her back and hips but may be too warm. A variation is for the mother to kneel and lean forward against a beanbag or the side of the bed. This variation reduces some of the strain of wrists and hands.StandingThis position may be tiring, and access to the woman’s perineum is difficult. Because the infant could fall to the ground if birth occurs rapidly, provide padding under the mother’s feet. Gravity aids fetal descent.Hands and KneesAdvantages and disadvantages are similar to those during first stage labor. In addition, caregivers must reorient themselves because the landmarks are upside down from their usual perspective.
SquattingAdvantagesAdds gravity to force of contractions to promote fetal descent. Straightens the pelvic curve slightly for more direct fetal descent. Increases dimensions of pelvis slightly. Promotes effective pushing efforts in the second stage. Caregivers can rub back or provide sacral pressure.DisadvantagesKnees and hips may become uncomfortable because of prolonged flexion. Tiring over a long time.Nursing ImplicationsProvide support with a squat bar attached to the bed or by two people standing on each side of the woman. If she becomes tired, or between contractions, she can lean back into the sitting position. Variation: Have the woman squat beside the bed as she pushes.
Semisitting Many women prefer this because they have the security of a back rest; it is also familiar to caregivers and allows easy observation of the perineum. Elevate the woman’s back at least 30 to 45 degrees so that gravity aids fetal descent. The woman pulls on her flexed knees (behind or in front of them) as she pushes. She should keep her head flexed and her back in a “C” curve.
Side-Lying The woman flexes her chin on her chest and curls around her uterus as she pushes. She pulls on her flexed knees or the knee of the superior leg as she pushes.
Teaching
First Stage.
Second Stage.
Laboring Down.
Positions.
Method and Breathing Pattern.
Encouragement
Giving of Self
Case Study 13-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions And Rationales
Evaluation:
Evidence-Based Practice
Technology and the Labor Nurse
Providing Welcome Care
Offering Choices
Following Birth Plans
Establishing Trust and Respect
Being an Advocate
Providing Reassurance and Support
Relying on Electronic Fetal Monitors and Assessments versus Nursing Presence
Having Epidurals Coupled with a Loss of Bodily Cues
Offering Pharmacologic Measures
Case Study 13-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions And Rationales
Evaluation:
Care for the Birth Partner
Evaluation
FIG 13-5 The provider arranges instruments in final preparation for birth. Although the vagina is not sterile, a sterile table is prepared to limit introduction of outside organisms into the birth canal. Included on the sterile table are infant care materials (e.g., cord clamp, cord blood tube), instruments for repair of maternal injury or episiotomy, and anesthesia materials (if needed).
Prevent Injury
Assessment
Nursing Diagnosis
Planning
Interventions
Transferring to a Delivery Room
Positioning for Birth
Observe the Perineum
Evaluation
Check Your Reading
Nursing Care during the Late Intrapartum Period
Responsibilities during Birth
FIG 13-6 Sequence for Delivery.
Responsibilities after Birth
Care of the Infant
FIG 13-7 Vaginal Birth.
B, Ritgen Maneuver. Pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput of the fetal head. This action aids the mechanism of extension as the fetal head comes under the symphysis.
C, Birth of the Head. As the head emerges, the attendant prepares to suction the nose and mouth to avoid aspiration of secretions when the infant takes the first breath.
D, Restitution and External Rotation. After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders internally rotate, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet.
E, Birth of the Anterior Shoulder. The attendant gently pushes the fetal head toward the woman’s perineum to allow the anterior shoulder to slip under her symphysis. The bluish skin color of the fetus is normal at this point; it becomes pink as the infant begins air breathing.
F, Birth of the Posterior Shoulder. The attendant now pushes the fetal head upward toward the woman’s symphysis to allow the posterior shoulder to slip over her perineum.
G, Completion of the Birth. The attendant supports the fetus during expulsion. Note that the fetus has excellent muscle tone, as evidenced by facial grimacing and flexion of the arms and hands.
H, Cord Clamping. While the infant is in skin-to-skin contact on the mother’s abdomen, the attendant doubly clamps the umbilical cord. The cord is then cut between the two clamps. Samples of cord blood are collected after it is cut.
I, Birth of the Placenta. The attendant applies gentle traction on the cord to aid expulsion of the placenta. This placenta is expelled in the more common Schultze mechanism, with the shiny fetal surface and membranes emerging. Note the fetal membranes that surrounded the fetus and amniotic fluid during pregnancy. The chorionic vessels that branch from the umbilical cord are readily visible on the fetal surface of the placenta.
Maintain Cardiopulmonary Function.
Support Thermoregulation.
Identify the Infant.
FIG 13-8 When the birthing room nurse transfers care of the infant to the nurse who will provide ongoing newborn care, both nurses check the identification bands and record the same information.
TABLE 13-2 APGAR SCORE*
Care of the Mother
Observe for Hemorrhage.
Vital Signs.
Fundus.
Bladder.
Lochia.
TABLE 13-3 MATERNAL PROBLEMS DURING THE FOURTH STAGE OF LABOR
Perineal and Labial Areas.
Promote Comfort
Ice Packs.
Analgesics.
Warmth.
Promote Early Family Attachment
Box 13-2
Common Nursing Diagnoses for Intrapartum Families
Summary Concepts
References & Readings
Pageburst Integrated Resource
Animations
Case Studies
Glossary
Key Points
Chapter 14 Intrapartum Fetal Surveillance
Objectives
Fetal Oxygenation
Uteroplacental Exchange
Fetal Circulation
Regulation of Fetal Heart Rate
Evidence-Based Practice
“We’ve Always Done It That Way” Is Not Adequate
Autonomic Nervous System
Baroreceptors
Chemoreceptors
Adrenal Glands
Central Nervous System
Pathologic Influences on Fetal Oxygenation
Maternal Cardiopulmonary Alterations
Uterine Activity
Placental Disruptions
Interruptions in Umbilical Flow
Fetal Alterations
Risk Factors
Check Your Reading
Auscultation and Palpation
Advantages
FIG 14-1 Low-Intervention Methods for Evaluating the Fetal Heart Rate during Labor. A, Fetoscope, showing the head attachment to enhance conduction of faint fetal heart sounds. Rarely used in U.S. hospital births. B, Transmission gel improves the clarity of the fetal heart movement sensed by the Doppler ultrasound transducer.
Box 14-1
Potential Maternal, Fetal, or Neonatal Risk Factors
Antepartum Period
Maternal History
Problems Identified during Pregnancy
Intrapartum Period
Maternal Problems
Fetal or Placental Problems
Limitations
Auscultation Equipment
Evaluation of Auscultated Fetal Heart Rate Data
Electronic Fetal Monitoring
Advantages
Procedure 14-1
Auscultating the Fetal Heart Rate
Auscultating the Fetal Heart Rate
FIG 14-2 Bedside Unit for Electronic Fetal Monitoring. In addition to fetal heart rate and uterine activity, the unit can help the nurse evaluate the woman’s pulse rate, blood pressure, and saturation of oxygen in her blood. Both fetuses in a twin gestation can be assessed.
Limitations
Electronic Fetal Monitoring Equipment
FIG 14-3 Electronic fetal monitoring can be continuous and provides nurses with monitor strips, either paper or computer based, on which uterine activity and fetal heart rate are permanently recorded.
Bedside Monitor Unit
Paper Strip
FIG 14-4 Paper Strip for Recording Electronic Fetal Monitoring Data. Each dark vertical line represents 1 minute, and each lighter vertical line represents 10 seconds. Paperless computer displays that depict the fetal heart rate and uterine activity patterns have a similar appearance.
Data Entry Devices and Computer Software
Remote Surveillance
FIG 14-5 The nurse applies the uterine activity transducer to the woman’s upper abdomen, in the fundal area. The Doppler transducer for sensing the fetal heart rate is usually placed on her lower abdomen when the fetus is in the cephalic presentation.
Devices for External Fetal Monitoring
Procedure 14-2
External Fetal Monitor
Fetal Heart Rate Monitoring with an Ultrasound Transducer
Uterine Activity Monitoring with a Tocotransducer
Devices for Internal Fetal Monitoring
Fetal Heart Rate Monitoring with a Scalp Electrode
FIG 14-6 Internal Spiral Electrode and Intrauterine Pressure Catheter (IUPC). A, Parts of the fetal scalp electrode before it is applied. B, Fetal scalp electrode and IUPC in place and connected to the bedside monitor unit.
FIG 14-7 Solid Intrauterine Pressure Catheter with Transducer in Its Tip. This model also has a lumen for amnioinfusion and is shown with its introducer over the catheter.
Uterine Activity Monitoring with an Intrauterine Pressure Catheter
Check Your Reading
Evaluating Intermittent Auscultation and Palpation Data
Evaluation of Electronic Fetal Monitoring Strips
Fetal Heart Rate Baseline
FIG 14-8 Electronic Fetal Monitor Strip Showing a Reassuring Pattern of Fetal Heart Rate (FHR) and Uterine Activity. The FHR baseline is 130 to 140 beats per minute (bpm); variability is about 10 bpm. There are no periodic changes in this strip. Contraction frequency is every 2 to 3 minutes, duration is about 50 to 60 seconds, intensity is 75 to 90 mm Hg with the internal spiral electrode, and uterine resting tone is approximately 10 mm Hg.
Baseline Fetal Heart Rate Variability
Periodic Patterns in the Fetal Heart Rate
Accelerations
FIG 14-9 Contrasts in Fetal Heart Rate (FHR) Variability. A fetal scalp electrode is being used. A, Minimal variability (less than 3 beats per minute [bpm]). Note the smooth, flat line in the upper graph for the FHR. B, Moderate variability (average 20 bpm). Note the marked zigzag appearance of the FHR line compared with the flat appearance in A.
Decelerations
Critical to Remember
Differences between Early and Late Decelerations
Both Early and Late Decelerations
Early Decelerations
Late Decelerations
Early Decelerations.
FIG 14-10 Acceleration of the Fetal Heart Rate.
Late Decelerations.
Variable Decelerations.
Uterine Activity
Critical Thinking Exercise 14-1
Questions
FIG 14-11 Early Decelerations. Note that the slowing of the fetal heart rate mirrors the contraction. It begins near the beginning of the contraction and returns to the baseline by the end of the contraction. Cause: fetal head compression.
FIG 14-12 Late Decelerations. Note that the decelerations look similar to early decelerations but are offset to the right. They begin at about the peak of the contraction, and the nadir occurs well after the peak of the contraction, often during the interval. Cause: uteroplacental insufficiency.
FIG 14-13 Variable Decelerations. The decelerations are sharp in onset and offset. Note slight rate accelerations (shoulders) after each variable deceleration. Cause: umbilical cord compression.
Check Your Reading
Significance of Fetal Heart Rate Patterns
Reassuring Patterns
Indeterminate Patterns
Nonreassuring Patterns
Critical to Remember
Nursing Responses to Nonreassuring (Abnormal) Fetal Heart Rate Patterns
TABLE 14-1 REASSURING (NORMAL) AND NONREASSURING (ABNORMAL) FETAL SURVEILLANCE ASSESSMENTS
Clarification of Data
Critical Thinking Exercise 14-2
Questions
Vibroacoustic Stimulation.
FIG 14-14 Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in the fetal heart rate (FHR) peaking 15 beats per minute above the baseline suggests that the fetus is in normal oxygen and acid-base balance. Accelerations often occur with vaginal examination unrelated to a nonreassuring FHR pattern.
Fetal Scalp Stimulation.
Fetal Scalp Blood Sample.
Cord Blood Gases and pH.
FIG 14-15 Obtaining a Blood Sample for Umbilical Cord Blood Gases and pH after Birth. Samples are drawn from the umbilical arteries, umbilical vein, or both. The samples in capped syringes may be kept for up to 60 minutes at room temperature and for 3 hours on ice.
Interventions for Nonreassuring (Category III) Patterns
Identify the Cause.
Improve Fetal Oxygenation.
Increasing Maternal Blood Oxygen Saturation.
Reducing Cord Compression.
Check Your Reading
Application of the Nursing ProcessIntermittent Auscultation and Electronic Fetal Monitoring
FIG 14-16 The nurse teaches the woman and her partner about electronic fetal monitoring to limit her anxiety and promote her comfort during labor. The nurse should help the woman understand that the electronic fetal monitor is only one method used to evaluate the fetal well-being during labor.
Learning Needs
Assessment
Nursing Diagnosis
Case Study 14-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Planning
Interventions
Parents Want to Know
About Electronic Fetal Monitoring
Explain Fetal Heart Rate Auscultation with Uterine Palpation
Explain the Electronic Fetal Monitor
Address Parents’ Safety Concerns
Coping with Misleading Data
Include the Labor Partner
Enhance Comfort
Evaluation
Fetal Oxygenation
Assessment
TABLE 14-2 GUIDELINES FOR ASSESSMENT AND DOCUMENTATION OF FETAL HEART RATE USING AUSCULTATION
Nursing Diagnosis
Planning
Interventions
Take Corrective Actions
Reassure Parents
Notify Birth Attendant
Document Assessments and Care
Box 14-2
Documenting Electronic Fetal Monitoring
Documentation When Monitoring is Initiated
Monitor Strip
Labor Record (if Paper-Only Documentation)
Continuing Documentation
Monitor Strip
Labor Record
Case Study 14-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Potential Complication:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Case Study 14-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Expected Outcomes
Interventions and Rationales
Evaluation:
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 15 Pain Management during Childbirth
Objectives
Unique Nature of Pain during Birth
Adverse Effects of Excessive Pain
Physiologic Effects
Psychological Effects
Check Your Reading
Variables in Childbirth Pain
Physical Factors
Sources of Pain
Tissue Ischemia.
Cervical Dilation.
Pressure and Pulling on Pelvic Structures.
Distention of the Vagina and Perineum.
Factors Influencing Perception or Tolerance of Pain
Labor Intensity.
FIG 15-1 Pathways of Pain Transmission during Labor.
Cervical Readiness.
Fetal Position.
Pelvic Readiness.
Fatigue and Hunger.
Caregiver Interventions.
Psychosocial Factors
Culture
Critical Thinking Exercise 15-1
Questions
Anxiety and Fear
Previous Experiences with Pain
Preparation for Childbirth
Support System
Check Your Reading
Standards for Pain Management
Nonpharmacologic Pain Management
Advantages
Limitations
Gate-Control Theory
Preparation for Pain Management
Application of Nonpharmacologic Techniques
Relaxation
Environmental Comfort.
General Comfort.
Reducing Anxiety and Fear.
FIG 15-2 General comfort measures such as the nurse’s reassuring presence or a cool cloth applied to the face supplement other methods of nonpharmacologic and pharmacologic pain control.
Specific Relaxation Techniques.
Cutaneous Stimulation
Self-Massage.
Massage by Others.
FIG 15-3 The coach applies sacral pressure to counter back pain, common during labor.
Counterpressure.
Touch.
Thermal Stimulation.
Acupressure.
Hydrotherapy
Mental Stimulation
Imagery.
Focal Point.
FIG 15-4 A woman and her partner who are prepared for labor have learned a variety of skills to master pain as labor progresses. The coach uses hand signals to tell the woman how to change her pattern of paced breathing.
Box 15-1
Use of Water Therapy during Labor
Benefits
Disadvantages
Contraindications and Precautions
Check Your Reading
Breathing Techniques
First-Stage Breathing.
Taking a Cleansing Breath.
FIG 15-5 Slow-Paced Breathing. Although a specific rate may or may not be used, slow-paced breathing should be no slower than half the woman’s usual respiratory rate to ensure adequate oxygenation. This pace is generally about six to nine breaths per minute.
Slow-Paced Breathing.
FIG 15-6 Modified-Paced Breathing. The pattern for modified-paced breathing should be comfortable to the woman and no faster than twice her normal respiratory rate to prevent hyperventilation or interference with relaxation.
FIG 15-7 Combining Techniques. Slow and modified-paced breathing can be combined by using the slower breathing at the beginning and end of the contraction and the more rapid breathing over the peak of the contraction.
Modified-Paced Breathing.
Patterned-Paced Breathing.
FIG 15-8 Patterned-Paced Breathing. Patterned-paced breathing adds a slight emphasis or “blow” on the exhalation in a pattern. The diagram shows the emphasis after every third inhalation.
Breathing to Prevent Pushing.
Overcoming Common Problems.
Second-Stage Breathing.
Case Study 15-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Critical Thinking:
Answer:
Interventions and Rationales
Evaluation:
Check Your Reading
Pharmacologic Pain Management
Special Considerations for Medicating a Pregnant Woman
Effects on the Fetus
Maternal Physiologic Alterations
Cardiovascular Changes.
Respiratory Changes.
Gastrointestinal Changes.
Nervous System Changes.
Effects on the Course of Labor
Effects of Complications
Interactions with Other Substances
Check Your Reading
Regional Pain Management Techniques
Epidural Block
Technique.
FIG 15-9 A, Cross-section of spinal cord, meninges, and protective vertebrae. The dura mater and arachnoid mater lie close together. The pia mater is the innermost of the meninges and covers the brain and spinal cord. The subarachnoid space is between the arachnoid mater and pia mater. B, Sagittal section of spinal cord, meninges, and vertebrae. The epidural and subarachnoid spaces are illustrated. Note that the spinal cord ends at the L2 vertebra.
Dural Puncture.
Contraindications and Precautions.
Adverse Effects of Epidural Block.
Maternal Hypotension.
FIG 15-10 Technique for Epidural Block.
Bladder Distention.
Prolonged Second Stage.
Catheter Migration.
Cesarean Births.
Maternal Fever.
Adverse Effects of Epidural Opioids.
Nausea and Vomiting.
Pruritus.
Delayed Respiratory Depression.
Nursing Care.
Intrathecal Opioid Analgesics
Technique.
Adverse Effects of Intrathecal Opioids.
TABLE 15-1 DRUGS COMMONLY USED FOR INTRAPARTUM PAIN MANAGEMENT
Nursing Care.
Case Study 15-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Additional Nursing Diagnoses and Collaborative Problems to Consider
Subarachnoid (Spinal) Block
Technique.
Contraindications and Precautions.
Adverse Effects.
Postdural Puncture Headache.
Systemic Drugs for Labor
Nitrous Oxide
Parenteral Analgesia
FIG 15-11 Technique for Subarachnoid Block.
FIG 15-12 Levels of Anesthesia for Epidural and Subarachnoid Blocks. A level of T10 through S5 is adequate for vaginal birth. A higher level of T4 to T6 is needed for cesarean birth.
FIG 15-13 Blood patch for relief of spinal headache. To seal a dural puncture, 10 to 15 mL of the woman’s blood is injected into the epidural space. Other fluids such as normal saline or dextran may be injected using a similar technique.
Opioid Antagonists
Drug Guide
Butorphanol (Stadol)
Classification:
Action:
Indications:
Dosage and Route
Intravenous
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions:
Nursing Considerations:
Adjunctive Drugs
Sedatives
Check Your Reading
Vaginal Birth Anesthesia
Local Infiltration Anesthesia
Pudendal Block
General Anesthesia
FIG 15-14 Local infiltration anesthesia numbs the perineum just before birth for an episiotomy or after birth for suturing of a laceration. The birth attendant protects the fetal head by placing a finger inside the vagina while injecting the perineum in a fanlike pattern or as needed.
FIG 15-15 Pudendal block provides anesthesia for an episiotomy and use of low forceps. A needle guide (“trumpet”) protects the maternal and fetal tissues from the long needle needed to reach the pudendal nerve. Only about 1.25 cm ( inch) of the long needle protrudes from the guide.
Technique.
Adverse Effects.
Maternal Aspiration of Gastric Contents.
FIG 15-16 Cricoid pressure, or Sellick’s maneuver, is used to prevent vomitus from entering the woman’s trachea while she is being intubated for general anesthesia. An assistant applies pressure to the cricoid cartilage to obstruct the esophagus. Once the woman is successfully intubated with a cuffed endotracheal tube, gastric secretions cannot enter the trachea.
Respiratory Depression.
Uterine Relaxation.
Methods to Minimize Adverse Effects.
Check Your Reading
Application of the Nursing ProcessPain Management
Pain
Assessment
Labor Status
Nursing Diagnosis
Planning
Interventions
Promoting Relaxation
Reducing Outside Sources of Discomfort
Reducing Anxiety and Fear
Helping the Woman Use Nonpharmacologic Techniques
Massage.
Mental Stimulation.
Breathing.
Incorporating Pharmacologic Methods
Parents Want to Know
How Will This Medicine Affect Our Baby?
Evaluation
Epidural Analgesia
Assessment
Nursing Diagnosis
Planning
Interventions
Maternal Hypotension
TABLE 15-2 PHARMACOLOGIC METHODS OF INTRAPARTUM PAIN MANAGEMENT
Avoidance of Injury
Evaluation
Respiratory Compromise
Assessment
Nursing Diagnosis
Planning
Interventions
Identifying Risk Factors
Reducing Risk for Aspiration or Lung Injury
Perioperative Care
Postoperative Care
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 16 Nursing Care during Obstetric Procedures
Objectives
Amniotomy
Indications
Risks
Prolapse of the Umbilical Cord
Infection
Abruptio Placentae
Technique
Nursing Considerations
Obtaining Baseline Information
Assisting with Amniotomy
FIG 16-1 A, Disposable plastic membrane perforator. B, Close-up of hook end of plastic membrane perforator. C, Correct method to open the package. D, Technique for artificial rupture of membranes.
Providing Care after Amniotomy
Identifying Complications.
Critical Thinking Exercise 16-1
Questions
Promoting Comfort.
Check Your Reading
Induction and Augmentation of Labor
Indications
Contraindications
Risks
Technique
Determining Whether Induction Is Indicated
TABLE 16-1 BISHOP SCORING SYSTEM TO EVALUATE THE CERVIX*
Cervical Ripening
Medical Methods.
Mechanical Methods.
Oxytocin Administration
TABLE 16-2 PROSTAGLANDIN PREPARATIONS FOR CERVICAL RIPENING AT TERM
Serial Induction of Labor
Nursing Considerations
Critical to Remember
Signs of Tachysystole (Hypertonic Uterine Activity)
Nursing Actions for Tachysystole (Hypertonic Uterine Activity)
FIG 16-2 Intravenous (IV) Pump Setup for Infusion from Two IV Lines. Fluid in the primary line (nonadditive, or maintenance line) contains no medication but is regulated by the infusion pump to maintain the correct rate. Oxytocin solution is regulated by a secondary line in the same pump, giving the nurse options to change or discontinue the oxytocin infusion rate while maintaining the primary line infusion at the same rate. A single IV line at the lower part of the pump connects to the woman’s infusion site.
Drug Guide
Oxytocin (Pitocin)
Classification:
Action:
Indications:
Dosage and Route
Induction or Augmentation of Labor
Control of Postpartum Bleeding
Intramuscular Injection
Inevitable or Incomplete Abortion
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions:
Nursing Considerations
Intrapartum
Postpartum
Inevitable or Incomplete Abortion
Observe the Fetal Response
Critical Thinking Exercise 16-2
Questions
Observe the Mother’s Response
Check Your Reading
Version
Indications
External Cephalic Version
Internal Version
Contraindications
Risks
Technique
External Cephalic Version
FIG 16-3 External Cephalic Version. Intravenous (IV) access is established, if needed. If terbutaline is used as a tocolytic or uterine relaxant medication, it is given by subcutaneous injection.
Internal Version
Nursing Considerations
Provide Information
Promote Maternal and Fetal Health
Reduce Anxiety
FIG 16-4 Obstetric Forceps and Their Application. A, Solid blade Tucker-McLean forceps. B, Direction of traction in a forceps-assisted birth.
Check Your Reading
Operative Vaginal Birth
Indications
Contraindications
Risks
FIG 16-5 Birth Assisted with a Vacuum Extractor. The chignon is scalp edema that often forms under the suction cup when the vacuum extractor is used.
Technique
Nursing Considerations
Episiotomy
Indications
Risks
Technique
Nursing Considerations
FIG 16-6 Types of Episiotomies.
Check Your Reading
Cesarean Birth
Evidence-Based Practice
Implementation of a System-Wide Policy for Labor Induction
Vaginal Birth after Cesarean
Indications
Contraindications
Box 16-1
Vaginal Birth after Cesarean Birth
Possible Candidates and Requirements for VBAC
Management of Women Who Plan VBAC
Risks
Technique
Preparation
Incisions
Sequence of Events in a Cesarean Birth
FIG 16-7 Skin (Abdominal Wall) Incisions for Cesarean Birth.
FIG 16-8 Uterine Incisions for Cesarean Birth. The abdominal and uterine incisions do not always match. VBAC, Vaginal birth after cesarean.
Nursing Considerations
Emotional Support
Box 16-2
Nursing Care for a Woman Having Cesarean Birth
Before the Cesarean Birth
During the Recovery Period
Box 16-3
Nursing Diagnoses for the Woman Undergoing an Operative Obstetric Procedure
Case Study 16-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes
Interventions and Rationales
Evaluation:
Teaching
Promoting Safety
Case Study 16-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Case Study 16-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Postoperative Care
Check Your Reading
Summary Concepts
The Cesarean Birth Story
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Part IV The Family Following Birth
Interactive Review – Part IV
Chapter 17 Postpartum Physiologic Adaptations
Objectives
Case Study 17-1
Introduction*
Reproductive System
Involution of the Uterus
Descent of the Uterine Fundus
Afterpains
Etiology.
TABLE 17-1 CHARACTERISTICS OF LOCHIA
Nursing Considerations.
Lochia
Changes in Color.
FIG 17-1 Involution of the Uterus. Height of the uterine fundus decreases by approximately 1 cm per day. The fundus is no longer palpable by 14 days.
FIG 17-2 Guidelines for Assessing the Amount of Lochia on the Perineal Pad.
Amount.
Cervix
Vagina
Perineum
Discomfort
Nursing Considerations
Box 17-1
Lacerations of the Birth Canal
Perineum
Periurethral Area
Vaginal Wall
Cervix
Check Your Reading
Cardiovascular System
Cardiac Output
Plasma Volume
Blood Values
Coagulation
Gastrointestinal System
Urinary System
Physical Changes
Musculoskeletal System
Muscles and Joints
FIG 17-3 A full bladder displaces and prevents contraction of the uterus.
Abdominal Wall
Integumentary System
FIG 17-4 Diastasis recti occurs when the longitudinal muscles of the abdomen separate during pregnancy.
FIG 17-5 Abdominal Exercises for Diastasis Recti. A, The woman inhales and supports the abdominal wall firmly with her hands. B, Exhaling, the woman raises her head as she pulls the abdominal muscles together.
Check Your Reading
Neurologic System
Endocrine System
Resumption of Ovulation and Menstruation
Lactation
Weight Loss
Check Your Reading
Postpartum Assessments
Initial Assessments
Chart Review
Need for Rho(D) Immune Globulin
Immunizations
Rubella Vaccine.
Drug Guide
Rubella Vaccine
Classification:
Action:
Indications for Childbearing Women:
Dosage and Route:
Absorption:
Contraindications and Precautions:
Adverse Reactions:
Nursing Implications:
Pertussis Vaccine.
Varicella Vaccine.
Risk Factors for Hemorrhage and Infection
Critical to Remember
Postpartum Risk Factors
Hemorrhage
Infection
Focused Assessments after Vaginal Birth
Vital Signs
Blood Pressure.
Orthostatic Hypotension.
Pulse.
Respirations.
Temperature.
Procedure 17-1
Assessing the Uterine Fundus
Purpose:
Pain.
Fundus
TABLE 17-2 ASSESSMENTS OF THE UTERINE FUNDUS AND NURSING ACTIONS
Lochia
Perineum
Procedure 17-2
Assessing the Perineum
Purpose:
Bladder Elimination
Case Study 17-1
Critical Thinking Exercise*
Questions
Breasts
FIG 17-6 Homans’ sign is positive when the mother experiences discomfort in the calf on sharp dorsiflexion of the foot.
Lower Extremities
Homans’ Sign.
Edema and Deep Tendon Reflexes.
FIG 17-7 Pedal Edema. A, Apply pressure to foot. B, “Pit” appears when fluid moves into adjacent tissue and away from point of pressure.
Check Your Reading
Care in the Immediate Postpartum Period
Providing Comfort Measures
Ice Packs
Sitz Baths
Perineal Care
Topical Medications
Sitting Measures
Analgesics
Promoting Bladder Elimination
Critical To Remember
Signs of a Distended Bladder
Providing Fluids and Food
Critical Thinking Exercise 17-1
Questions
Preventing Thrombophlebitis
Case Study 17-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Expected Outcome:
Interventions and Rationales
Evaluation:
Nursing Care after Cesarean Birth
Assessment
Pain Relief
Respirations
FIG 17-8 This cesarean incision is closed with staples. Note the absence of all signs of infection, such as redness, edema, bruising (ecchymosis), discharge, and loss of approximation.
Abdomen
Intake and Output
Interventions
The First 24 Hours
Providing Pain Relief.
Overcoming Effects of Immobility.
Providing Comfort.
After 24 Hours
Resuming Normal Activities.
Assisting the Mother with Infant Feeding.
Preventing Abdominal Distention.
Teaching for Discharge.
Check Your Reading
Application of the Nursing ProcessKnowledge of Self-Care
Assessment
Nursing Diagnosis
Planning
Box 17-2
Common Nursing Diagnoses for Postpartum Women
Interventions
Preparing for Teaching
Determining Teaching Topics
Teaching about the Process of Involution
Teaching Self-Care
Handwashing.
Breast Care for Lactating Mothers.
Measures to Suppress Lactation.
Care of the Cesarean Incision.
Perineal Care.
Kegel Exercises.
Promoting Rest and Sleep
Rest at the Birth Facility.
Rest at Home.
Infant Sleep and Feeding Schedules.
Evidence-Based Practice
Coping with Postpartum Fatigue
Providing Nutrition Counseling
Food Supply.
Diet.
Promoting Regular Bowel Elimination
Promoting Good Body Mechanics
Exercise.
Prevention of Back Strain.
Counseling about Sexual Activity
FIG 17-9 Postpartum Exercises. Exercises should be approved by the woman’s physician, nurse-midwife, or nurse practitioner before she begins them.
Case Study 17-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Instructing about Follow-Up Appointments
Teaching about Signs and Symptoms That Should Be Reported
Ensuring That All Elements Have Been Taught
Box 17-3
Postpartum Discharge Teaching Topics
Documenting Teaching
Evaluation
Postpartum Discharge and Community-Based Care
Criteria for Discharge
Community-Based Care
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Case Studies
Glossary
Key Points
Chapter 18 Postpartum Psychosocial Adaptations
Objectives
The Process of Becoming Acquainted
Bonding
Attachment
FIG 18-1 The infant is quiet and alert during the initial sensitive period. The newborn gazes at the mother and responds to her voice and touch. The mother fingertips her infant by touching only with the fingertips.
Critical to Remember
Reciprocal Attachment Behaviors
Maternal Touch
FIG 18-2 The mother begins to stroke the infant as she progresses in becoming acquainted.
FIG 18-3 Mothers progress from exploratory touching to enfolding the infant. Their pleasure is enhanced by skin-to-skin contact.
FIG 18-4 During the binding-in or claiming process the mother identifies her baby’s specific features and relates them to other family members. This mother states, “His long toes are exactly like mine.”
Verbal Behaviors
Check Your Reading
The Process of Maternal Adaptation
Puerperal Phases
Taking-In Phase
Taking-Hold Phase
Letting-Go Phase
Critical Thinking Exercise 18-1
Questions
Questions
Questions
Maternal Role Attainment
Heading toward a New Normal
Appreciating the Body
Settling-In
Becoming a New Family
Redefined Roles
Role Conflict
Nursing Care Plan
Adaptation of the Working Mother
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Major Maternal Concerns
Body Image
Therapeutic Communications
Body Image
Smoking
Postpartum Blues
Check Your Reading
The Process of Family Adaptation
Case Study 18-1
Introduction*
Fathers
FIG 18-5 Fathers’ behaviors during initial contact with their infants often correspond to maternal behaviors. The intense fascination that fathers exhibit is called engrossment. Note eye-to-eye contact between the father and the infant.
EVIDENCE-BASED Practice
Learning about Fatherhood
Overlapping Themes
Dads Left Out
Breadwinners or Nurturers?
Making a Space for Fathers
Siblings
FIG 18-6 A, Although they may hesitate to touch the infant, children often want to be close. B, This boy’s relief and joy are obvious as he reclaims a favorite spot.
Grandparents
Factors That Affect Family Adaptation
Critical to Remember
Factors That Affect Adaptation
FIG 18-7 Grandparents may develop strong bonds with grandchildren.
Discomfort and Fatigue
Case Study 18-1
Therapeutic Communication*
Knowledge of Infant Needs
Previous Experience
Expectations about the Newborn
Maternal Age
Maternal Temperament
Temperament of the Infant
Availability of a Strong Support System
Other Factors
Cesarean Birth
Preterm or Ill Infant
Birth of Multiple Infants
Case Study 18-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Goals/Expected Outcomes:
Interventions and Rationales
Evaluation:
Check Your Reading
Cultural Influences on Adaptation
Communication
Health Beliefs
Dietary Practices
Home and Community-Based Care
Application of the Nursing ProcessMaternal Adaptation
Assessment
Nursing Diagnosis
Planning
Interventions
Assisting the Mother through Recovery Phases
“Mother” the Mother.
Monitor and Protect.
Listen to the Birth Experience.
Foster Independence
Promote Bonding and Attachment
TABLE 18-1 Assessing Maternal Adaptation
Box 18-1
Common Nursing Diagnoses for Postpartum Period
FIG 18-8 By teaching about the newborn and family, the nurse helps parents develop confidence in their ability to provide care for the infant.
Involve Parents in Infant Care
Evaluation
Application of the Nursing ProcessFamily Adaptation
Assessment
Fathers
Siblings
Support System
Nonverbal Behavior
Nursing Diagnosis
Planning
Interventions
Teaching the Family about the Newborn
TABLE 18-2 Assessing Family Adaptation
Case Study 18-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Goals/Expected Outcomes:
Interventions and Rationales
Evaluation:
Infant Needs.
Infant Signals.
Helping the Family Adapt
Providing Anticipatory Guidance about Stress Reduction.
Helping the Father Co-Parent.
Providing Ways to Reduce Sibling Rivalry.
Identifying Resources.
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 19 Normal Newborn: Processes of Adaptation
Objectives
Initiation of Respirations
Development of the Lungs
Causes of Respirations
Chemical Factors
Mechanical Factors
FIG 19-1 Internal causes of the initiation of respirations are the chemical changes that take place at birth. External causes of respirations include thermal, sensory, and mechanical factors.
Thermal Factors
Sensory Factors
Continuation of Respirations
Check Your Reading
Cardiovascular Adaptation: Transition From Fetal to Neonatal Circulation
Ductus Venosus
Foramen Ovale
Pulmonary Blood Vessels
Ductus Arteriosus
Changes at Birth
Critical Thinking Exercise 19-1
Question
TABLE 19-1 CIRCULATORY CHANGES AT BIRTH
Check Your Reading
Neurologic Adaptation: Thermoregulation
Newborn Characteristics That Lead to Heat Loss
Methods of Heat Loss
Evaporation
Conduction
FIG 19-2 Methods of heat loss.
Convection
Radiation
FIG 19-3 Radiant warmers allow easy access to the infant without increasing heat loss resulting from exposure. The nurse is careful not to come between the infant and the overhead source of heat when caring for the infant.
Critical Thinking Exercise 19-2
Question
Nonshivering Thermogenesis
FIG 19-4 Sites of brown fat in the neonate.
Critical to Remember
Hazards of Cold Stress
Effects of Cold Stress
Neutral Thermal Environment
FIG 19-5 Effects of cold stress.
Hyperthermia
Check Your Reading
Hematologic Adaptation
Factors That Affect the Blood
TABLE 19-2 LABORATORY VALUES IN THE NEWBORN
Blood Values
Erythrocytes and Hemoglobin
Hematocrit
Leukocytes
Risk of Clotting Deficiency
Gastrointestinal System
Stomach
Intestines
Digestive Enzymes
Stools
Check Your Reading
Hepatic System
Blood Glucose Maintenance
Conjugation of Bilirubin
Source and Effect of Bilirubin
FIG 19-6 Sources of bilirubin and how it is removed from the body.
Normal Conjugation
Factors in Increased Bilirubin
Excess Production.
Red Blood Cell Life.
Albumin.
Liver Immaturity.
Blood Incompatibility.
Gestation.
Intestinal Factors.
Delayed Feeding.
Trauma.
Fatty Acids.
Family Background.
Other Factors.
Critical to Remember
Factors That Increase Risk of Hyperbilirubinemia
Hyperbilirubinemia
Physiologic Jaundice
Nonphysiologic Jaundice
Jaundice Associated with Breastfeeding
Breastfeeding or Early-Onset Jaundice.
True Breast Milk Jaundice.
Blood Coagulation
Iron Storage
Metabolism of Drugs
Check Your Reading
Urinary System
Kidney Development
Kidney Function
Fluid Balance
Water Distribution
Box 19-1
Daily Intake and Output in the Newborn
First 3-5 Days of Life
After the First 3-5 Days
Insensible Water Loss
Urine Dilution and Concentration
Acid-Base and Electrolyte Balance
Immune System
Immunoglobulin G
Immunoglobulin M
Immunoglobulin A
Check Your Reading
Psychosocial Adaptation
Periods of Reactivity
First Period of Reactivity
Period of Sleep or Decreased Activity
Second Period of Reactivity
Behavioral States
Deep or Quiet Sleep State
Light or Active Sleep State
Drowsy State
Quiet Alert State
Active Alert State
Crying State
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 20 Assessment of the Normal Newborn
Objectives
Early Focused Assessments
Safety Alert
History
Assessment of Cardiorespiratory Status
Airway
Respiratory Rate.
Procedure 20-1
Assessing Vital Signs in the Newborn
Respirations
Pulse
Temperature
Axillary
Breath Sounds.
Signs of Respiratory Distress.
Tachypnea.
Retractions.
FIG 20-1 Acrocyanosis.
Flaring of the Nares.
Cyanosis.
Grunting.
Seesaw or Paradoxical Respirations.
Asymmetry.
Choanal Atresia.
Color
Pallor.
Ruddy Color.
Heart Sounds
Position.
Rhythm and Murmurs.
Brachial and Femoral Pulses
Blood Pressure
Capillary Refill
Assessment of Thermoregulation
FIG 20-2 The infant is held securely to prevent injury and obtain an accurate reading when taking the temperature.
Box 20-1
Normal Vital Signs in the Newborn
Check Your Reading
General Assessment
Head
Molding.
Fontanels.
FIG 20-3 Palpation of the anterior fontanel. Note elevation of the head.
Caput Succedaneum.
Cephalhematoma.
FIG 20-4 Caput succedaneum is an edematous area on the head from pressure against the cervix. It may cross suture lines.
Face.
Neck and Clavicles
FIG 20-5 A cephalhematoma is characterized by bleeding between the bone and its covering, the periosteum. It may occur on one or both sides and does not cross suture lines.
Fig 20-6 A, The nurse palpates the clavicles to identify fractures. A fracture of the left clavicle is present. B, The arm on the side of the fractured clavicle is immobilized by pinning the sleeve to the shirt.
Cord
Extremities
Hands and Feet.
Hips.
FIG 20-7 Assessment of the hips. Place the fingers over the infant’s greater trochanter and thumbs over the femur. Flex the knees and hips. A, Barlow test. Adduct the hips, and apply gentle pressure down and back with the thumbs. In hip dysplasia the examiner can feel the femoral head move out of the acetabulum. B, Ortolani test. Abduct the thighs, and apply gentle pressure forward over the greater trochanter. A “clunking” sensation indicates a dislocated femoral head moving into the acetabulum. A hip click is from ligament movement and is not a problem.
Vertebral Column
FIG 20-8 Note the symmetry of gluteal and thigh creases.
Measurements
Procedure 20-2
Weighing and Measuring the Newborn
Weight
Length
Ruler Printed on Scale or Crib
Tape Measure
Head and Chest Circumference
Weight
Length
Head and Chest Circumference
Check Your Reading
Assessment of Body Systems
Neurologic System
Reflexes
Critical Thinking Exercise 20-1
Sensory Assessment
Ears.
TABLE 20-1 SUMMARY OF NEONATAL REFLEXES
Eyes.
FIG 20-9 Reflexes.
FIG 20-10 An imaginary line is drawn from the outer canthus of the eye to the ear. The line should intersect with the area where the upper ear joins the head.
Sense of Smell and Taste.
Other Neurologic Signs
Safety Alert
Jitteriness or Tremors
Seizures
Hepatic System
Blood Glucose
Box 20-2
Risk Factors for Neonatal Hypoglycemia
Critical to Remember
Signs of Neonatal Hypoglycemia
Procedure 20-3
Obtaining Blood Samples From the Newborn by Heel Puncture
Bilirubin
Check Your Reading
Gastrointestinal System
Mouth
FIG 20-11 A precocious tooth.
Suck
Initial Feeding
Abdomen
Stools
Critical Thinking Exercise 20-2
Question
Check Your Reading
Genitourinary System
Kidney Palpation
Urine
Genitalia
Female.
Male.
FIG 20-12 The testes are palpated from front to back with the thumb and forefinger. Placing a finger over the inguinal canal holds the testes in place for palpation.
Integumentary System
Skin
Color.
Harlequin Color Change.
Mottling (Cutis Marmorata).
Vernix Caseosa.
FIG 20-13 Lanugo is abundant on this slightly preterm infant.
FIG 20-14 Milia.
Lanugo.
Milia.
Erythema Toxicum.
FIG 20-15 Erythema toxicum.
FIG 20-16 Mongolian spots.
Birthmarks.
FIG 20-17 Nevus simplex, salmon patch, or stork bite.
FIG 20-18 Port-wine stain (nevus flammeus).
Marks from Delivery.
Other Skin Assessments.
Documentation
Breasts
Hair and Nails
Assessment of Gestational Age
TABLE 20-2 SUMMARY OF NEWBORN ASSESSMENT
Assessment Tools
Neuromuscular Characteristics
Posture
Square Window
Arm Recoil
FIG 20-19 New Ballard Score.
Popliteal Angle
FIG 20-20 Posture in newborns. A, The healthy full-term infant remains in a strongly flexed position. B, The preterm infant’s extremities are extended.
FIG 20-21 The square window sign is performed on the arm without the identification bracelet. The nurse flexes the wrist and measures the angle. A, Infant near full term. B, Preterm infant.
Scarf Sign
Heel to Ear
Physical Characteristics
Skin
Lanugo
FIG 20-22 Arm recoil. A, Arms flexed. B, Arms extended. C, Recoil for the full-term infant.
FIG 20-23 The popliteal angle is measured by flexing the thigh against the abdomen and extending the lower leg to the point of resistance. A, Full-term infant. B, Preterm infant.
Plantar Surface
Breasts
FIG 20-24 Scarf sign. The nurse determines how far the arm will move across the chest and observes the position of the elbow when resistance is felt. A, Full-term infant. B, Preterm infant. (Note the many visible veins in the preterm infant and the absence of visible veins in the full-term infant.)
Eyes and Ears
FIG 20-25 Heel-to-ear assessment. The nurse grasps the foot and brings it up toward the ear. The score is recorded when resistance is felt. A, Full-term infant. B, Preterm infant.
FIG 20-26 Plantar creases begin to develop at the base of the toes and extend to the heel. A, The postterm infant has deep creases. B, The preterm infant has few creases on the entire foot.
Genitals
FIG 20-27 The nurse places a finger on either side of the breast bud and measures the size. In the full-term infant, breast tissue is raised and the nipple is easily distinguished from surrounding skin. (Note the peeling skin.)
FIG 20-28 Ear maturation. A, The nurse folds the ears and notes how quickly they return to position. B, Ears in the full-term infant are well formed and have instant recoil. C, In the preterm infant, ears show less incurving of the pinna and recoil slowly or not at all.
Scoring
Gestational Age and Infant Size
Further Assessments
Assessment of Behavior
FIG 20-29 Female genitals. As the female matures, the labia majora cover the labia minora and clitoris completely; in the preterm infant, these structures are not covered. A, Near-term infant. B, Preterm infant.
FIG 20-30 Male genitals. A, The full-term infant has a pendulous scrotum with deep rugae. B, In the preterm infant, the testes may not be descended and rugae are few.
Periods of Reactivity
Behavioral Changes
Orientation
Habituation
Self-Consoling Activities
Parents’ Response
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 21 Care of the Normal Newborn
Objectives
Early Care
Administering Vitamin K
Providing Eye Treatment
FIG 21-1 Administration of Ophthalmic Ointment. The nurse wears gloves and gently cleans the eyes of blood or vernix. Then, placing a finger and thumb near the edge of each lid, the nurse gently presses against the periorbital ridges to open the eyes, avoiding pressure on the eye itself. The tube is held horizontally as a ribbon of ointment is squeezed into each conjunctival sac from the inner canthus to the outer canthus. The tube should not touch any part of the eye. Use a new tube for each infant.
Procedure 21-1
Administering Intramuscular Injections to Newborns
Drug Guide
Vitamin K1 (Phytonadione)
Classification:
Other Names:
Action:
Indication:
Neonatal Dosage and Route:
Absorption:
Adverse Reactions:
Nursing Considerations:
Drug Guide
Erythromycin Ophthalmic Ointment
Classification:
Other Name:
Action:
Indications:
Neonatal Dosage and Route:
Adverse Reactions:
Nursing Considerations:
Application of the Nursing ProcessCardiorespiratory Status
Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Positioning and Suctioning Secretions
Procedure 21-2
Using a Bulb Syringe
Providing Continuing Care
Evaluation
Case Study 21-1
Introduction*
Application of the Nursing ProcessThermoregulation
Assessment
Nursing Diagnosis
Expected Outcome
Interventions
Preventing Heat Loss
Preparing the Environment before Birth.
Providing Immediate Care.
Providing Ongoing Prevention.
Restoring Thermoregulation
Performing Expanded Assessments
Evaluation
Check Your Reading
Application of the Nursing ProcessHepatic Function
Case Study 21-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes
Interventions and Rationales
Evaluation:
Blood Glucose
Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Maintaining Safe Glucose Levels
Repeating Glucose Tests
Providing Other Care
Evaluation
Case Study 21-1
Critical Thinking Exercise*
Questions
Bilirubin
Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Evaluation
Check Your Reading
Ongoing Assessments and Care
Providing Skin Care
Bathing
Evidence-Based Practice
The Newborn’s First Bath
Providing Cord Care
Cleansing the Diaper Area
FIG 21-2 The cord clamp is removed when the end of the cord is dry and crisp. The clamp is cut (A) and separated (B).
Assisting with Feedings
Positioning for Sleep
Positioning and Head Shape
Case Study 21-1
Critical Thinking Exercise*
Question
Protecting the Infant
Identifying the Infant
Preventing Infant Abduction
FIG 21-3 The nurse unwraps the infant to compare the infant’s identification band with the mother’s band.
Box 21-1
Precautions to Prevent Infant Abductions
FIG 21-4 The nurse uses a code to open the door to the nursery.
Preventing Infection
Preventing Infant Falls
Check Your Reading
Circumcision
Reasons for Choosing Circumcision
Reasons for Rejecting Circumcision
Pain Relief
FIG 21-5 Circumcision Using the Gomco (Yellen) Clamp. The physician pulls the prepuce over a cone-shaped device that rests against the glans. A clamp is placed around the cone and the prepuce and tightened to provide enough pressure to crush the blood vessels. This prevents bleeding when the prepuce is removed after 3 to 5 minutes.
Methods
Nursing Considerations
Assisting in Decision Making
FIG 21-6 Circumcision Using the PlastiBell Ring. The physician places the PlastiBell, a plastic ring, over the glans, draws the prepuce over it, and ties a suture around the prepuce and the PlastiBell ring. This prevents bleeding when the excess prepuce is removed. The handle is removed, leaving only the ring in place over the glans.
Providing Care during Circumcision
Parents Want to Know
How to Care for the Uncircumcised Penis
FIG 21-7 The infant is placed on the circumcision board just before the procedure is begun.
Evaluating Pain
Providing Postprocedure Care
FIG 21-8 An infant with a recently circumcised penis.
Safety Alert
Teaching Parents
Parents Want to Know
How to Care for the Circumcision Site
Check Your Reading
Application of the Nursing ProcessParents’ Knowledge of Newborn Care
Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Determining Who Teaches
Box 21-2
Common Nursing Diagnoses for Newborns
Setting Priorities
Using Various Teaching Methods
Box 21-3
Major Teaching Topics
Modeling Behavior
Teaching Intermittently
Including the Father
Documenting Teaching
Providing for Follow-Up Care
Incorporating Cultural Considerations
Evaluation
Immunization
Parents Want to Know
Techniques of Infant Care
Handling the Infant
Head Support
Positions
Wrapping
Normal Body Processes
Breathing
Using a Bulb Syringe
Regulating Temperature
Using a Thermometer
Urine Output
Stool Output
Diarrhea
Skin Care
Cord
Diaper Area
Bathing
Sponge Baths
Tub Bath
Feeding
Behavior
Sleep Phases
Awake Phases
Socialization
Stimulation
Drug Guide
Hepatitis B Vaccine
Classification:
Other Names:
Action:
Indications:
Neonatal Dosage and Route
Recombivax HB
Engerix-B
Infants of HBsAg-Negative Mothers:
Infants of HBsAg-Positive Mothers:
Infants of Mothers Whose HBsAg Status Is Unknown:
Absorption:
Contraindications:
Adverse Reactions:
Nursing Considerations:
Drug Guide
Hepatitis B Immune Globulin (HBIG)
Classification:
Other Names:
Action:
Indications:
Neonatal Dosage and Route:
Absorption:
Contraindications:
Adverse Reactions:
Nursing Considerations:
Newborn Screening Tests
Critical Congenital Heart Defect Screening
Hearing Screening
Other Screening Tests
Commonly Screened Conditions
Phenylketonuria
Congenital Hypothyroidism
Galactosemia
Hemoglobinopathies
Congenital Adrenal Hyperplasia
Other Conditions
Check Your Reading
Discharge and Newborn Follow-Up Care
Discharge
Follow-Up Care
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Nursing Skills
Chapter 22 Infant Feeding
Objectives
Nutritional Needs of the Newborn
Calories
Nutrients
Water
Box 22-1
Daily Calorie and Fluid Needs of the Newborn
Calories
Fluid
Breast Milk and Formula Composition
Breast Milk
Changes in Composition
Lactogenesis I.
Lactogenesis II.
Lactogenesis III.
Nutrients
Protein.
Carbohydrate.
Fat.
Vitamins.
Minerals.
Enzymes.
Check Your Reading
Infection-Preventing Components
Effect of Maternal Diet
Formulas
Cow’s Milk
Formulas for Infants with Special Needs
Considerations in Choosing a Feeding Method
Breastfeeding
Box 22-2
Benefits of Breastfeeding
For the Infant
For the Mother
Formula Feeding
Combination Feeding
Factors Influencing Choice
Support from Others
Culture
Employment
Staff Knowledge
Other Factors
Check Your Reading
Normal Breastfeeding
Breast Changes during Pregnancy
Milk Production
Hormonal Changes at Birth
Prolactin
Oxytocin
FIG 22-1 Effect of Prolactin and Oxytocin on Milk Production. When the infant begins to suckle at the breast, nerve impulses travel to the hypothalamus, causing the anterior pituitary to secrete prolactin to increase milk production. Suckling causes the posterior pituitary to secrete oxytocin, producing the let-down reflex, which releases milk from the breast. Oxytocin also causes the uterus to contract, which aids in involution.
Continued Milk Production
Preparation of Breasts for Breastfeeding
FIG 22-2 Normal everted nipple and other types of nipples that may cause the infant difficulty in latching on.
Check Your Reading
Application of the Nursing ProcessBreastfeeding
Assessment
Maternal Assessment
Breasts and Nipples.
Therapeutic Communications
Anxiety about Breastfeeding
Knowledge.
Infant Feeding Behaviors
Nursing Diagnosis
Expected Outcomes
TABLE 22-1 THE LATCH SCORING TOOL*
Box 22-3
Hunger Cues in Infants
Interventions
Assisting with the First Feeding
Teaching Feeding Techniques
Position of the Mother and Infant.
Position of the Mother’s Hands.
FIG 22-3 For the cradle hold, the mother positions the infant’s head at or near the antecubital space and level with her nipple, with her arm supporting the infant’s body. Her other hand is free to hold the breast. Once the infant is positioned, pillows or blankets can be used to support the mother’s arm, which may tire from holding the baby.
FIG 22-4 For the football or clutch hold, the mother supports the infant’s head and neck in her hand, with the infant’s body resting on pillows alongside her hip. This method allows the mother to see the position of the infant’s mouth on the breast, helps her control the infant’s head, and is especially helpful for mothers with heavy breasts. This hold also avoids pressure against an abdominal incision.
FIG 22-5 The cross-cradle or modified cradle hold is helpful for infants who are preterm or have a fractured clavicle. The mother holds the infant’s head with the hand opposite the side on which the infant will feed and supports the infant’s body across her lap with her arm. The other hand holds the breast. The mother can guide the infant’s head to the breast and see the mouth on the breast during the feeding.
FIG 22-6 The side-lying position avoids pressure on episiotomy or abdominal incisions and allows the mother to rest while feeding. She lies on her side, with her lower arm supporting her head or placed around the infant. Pillows behind her back and between her legs provide comfort. Her upper hand and arm are used to position the infant on the side at nipple level and hold the breast. When the infant’s mouth opens to nurse, the mother draws the infant to her to insert the nipple into the mouth. A small blanket or towel can be placed over an abdominal incision to protect it from infant movement.
FIG 22-7 “C” Position of Hand on Breast. The hand is positioned so that the thumb is on top of the breast while the fingers support the breast from below. Note the flaring of the infant’s lips.
Latch-On Techniques.
Eliciting Latch-On.
Position of the Mouth.
Suckling Pattern.
FIG 22-8 Position of the Infant’s Mouth While Suckling. When the nipple and areola are properly positioned in the infant’s mouth, the gums compress the areola instead of the nipple. The tongue is between the lower gum and breast. The infant’s lips are flared outward.
Removal from the Breast.
Frequency of Feedings.
Length of Feedings.
Preventing Problems.
Teaching.
Minimizing Interruptions.
Evidence-Based Practice
Formula Gift Packs.
Formula Supplementation.
Insufficient Milk Supply.
Mothers Want to Know
Is My Baby Getting Enough Milk?
Getting Help from Family.
Increasing Confidence.
Providing Resources.
Evaluation
Check Your Reading
Common Breastfeeding Concerns
Case Study 22-1
Introduction*
Infant Problems
Safety Alert
Sleepy Infant
Nipple Confusion
Suckling Problems
Infant Complications
Jaundice.
Prematurity.
Illness and Congenital Defects
Case Study 22-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Goals or Expected Outcomes:
Interventions and Rationales
Critical Thinking:
Answer:
Evaluation:
Maternal Concerns
Common Breast Problems
Engorgement.
Safety Alert
Nipple Pain.
Case Study 22-1
Nursing Care Plan*
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Goals or Expected Outcomes:
Interventions and Rationales
Critical Thinking:
Answer:
Evaluation:
Flat and Inverted Nipples.
Plugged Ducts.
FIG 22-9 Note the cracked area on this nipple.
FIG 22-10 Rolling helps flat nipples become erect in preparation for latch-on.
FIG 22-11 To massage the breasts, the mother places her hands against the chest wall with her fingers encircling the breasts. She gently slides her hands forward until the fingers overlap. The position of the hands is rotated to cover all breast tissue. Massaging with the fingertips in a circular motion over all areas of the breast is also helpful.
Check Your Reading
Illness in the Mother
Drug Transfer to Breast Milk
Breastfeeding Mothers Want to Know
Solutions to Common Breastfeeding Problems
Problem: Sleepy Infant
Prevention
Solutions
Problem: Nipple Confusion
Prevention
Solution
Problem: Latch-On Difficulty
Prevention
Solutions
Problem: Engorgement
Prevention
Solutions
Problem: Sore Nipples
Prevention
Solutions
Problem: Flat or Inverted Nipples
Prevention
Solutions
Conditions in which Breastfeeding Should be Avoided.
Previous Breast Surgery
Employment
FIG 22-12 To express milk from the breast, the mother places her hand just behind the areola, with the thumb on top and the fingers supporting the breast. The tissue is pressed back against the chest wall; then the fingers and thumb are brought together and toward the nipple. This compresses the ducts and causes milk to flow. The action is repeated to simulate the suckling of the infant. Moving the hands around the areola allows compression of all areas and increases removal of milk from the breast. Compression should be gentle to avoid trauma. Application of heat and massage before expression increase the flow of milk.
Milk Expression and Storage
Hand Expression.
Use of a Breast Pump.
FIG 22-13 The nurse helps the mother use an electric breast pump.
Milk Storage.
Breastfeeding after Multiple Births
Breastfeeding Mothers Want to Know
Breastfeeding after the Birth of More than One Infant
Ensuring Adequate Milk Production
Using a Breast Pump
Feeding Simultaneously or Individually
Positioning Infants for Simultaneous Feeding
Keeping Track
Care for Yourself
Weaning
Breastfeeding Mothers Want to Know
How to Wean from Breastfeeding
Deciding When to Wean
How to Proceed
Home Care
FIG 22-14 The nurse offers suggestions on hand position during the clinic visit.
Check Your Reading
Formula Feeding
Application of the Nursing ProcessFormula Feeding
Assessment
Mother’s Knowledge
Infant Feeding Behaviors
Nursing Diagnosis
Expected Outcomes
Interventions
Teaching about Formula
Types of Formula.
Ready-to-Use Formula.
Concentrated Liquid Formula.
Powdered Formula.
Safety Alert
Equipment.
Preparation.
Explaining Feeding Techniques
Positioning.
Burping.
FIG 22-15 This mother holds her infant close during bottle feeding. The bottle is positioned such that the nipple is filled with milk at all times. The father offers encouragement.
FIG 22-16 The mother burps the infant by holding him in the sitting position. She supports the infant’s head and chest with one hand and gently pats the back with the other hand.
Frequency and Amount.
Cautions.
Infant Variations.
Evaluation
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 23 Home Care of the Infant
Objectives
Information for New Parents
Needs
Sources of Information
Care after Discharge
Home Visits
Visits to Low-Risk Families
FIG 23-1 During the home visit, the nurse performs a complete assessment of the infant. Here, she is checking the apical pulse and listening to breath sounds.
FIG 23-2 Jaundice is especially of concern when infants are discharged early after birth. The nurse shows the mother how to blanch the skin to check for jaundice and discusses what the mother should do if she sees jaundice in her baby.
FIG 23-3 The nurse discusses thermoregulation with the mother and demonstrates swaddling.
FIG 23-4 The nurse observes a feeding during the visit to assess feeding techniques and provide a chance for parents to ask questions about feeding. This is a good time to assess parent–infant interaction. The infant is weighed to help determine adequacy of intake.
Visits to Families with High-Risk Infants
General Considerations in Home Visits
Outpatient Visits
Parenting Classes
Telephone Counseling
Follow-Up Calls
Warm Lines
Telephone Techniques
Critical To Remember
Red Flags of Telephone Triage
Guidelines and Documentation
Check Your Reading
Infant Equipment
Safety Considerations
Car Safety Seats
Box 23-1
Safety Considerations for Infant Equipment
Cribs
Other Equipment
FIG 23-5 A car seat for an infant under 2 years should face the rear of the car. Note the clip that holds the straps together for a snug fit.
Box 23-2
Safety Considerations for Infant Car Seats
Check Your Reading
Early Problems
Crying
Parents Want to Know
Methods to Relieve Crying in Infants
Treating Common Causes
Quieting Techniques
Colic
Description
Interventions
Therapeutic Communications
Coping with Crying
Check Your Reading
Sleep
Parents
Infant Sleep Patterns
Sleeping through the Night
Parents Want to Know
How to Help Infants Sleep through the Night
Concerns of Working Mothers
Concerns of Adoptive Parents
Critical Thinking Exercise 23-1
Questions
Common Questions and Concerns
Dressing and Warmth
Stool and Voiding Patterns
Smoking
Eyes
Baths
Nails
Sucking Needs
Common Rashes
Diaper Rash (Diaper Dermatitis)
Miliaria (Prickly Heat)
Seborrheic Dermatitis (Cradle Cap)
Feeding Concerns
Regurgitation
Introduction of Solid Foods
Check Your Reading
Growth and Development
Anticipatory Guidance
Growth and Developmental Milestones
Accident Prevention
Well-Baby Care
Well-Baby Checkups
Immunizations
Check Your Reading
Illness
Recognizing Signs
Calling the Pediatrician or Nurse Practitioner
Knowing When to Seek Immediate Help
Box 23-3
Common Signs of Illness in Infants
Learning about Sudden Infant Death Syndrome
Box 23-4
Calling the Pediatrician or Nurse Practitioner
Parents Want to Know
How Can I Help Prevent SIDS?
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Case Studies
Glossary
Key Points
Nursing Skills
Part V Families at Risk during the Childbearing Period
Interactive Review – Part V
Chapter 24 The Childbearing Family with Special Needs
Objectives
Adolescent Pregnancy
Incidence
Factors Associated with Teenage Pregnancy
FIG 24-1 Pregnant Adolescent. Approximately 20% of pregnant adolescents have had one or more previous births.
Box 24-1
Factors That Contribute to Teenage Pregnancy
Sex Education
Options When Pregnancy Occurs
Socioeconomic Implications
TABLE 24-1 IMPACT OF PREGNANCY ON THE DEVELOPMENTAL TASKS OF ADOLESCENCE
Implications for Maternal Health
Implications for Fetal and Neonatal Health
The Teenage Expectant Father
Impact of Teenage Pregnancy on Parenting
Check Your Reading
Application of the Nursing ProcessThe Pregnant Teenager
Assessment
Physical Assessment
Cognitive Development
Knowledge of Infant Needs
Family Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Eliminating Barriers to Health Care
Nursing Care Plan
Adolescent Responses to Pregnancy and Birth
Assessment:
Nursing Diagnosis:
Goals/Expected Outcomes:
Interventions and Rationales
Evaluation:
Assessment:
Nursing Diagnosis:
Goals and Expected Outcomes:
Interventions and Rationales
Evaluation:
Assessment:
Nursing Diagnosis:
Goals and Expected Outcomes:
Interventions and Rationales
Evaluation:
Applying Teaching and Learning Principles
Box 24-2
Recommended Methods for Teaching Pregnant Adolescents
Counseling
Nutrition.
Self-Care.
Stress Reduction.
Attachment to the Fetus.
Infant Care.
Breastfeeding.
Promoting Family Support
Providing Support during Labor
Evidence-Based Practice
Labor Support for Adolescents
Providing Referrals
Evaluation
Check Your Reading
Delayed Pregnancy
Maternal and Fetal Implications
Advantages of Delayed Childbirth
Disadvantages of Delayed Childbirth
FIG 24-2 Older primigravidas bring maturity and problem-solving skills to the maternal role, but they are at somewhat increased risk for physiologic problems related to pregnancy and birth.
Nursing Considerations
Preconception Care
Reinforcing and Clarifying Information
Facilitating Expression of Emotions
Providing Parenting Information
Check Your Reading
Substance Abuse
Incidence
Maternal and Fetal Effects
TABLE 24-2 MATERNAL AND FETAL OR NEONATAL EFFECTS OF COMMONLY ABUSED SUBSTANCES
Tobacco
Maternal and Fetal Effects.
Neonatal Effects.
Alcohol
Marijuana
Cocaine
Maternal and Fetal Effects.
Neonatal Effects.
Amphetamines and Methamphetamines
Maternal and Fetal Effects.
Neonatal Effects.
Antidepressants
Maternal and Fetal Effects.
Neonatal Effects.
Opiates
Fetal Effects.
Neonatal Effects.
Diagnosis and Management of Substance Abuse
Check Your Reading
Application of the Nursing ProcessMaternal Substance Abuse
Antepartum Period
Assessment
Safety Alert
Signs of Possible Drug Use
Medical History
Obstetric History
History of Substance Abuse
Nursing Diagnosis
Expected Outcomes
Box 24-3
Techniques for Interviewing a Woman About Substance Abuse
Interventions
Examining Attitudes
Preventing Substance Abuse
Communicating with the Woman
Helping the Woman Identify Strengths
Providing Ongoing Care
Evaluation
Intrapartum Period
Assessment
Cocaine
Heroin
Nursing Diagnosis
Expected Outcomes
Interventions
Preventing Injury
Admitting Procedure.
Setting Limits.
Initiating Seizure Precautions.
Maintaining Effective Communication
Providing Pain Control
Preventing Heroin Withdrawal
Evaluation
Postpartum Period
Check Your Reading
Birth of an Infant with Congenital Anomalies
Factors Influencing Emotional Responses of Parents
Timing and Manner of Being Told
Prior Knowledge of the Defect
Type of Defect
Irreparable Defect
Grief and Mourning
Check Your Reading
Nursing Considerations
Assisting with the Grieving Process
Promoting Bonding and Attachment
FIG 24-3 Touching and cuddling by a mother whose infant has a congenital anomaly fosters attachment and helps them cope with the grieving process. This infant has anomalies of the hand and arm.
Providing Accurate Information
Facilitating Communication
Participating in Infant Care
Planning for Discharge
Providing Referrals
Check Your Reading
Perinatal Loss
Early Pregnancy Loss
Concurrent Death and Survival in Multifetal Pregnancy
Perinatal Palliative or Hospice Care Services
Previous Pregnancy Loss
Application of the Nursing ProcessPregnancy Loss
Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Allowing Expression of Feelings
Acknowledging the Infant
Presenting the Infant to the Parents
Preparing a Memory Packet
Respecting Cultural Practices
Assisting with Other Needs
Providing Follow-Up Care
Providing Referrals
Evaluation
Check Your Reading
Adoption
Check Your Reading
Intimate Partner Violence
FIG 24-4 The woman who is abused by her partner lives with an ever-present risk of violence. Because an abused woman may not seek help, all women should be asked about abuse whenever they receive health care.
Effects of Intimate Partner Violence during Pregnancy
Factors That Promote Violence
TABLE 24-3 MYTHS AND REALITIES OF VIOLENCE AGAINST WOMEN
Characteristics of the Abuser
Cycle of Violence
Nurse’s Role in Prevention of Abuse
FIG 24-5 Types of behaviors that are evident in each step of the cycle of violence.
Check Your Reading
Application of the Nursing ProcessThe Battered Woman
Assessment
Critical Thinking Exercise 24-1
Questions
Questions
Critical to Remember
Cues Indicating Violence Against Women
Nursing Diagnosis
Expected Outcomes
Box 24-4
Common Nursing Diagnoses for Families with Special Needs
Interventions
Listening
Developing a Personal Safety Plan
Affirming She Is Not to Blame
Providing Education
Providing Referrals
Evaluation
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 25 Complications of Pregnancy
Objectives
Hemorrhagic Conditions of Early Pregnancy
Abortion
Spontaneous Abortion
Incidence and Etiology.
FIG 25-1 Three types of spontaneous abortion, also called miscarriage.
Threatened Abortion
Clinical Manifestations.
Therapeutic Management.
Inevitable Abortion
Clinical Manifestations.
Therapeutic Management.
Incomplete Abortion
Clinical Manifestations.
Therapeutic Management.
Complete Abortion
Clinical Manifestations.
Therapeutic Management.
Missed Abortion
Clinical Manifestations.
Therapeutic Management.
Recurrent Spontaneous Abortion
Clinical Manifestations.
Therapeutic Management.
Nursing Considerations.
Disseminated Intravascular Coagulation
Nursing Considerations
Check Your Reading
Ectopic Pregnancy
Incidence and Etiology
FIG 25-2 Sites of tubal ectopic pregnancy. Numbers indicate the order of prevalence.
Clinical Manifestations
Box 25-1
Risk Factors for Ectopic Pregnancy
Diagnosis
Therapeutic Management
FIG 25-3 Linear salpingostomy.
Nursing Considerations
Gestational Trophoblastic Disease (Hydatidiform Mole)
Incidence and Etiology
FIG 25-4 Gestational trophoblastic disease, also called hydatidiform mole.
Clinical Manifestations
Diagnosis
Therapeutic Management
Nursing Considerations
Check Your Reading
Application of the Nursing ProcessHemorrhagic Conditions of Early Pregnancy
Assessment
Critical Thinking Exercise 25-1
Question
Nursing Diagnosis
Planning
Interventions
Provide Information about Tests and Procedures
Teach Measures to Prevent Infection
Provide Dietary Information
Teach Signs of Infection to Report
Reinforce Follow-Up Care
Critical Thinking Exercise 25-2
Questions
Evaluation
Hemorrhagic Conditions of Late Pregnancy
Placenta Previa
FIG 25-5 Examples of three classifications of placenta previa.
Case Study 25-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Critical Thinking:
Answer:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Incidence and Etiology
Clinical Manifestations
Therapeutic Management
Home Care.
Case Study 25-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Nursing Considerations
Home Care.
Inpatient Care.
Abruptio Placentae
Incidence and Etiology
Clinical Manifestations
FIG 25-6 Types of abruptio placentae.
Therapeutic Management
Nursing Considerations
Check Your Reading
Safety Alert
Application of the Nursing ProcessHemorrhagic Conditions of Late Pregnancy
Assessment
Nursing Diagnosis
Planning
Interventions
Monitor for Signs of Hypovolemic Shock
Monitor the Fetus
Promote Tissue Oxygenation
Collaborate with the Physician for Fluid Replacement
Prepare the Woman for Surgery
Safety Alert
Provide Emotional Support
Evaluation
Hyperemesis Gravidarum
Etiology
Therapeutic Management
Nursing Considerations
Reducing Nausea and Vomiting
Maintaining Nutrition and Fluid Balance
Providing Emotional Support
Check Your Reading
Hypertensive Disorders of Pregnancy
TABLE 25-1 CLASSIFICATIONS OF HYPERTENSION IN PREGNANCY
Preeclampsia
Incidence and Risk Factors
Box 25-2
Risk Factors for Pregnancy-Related Hypertension
Pathophysiology
Preventive Measures
Prenatal Care.
Clinical Manifestations of Preeclampsia
Classic Signs.
Additional Signs.
Symptoms.
FIG 25-7 The pathologic processes of preeclampsia.
Therapeutic Management of Mild Preeclampsia
Case Study 25-2
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Home Care.
Activity Restrictions.
FIG 25-8 Generalized edema is a possible sign identified with preeclampsia, although it may occur in normal pregnancy or in a pregnancy complicated by another disorder. A, Facial edema may be subtle. B, Pitting edema of the lower leg.
Blood Pressure.
Weight.
Urinalysis.
Fetal Assessment.
Diet.
Case Study 25-2
Nursing Care Plan*
Evaluation:
Assessment:
Nursing Diagnosis:
Expected Outcomes:
INTERVENTIONS AND Rationales
Critical Thinking
Answers
Evaluation:
Inpatient Management of Severe Preeclampsia
TABLE 25-2 MILD VERSUS SEVERE PREECLAMPSIA
Antepartum Management.
Bed Rest.
Antihypertensive Medications.
Anticonvulsant Medications.
Drug Guide
Magnesium Sulfate
Classification:
Action:
Indications:
Dosage and Route:
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions:
Nursing Implications:
Procedure 25-1
Assessing Deep Tendon Reflexes
Deep Tendon Reflex Rating Scale*
Intrapartum Management.
Postpartum Management.
Therapeutic Management of Eclampsia
Check Your Reading
Application of the Nursing ProcessPreeclampsia
Assessment
TABLE 25-3 ASSESSMENT OF EDEMA
Assessments for Magnesium Toxicity
Psychosocial Assessment
Nursing Diagnosis
Planning
TABLE 25-4 NURSING ASSESSMENTS FOR PREECLAMPSIA AND MAGNESIUM TOXICITY
Interventions
Interventions for Seizures
Monitor for Signs of Impending Seizures.
Initiate Preventive Measures.
Prevent Seizure-Related Injury.
Protect the Woman and the Fetus during a Seizure.
Provide Information and Support for the Family.
Interventions for Magnesium Toxicity
Monitor for Signs of Magnesium Toxicity.
Respond to Signs of Magnesium Toxicity.
Evaluation
Check Your Reading
Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome
Chronic Hypertension
Check Your Reading
Incompatibility between Maternal and Fetal Blood
Rh Incompatibility
Pathophysiology
Fetal and Neonatal Implications
Prenatal Assessment and Management
Safety Alert
FIG 25-9 The process of maternal sensitization to the Rh factor.
Postpartum Management
FIG 25-10 Sequence of assessments for Rh sensitization, as needed. Delta-OD (ΔOD), change in optical density of bilirubin.
Drug Guide
Rho(D) Immune Globulin (RhoGAM, Hyprho-D, Gamulin Rh)
Classification:
Action:
Indications (Pregnancy Related):
Dosage and Route:
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions:
Nursing Implications:
ABO Incompatibility
Parents Want to Know
About Rh Incompatibility
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Case Studies
Glossary
Key Points
Chapter 26 Concurrent Disorders during Pregnancy
Objectives
Diabetes Mellitus
Pathophysiology
Etiology
Effect of Pregnancy on Fuel Metabolism
Early Pregnancy.
Late Pregnancy.
Birth.
Postpartum Period.
Classification
Box 26-1
Classification of Diabetes Mellitus
Incidence
Preexisting Diabetes Mellitus
Maternal Effects
TABLE 26-1 MAJOR EFFECTS OF DIABETES MELLITUS ON PREGNANCY
Fetal Effects
Congenital Malformation.
Variations in Fetal Size.
Neonatal Effects
Hypoglycemia.
Hypocalcemia.
Hyperbilirubinemia.
Respiratory Distress Syndrome.
Check Your Reading
Maternal Assessment
History.
Physical Examination.
Laboratory Tests.
Fetal Surveillance
Therapeutic Management
Preconception Care.
Diet.
Self-Monitoring of Blood Glucose Level.
Insulin Therapy.
First Trimester.
Second and Third Trimesters.
During Labor.
Postpartum Period.
Oral Therapy.
Timing of Delivery.
Gestational Diabetes Mellitus
Risk Factors
Identifying Gestational Diabetes Mellitus
Screening
Glucose Challenge Test.
Oral Glucose Tolerance Test.
Maternal, Fetal, and Neonatal Effects
Therapeutic Management
Diet.
Exercise.
Blood Glucose Monitoring.
Fetal Surveillance.
Nursing Considerations
Increasing Effective Communication.
Case Study 26-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Providing Opportunities for Control.
Providing Normal Pregnancy Care.
Critical Thinking Exercise 26-1
Questions
Questions
Check Your Reading
Application of the Nursing ProcessThe Pregnant Woman with Diabetes Mellitus
Case Study 26-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Additional Nursing Diagnoses to Consider
Assessment
Nursing Diagnosis
Planning
Interventions
Teaching Self-Care Skills
Self-Monitoring of Blood Glucose Level.
Insulin Administration.
Continuous Subcutaneous Insulin Infusion.
Teaching Dietary Management
Managing Hypoglycemia and Hyperglycemia
Hypoglycemia.
Safety Alert
Hyperglycemia.
Safety Alert
Explaining Procedures, Tests, and Plan of Care
Evaluation
Cardiac Disease
Evidence-Based Practice
Coronary Heart Disease is the Greatest Killer of American Women
U.S. Preventive Services Task Force (USPSTF) CHD Screening Recommendations
Implications for Nursing Practice
Incidence and Classification
Rheumatic Heart Disease
Congenital Heart Disease
Left-to-Right Shunt
Atrial Septal Defect.
Ventricular Septal Defect.
Patent Ductus Arteriosus.
Right-to-Left Shunt
Tetralogy of Fallot.
Eisenmenger’s Syndrome.
Mitral Valve Prolapse.
Peripartum and Postpartum Cardiomyopathy
Diagnosis and Classification
Box 26-2
New York Heart Association Functional Classification of Heart Disease*
Therapeutic Management
Class I or II Heart Disease
Class III or IV Heart Disease
Drug Therapy
Anticoagulants.
Antidysrhythmics.
Antiinfectives.
Drugs for Heart Failure.
Intrapartum Management
Postpartum Management
Safety Alert
Application of the Nursing ProcessThe Pregnant Woman with Heart Disease
Assessment
Nursing Diagnosis
Planning
Interventions
Teaching about Increased Cardiac Workload
Excessive Weight Gain and Anemia.
Exertion.
Exposure.
Emotional Stress.
Helping Family Accept Restrictions on Activity
Providing Postpartum Care
Evaluation
Check Your Reading
Anemias
Iron Deficiency Anemia
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Folic Acid Deficiency (Megaloblastic) Anemia
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Check Your Reading
Sickle Cell Disease
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Thalassemia
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Check Your Reading
Medical Conditions
Immune-Complex Diseases
Systemic Lupus Erythematosus
Antiphospholipid Syndrome
TABLE 26-2 MEDICAL CONDITIONS AND THEIR EFFECTS ON PREGNANCY
Hashimoto’s Thyroiditis
Rheumatoid Arthritis
Neurologic Disorders
Seizure Disorders
Bell’s Palsy
Check Your Reading
Infections during Pregnancy
Viral Infections
Cytomegalovirus
Fetal and Neonatal Effects.
Therapeutic Management.
Rubella
Fetal and Neonatal Effects.
Therapeutic Management.
Varicella-Zoster Virus
Fetal and Neonatal Effects.
Therapeutic Management.
Herpes Simplex Virus
Fetal and Neonatal Effects.
Therapeutic Management.
TABLE 26-3 SEXUALLY TRANSMITTED DISEASES, URINARY TRACT AND VAGINAL INFECTIONS: IMPACT ON PREGNANCY
Therapeutic Communications
Concern about Confidentiality
Check Your Reading
Parvovirus B19
Fetal and Neonatal Effects.
Therapeutic Management.
Hepatitis B
Fetal and Neonatal Effects.
Therapeutic Management.
Human Immunodeficiency Virus
Pathophysiology.
Critical to Remember
Facts about Human Immunodeficiency Virus
Fetal and Neonatal Effects.
Prevention.
Therapeutic Management.
Nursing Considerations.
Box 26-3
Recommendations for the Prevention of Perinatal Human Immunodeficiency Virus Infection of the Infant
Check Your Reading
Nonviral Infections
Toxoplasmosis
Fetal and Neonatal Effects.
Therapeutic Management.
Group B Streptococcus Infection
Fetal and Neonatal Effects.
Therapeutic Management.
Tuberculosis
Fetal and Neonatal Effects.
Therapeutic Management.
Check Your Reading
Application of the Nursing ProcessThe Pregnant Woman with Tuberculosis
Assessment
Analysis
Planning
Interventions
Providing Information
Providing Support
Evaluation
Summary Concepts
Box 26-4
Common Nursing Diagnoses for Women WHO Have Medical Complications of Pregnancy
References & Readings
Pageburst Integrated Resource
Case Studies
Glossary
Key Points
Chapter 27 Intrapartum Complications
Objectives
Dysfunctional Labor
Problems of the Powers
Ineffective Contractions
TABLE 27-1 PATTERNS OF LABOR DYSFUNCTION
Hypotonic Dysfunction.
Hypertonic Dysfunction.
Ineffective Maternal Pushing
Problems with the Passenger
Fetal Size
Macrosomia.
Shoulder Dystocia.
Abnormal Fetal Presentation or Position
Rotation Abnormalities.
FIG 27-1 Methods That May Be Used to Relieve Shoulder Dystocia. A, McRobert’s maneuver. The woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve somewhat. A supported squat has a similar effect and adds gravity to her pushing efforts. B, Suprapubic pressure by an assistant pushes the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis. Fundal pressure should not be used because it will push the anterior shoulder even more firmly against the mother’s symphysis.
Critical Thinking Exercise 27-1
Questions
Deflexion Abnormalities.
FIG 27-2 A hands-and-knees position helps this fetus rotate from a left occiput posterior (LOP) position to an occiput anterior position.
Breech Presentation.
FIG 27-3 The “lunge” to one side promotes rotation of the fetal occiput from a posterior position to an anterior one.
FIG 27-4 Sequence for Vaginal Birth in a Frank Breech Presentation. A, Descent and internal rotation of the fetal body. B, Internal rotation complete; extension of the fetal back and neck as the trunk slips under the symphysis pubis. The birth attendant uses a towel for traction when grasping the fetal legs. C, After the birth of the shoulders, the attendant maintains flexion of the fetal head by using the fingers of the left hand to apply pressure to the lower face. The fetal body straddles the attendant’s left arm. An assistant provides suprapubic pressure to help keep the fetal head well-flexed. D, After the fetal head is brought under the symphysis pubis, an assistant grasps the fetal legs with a towel for traction while the attendant delivers the face and head over the mother’s perineum.
Multifetal Pregnancy
FIG 27-5 Twins can present in any combination of presentations and positions.
Fetal Anomalies
Check Your Reading
Problems with the Passage
Pelvis
FIG 27-6 Pelvic shapes.
Maternal Soft Tissue Obstructions
Problems of the Psyche
Check Your Reading
Abnormal Labor Duration
Prolonged Labor
Precipitate Labor
Check Your Reading
Application of the Nursing Process Dysfunctional Labor
Intrauterine Infection
Assessment
Nursing Diagnosis
Planning
Interventions
Reducing the Risk for Infection
Safety Alert
Identifying Infection
Evaluation
Maternal Exhaustion
Assessment
Nursing Diagnosis
Planning
Interventions
Conserving Maternal Energy
Promoting Coping Skills
Evaluation
Premature Rupture of the Membranes
Etiology
Complications
Therapeutic Management
Determining True Membrane Rupture
Gestation Near Term.
Preterm Gestation.
Maternal Antibiotics
Nursing Considerations
Check Your Reading
Preterm Labor
Evidence-Based Practice
Important Basic Nursing Actions for Care of Early Term (Late Preterm) Babies
Associated Factors
Signs and Symptoms
Preventing Preterm Birth
Community Education
Case Study 27-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcome:
Interventions and Rationales
Evaluation:
During Pregnancy
Improving Access to Care.
Identifying Risk Factors.
Progesterone Supplementation.
Promoting Adequate Nutrition.
Educating Women and Their Partners about Preterm Labor.
Empowering Women and Their Partners.
Therapeutic Management
Predicting Preterm Birth
Cervical Length.
PPROM in a Previous Birth.
Fetal Fibronectin.
Infections.
Identifying Preterm Labor
Frequent Prenatal Visits.
Stopping Preterm Labor
Initial Measures.
Identifying and Treating Infections.
Identifying Other Causes for Preterm Contractions.
Limiting Activity.
Hydrating the Woman.
Tocolytics.
Magnesium Sulfate.
Calcium Antagonists.
TABLE 27-2 DRUGS USED IN PRETERM LABOR
TABLE 27-3 MATERNAL RISK FACTORS FOR PRETERM LABOR
Prostaglandin Synthesis Inhibitors.
Beta-Adrenergic Drugs.
Accelerating Fetal Lung Maturity
Case Study 27-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcome:
Interventions and Rationales
Evaluation:
Additional Nursing Diagnoses to Consider
Drug Guide
Betamethasone, Dexamethasone
Classification:
Indications:
Dosage and Route
Absorption:
Excretion:
Contraindications:
Precautions:
Adverse Reactions:
Nursing Considerations:
Check Your Reading
Application of the Nursing Process Preterm Labor
Psychosocial Concerns
Assessment
Nursing Diagnosis
Planning
Interventions
Providing Information
Promoting Expression of Concerns
Teaching What May Occur during a Preterm Birth
Evaluation
Management of Home Care
Assessment
Nursing Diagnosis
Planning
Interventions
Caring for Children
Maintaining the Household
Evaluation
Boredom
Assessment
Nursing Diagnosis
Planning
Interventions
Identifying Appropriate Activities
Changing the Physical Surroundings
Evaluation
Prolonged Pregnancy
Complications
Therapeutic Management
Nursing Considerations
FIG 27-7 Variations of prolapsed umbilical cord.
Intrapartum Emergencies
Placental Abnormalities
Prolapsed Umbilical Cord
Causes
Signs of Prolapse
Safety Alert
Therapeutic Management
FIG 27-8 Measures that may be used to relieve pressure on a prolapsed umbilical cord until delivery can take place.
Nursing Considerations
Uterine Rupture
FIG 27-9 Uterine rupture in the lower uterine segment.
Causes
Signs and Symptoms
Therapeutic Management
Nursing Considerations
Check Your Reading
Uterine Inversion
Causes
Signs and Symptoms
Management
Nursing Considerations
Anaphylactoid Syndrome
Trauma
Management
Nursing Considerations
Check Your Reading
Application of the Nursing Process Intrapartum Emergencies
Assessment
Nursing Diagnosis
Planning
Interventions
Evaluation
Summary Concepts
Box 27-1
Nursing Diagnoses to Consider When Caring for Women with Intrapartum Complications
References & Readings
Pageburst Integrated Resource
Animations
Case Studies
Glossary
Key Points
Chapter 28 Postpartum Maternal Complications
Objectives
Postpartum Hemorrhage
Early Postpartum Hemorrhage
Uterine Atony
Predisposing Factors.
Clinical Manifestations.
FIG 28-1 A, When the uterus remains contracted, the placental site is smaller, so bleeding is minimal. B, If uterine muscles fail to contract around the endometrial arteries at the placental site, hemorrhage occurs.
Box 28-1
Common Predisposing Factors for Postpartum Hemorrhage
Therapeutic Management.
Drug Guide
Methylergonovine (Methergine)
Classification:
Action:
Indications:
Dosage and Route:
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions:
Nursing Considerations:
Drug Guide
Carboprost Tromethamine (Hemabate, Prostin/15M)
Classification:
Action:
Indications:
Dosage and Route:
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions and Side Effects:
Nursing Considerations:
FIG 28-2 Technique for fundal massage.
FIG 28-3 Bimanual compression. One hand is inserted in the vagina, and the other compresses the uterus through the abdominal wall.
FIG 28-4 A vulvar hematoma is caused by rapid bleeding into soft tissue, and it causes severe pain and feelings of pressure.
Trauma
Predisposing Factors.
Lacerations.
Hematomas.
Therapeutic Management.
Late Postpartum Hemorrhage
Predisposing Factors
Therapeutic Management
Check Your Reading
Hypovolemic Shock
Pathophysiology
Clinical Manifestation
Therapeutic Management
Nursing Considerations
Immediate Care
Safety Alert
Application of the Nursing Process The Woman with Excessive Bleeding
Assessment
Uterine Atony
Safety Alert
Trauma
Nursing Diagnosis
Planning
TABLE 28-1 NURSING ASSESSMENTS FOR POSTPARTUM HEMORRHAGE
Interventions
Preventing Hemorrhage
Collaborating with the Health Care Provider
Providing Support for the Family
Posthemorrhage Care
Home Care
Evaluation
Critical Thinking Exercise 28-1
Questions
Subinvolution of the Uterus
Therapeutic Management
Nursing Considerations
Check Your Reading
Thromboembolic Disorders
Incidence and Etiology
Venous Stasis
FIG 28-5 The venous system of the leg is affected when deep venous thrombosis occurs.
Hypercoagulation
Blood Vessel Injury
Box 28-2
Factors That Increase the Risk of Thrombosis
Superficial Venous Thrombosis
Clinical Manifestations
Therapeutic Management
Deep Venous Thrombosis
Diagnosis
Therapeutic Management
Preventing Thrombus Formation.
Initial Treatment.
Subsequent Treatment.
Check Your Reading
Women Want to Know
How Do I Prevent Thrombosis (Blood Clots)?
Application of the Nursing Process The Mother with Deep Venous Thrombosis
Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions
Monitoring for Signs of Bleeding
Explaining Continued Therapy
Helping the Family Adapt to Home Care
Evaluation
Pulmonary Embolism
Pathophysiology
Clinical Manifestations
Therapeutic Management
Nursing Considerations
Monitoring for Signs.
Facilitating Oxygenation.
Seeking Assistance.
Check Your Reading
Puerperal Infection
Definition
Effect of Normal Anatomy and Physiology on Infection
TABLE 28-2 RISK FACTORS FOR PUERPERAL INFECTION
Other Risk Factors
Check Your Reading
Specific Infections
Endometritis
Incidence and Etiology.
Clinical Manifestations.
Therapeutic Management.
Complications.
FIG 28-6 Areas of spread of uterine infection.
Nursing Considerations.
Wound Infection
Clinical Manifestations.
Therapeutic Management.
Nursing Considerations.
Check Your Reading
Urinary Tract Infections
Etiology.
Clinical Manifestations.
Therapeutic Management.
Nursing Considerations.
Mastitis
Incidence and Etiology.
Clinical Manifestations.
Therapeutic Management.
Nursing Considerations.
Septic Pelvic Thrombophlebitis
Incidence and Etiology.
Clinical Manifestations.
FIG 28-7 Mastitis typically occurs after 2 to 3 weeks following birth in the breast of a woman who breastfeeds.
Therapeutic Management.
Application of the Nursing Process Infection
Assessment
Nursing Diagnosis
Planning
Safety Alert
Interventions
Preventing Infection
Promoting Hygiene.
Preventing Urinary Stasis.
Teaching Breastfeeding Techniques.
Providing Information.
Nursing Care Plan 28-1
Postpartum Infection
Assessment:
Critical Thinking:
Answer:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Teaching Signs and Symptoms That Should Be Reported
Evaluation
Check Your Reading
Affective Disorders
Postpartum Mood Disorders
Postpartum Depression
Incidence.
Predictors of Postpartum Depression.
Clinical Manifestations.
Safety Alert
Impact on the Family.
Box 28-3
Risk Factors for Postpartum Depression
Therapeutic Management.
Postpartum Psychosis
Bipolar II Disorder
Postpartum Anxiety Disorders
Evidence-Based Practice
Questions
Cultural Aspects
Critical Thinking Exercise 28-2
Questions
Application of the Nursing Process Postpartum Affective Disorders
Assessment
Nursing Diagnosis
Box 28-4
Common Nursing Diagnoses for the Woman with a Postpartum Complication
Planning
Interventions
Providing Anticipatory Guidance
Demonstrating Caring
Helping the Mother Verbalize Feelings
Enhancing Sensitivity to Infant Cues
Helping Family Members
Providing Help
Discussing Options and Resources
Evaluation
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 29 High-Risk Newborn: Complications Associated with Gestational Age and Development
Objectives
Care of High-Risk Newborns
Multidisciplinary Approach
Late Preterm Infants
Incidence and Etiology
FIG 29-1 The infant in a neonatal intensive care unit is cared for by nurses with highly specialized skills.
Characteristics of Late Preterm Infants
Therapeutic Management
Nursing Considerations
Assessment and Care of Common Problems
Thermoregulation.
Feedings.
Discharge.
Preterm Infants
Incidence and Etiology
Scope of Problem
Causes
Prevention
Characteristics of Preterm Infants
Appearance
Behavior
Assessment and Care of Common Problems
Problems with Respiration
Assessment.
Nursing Interventions.
Working with Respiratory Equipment.
FIG 29-2 The oxygen hood is one way of delivering oxygen to an infant who can breathe unassisted.
Positioning the Infant.
Suctioning Secretions.
Maintaining Hydration.
Check Your Reading
Problems with Thermoregulation
Assessment.
FIG 29-3 This preterm infant has mildly mottled skin and slight abdominal distention and retractions.
Critical to Remember
Signs of Inadequate Thermoregulation
Nursing Interventions.
Maintaining a Neutral Thermal Environment.
Weaning to an Open Crib.
Problems with Fluid and Electrolyte Balance
Assessment.
Urine Output.
Weight.
Signs of Dehydration or Overhydration.
Critical to Remember
Signs of Fluid Imbalance in the Newborn
Dehydration
Overhydration
Nursing Interventions.
Problems with the Skin
Assessment.
Nursing Interventions.
Problems with Infection
Assessment.
Nursing Interventions.
Problems with Pain
Assessment.
Critical to Remember
Common Signs of Pain in Infants
Nursing Interventions.
Check Your Reading
Application of the Nursing Process The Preterm Infant
Case Study 29-1
Introduction*
Environmentally Caused Stress
Assessment
Critical to Remember
Signs of Overstimulation in Preterm Infants
Oxygenation Changes
Behavior Changes
Nursing Diagnosis
Expected Outcomes
Interventions
Scheduling Care
Reducing Stimuli
Promoting Rest
Promoting Motor Development
Individualizing Care
Communicating Infants’ Needs
Evaluation
Case Study 29-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Critical Thinking:
Answer:
Evaluation:
Nutrition
Assessment
Feeding Tolerance
Readiness for Nipple Feeding
Case Study 29-1
Critical Thinking Exercise*
Nursing Diagnosis
Expected Outcomes
Interventions
Administering Parenteral Nutrition
Administering Enteral Feedings
Administering Gavage Feedings
Administering Oral Feedings
Preparing for Feedings.
FIG 29-4 The nurse feeds a preterm infant.
Procedure 29-1
Administering Gavage Feeding
Critical to Remember
Nipple Feedings
Signs of Readiness for Nipple Feedings
Signs of Nonreadiness for Nipple Feedings
Adverse Signs during Nipple Feedings
Choosing a Nipple.
Case Study 29-1
Nursing Care Plan*
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Facilitating Breastfeeding
Box 29-1
Common Nursing Diagnoses for Preterm Infants
Making Ongoing Assessments
Evaluation
Check Your Reading
Parenting
Assessment
Critical to Remember
Signs That Bonding May Be Delayed
Nursing Diagnosis
Expected Outcomes
Interventions
Making Advance Preparations
Evidence-Based Practice
A Nurse-led Intervention for Maternal Stress
Assisting Parents after Birth
FIG 29-5 An infant in the neonatal intensive care unit is surrounded by highly technologic equipment. This can be very frightening to parents at first. Preparation of parents before they visit is an important nursing responsibility.
Supporting Parents during Early Visits
Therapeutic Communications
Reassuring Parents during Visits to the NICU
Box 29-2
Introducing Parents to the NICU Setting
Before Parents Visit the NICU
When Parents Visit the NICU
Supporting the Father
Providing Information
Critical Thinking Exercise 29-1
Questions
Instituting Kangaroo Care
FIG 29-6 This mother has her 27-week-gestation preterm infant tucked under her clothes against her skin as she gives kangaroo care. Such care enhances bonding and has many other benefits for infants and parents.
Facilitating Interaction
FIG 29-7 Even though he is intubated, this 1 lb, 8 oz preterm infant goes to sleep against his father’s chest.
FIG 29-8 To promote family bonding with the infant, parents are involved as much as possible in the care of their infant. This father bottle feeds his infant who is in a radiant warmer.
Increasing Parental Decision Making
Alleviating Concerns
FIG 29-9 The parents look on while the grandmother holds the infant in the neonatal intensive care unit.
Helping with Ongoing Problems
Preparing for Discharge
Evaluation
Case Study 29-1
Critical Thinking Exercise*
Question:
Check Your Reading
Common Complications of Preterm Infants
Respiratory Distress Syndrome
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Bronchopulmonary Dysplasia (Chronic Lung Disease)
Pathophysiology
Manifestations
Therapeutic Management
Intraventricular Hemorrhage
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Retinopathy of Prematurity
Pathophysiology
Therapeutic Management
Nursing Considerations
Necrotizing Enterocolitis
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Short Bowel Syndrome
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Postterm Infants
Scope of the Problem
Assessment
FIG 29-10 The postmature infant has no vernix and dry, cracked, peeling skin.
Therapeutic Management
Nursing Considerations
Small-for-Gestational-Age Infants
Causes
Scope of the Problem
Characteristics of Small-for-Gestational-Age Infants
Therapeutic Management
Nursing Considerations
Large-for-Gestational-Age Infants
Causes
Scope of the Problem
Therapeutic Management
Nursing Considerations
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 30 High-Risk Newborn: Acquired and Congenital Conditions
Objectives
Respiratory Complications
Asphyxia
Box 30-1
Common Nursing Diagnoses for Families of Newborns with Complications
Manifestations
Infants at Risk
Drug Guide
Naloxone Hydrochloride (Narcan)
Classification:
Action:
Indications:
Dosage and Route:
Absorption:
Excretion:
Contraindications and Precautions:
Nursing Considerations:
Neonatal Resuscitation
Transient Tachypnea of the Newborn (Retained Lung Fluid)
Cause
Manifestations
Therapeutic Management
Nursing Considerations
Check Your Reading
Meconium Aspiration Syndrome
Causes
Manifestations
Therapeutic Management
Procedure 30-1
Performing Resuscitation in the Newborn
Nursing Considerations
Persistent Pulmonary Hypertension of the Newborn
Causes
Manifestations
Therapeutic Management
Nursing Considerations
FIG 30-1 Flow chart showing the effects of meconium aspiration syndrome.
Check Your Reading
Hyperbilirubinemia (Pathologic Jaundice)
Causes
Therapeutic Management
Phototherapy
FIG 30-2 An infant receiving phototherapy is wearing eye patches to protect the eyes.
Exchange Transfusions
Procedure.
Complications.
Role of the Nurse.
Application of the Nursing Process Hyperbilirubinemia
Nursing Care Plan
The Infant with Jaundice
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions AND Rationales
Evaluation:
Assessment:
Nursing Diagnosis:
Expected Outcome:
Interventions and Rationales
Evaluation:
Assessment
Nursing Diagnosis
Expected Outcomes
Interventions
Maintaining a Neutral Thermal Environment
Providing Optimal Nutrition
Protecting the Eyes
Critical Thinking Exercise 30-1
Enhancing Response to Therapy
Detecting Complications
Teaching Parents
Evaluation
Check Your Reading
Infection
Transmission of Infection
Sepsis Neonatorum
TABLE 30-1 COMMON INFECTIONS IN THE NEWBORN*
Causes
Therapeutic Management
Diagnostic Testing.
Treatment.
Nursing Considerations
Assessment
Risk Factors.
Signs of Infection.
Critical to Remember
Signs of Sepsis in the Newborn
General Signs
Respiratory Signs
Cardiovascular Signs
Gastrointestinal Signs
Neurologic Signs
Signs That May Indicate Advanced Infection
Nursing Interventions
Preventing Infection.
Providing Antibiotics.
Providing Other Supportive Care.
Supporting Parents.
Infant of a Diabetic Mother
Scope of the Problem
FIG 30-3 Macrosomia is common in infants of mothers with diabetes.
Characteristics of Infants of Diabetic Mothers
Therapeutic Management
Nursing Considerations
Assessment
Nursing Interventions
Check Your Reading
Polycythemia
Causes
Manifestations
Therapeutic Management
Nursing Considerations
Hypocalcemia
Causes
Manifestations
Therapeutic Management
Nursing Considerations
Prenatal Drug Exposure
Identification of Drug-Exposed Infants
Therapeutic Management
Critical to Remember
Signs of Intrauterine Drug Exposure*
Behavioral Signs
Signs Relating to Feeding
Respiratory Signs
Other Signs
Procedure 30-2
Applying a Pediatric Urine Collection Bag
Nursing Considerations
Feeding
Assessment.
Nursing Interventions.
Rest
Assessment.
Nursing Interventions.
Bonding
Assessment.
Nursing Interventions.
Parents Want to Know
Measures to Prevent Frantic Crying in a Drug-Exposed Infant
Check Your Reading
Phenylketonuria
Causes
Manifestations
Therapeutic Management
Nursing Considerations
Congenital Anomalies
Nursing Care Plan
The Drug-Exposed Infant
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Assessment:
Nursing Diagnosis:
Expected Outcomes:
Interventions and Rationales
Evaluation:
Box 30-2
Common Congenital Anomalies
Gastrointestinal Tract
Cleft Lip and Palate
Assessment
Therapeutic Management
Nursing Considerations
Esophageal Atresia and Tracheoesophageal Fistula
Assessment
Therapeutic Management
Nursing Considerations
Omphalocele and Gastroschisis
Assessment
Therapeutic Management
Nursing Considerations
Diaphragmatic Hernia
Assessment
Therapeutic Management
Nursing Considerations
Central Nervous System
Neural Tube Defects
Assessment
Therapeutic Management
Nursing Considerations
Congenital Hydrocephalus
Assessment
Therapeutic Management
Nursing Considerations
Congenital Cardiac Defects
Classification of Cardiac Defects
Acyanotic Defects
Cyanotic Defects
FIG 30-4 Common Congenital Heart Defects. A, Ventricular septal defect. B, Patent ductus arteriosus. C, Coarctation of the aorta. D, Tetralogy of Fallot. E, Transposition of the great arteries.
Left-to-Right Shunting Defects
Defects with Obstruction of Blood Outflow
Defects with Decreased Pulmonary Blood Flow
Cyanotic Defects with Increased Pulmonary Blood Flow
Manifestations
Cyanosis
Heart Murmurs
Tachycardia and Tachypnea
Other Signs
Critical to Remember
Common Signs of Cardiac Anomalies
Therapeutic Management
Nursing Considerations
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Part VI Women’s Health Care
Interactive Review – Part VI
Chapter 31 Family Planning
Objectives
Information About Contraception
Common Sources
Role of the Nurse
Considerations When Choosing a Contraceptive Method
FIG 31-1 Success of contraception is more likely when both the woman and her partner are involved in discussions. The nurse demonstrates filling a foam applicator.
Safety
Protection from Sexually Transmitted Diseases
Effectiveness
TABLE 31-1 ADVANTAGES AND DISADVANTAGES OF THE MOST COMMON CONTRACEPTIVE METHODS
Acceptability
TABLE 31-2 DISCONTINUATION OF VARIOUS TYPES OF CONTRACEPTION
Convenience
Education Needed
TABLE 31-3 COMPARISON OF PREGNANCY RATES AMONG COMMON CONTRACEPTIVE METHODS
Benefits
Side Effects
Effect on Spontaneity
Availability
Expense
Preference
Religious and Personal Beliefs
Culture
Other Considerations
Informed Consent
Check Your Reading
Adolescents and Contraception
Adolescent Knowledge
Misinformation
Risk-Taking Behavior
Counseling Adolescents
FIG 31-2 Although many adolescents choose oral contraceptives, the nurse emphasizes the need to use condoms for protection against sexually transmitted diseases. Demonstrating with actual contraceptives increases understanding.
Critical Thinking Exercise 31-1
Questions
Contraception Use in Perimenopausal Women
Check Your Reading
Methods of Contraception
Sterilization
Tubal Sterilization
Vasectomy
FIG 31-3 The Copper T 380A (ParaGard) intrauterine device (IUD) and the levonorgestrel intrauterine system (LNG-IUS or Mirena). Currently, IUDs are considered a very safe method for preventing pregnancy.
Intrauterine Devices
Action
Side Effects
Teaching
Check Your Reading
Hormonal Contraceptives
Hormone Implant
Hormone Injections
Oral Contraceptives
Combination OCs.
Progestin Only.
Benefits, Risks, and Cautions.
Critical to Remember
Cautions in Using Combined Oral Contraceptives
TABLE 31-4 POTENTIAL BENEFITS, DISADVANTAGES, AND RISKS OF ORAL CONTRACEPTIVES
Side Effects.
Teaching.
Blood Hormone Levels.
Missed Doses.
Women Want to Know
What to Do If an Oral Contraceptive Dose Is Missed
General
Combined Oral Contraceptives
One Missed Pill
Two or More Missed Pills in the First 2 Weeks
Two Missed Pills in the Last Week of Active Pills
Postpartum and Lactation.
Other Medications.
Follow-Up.
Emergency Contraception
TABLE 31-5 ACHES:* WARNING SIGNS OF ORAL CONTRACEPTIVE COMPLICATIONS
Transdermal Contraceptive Patch
Contraceptive Vaginal Ring
FIG 31-4 The vaginal contraceptive ring (NuvaRing) is 5 cm (2 inches) across and 4 mm thick.
Check Your Reading
Barrier Methods
Chemical Barriers
Mechanical Barriers
Male Condom.
Couples Want to Know
What Is the Proper Way to Use Male Condoms?
Female Condom.
Sponge.
FIG 31-5 The Female Condom. A woman can protect herself from sexually transmitted diseases without relying on use of the male condom.
Diaphragm.
Women Want to Know
How to Use a Diaphragm
Cervical Cap.
Natural Family Planning Methods
TABLE 31-6 NATURAL FAMILY PLANNING METHODS
Calendar
Standard Days Method
Cervical Mucus
Women Want to Know
How to Assess Cervical Mucus and Basal Body Temperature
Cervical Mucus Assessment
Basal Body Temperature
Two-Day Method
Symptothermal Method
Check Your Reading
Abstinence
Least Reliable Methods of Contraception
Breastfeeding
Coitus Interruptus
Application of the Nursing ProcessChoosing a Contraceptive Method
Assessment
Introducing the Subject
Determining the Woman’s Understanding
Assessing the Woman’s Satisfaction
Assessing Appropriate Choices
Nursing Diagnosis
Expected Outcomes
Interventions
Increasing Understanding of the Chosen Method
Teaching about Other Methods
Protecting against Sexually Transmitted Diseases
Including the Woman’s Partner
Providing Ongoing Teaching
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 32 Infertility
Objectives
Extent of Infertility
Factors Contributing to Infertility
Factors in the Man
Abnormalities of the Sperm
FIG 32-1 Abnormal infertile sperm compared with a normal sperm on the left.
Abnormal Erections
Abnormal Ejaculation
Abnormalities of Seminal Fluid
TABLE 32-1 SELECTED DIAGNOSTIC TESTS ON INFERTILITY
Check Your Reading
Factors in the Woman
Disorders of Ovulation
Abnormalities of the Fallopian Tubes
FIG 32-2 A radiographic hysterosalpingogram (HSG) evaluates patency of fallopian tubes. Contrast medium that was injected through the cervix spills out of the fallopian tubes into the peritoneal cavity if tubes are open. Sonohysterographic technique with ultrasound is becoming more common and uses contrast medium with hypoechoic effects.
Abnormalities of the Cervix
Check Your Reading
Repeated Pregnancy Loss
Abnormalities of the Fetal Chromosomes
FIG 32-3 Types of uterine malformations that may cause infertility or repeated pregnancy loss.
Abnormalities of the Cervix or Uterus
Endocrine Abnormalities
Immunologic Factors
Environmental Agents
Infections
Check Your Reading
Evaluation of Infertility
Preconception Counseling
History and Physical Examination
History
Physical Examination
Diagnostic Tests
Infertile Couples Want to Know
What Is Infertility Treatment Like?
General
Men
Women
Therapies to Facilitate Pregnancy
TABLE 32-2 SELECTED MEDICATIONS USED IN INFERTILITY THERAPY
Medications
Drug Guide
Clomiphene Citrate (Clomid, Serophene)
Classification:
Action:
Indications:
Dosage and Route:
Absorption:
Excretion:
Contraindications and Precautions:
Adverse Reactions:
Nursing Considerations:
Surgical Procedures
Therapeutic Insemination
Egg Donation
Surrogate Parenting
Assisted Reproductive Technologies
In Vitro Fertilization
FIG 32-4 In vitro fertilization. Multiple oocytes are obtained by using a transvaginal or laparoscopic approach. The retrieved oocytes are mixed with prepared sperm and incubated 1 to 2 days. Embryos are then transferred to the uterine cavity to allow implantation and continued development.
Gamete Intrafallopian Transfer
Zygote Intrafallopian Transfer
Comparison of In Vitro Fertilization, Gamete Intrafallopian Transfer, and Tubal Embryo Transfer
FIG 32-5 Gamete intrafallopian transfer (GIFT). Multiple ova aspirated from the ovary in this illustration are combined with washed sperm. The mixture of ova and sperm is then transferred directly to a fallopian tube.
Intracytoplasmic Sperm Injection (ICSI)
Preimplantation Genetic Testing
Check Your Reading
Responses to Infertility
Assumption of Fertility
Growing Awareness of a Problem
Seeking Help for Infertility
Identifying the Importance of Having a Baby
Sharing Intimate Information
Considering Financial Resources
Committing to Involvement in Care
Reactions during Evaluation and Treatment
Influences on Decision Making
Social, Cultural, and Religious Values.
Difficulty of Treatment.
Probability of Success.
Financial Concerns.
Psychological Reactions
Guilt.
Isolation.
Depression.
Stress on the Relationship.
Check Your Reading
Outcomes after Infertility Therapy
Pregnancy Loss after Infertility Therapy
Parenthood after Infertility Therapy
Choosing to Adopt
Menopause after Infertility
Check Your Reading
Application of the Nursing ProcessCare of the Infertile Couple
Assessment
Nursing Diagnosis
Planning
Interventions
Assist Communication
Increase the Couple’s Sense of Control
Reduce Isolation
Promote a Positive Self-Image
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Glossary
Key Points
Chapter 33 Preventive Care for Women
Objectives
National Emphasis on Women’s Health
Healthy People 2020 Goals
Health Maintenance
Health History
Box 33-1
Health History
Personal History
Menstrual History
Obstetric History
Sexual History
Family History
Psychosocial History
Check Your Reading
Physical Assessment
Preventive Counseling
Box 33-2
Risk Factors for Breast Cancer
Screening Procedures
Women Want to Know
How to Perform Breast Self-Examination and Become Aware
Breast Self-Awareness and Breast Self-Examination
Clinical Breast Examination
Inspection
Palpation
Mammography
Vulvar Self-Examination
Pelvic Examination
External Organs.
Box 33-3
Female Genital Mutilation (FGM)
Speculum Examination.
FIG 33-1 Bimanual palpation provides information about the uterus, fallopian tubes, and ovaries.
Bimanual Examination.
Cervical Cytology or Pap Test
Purpose.
Procedure.
Classification of Cervical Cytology.
Rectal Examination
Box 33-4
Risk Factors for Coronary Artery Disease in Women
Screening Tests
TABLE 33-1 SCREENING PROCEDURES
Immunizations
Drug Guide
Human Papillomavirus Quadrivalent Vaccine (Gardasil)
Classification:
Indications:
Dosage and Route:
Contraindications:
Adverse Reactions:
Nursing Considerations:
Check Your Reading
Application of the Nursing ProcessPromoting Health
Assessment
Nursing Diagnosis
Planning
Interventions
Reinforce the Woman’s Desire for Change
Identify Food Preferences
Financial Assistance
Activity
Evaluation
Summary Concepts
References & Readings
Pageburst Integrated Resource
Case Studies
Glossary
Key Points
Nursing Skills
Chapter 34 Women’s Health Problems
Objectives
Breast Disorders
Diagnostic Evaluation
Benign Disorders of the Breast
Fibrocystic Breast Changes
Fibroadenoma
Box 34-1
Complementary/Alternative Therapy for Breast Pain
Ductal Ectasia
Intraductal Papilloma
Nursing Considerations
Check Your Reading
Malignant Tumors of the Breast
Incidence
Risk Factors
Pathophysiology
Staging
Management
Surgical Treatment.
Adjuvant Therapy.
Radiation Therapy.
Chemotherapy.
Hormone Therapy.
Immunotherapy.
Breast Reconstruction
Timing.
Methods.
Psychosocial Consequences of Breast Cancer
Nursing Considerations
Check Your Reading
Cardiovascular Disease
Recognition of Coronary Artery Disease
Evidence-Based Practice
Cardiovascular Disease: A Woman’s Number One Killer
Risk Factors
Prevention
Women Want to Know
How to Reduce the Risk for Coronary Artery Disease
Hypertension
Smoking Cessation
Diet and Glucose Control
Increased Activity
Aspirin
Check Your Reading
Menstrual Cycle Disorders
Amenorrhea
Primary Amenorrhea
Secondary Amenorrhea
Nursing Considerations
Abnormal Uterine Bleeding
Etiology
Management
Nursing Considerations
Check Your Reading
Cyclic Pelvic Pain
Mittelschmerz
Primary Dysmenorrhea
Endometriosis
Pathophysiology
FIG 34-1 Common sites of endometriosis.
Signs and Symptoms
Management
Nursing Considerations
Box 34-2
Pain Relief for Premenstrual Syndrome
Check Your Reading
Premenstrual Syndrome (PMS)
Etiology
Impact on Family
Box 34-3
Symptoms of Premenstrual Syndrome
Physical Symptoms
Behavioral Symptoms
Management
Women Want to Know
How to Relieve Symptoms of Premenstrual Syndrome
Diet
Exercise
Stress Management
Sleep and Rest
Nursing Considerations
Box 34-4
Complementary/Alternative Therapy for Premenstrual Syndrome
Elective Termination of Pregnancy
Methods of Elective Termination of Pregnancy
Nursing Considerations
Women Want to Know
Guidelines for Self-Care after Elective Termination of Pregnancy
Check Your Reading
Menopause
Age of Menopause
Physiologic Changes
Psychological Responses
Therapy for Menopause
Women Want to Know
About Hormone Replacement Therapy
Risks
Box 34-5
Contraindications and Cautions Related to Estrogen Replacement Therapy
Nursing Considerations
Box 34-6
Complementary/Alternative Therapy for Menopause
Check Your Reading
Osteoporosis
Risk Factors
Signs and Symptoms
FIG 34-2 With progression of osteoporosis, the vertebral column collapses, causing loss of height and back pain. Dowager’s hump is the term used for this curvature of the upper back.
Prevention and Medical Management
Drug Therapy.
Calcium and Vitamin D.
Exercise.
Nursing Considerations
Nursing Diagnoses
Check Your Reading
Pelvic Floor Dysfunction
Vaginal Wall Prolapse
Cystocele
Enterocele
FIG 34-3 Three types of vaginal wall prolapse. A, Note bulging of bladder into the vagina. B, Note loop of bowel between rectum and uterus. C, Note bulging of rectum into vagina.
Rectocele
FIG 34-4 Three degrees of uterine prolapse.
Uterine Prolapse
Symptoms
Management
Nursing Considerations
Pelvic Exercises.
Urinary Incontinence.
Check Your Reading
Disorders of the Reproductive Tract
Benign Disorders
Cervical Polyps
FIG 34-5 Sites within the uterus where fibroids commonly occur.
Uterine Leiomyomas
Ovarian Cysts
Malignant Disorders
Critical to Remember
Symptoms That Should Always Be Investigated
Signs and Symptoms
Risk Factors
Diagnosis
Box 34-7
Risk Factors for Cancer of the Reproductive Organs
Uterus
Cervix
Ovaries
Management
Cervical Cancer.
Endometrial Cancer.
Ovarian Cancer.
Check Your Reading
Infectious Disorders of the Reproductive Tract
Candidiasis
Sexually Transmitted Diseases
Incidence
Types of Sexually Transmitted Diseases
Trichomoniasis.
Bacterial Vaginosis.
Chlamydial Infection.
Gonorrhea.
Syphilis.
Herpes Genitalis.
Human Papillomavirus (HPV).
FIG 34-6 Condylomata acuminata, also called venereal or genital warts, are caused by the human papillomavirus (HPV).
Acquired Immunodeficiency Syndrome.
Nursing Considerations
Women Want to Know
About Sexually Transmitted Diseases
Check Your Reading
Pelvic Inflammatory Disease
Etiology
Symptoms
Management
Nursing Considerations
Toxic Shock Syndrome
Check Your Reading
Summary Concepts
References & Readings
Pageburst Integrated Resource
Animations
Case Studies
Glossary
Key Points
Appendixes
Appendix A Use of Drug and Botanical Preparations during Pregnancy and Breastfeeding
FDA Pregnancy Risk Categories
Drug Use during Lactation
HERBAL AND BOTANICAL PREPARATIONS
References
Appendix B Keys to Clinical Practice: Components of Daily Care
Intrapartum Care
Text to Prepare You for Clinical Practice
New Terms
Equipment and Supplies
Normal Assessments
Fetus
Gestation.
Fetal Heart Rate (FHR).
Amniotic Fluid.
Woman
Temperature.
Blood Pressure.
Pulse Rate.
Respirations.
Contractions.
Bloody Show.
Lochia (Fourth Stage).
Fundus (Fourth Stage).
Nursing Care
Assessments
Interventions
Postpartum Care: Physiologic Aspects
Text to Prepare You for Clinical Practice
New Terms
Equipment and Supplies
Normal Assessments
Vital Signs
Temperature.
Blood Pressure.
Pulse Rate.
Respirations.
Breasts
Gastrointestinal System
Genitourinary System
Nursing Care
Assessments
Interventions
Postpartum Care: Psychosocial Aspects
Text to Prepare You for Clinical Practice
New Terms
Normal Assessments
Maternal Touch.
Verbal Expressions.
Taking-In Phase.
Taking-Hold Phase.
Letting-Go Phase.
Fathers.
Family.
Nursing Care
Assessments
Interventions
The Newborn: Initial Assessments and Care
Text to Prepare You for Clinical Practice
New Terms
Equipment and Supplies
Normal Assessments
Vital Signs
Temperature.
Heart rate.
Respirations.
Blood Glucose
Measurements
Weight.
Length.
Head Circumference.
Chest Circumference.
Nursing Care
Assessments
Interventions
The Newborn: Continued Care
Text to Prepare You for Clinical Practice
New Terms
Equipment and Supplies
Normal Assessments
Vital Signs
Temperature.
Heart Rate.
Respirations.
Blood Glucose
Nursing Care
Assessments
Interventions
Assisting the Inexperienced Breastfeeding Mother
Text to Prepare You for Clinical Practice
New Terms
Normal Assessments
Nursing Care
Assessments
Interventions
Appendix C Answers to Check Your Reading
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Appendix D Answers to Critical Thinking Exercises
Chapter 3
Critical Thinking Exercise 3-1
Chapter 7
Case Study 7-1, Introduction, Critical Thinking Exercise
Case Study 7-1, Critical Thinking Exercise
Chapter 8
Critical Thinking Exercise 8-1
Chapter 9
Case Study 9-1, Introduction, Critical Thinking Exercise
Critical Thinking Exercise 9-1
Chapter 11
Case Study 11-1, Introduction, Critical Thinking Exercise
Critical Thinking Exercise 11-1
Chapter 12
Critical Thinking Exercise 12-1
Critical Thinking Exercise 12-2
Chapter 13
Critical Thinking Exercise 13-1
Critical Thinking Exercise 13-2
Chapter 14
Critical Thinking Exercise 14-1
Critical Thinking Exercise 14-2
Chapter 16
Critical Thinking Exercise 16-1
Critical Thinking Exercise 16-2
Chapter 17
Case Study 17-1, Critical Thinking Exercise
Critical Thinking Exercise 17-1
Chapter 18
Critical Thinking Exercise 18-1
Chapter 19
Critical Thinking Exercise 19-1
Critical Thinking Exercise 19-2
Chapter 20
Critical Thinking Exercise 20-1
Critical Thinking Exercise 20-2
Chapter 21
Case Study 21-1, Critical Thinking Exercise
Case Study 21-1, Critical Thinking Exercise
Chapter 23
Critical Thinking Exercise 23-1
Chapter 24
Critical Thinking Exercise 24-1
Chapter 25
Critical Thinking Exercise 25-1
Critical Thinking Exercise 25-2
Chapter 26
Critical Thinking Exercise 26-1
Chapter 27
Critical Thinking Exercise 27-1
Chapter 28
Critical Thinking Exercise 28-1
Critical Thinking Exercise 28-2
Chapter 29
Critical Thinking Exercise 29-1
Case Study 29-1, Critical Thinking Exercise
Case Study 29-1, Critical Thinking Exercise
Chapter 30
Critical Thinking Exercise 30-1
Chapter 31
Critical Thinking Exercise 31-1
Glossary
Glossary
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
Specialty Maternal-Newborn Abbreviations
Specialty Maternal-Newborn Abbreviations

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