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Nursing Key Topics Review
Maternity
Table of Contents
Cover image
Title page
Copyright
Reviewers
Preface
1. Conception and fetal development
Conception
Embryo and fetus
Application and review
Nongenetic factors influencing development
Application and review
Answer key: Review questions
2. Anatomy and physiology of pregnancy
Gravidity and parity
Pregnancy tests
Adaptations to pregnancy
Application and review
Answer key: Review questions
3. Nursing care of the family during pregnancy
Preconception care
Patient teaching
Diagnosis of pregnancy
Adaptation to pregnancy
Application and review
Care management
Application and review
Application and review
Variations in prenatal care
Perinatal and childbirth education
Perinatal care choices
Answer key: Review questions
4. Maternal and fetal nutrition
Nutrient needs before conception
Nutrient needs during pregnancy
Application and review
Nutrient needs during lactation
Care management
Application and review
Answer key: Review questions
5. Assessment of high-risk pregnancy
Assessment of risk factors
Antepartum testing
Biophysical assessment
Biochemical assessment
Assessment and review
Antepartum assessment using electronic fetal monitoring
Psychologic considerations related to high-risk pregnancy
Nurses’ role in assessment and management of the high-risk pregnancy
Assessment and review
Answer key
6. High-risk complications of pregnancy
Hypertensive disorders
Application and review
Hemorrhagic disorders
Application and review
Endocrine and metabolic disorders
Application and review
Medical-surgical disorders
Application and review
Cancer
Surgical emergencies during pregnancy
Application and review
Trauma
Nursing care of pregnant women with special needs
Application and review
Answer key: Review questions
7. Mental health disorders and substance abuse
Mental health disorders during pregnancy
Application and review
Anxiety disorders
Application and review
Postpartum mood disorders
Application and review
Perinatal substance abuse
Application and review
Answer key: Review questions
8. Labor and birth processes
Factors affecting labor
Process of labor
Application and review
Answer key: Review questions
9. Maximizing comfort for the laboring woman
Pain during labor and birth
Factors influencing pain response
Application and review
Nonpharmacologic pain management
Application and review
Pharmacologic pain management
Care management
Application and review
Answer key: Review questions
10. Fetal assessment during labor
Basis for monitoring
Monitoring techniques
Application and review
Fetal heart rate patterns
Other methods of assessment and interventions
Client and family teaching
Documentation
Application and review
Answer key: Review questions
11. Nursing care of the family during labor and birth
First stage of labor
Application and review
Second stage of labor
Third stage of labor
Fourth stage of labor
Application and review
Answer key: Review questions
12. Labor and birth complications
Preterm labor and birth
Premature rupture of membranes
Chorioamnionitis
Postterm pregnancy, labor, and birth
Dysfunctional labor (dystocia)
Precipitous labor
Obesity
Application and review
Obstetric procedures
Obstetric emergencies
Application and review
Answer key: Review questions
13. Postpartum physiologic changes
Puerperium
Reproductive system and associated structures
Endocrine system
Breasts
Weight loss
Urinary system
Application and review
Cardiovascular system
Respiratory system
Gastrointestinal system
Neurologic system
Musculoskeletal system
Integumentary system
Immune system
Application and review
Answer key: Review questions
14. Nursing care of the family during the postpartum period
Transfer from the recovery area
Planning for discharge
Care management: Physical needs
Application and review
Care management: Psychosocial needs
Discharge teaching
Application and review
Answer key: Review questions
15. Transition to parenthood
Parental attachment, bonding, and acquaintance
Parent–infant contact
Communication between parent and infant
Parental role after birth
Diversity in transitions to parenthood
Parental sensory impairment
Sibling adaptation
Grandparent adaptation
Care management
Application and review
Answer key: Review questions
16. Postpartum complications
Postpartum hemorrhage
Application and review
Hemorrhagic (hypovolemic) shock
Application and review
Coagulopathies
Episiotomy
Application and review
Venous thromboembolic disorders
Postpartum infections
Maternal death
Answer key: Review questions
17. Nursing care of the newborn and family
Physiologic and behavioral adaptations of the newborn
Application and review
Care management: Birth through the first 2 hours
Application and review
Care management: From 2 hours after birth to discharge
Application and review
Answer key: Review questions
18. Newborn nutrition and feeding
Recommended infant nutrition
Choosing an infant feeding method
Application and review
Cultural influences on infant feeding
Nutrient needs
Anatomy and physiology of lactation
Supporting breastfeeding mothers and infants
Indicators of effective breastfeeding
Special considerations
Application and review
Answer key: Review questions
19. Newborn complications
Nursing care of high-risk newborns
Application and review
Acquired problems of newborns
Application and review
Hemolytic disorders
Application and review
Infants of diabetic mothers
Congenital anomalies
Application and review
Preterm infants
Late preterm infants
Postterm/postmature infants
Large-for-gestational-age infants
Answer key: Review questions
20. Perinatal loss, bereavement, and grief
Loss, grief, and bereavement: Basic concepts and theories
Types of loss associated with pregnancy
Miles’ model of parental grief responses
Family aspects of grief
When a loss is diagnosed: Helping the woman and her family in the aftermath
Nurses’ reactions to caring for grieving families
Application and review
Answer key: Review questions
Bibliography
Index
Copyright
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NURSING KEY TOPICS REVIEW: MATERNITY ISBN: 978-0-323-44494-1
Copyright © 2017 by Elsevier, Inc. All rights reserved.
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Reviewers
Melissa Bear, RN Staff Nurse, DePaul Hospital, St. Louis, Missouri
Michelle Bonnheim N ursing S tudent, California S tate University, Fresno,
Fresno, California
Crystal G allardo
California
CN A N ursing A ssistant , Cypress College, Cypress,
Carolyn M . Kruse, BS, D C Educational Consultant/O wner, Kruisin Editorial,
O’Fallon, Missouri
Katelynn Landers N ursing S tudent, Brockton Hospital S chool of N ursing,
Brockton, Massachusetts
A ngela Lanzoni N ursing S tudent, Brockton Hospital S chool of N ursing,
Brockton, Massachusetts
Reagan Lizardi Nursing Student, Polk State College, Lakeland, Florida
Michelle Lucke
Florida
N ursing S tudent, Polk S tate College, Winter Haven,
D awn Piacenza, A PRN , RN C-O B, C-EFT Clinical N urse S pecialist –
Obstetrics, Wesley Medical Center, Wichita, Kansas
Karla Psaros N ursing S tudent, Brockton Hospital S chool of N ursing,
Brockton, Massachusetts
Gina Rena Nursing Student, Polk State College, Lakeland, Florida
Cianna Simpson N ursing S tudent, Brockton Hospital S chool of N ursing,
Brockton, Massachusetts
Briana Sundlie Nursing Student, Cypress College, Cypress, California
D onna Wilsker, M SN , RN A ssistant Professor, D ishman D epartment of
Nursing, Lamar University, Beaumont, Texas
Preface
T he N ursing Key Topics Reviewbook series was developed and designed with
you, the nursing student, in mind. We know how difficult nursing school can
b e ! How do you focus your study? How can you learn in the most timeefficient way possible? Where do you go when you need help?
We asked YOU and this is what we learned:
• You think textbooks are useful, but they can be overwhelming
(also . . . heavy)
• You want quick and easy access to manageable levels of nursing
information
• You like questions and rationales to challenge you and make sure you
know what you need to know
N ursing Key Topics Reviewis your solution, whether you’re looking for a
textbook supplement or N CLEX® examination study aid.Review questions
interspersed throughout the text make it easy to test your knowledge. The
bulleted outline format allows for quick comprehension. A mobile app with
key points lets you take your review with you anywhere you go!
I n short, N ursing Key Topics Review helps you narrow down what’s
important and tells you what to focus on. Be sure to look for all the titles in
the series to make your studies more effective . . . and your journey a li le bit
lighter!
C H AP T E R 1
Conception and fetal development
Conception
Cell division
• Mitosis
• Cell division purposes
■ Growth of tissues and organs
■ Differentiation of tissues
■ Replacement of cells that have become less functional with age or
damage
■ Body cells replicate to make two daughter cells with the same
genetic material as the parent cell
○ First the cell replicates its DNA; then it divides the nucleus that
contains the DNA and the cell’s cytoplasm
○ Thus both new cells have a complete copy of the parent cell’s
DNA
• Meiosis
• Meiosis differs from mitosis
■ In meiosis the DNA of sperm or ova is divided in half
■ Each resulting cell has half the genetic material of the original cell
■ Resultant cells are termed haploid because they have half the usual
amount of genetic material
■ This is how half the genetic material of an individual human is
contributed by the father and half by the mother
Gametogenesis
• Gametes (ovum and spermatozoon) are formed by meiosis; each has one
set of 23 chromosomes; other body cells have two sets (46 chromosomes,
23 pairs)
• Oogenesis = the process of egg (ovum/oocyte) formation in the female
• Begins during fetal life in the female
• All ova that may undergo meiosis in a lifetime are contained in a girl’s
ovaries at birth
• Usually monthly, one oocyte matures and is released, called ovulation
• Spermatogenesis = the process of sperm (spermatocyte) formation in the
male
Fertilization
• The joining of the egg and sperm is fertilization, usually in the outer 1⁄3 of
the fallopian tube
• It occurs about 24 hours after ovulation when sperm enters the ovum
• The new cell contains 23 chromosomes from the sperm and 23
chromosomes from the ova
• The fertilized ovum is termed a zygote; the chromosome number is thus
restored to two sets (46 chromosomes)
• Cleavage: rapid mitotic cell division of zygote produces a morula (a ball of
16 cells) that divides to form a blastocyst (Fig. 1.1)
• Morula divides into trophoblast (which becomes the placenta and
chorion) and embryoblast (which becomes the embryon)
• The total structure of the developing embryo is called a blastocyst
FIG. 1.1 Stages of early embryonic development: from zygote to
blastocyst. Source: (From Herlihy, B. [2015]. The human body in health and illness [5th ed.].
Philadelphia: Saunders.)
Implantation
• Blastocyst implants in uterine wall 7 to 8 days after fertilization
• Chorionic villi extend into the endometrium
• Area of endometrium under the blastocyst becomes part of the placenta,
called the decidua basalis
Embryo and fetus
Primary germ layers (fig. 1.2)
• Each germ layer (ectoderm, mesoderm, endoderm) develops into different
tissues
• Ectoderm
• Epidermis (outermost layer of skin), hair, and nails; oil glands, entire
nervous system, eye lens, tooth enamel, floor of the amniotic cavity
• Mesoderm (meso, muscle)
• Dermis (main skin layer), skeleton, muscles, blood and blood vessels,
kidneys, and gonads
• Endoderm (endo, inside)
• Lining of the respiratory tract, lining of the digestive tract, and linings
of the bladder and urethra
FIG. 1.2 Primary germ layers and the tissues and body systems into which they
develop. Source: (From Patton, K.T. & Thibodeau, G.A. [2016]. Anatomy & physiology [9th ed.]. St.
Louis: Elsevier.)
Development of the embryo
• Genes
• Chromosomes: carry sets of matching genes (alleles); one may be
dominant, the other recessive, or have blending expressions
• Sex-linked genes: carried on X chromosome are always expressed in the
male, even if recessive (eg, hemophilia, color blindness)
• Multiple genes: may combine to produce cumulative effects (eg, degree
of pigmentation, height)
• Multiple alleles: influence human traits (eg, blood types, eye color)
• Sex determination in humans
• Females have two X chromosomes; males have one X and one Y
chromosome
• Ovum has one X chromosome; sperm have either an X or a Y
chromosome
• X-bearing sperm that fertilizes an ovum results in a female; Y-bearing
sperm that fertilizes an ovum results in a male
• Chromosomal alterations
• Abnormalities of the number of chromosomes
■ Most cases of Down syndrome (trisomy 21)
■ Additional sex chromosomes
■ Turner syndrome (monosomy X)
■ Klinefelter syndrome (trisomy XXY)
• Abnormalities of the structure of chromosomes
■ Translocation of chromosomes
■ Deletion of chromosomes
• Mutations
■ Changes in DNA: chromosomal changes
■ Risk factors: ultraviolet radiation, x-rays, radioactive radiation,
chemical substances
• Embryonic development
• Conceptus: embryo during first 2 months; fetus thereafter
• First 8 weeks: period of organogenesis (rapid growth and development
of organs)
■ Interference can cause irreparable fetal damage
■ Preconception counseling includes avoidance of alcohol, tobacco,
illegal, and over-the-counter drugs
• At 14 days: heart begins to beat; brain, early spinal cord, and muscle
segments present
• At 30 days: embryo ¼ to ½ inch (0.6–1.2 cm) in length, definite form,
umbilical cord becomes visible
• At 31 to 36 days: both arms and legs have digits but may be webbed; 46
to 48 days: cartilage in upper arms replaced by first bone cells
• At 6 weeks, the bones of the shoulders, arms, pelvis, and legs appear,
but no joints are yet formed; at 7 weeks, muscles contract
• End of 8 weeks: organ systems and external structures are recognizable
Membranes (fig. 1.3)
• Chorion
• Develops from trophoblast
• Envelops amnion, embryo, and yolk sac
• Thick membrane has projections called villi
• Villi extend into decidua basalis (endometrium under the blastocyst) on
uterine wall
■ Form the embryonic/fetal portion of placenta
• Amnion
• Develops from interior of blastocyst
• Thin structure that envelops and protects embryo
• Together, chorion and amnion form an amniotic sac filled with fluid
(bag of waters)
FIG. 1.3 The embryo in utero at approximately 7 weeks. Source: (From Leonard, P.C.
[2015]. Building a medical vocabulary [9th ed.]. St. Louis: Elsevier.)
Amniotic fluid
• Amniotic fluid is clear, has a mild odor, and may contain bits of vernix or
lanugo
• Volume of fluid steadily increases from ∼30 mL at 10 weeks to 350 mL at
20 weeks; at 37 weeks, fluid is ∼1000 mL (∼1 liter)
■ Oligohydramnios = less than 300 mL
■ Polyhydramnios (hydramnios) = more than 2 liters (2000 mL)
• Functions
• Maintains constant body temperature
• Source of oral fluid
• Repository for waste
• Assists in fluid and electrolyte homeostasis
• Permits buoyancy and movement for musculoskeletal development
• Barrier to infection
• Allows fetal lung development
• Usually prevents amniotic sac from adhering to fetal skin
• Acts as a cushion to protect the fetus and umbilical cord from injury
Yolk sac
• This cavity develops on the ninth day after fertilization
• Folding in of the embryo during the 4th week incorporates the yolk sac
into the embryo as the beginning digestive system
• Umbilical cord encompasses yolk sac, which then degenerates
• Functions
• Only during embryonic life
• Aids in transferring maternal nutrients and oxygen through the chorion
to the embryo
• Initiates production of red blood cells and plasma (during second and
third weeks) while uteroplacental circulation is being established
Umbilical cord
• Location: in central portion of placenta; attached to fetus
• Structures and functions
• One vein transports maternal nourishment from placenta to fetus; two
arteries transport fetal wastes to placenta
• Wharton jelly: protective covering surrounding cord
Placenta
• Structure
• Dual origin: maternal and embryonic
• Chorion: becomes major part of placenta; forms chorionic villi
(fingerlike projections growing into uterine endometrium)
• Organization and growth
■ Divides into 15 to 20 cotyledons, each a functional unit
■ Complete by 12 weeks, grows in diameter until 20 weeks, covering
about half the uterine surface; then thickens
• Function
• Provides circulation between mother and fetus; circulation in place by
day 17
• Serves as site for interchange of food, gases, and wastes between
mother and embryo/fetus
• Produces hormones
■ Progesterone maintains uterine lining for implantation of the zygote;
reduces uterine contractions to prevent spontaneous abortion;
prepares the glands of the breasts for lactation; stimulates testes to
produce testosterone, which aids the male fetus in developing the
reproductive tract
■ Estrogens stimulates uterine growth and development of the breast
ducts to prepare for lactation
■ Human chorionic gonadotropin (hCG) (the basis for pregnancy tests)
causes the corpus luteum to persist and continue production of
estrogen and progesterone to sustain pregnancy
■ Human chorionic somatomammotropin (hCS) (formerly known as
human placental lactogen [hPL]) helps make more glucose available to
fetus to meet growth needs
• Acts as a protective barrier against harmful effects of some drugs and
microorganisms
Fetal maturation
• Fetal development
• Stage of the fetus is from 9 weeks until pregnancy ends
• At 9 weeks: genitalia begin to differentiate; fully differentiated by 12
weeks
• At 12 weeks: moves, swallows, respiratory movements present; weighs
28 g (1 oz); fetal heart audible with Doptone (fetal heart rate [FHR] 110
to 160 beats/min); chorionic villi sampling at 10 to 12 weeks
• At 16 to 20 weeks: fetal movements felt by mother (quickening); weighs
170 g (6 oz); 20 to 25 cm (8 to 10 inches) in length; 200 mL of amniotic
fluid enables amniocentesis at 14 to 16 weeks; vernix and lanugo cover
and protect fetus
• At 20 to 24 weeks: hair growth on head, eyelashes, and brow; skeleton
hardens; eyelids closed; weighs 0.45 kg (1 lb); 30.5 cm (12 inches) in
length; respiratory movements become more regular
• At 24 to 28 weeks: eyelids open; amniotic fluid increases; weighs 0.5 kg
(1¼ lb); alveolar cells of lungs produce pulmonary surfactants that
minimize surface tension
• At 28 to 32 weeks: brown fat begins to deposit; weighs 0.5 to 0.7 kg (1 to
1½ lb)
• At 32 to 36 weeks: stores protein for extrauterine life; gains 1.8 kg (4 lb)
• At 36 to 40 weeks: lanugo disappears; vernix present, particularly
increases; nails extend; visible mammary glands; testes palpable in
scrotum; weighs 3 to 3.6 kg (6 lb, 10 oz to 7 lb, 15 oz) but varies; fullterm birth is 38 to 40 weeks.
• Fetal circulation
• Contains mixed blood with low oxygenation; 30% to 70% oxygen
saturation
• Foramen ovale: opening between right and left atria, bypasses fetal
lungs
• Ductus arteriosus: connection between pulmonary trunk and aorta,
bypasses fetal lungs
• Ductus venosus: connection between umbilical vein and ascending vena
cava, bypasses fetal liver
• Pattern of circulation (heart, head, neck, and arms receive most of the
oxygen-rich blood) enhances cephalocaudal (head-to-rump)
development of the embryo/fetus
• Viability
• The ability of fetus to survive outside the uterus, usually defined by
weight and pregnancy duration
• Common definition is 22 weeks’ gestation (20 since last menstrual
period [LMP]); birthweight from 350 to 500 grams, but definition varies
by state
• Infant requires neonatal intensive care unit (NICU) to survive
Multifetal pregnancy
• Twins occur once in every 43 births (monozygotic only 3 to 4 per 1000)
• More frequently, when hormones are used to assist with ovulation,
twinning and other multifetal pregnancies occur
• Dizygotic twins
■ When two mature ova are produced in one ovarian cycle, both can be
fertilized by different sperm
■ Dizygotic twins are from two separate fertilized ova (fraternal)
■ Result is two zygotes, two amnions, two chorions, two placentas
(placentas may be fused)
■ Can be same or different gender
■ Genetically like siblings (same father and mother, but not identical)
■ Increased incidence up to maternal age 35 years, with parity and with
fertility drugs
• Monozygotic twins
■ Develop from a single fertilized ovum (identical)
■ Then fertilized ovum divides
■ Most often division occurs 4 to 8 days after fertilization, producing
two embryos, two amnions, one chorion, and one placenta
■ Conjoined twins are a type of monozygotic twin in which cleavage is
incomplete and occurs late; rare (1.5 in 100,000 births)
• Three or more fetuses
• Incidence has increased with fertility drugs and in vitro fertilization
• Triplets can occur from one zygote dividing into two, then one of those
dividing again (identical); or from two zygotes, one of which divides
into a set of identical twins, the other a single fraternal sibling
• Quadruplets, etc., can occur from similar divisions
Application and review
1. A nurse is teaching a childbirth class to a group of pregnant women. One
of the women asks the nurse at what point during the pregnancy the
embryo becomes a fetus. How should the nurse respond?
1. During the eighth week of the pregnancy
2. At the end of the second week of pregnancy
3. When the fertilized ovum becomes implanted
4. When the products of conception are visualized on the sonogram
2. At what time during prenatal development should the nurse expect the
greatest fetal weight gain?
1. Third trimester
2. Second trimester
3. First 8 weeks
4. Implantation period
See Answers on page 9.
Nongenetic factors influencing development
Congenital disorders
• “Congenital” indicates present at birth (it is not synonymous with
inherited)
• Sources
• Inherited
■ Abnormal genes or inheritance of an abnormal number of genes
• Environmental factors
■ Teratogens
■ Greatest effects are during embryonic period; can even cause
spontaneous abortion
■ Include radiation, chemicals (drugs, alcohol, cigarettes), and
infections in the mother (eg, rubella or toxoplasmosis)
■ Environmental factors can affect genetic factors (eg, radiation)
• Inadequate maternal nutrition
■ Fetal growth limited by nutrients and oxygen received from mother
■ Inadequate nutrition can result in permanent changes in fetal
structure, physiology, and metabolism and development of chronic
conditions later in life
Application and review
3. What is the best advice a nurse can give to a pregnant woman in her first
trimester?
1. “Cut down on drugs, alcohol, and cigarettes.”
2. “Avoid drugs, and refrain from smoking and ingesting alcohol.”
3. “Avoid smoking, limit alcohol consumption, and do not take
aspirin.”
4. “Take only prescription drugs, especially in the second and third
trimesters.”
4. Genetic testing is being discussed with a couple at the fertility clinic. What
is the nurse’s best response when they express concerns?
1. “You should be tested because it will be to your benefit.”
2. “Environmental factors can have an impact on genetic factors.”
3. “This type of testing will determine whether you’ll need in vitro
fertilization.”
4. “If you have a gene for a disease, there is a probability that your
children will inherit it.”
5. When is it most important for a female client to know that a fetus may be
structurally damaged by the ingestion of drugs?
1. During early adolescence
2. Throughout the entire pregnancy
3. When planning to become pregnant
4. At the beginning of the first trimester
See Answers on page 9.
Answer key: Review questions
1. 1 During the eighth week of pregnancy the organ systems and other
structures are developed to the extent that they take the human form; at
this time the embryo becomes a fetus and remains so until birth.
2 At this time the developing cells are called an embryo. 3 At the time of
implantation the group of developing cells is called a blastocyst. 4 The
embryo can be visualized on a sonogram before it becomes a fetus.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation
2. 1 The third trimester is the period in which the fetus stores deposits of fat.
2 There is growth in the second trimester, but fat deposition does not
occur in this period. 3 The first 8 weeks is the period of organogenesis,
when cells differentiate into major organ systems. 4 The implantation
period is the period of the blastocyst, when initial cell division takes
place.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Knowledge; Nursing Process: Assessment/Analysis
3. 2 The first trimester is the period when all major embryonic organs are
forming; drugs, alcohol, and tobacco may cause major defects.
1 Cutting down on these substances is insufficient; they are teratogens
and should be eliminated. 3 Even 1 ounce of an alcoholic drink is
considered harmful; baby aspirin may be prescribed to some women
who are considered at risk for preeclampsia, but not during the first
trimester. 4 Medications, unless absolutely necessary, should be
avoided throughout pregnancy, but the first trimester is most
significant.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
4. 2 “Environmental factors can have an impact on genetic factors” is an
accurate, objective statement that should be included in a discussion of
genetic factors that influence fertility.
1 It is not the role of the nurse to make a decision on testing; based on the
objective data imparted by the nurse, the couple should make the
decision whether or not to be tested. 3, 4 Information regarding in vitro
fertilization and genetic markers for disease is not relevant at this time
and might cause unnecessary concern.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
5. 3 The greatest danger of drug-induced malformations is in the first
trimester of pregnancy during the period of organogenesis; because a
woman may not know she is pregnant, she should be aware of this before
becoming pregnant.
1 Although adolescent girls may be aware of the harmful effects of drugs
on a fetus, it is not a priority concern at this age. 2 Drugs should be
avoided throughout pregnancy, but the first trimester (period of
organogenesis) is the most critical. 4 If the client is not aware of her
pregnancy, it may be too late to start discontinuing drugs.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
C H AP T E R 2
Anatomy and physiology of
pregnancy
Gravidity and parity
Terms related to pregnancy
• Gravidity = pregnancy
• Gravida, a woman who is pregnant
■ Nulligravida, a woman who has never been pregnant and is not now
pregnant
■ Primigravida, a woman pregnant for the first time
■ Multigravida, a woman who has been pregnant two or more times
• Parity = the number of pregnancies in which the fetus or fetuses have
reached 20 weeks of gestation; not the number of fetuses
• Nullipara, a woman who has not completed a pregnancy that resulted in
a fetus that reached at least 20 weeks of gestation
• Primipara, a woman who has had one pregnancy that resulted in a fetus
that reached at least 20 weeks of gestation
• Multipara, a woman who has had two or more pregnancies that resulted
in fetuses that reached at least 20 weeks of gestation
• Gravidity/parity
• Systems for recording gravidity/parity are discussed in Chapter 3
Pregnancy tests
Human chorionic gonadotropin (hCG)
• hCG, hormone produced by the fertilized ovum and the chorionic villi, is
the basis for pregnancy tests
• Its levels rise quickly until ∼65 days, then fall to ∼115 days
• hCG is detectable in serum or urine
• Quantitative hCG serum (blood) testing has high accuracy
• Home pregnancy tests use an hCG antibody that binds with hCG
• Accuracy depends on following instructions
• Some tests’ instructions not easily understood
• Performing test too early in pregnancy, before hCG levels are high
enough, can result in false negative
• Counsel women to use caution when interpreting home pregnancy tests
• Test interpretation
• Requires judgment; need to consider last menstrual period (LMP), usual
cycle length, results of previous tests
• Test results may be influenced by medications, giving false-positive or
false-negative results
• When there is any question, further evaluation or retesting is advised
Adaptations to pregnancy
Signs of pregnancy
• Presumptive signs: subjective (may be indicative of illness)
• Amenorrhea
• Fatigue and drowsiness
• Nausea and vomiting
• Breast changes, especially tenderness
• Urinary frequency
• Darkening of pigmentation on face, breasts, and abdomen
• Quickening (feeling of movement at about 16 to 20 weeks)
• Probable signs: objective but not definite confirmation
• Uterine changes
■ Uterine enlargement
■ Hegar sign (lower uterine segment softens)
■ Goodell sign (cervix softens)
• Vaginal change: Chadwick sign (color becomes purplish)
• Fetal outline; ballottement
• Pregnancy tests: urine and blood detect hCG
• Preparatory contractions (formerly called Braxton Hicks)
• Positive signs: confirmation
• Fetal heartbeat: heard with fetoscope, Doppler
• Fetal outline and movement: felt by examiner
• Ultrasonography: visualization of fetus and movement of fetal heart
Reproductive system and breasts
• Ovaries
• Ovulation inhibited by high levels of circulating estrogen and
progesterone secreted by corpus luteum
• Produce progesterone to maintain decidua (uterine lining) during first 6
to 7 weeks of gestation until placenta can take over task
• Uterus
• Circulatory, hormonal, and other changes related to fetal growth
• Amenorrhea resulting from continuation of corpus luteum
• Enlarges from 70 g to 1000 g (2.5 oz to 35 oz)
• Rises from pelvis to abdomen after first trimester (Fig. 2.1); becomes
temporary abdominal organ; fundal height decreases between weeks 38
to 40, called lightening
• Hegar sign is when the lower uterine segment softens at about 6 weeks
of gestation
• Uteroplacental blood flow
■ Uterine blood flow increases by a factor of 10 in pregnancy compared
with nonpregnant flow
■ Fetus and placenta grow faster than uterine blood flow increases, so
more oxygen is taken from uterine blood toward the end of
pregnancy
■ Estrogen stimulation can increase uterine blood flow
■ Factors that decrease blood flow: low maternal arterial blood
pressure, uterine contractions, maternal supine position
○ Uterine souffle is a rushing or blowing sound of maternal blood
flowing through uterine arteries
○ Funic souffle is caused by fetal blood flowing through the
umbilical cord
• After the fourth month, increased contractility produces preparatory
contractions, which are irregular, intermittent, painless contractions
• Cervical changes
• Goodell sign: cervix softens around the sixth week
• Can have increased friability, resulting in slight bleeding after
examination or coitus
• Changes in color and consistency, glands in cervical mucosa increase
• Mucus plug formed to prevent ascent of organisms into uterus
• Vagina
• Vaginal secretions increase, pH more acidic (acidity increases)
• Leukorrhea (white discharge) can result from increased secretions
• Chadwick sign (color becomes purplish); increased blood supply causes
it to have a bluish color
• Higher glycogen level, which promotes Candida albicans (yeast) growth
• Breasts
• Fullness, tingling, soreness, darkened areolae and nipples
• High levels of estrogen and progesterone prepare breasts for lactation
• Tubercles of Montgomery secrete substance to lubricate nipples
FIG. 2.1 Changes in fundal height with pregnancy. Source: (From Ball, J.W., Dains, J.E.,
Flynn, J.A., Solomon, B.S., & Stewart, R.W. [2015]. Seidel’s guide to physical examination [8th ed.].
St. Louis: Elsevier.)
General body systems
• Cardiovascular system (Table 2.1)
• Blood volume: increases 45% to 50% to meet needs of woman and fetus
• Physiologic anemia: caused by hemodilution
■ Ratio of 75% plasma to 25% red blood cells (RBCs)
■ Imbalance between plasma and RBCs reduces hematocrit and
hemoglobin
■ Anemia diagnosed when hemoglobin is less than 11 g/dL
• Cardiac output: increases 30% to 50%, peaking at 28 to 32 weeks
• Heart rate: increases 10 to 15 beats/min in latter half of pregnancy
■ Palpitations in early months from sympathetic nervous stimulation,
in later months from increased thoracic pressure caused by enlarged
uterus
• Blood pressure
■ Slight decrease in second trimester
■ Orthostatic hypotension may occur
■ Supine hypotension (vena cava syndrome): weight of enlarged uterus
compresses vena cava; blood return to heart decreases; cardiac
output decreases causing lightheadedness, faintness, and
palpitations (Fig. 2.2)
• Blood components: white blood cells (WBCs) (from 5000/mm3 to
12,000/mm3), fibrinogen, and other clotting factors increase
• Pelvic hyperemia and pressure of uterus on pelvic blood vessels: can
cause varicose veins of legs, vulva, and perianal area
• Peripheral edema in last 6 weeks: caused by venous stasis
• Increased clotting factors in second and third trimesters
■ Increases risk of thrombophlebitis: heparin or low-molecular-weight
heparin (enoxaparin) may be administered because they do not cross
placental barrier; bed rest with leg elevation prescribed
• Supine hypotension syndrome may occur; occurs if woman lies flat on
her back
■ Allows heavy uterus to compress inferior vena cava
■ Reduces blood returned to her heart
■ Can lead to fetal hypoxia
• Symptoms: faintness, lightheadedness, dizziness, agitation
• Turning to one side relieves pressure on inferior vena cava, preferably
the left side
• Respiratory system (Table 2.2)
• Respiration rate: unchanged or slightly increased
• Oxygen consumption: increases by 20% to 40% by 40 weeks; slight
increase in vital capacity; thoracic cavity expands up to 40%; tidal
volume increases by 33% (1⁄3 more than prepregnancy)
• Hyperventilation: caused by need to blow off increased carbon dioxide
transferred from fetus
• Nasal congestion and epistaxis: response to increased estrogen levels
• Third trimester: pressure of enlarged uterus on diaphragm and lungs
may cause dyspnea; subsides with lightening at about 38 weeks
• Urinary system
• Glomerular filtration rate increases by 50% by end of first trimester
• Increased urination frequency: caused initially by increased sensitivity,
then by weight of uterus on bladder in late pregnancy
• Increased bladder capacity: smooth muscle relaxation reduces bladder
tone, increases capacity to 1500 mL
• Dilation of renal pelvises and ureters: caused by pressure of enlarging
uterus; right ureter displaced more than left
• Progesterone causes renal pelvis to lose tone, leading to urinary stasis,
risk for infection
• Lowered renal threshold; glycosuria and mild proteinuria more
common
• Lateral recumbent position makes renal function most efficient; it
increases urine output and decreases edema
• Integumentary system
• Sweat and sebaceous glands become more active
■ Diaphoresis: excretion of wastes through skin
■ Helps dissipate heat from woman and fetus
• Skin changes: increased melanin causes
■ Darkening of areolae, nipples, axillae, vulva
■ Dark patches on face (melasma, chloasma)
■ Linea nigra on abdomen, a pigmented vertical line
• Erythematous changes on palms (palmar erythema) and face in some
women
• Striae gravidarum (“stretch marks”) on abdomen and legs caused by
skin stretching as pregnancy advances
• Pruritic urticarial papules and plaques of pregnancy (PUPPP)
■ Can cause significant maternal discomfort
■ Not associated with poor maternal or fetal outcome
• Angiomas (vascular spiders) from elevated estrogens
• Musculoskeletal system
• Ligaments and joints: soften, especially pelvic joints (symphysis pubis
and sacroiliac joint); caused by increased hormonal action of estrogens
and relaxin
• Can produce a waddling gait
• Change in center of gravity produces postural changes; may result in
ache in lower back; balance may become an issue
• Leg cramps: caused by imbalance of calcium (hypocalcemia), pressure
of gravid uterus on nerves supplying lower extremities, insufficient
dietary calcium
• Vertical abdominal muscles (rectus abdominis) can separate (diastasis
recti abdominis)
• Neurologic system
• Physiologic alterations
■ Pelvic nerve compression from enlarging uterus can alter sensation in
the legs
■ Increased lumbar lordosis can cause pain from traction or
compression of nerve roots
■ Edema in peripheral nerves can result in carpal tunnel syndrome
■ Acroesthesia (altered sensations in hands) can result from loss of
normal cervical lordosis/postural changes
■ Vasomotor instability, postural hypotension, and/or hypoglycemia
can cause lightheadedness, faintness, and syncope
• Emotional changes
■ Ambivalence about pregnancy, parenting, and impact on family is
normal, even in second and subsequent pregnancies
■ Mood swings
■ Sexual desire may increase or decrease
■ First trimester: acceptance of biologic fact of pregnancy; acquires
knowledge regarding physical, physiologic, and emotional changes of
pregnancy
■ Second trimester: acceptance of growing fetus as distinct from self
■ Third trimester: preparation for birth; anxiety related to birth,
newborn’s health, additional responsibilities
• Gastrointestinal system
• Abdominal contents compressed by increased fundal height (Fig. 2.3)
• Nausea and vomiting (morning sickness) during first trimester; related
to hCG hormone; usually decreases by end of first trimester
• Excessive salivation (ptyalism)
• Gingivitis: caused by hyperemia and softening of gums
■ Oral mucosa may become tender and bleed more easily
■ Hyperacidity of oral secretions; increased vitamin C intake and
regular oral hygiene relieve problem
• Gallbladder: emptying time decreases because tone decreased by
estrogen and progesterone
■ May precipitate gallstone formation
■ May cause pruritus
• Appetite and thirst may increase
• Development of food cravings: unusual cravings for clay, starch, dirt
(pica); may be harmful
• Heartburn (pyrosis): caused by delayed emptying time of stomach,
reflux of gastric acid contents into esophagus, gastric irritants (eg,
coffee, tea, chocolate)
• Hiatal hernia: risk in older, obese women or if carrying multiple fetuses
• Constipation: caused by decreased gastrointestinal (GI) motility
■ Low fluid intake, low fiber intake contribute
■ Pressure of enlarged uterus on internal organs
■ Straining on defecation may contribute to development of
hemorrhoids
• Endocrine system
• Addition of placenta as a temporary endocrine organ
■ Primary role is to produce estrogen and progesterone to maintain
pregnancy
■ Hormones secreted by placenta
■ hCG: confirms pregnancy; maintains pregnancy; continues
secretion of progesterone and estrogen from corpus luteum during
first trimester; causes morning sickness; peaks at end of first
trimester, then drops; high levels associated with hydatidiform
mole
■ Estrogen: secreted during last two trimesters; promotes
vasodilation; softens cervix; helps prepare breasts for lactation;
causes sodium and water retention; increased estriol levels in
maternal saliva may indicate preterm labor
■ Progesterone: inhibits uterine contractions; promotes smooth
muscle relaxation, causing decreased GI motility and increased
bladder capacity; promotes sodium loss
■ Human placental lactogen (hPL) or human chorionic
somatomammotropin (hCS): diabetogenic (diminished insulin
efficiency); decreases maternal utilization of glucose, providing
more glucose for fetal growth; affects lipid and protein
metabolism; helps prepare breasts for lactation
• Thyroid: increased secretion may mimic mild hyperthyroidism
• Parathyroids: increased secretion affects calcium metabolism
• Adrenal cortex
■ Cortisol: promotes carbohydrate, protein, and fat metabolism;
activates gluconeogenesis to produce glucose for more energy
■ Aldosterone: production increases; renin and angiotensin II levels
rise; protects against excessive sodium loss
• Pituitary
■ Anterior: enlarges; ovulatory hormones are suppressed; prolactin
secreted to help prepare breasts for lactation
■ Posterior: releases oxytocin, which stimulates uterine contractions
that initiate labor; after birth, contracts uterus and stimulates milk
ejection reflex
• Pancreas: increases insulin production early in pregnancy
FIG. 2.2 Supine hypotension. Source: (From Matteson, P.S. [2001]. Women’s health during
the childbearing years: A community-based approach. St. Louis: Mosby.)
FIG. 2.3 Gastrointestinal contents compressed by increased fundal
height. Source: (From Moore, K.L., Persaud, T.V.N., Torchia, M.G. [2016]. The developing human:
Clinically oriented embryology [10th ed.]. Philadelphia: Saunders.)
TABLE 2.1
Cardiovascular Changes in Pregnancy
Parameter
Change
Heart rate
Increases 10–15 beats/min
Location
Heart is displaced upward
Blood
pressure
Systolic
Slight or no decrease from prepregnancy levels
Diastolic
Slight decrease to midpregnancy (24–32 weeks) and gradual return to prepregnancy levels by end
of pregnancy
Blood
volume
Increases by 1200–1500 milliliters (1.2–1.5 liters) or 40%–45% above prepregnancy level
Cardiac
output
Increases 30%–50%
Modified from Lowdermilk, D.L., Perry, S.E., Cashion, K., & Alden, K.R. (2016). Maternity and women’s
health care (11th ed.). St Louis: Elsevier.
TABLE 2.2
Respiratory Changes in Pregnancy
Parameter
Diaphragm position
Change
Displaced superiorly up to 4 cm
Respiratory rate
Unchanged or slightly increased
Tidal volume
Increased 33%
Total lung capacity
Unchanged to slightly decreased
Minute ventilation
Increased 30%–50%
Oxygen consumption Increased 20%–40%
Modified from Lowdermilk, D.L., Perry, S.E., Cashion, K., & Alden, K.R. (2016). Maternity and women’s
health care (11th ed.). St Louis: Elsevier.
Application and review
1. A woman visits the prenatal clinic because an over-the-counter (OTC)
pregnancy test was positive. After the initial examination verifies the
pregnancy, the nurse explains some of the metabolic changes that occur
during the first trimester of pregnancy. Select all that apply.
1. Need for sleep increases
2. Fluid retention increases
3. Body temperature decreases
4. Calcium requirements increase
5. Need for carbohydrates decreases
2. During a physical in the prenatal clinic the client’s vaginal mucosa is
observed to have a purplish discoloration. What sign should the nurse
document in the client’s clinical record?
1. Hegar
2. Goodell
3. Chadwick
4. Preparatory contractions
3. When involved in prenatal teaching, a nurse should inform clients that
there is an increase in vaginal secretions during pregnancy called
leukorrhea. What causes this increase?
1. Metabolic rate
2. Production of estrogen
3. Secretion from the Bartholin glands
4. Supply of sodium chloride to the vaginal cell
4. Which research-based knowledge guides a nurse regarding the emotional
factors of pregnancy?
1. A rejected pregnancy will result in a rejected infant.
2. Ambivalence and anxiety about mothering are common.
3. A mother’s love usually develops within the first week after birth.
4. An effective mother does not experience ambivalence and anxiety
about mothering.
5. A pregnant woman reports nausea and vomiting during the first trimester
of pregnancy. An increase in which hormone should the nurse explain is
the precipitating cause of this?
1. Estrogen
2. Progesterone
3. Luteinizing hormone
4. Chorionic gonadotropin
6. What change does a nurse expect in a client’s hematologic system during
the second trimester of pregnancy?
1. An increase in hematocrit
2. An increase in blood volume
3. A decrease in sedimentation rate
4. A decrease in white blood cells
7. A nurse at the prenatal clinic examines a client and determines that her
uterus has risen out of the pelvis and is now an abdominal organ. At what
week of gestation does this occur?
1. 8th week of pregnancy
2. 10th week of pregnancy
3. 12th week of pregnancy
4. 18th week of pregnancy
8. A nurse is planning a prenatal class about the changes that occur during
pregnancy and the necessity of routine health care supervision throughout
pregnancy. Which cardiovascular compensatory mechanisms should the
nurse explain will occur? Select all that apply.
1. Systemic vasodilation
2. Increased blood volume
3. Elevated blood pressure
4. Increased cardiac output
5. Enlargement of the heart
6. Decreased erythrocyte production
9. A client at 35 weeks’ gestation asks a nurse why her breathing has become
more difficult. How should the nurse respond?
1. “Your lower rib cage is more restricted.”
2. “Your diaphragm has been displaced upward.”
3. “There is an increase in the size of your lungs.”
4. “There is an increase in the height of your rib cage.”
10. What does a nurse explain to a pregnant client about the cause of her
physiologic anemia?
1. Erythropoiesis decreases
2. Plasma volume increases
3. Utilization of iron decreases
4. Detoxification by the liver increases
11. A nurse is assessing a pregnant client during the third trimester. What
clinical finding is an expected response to the pregnancy?
1. Tachycardia
2. Dyspnea at rest
3. Progressive dependent edema
4. Shortness of breath on exertion
12. A client at 8 weeks’ gestation reports having to urinate more often. The
nurse explains that urinary frequency often occurs because bladder
capacity during pregnancy is diminished by what?
1. Atony of the detrusor muscle
2. Compression by the enlarging uterus
3. Compromise of the autonomic reflexes
4. Narrowing of the ureteral entrance at the trigone
13. A nurse is teaching a class of expectant parents about changes that are to
be expected during pregnancy. What changes does the nurse explain result
from the melanocyte-stimulating hormone? Select all that apply.
1. Chloasma
2. Linea nigra
3. Effacement
4. Morning sickness
5. Cervical softening
6. Urinary frequency
14. A pregnant client uses a computer continuously during her working
hours. This has implications for her plan of care during pregnancy. What
should a nurse recommend?
1. “Try to walk around every few hours during the workday.”
2. “Ask for time in the morning and afternoon to elevate your legs.”
3. “Tell your boss that you cannot work beyond the second trimester.”
4. “Ask for time in the morning and afternoon to get something to
eat.”
15. A nurse is teaching a prenatal class about the changes that occur during
the second trimester of pregnancy. What cardiovascular changes should
the nurse include? Select all that apply.
1. Cardiac output increases.
2. Blood pressure decreases.
3. Heart is displaced upward.
4. Blood plasma volume peaks.
5. Hematocrit levels are lowered.
See Answers on pages 19-21.
Answer key: Review questions
1. 1, 2, 4, 1 Estrogen increases the secretion of corticosteroids, which
decreases the basal metabolic rate, causing fatigue. 2 Sodium is retained,
and fluid retention increases to meet total needs. 4 During the first
trimester, approximately 1.2 g of calcium is needed daily; this need
continues throughout pregnancy to help form the fetal skeleton.
3 Body temperature increases because of the increased metabolism
related to the growth of the fetus. 5 Carbohydrate needs increase
because the secretion of insulin by the pancreas is increased; however,
insulin is destroyed rapidly by the placenta. The stress of pregnancy
may precipitate gestational diabetes.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation; Clinical Area:
Childbearing and Women’s Health Nursing; Integrated Process:
Teaching/Learning
2. 3 A purplish color results from the increased vascularity and blood vessel
engorgement of the vagina.
1 The Hegar sign is softening of the lower uterine segment. 2 The Goodell
sign is softening of the cervix. 4 After the fourth month of pregnancy,
uterine contractions can be felt through the abdominal wall. They are
irregular and painless, and they increase blood flow to the placenta.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Knowledge; Integrated Process: Communication/Documentation;
Nursing Process: Assessment/Analysis
3. 2 Increased estrogen production during pregnancy causes hyperplasia of
the vaginal mucosa, which leads to increased production of mucus by the
endocervical glands. The mucus contains exfoliated epithelial cells.
1 Increased metabolism leads to systemic changes but does not increase
vaginal discharge. 3 The amount of secretion from the Bartholin glands,
which lubricates the vagina during intercourse, remains unchanged
during pregnancy. 4 There is no additional supply of sodium chloride to
the vaginal cells during pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
4. 2 Because mothering is not an inborn instinct in humans, almost all
mothers, including multiparas, report some ambivalence and anxiety
about their mothering ability.
1 Frequently maternal feelings are nurtured by the sight of the infant. 3
The length of time it takes to develop these feelings is specific for each
individual. With some mothers, it may take a much longer time. 4
Ambivalent feelings are universal in response to a neonate.
Client Need: Psychosocial Integrity; Cognitive Level: Comprehension;
Nursing Process: Assessment/Analysis
5. 4 Chorionic gonadotropin, secreted in large amounts by the placenta
during gestation, and the metabolic changes associated with pregnancy
can precipitate nausea and vomiting in early pregnancy; usually the
manifestations of morning sickness disappear after the first trimester.
1 Estrogen is elevated throughout pregnancy, but it is not the instigator of
the nausea and vomiting. 2 Progesterone is elevated throughout
pregnancy, but it is not the instigator of the nausea and vomiting. 3 The
luteinizing hormone is present only during ovulation.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Planning/Implementation
6. 2 The blood volume increases by approximately 50% during pregnancy.
Peak blood volume occurs between 28 and 32 weeks’ gestation.
1 The hematocrit decreases as a result of hemodilution. 3 The
sedimentation rate increases because of a decrease in plasma proteins.
4 WBC values remain stable during the antepartum period.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
7. 3 By the 12th week of pregnancy, the fetus and placenta have grown,
expanding the size of the uterus. The enlarged uterus extends into the
abdominal cavity.
1, 2 Between 8 and 10 weeks, the uterus is still within the pelvic area. 4 At
the 18th week of pregnancy, the uterus has already risen out of the
pelvis and is extending farther into the abdominal area.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
8. 2, 4, 5, 2 Blood volume is increased to meet the metabolic demands of
pregnancy. 4 An increased cardiac output is necessary to accommodate
the increased blood volume needed to meet the demands of the growing
fetus. 5 Cardiac hypertrophy is a result of the demands made by the
increased blood volume and cardiac output.
1 Systemic vasodilation is not expected. 3 There is little variation in blood
pressure with a slight decrease during the second trimester. 6
Erythrocyte production increases; because the plasma volume increases
more than the RBCs, the hematocrit is lower.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
9. 2 The pressure of the enlarging fetus causes upward displacement of the
diaphragm, which results in thoracic breathing; this limits the descent of
the diaphragm on inspiration.
1 The lower rib cage expands. 3 There is no change in the size of the lung
during pregnancy. 4 The thoracic cage enlarges; it does not rise.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
10. 2 There is a 30% to 50% increase in maternal plasma volume at the end of
the first trimester, leading to a decrease in the concentrations of
hemoglobin and erythrocytes.
1 Erythropoiesis increases after the first trimester. 3 Iron utilization is
unrelated to the development of physiologic anemia of pregnancy. 4
Detoxification demands are unchanged during pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation
11. 4 Shortness of breath on exertion is an expected cardiopulmonary
adaptation during pregnancy caused by an increased ventricular rate and
elevated diaphragm.
1, 2, 3 Tachycardia, dyspnea at rest, and progressive dependent edema are
pathologic signs of impending cardiac decompensation.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
12. 2 The uterus and bladder occupy the pelvic cavity and lie closely
together; as the uterus enlarges with the growing fetus, it impinges on the
space occupied by the bladder and thereby diminishes bladder capacity.
1 Atony does not cause frequency; more likely, it may lead to retention. 3
Compromise of the autonomic reflexes will lead to incontinence rather
than frequency. 4 Narrowing of the ureteral entrance at the trigone is
an unlikely occurrence; the uterus does not impinge on this area.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
13. 1, 2 Melanocyte-stimulating hormone during pregnancy causes
pigmentation over the bridge of the nose and cheeks (chloasma, mask of
pregnancy). 2 The concentration of melanocyte-stimulating hormone rises
from the end of the second month of pregnancy until term, causing in
some women a line of pigmentation on the abdomen from the umbilicus
to the symphysis pubis (linea nigra).
3 Effacement of the cervix is due to increased mucoidal secretions and the
effects of labor. 4 High levels of chorionic gonadotropin, secreted by the
placental chorion, are associated with nausea and vomiting that occur
early in pregnancy. 5 Cervical softening occurs as a result of increased
mucoidal secretions. 6 Urinary frequency is related to advancing growth
and pressure of the uterus on the bladder.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Clinical Area: Childbearing and Women’s Health Nursing;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
14. 1 Maintaining the sitting position for prolonged periods may constrict
the vessels of the legs, particularly in the popliteal spaces, as well as
diminish venous return. Walking contracts the leg muscles and applies
gentle pressure to the veins, thus promoting venous return.
2 A better means of improving circulation is to walk around several times
each morning and afternoon; the legs can be elevated while sitting at
her desk. 3 If the client is feeling well, there are no contraindications to
working throughout her pregnancy. 4 Adequate nourishment can be
obtained during mealtimes; the client does not require extra nutrition
breaks.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
15. 1, 2, 3 Cardiac output increases during the second trimester because of an
increasing plasma volume. 2 The blood pressure decreases because of the
enlarged intravascular compartment and hormonal effects on peripheral
resistance. 3 As the fetus grows and the enlarging uterus exits the pelvic
cavity, it displaces the heart upward and to the left.
4 The blood volume starts to increase earlier, but it does not peak until
the third trimester. 5 This occurs in the first trimester; the erythrocyte
increase may not be in direct proportion to the blood volume, lowering
hematocrit and hemoglobin levels, which remain lower throughout
pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Clinical Area: Childbearing and Women’s Health Nursing;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
C H AP T E R 3
Nursing care of the family during
pregnancy
Preconception care
Rationale
• Half of pregnancies are unplanned, so all reproductive-age women should
be asked about their plans for pregnancy at routine gynecologic visits
• Many women do not realize they are pregnant for the first 8 weeks
• Most birth defects occur between the second and eighth weeks of
gestation
Purpose
• Risk assessment
• Best achieved when a pregnancy is planned
• Health care and screening conducted before pregnancy occur so that
medical risk factors or lifestyle behaviors can be identified, managed,
or changed before conception
■ Examples: anemia, hypothyroidism, hypertension, diabetes are better
managed before pregnancy begins
• Genetic testing and counseling
■ Tay-Sachs, Canavan disease, cystic fibrosis, hemoglobinopathies:
resolution of these issues preconceptually avoids the time limits of
an advancing pregnancy
■ Systemic lupus erythematosus best evaluated and counseled before
pregnancy
■ Patients with serious risks for progressive disease, end-organ
damage, and death should be so counseled so that they can make a
fully informed decision about pregnancy
■ Significant risk factors may be able to be treated to reduce risk
• Preventive care
• Manage medical conditions
■ Examples: management of diabetes and phenylketonuria before
conception positively influences pregnancy outcome
• Treat infections
• Update immunizations before becoming pregnant
■ Check rubella titer; offer human immunodeficiency virus (HIV)
testing
■ Varicella titer/immunization if no history of chickenpox
■ Toxoplasmosis screening based on risk factors
■ Avoid pregnancy for up to 3 months following immunizations
■ Avoid pregnancy for at least 1 month after receiving a
measles/mumps/rubella (MMR) vaccine
• Occupational exposures to teratogens
• Nutrition needs before conception: see Chapter 4
Patient teaching
• Cease smoking and alcohol consumption
• Smoking causes vasoconstriction of maternal and fetal blood vessels,
resulting in fetal growth restriction and increased fetal and infant
mortality
• Alcohol is a known teratogen at embryonic and fetal stages of
development
• Discuss current medications (prescribed, over-the-counter [OTC], any
illicit medications), supplements (including herbs), and caffeine
• Risks/benefits of altering, stopping, or continuing medication
• Take 400 mcg/day of supplemental folic acid = 0.4 mg/day per Centers
for Disease Control and Prevention (CDC)
■ During pregnancy, recommendation rises to 0.6 mg/day (= 600
mcg/day) for women who have no previously affected child with
neural tube disorder (NTD) such as spina bifida
■ For women with a previously affected child, the CDC
recommendation is 4 mg/day from 4 weeks before conception
through the first 3 months of pregnancy. She should take this
supplement even if she is not planning to become pregnant. Note
this is 10 times the usual preconception dose: 4 mg/day (instead of
the usual 0.4 mg/day).
■ Note that long-term use of oral contraceptives inhibits folate
absorption and enhances its degradation by the liver. Folate stores
may be more rapidly depleted in women who have used oral
contraceptives, which may lead to higher incidence of deficiency in
these women if they become pregnant.
• Limit caffeine to 200 mg/day
• See Chapter 4 for additional nutrition needs before conception
• For overweight or obese women, their pregnancies will be healthier if they
lose weight before pregnancy; weight loss during pregnancy is not advised
• Keep an accurate menstrual calendar to assist determination of
gestational age
• Accurate dates assist in planning other diagnostic procedures
Diagnosis of pregnancy
Estimating date of birth
• Naegele’s rule to determine the estimated date of delivery (EDD)
• Identify first day of last menstrual period (LMP)
• Count backward 3 months
• Add 7 days
• Update year, if applicable
• Example: date of LMP = 8-15-16; count backward 3 months = 5-15-16; add
7 days = 5-22-16; update year = 5-22-17
• Summary: EDD = last menstrual period + 1 year – 3 months + 7 days
Signs of pregnancy (see chapter 2 for presumptive,
probable, and positive signs of pregnancy)
Adaptation to pregnancy
Maternal adaptation
• Expected periods of marked change and adjustment are called
developmental crises
• According to Reva Rubin, there are four maternal tasks the woman
accomplishes during pregnancy:
• Seeing safe passage for herself and her fetus
• Securing acceptance of herself as a mother and for her fetus
• Learning to give of self and to receive the care and concern of others
• Committing herself to the child as she progresses through pregnancy
• Emotional ranges and adjustments vary: emotional lability, heightened
sensitivity, increased need for affection, greater irritability, fear, anxiety
• Maternal ambivalence (having conflicted feelings) is common, even in
planned pregnancies
• Single mother
• May have additional emotional needs
• May have difficulty completing tasks of pregnancy
• May see pregnancy as financial burden, or may have planned for the
event
• May face issues of social acceptance
Paternal adaptation
• Stages
• Accepting the pregnancy/announcement
• Adjustment
■ Reordering personal relationships; identifying with father role
■ Establishing relationship with fetus; may begin to feel like a parent
■ Possibility of Couvade syndrome: father experiencing pregnancy-like
signs/symptoms
• Preparation
■ Creative energy; channeling anxiety into productive activities
■ Active plans for participation in birth process
• Cultural considerations
• Less active role of father may reflect cultural heritage
• Family is strengthened by father’s acceptance of new role
• Single father
• May take active interest in and financial responsibility for child
• May want to participate in plans for the child
• Participation may not be accepted by the mother
Sibling adaptation
• Dependent on age, dependency needs, and developmental stage
Grandparent adaptation
• Supportive
• May eagerly anticipate the woman’s pregnancy
■ Recognize legacy
■ Evidence of their own aging
• Some may help care for grandchildren
• Nonsupportive
• Nurse may help new parents understand their own parents’ roles,
negotiate solutions to conflicts
Application and review
1. At her first visit to the prenatal clinic, a client tells the nurse she is
ambivalent about continuing the pregnancy. Why does the nurse conclude
that the client is experiencing a crisis?
1. Mood changes occur during pregnancy.
2. Pregnancy is a period of change and adjustment to change.
3. Hormonal and physiologic changes occur during pregnancy.
4. Pregnancy changes the future parents’ relationship with each other.
2. A pregnant client asks the clinic nurse how smoking will affect her baby.
What information about cigarette smoking will influence the nurse’s
response?
1. It relieves tension and the fetus responds accordingly.
2. The resulting vasoconstriction affects both fetal and maternal blood
vessels.
3. Substances contained in smoke diffuse through the placenta and
compromise the fetus’s well-being.
4. Effects are limited because fetal circulation and maternal circulation
are separated by the placental barrier.
See Answers on pages 34-36.
Care management
Goals of prenatal care
• Ensure a safe birth for mother and child by promoting good health habits
and reducing risk factors
• Teach health habits that may be continued after pregnancy
• Educate in self-care for pregnancy
• Provide physical assessment and care
• Prepare parents for the responsibilities of parenthood
Initial visit
• Patient’s understanding of reason for seeking care
• Be sure to address chief concern (“complaint”) of patient
• Health history
• Personal health and social history
■ Social and occupational history
■ Identify current social problems, evidence of domestic violence
■ Identify perception of pregnancy
■ Coping mechanisms
■ Family support
■ Cultural considerations
■ Identify risk factors
■ Identify current medications, supplements, use of alcohol, smoking
■ Current OTC medications, complementary and alternative
medications, supplements, herbal remedies, etc.
■ Alcohol use
■ Smoking/tobacco use
• Date of LMP
• Average pregnancy is 40 weeks (280 days) after first day of LMP, plus or
minus 2 weeks
• Naegele’s Rule (see earlier) to determine EDD
• Family medical history of genetic or concurrent medical disorders
■ Mother
■ Father
• Gynecologic (including menstrual)
■ Menstrual history
■ Contraceptive history
• Obstetric history using GTPAL system
■ Gravida: number of conceptions
■ Term births: number of births between 37 and 40 weeks’ gestation
■ Preterm births: number of births between 20 and 36 weeks’ gestation
■ Abortions: number of spontaneous or induced terminations of
pregnancy before 20 weeks’ gestation
■ Living children: number of children alive at time of assessment
■ Example: Bonnie (3 months pregnant) is visiting her obstetrician, who
makes this notation: 3-1-1-1-3. Discern what each number tells us
about Bonnie’s obstetric history:
■ Bonnie has been pregnant (gravid) three times, G1
■ She carried one pregnancy to term, T1
■ She has had one premature birth, P1
■ She has had one abortion, A1
■ She has 3 living children, L3
■ Bonnie’s history shows that she had one pregnancy to term with a
surviving infant; carried one pregnancy to 35 weeks with surviving
twins; carried one pregnancy to 8 weeks as an ectopic pregnancy,
and has 3 living children: Jorge, age 9, and Selena and Victoria, the
3-year-old twins
• Current nutritional status; dietary history (see Chapter 4)
• Immunization history
■ Live virus vaccines are contraindicated during pregnancy
■ Select immunizations are allowable during pregnancy, such as
influenza vaccine and H1N1 vaccine
• Review of systems
■ Ask patient to describe any concurrent or previous disorders or
symptoms in each body system: reproductive, cardiovascular,
respiratory, immunologic, urinary, gastrointestinal, endocrine,
neurologic, or musculoskeletal
• Physical examination
• Baseline vital signs, weight (repeated on all visits)
• Pelvic examinations: vaginal, rectal
■ Size of pelvis, adequacy and condition of reproductive organs
• Assess for signs of pregnancy (see Chapter 2)
• At all visits
■ Abdominal palpation; auscultation of fetal heart, fetal activity; height
and size of fundus
■ Be sure to advise the mother that a fetal heart rate (FHR) is usually
between 110 and 160 beats/min, faster than the adult heart rate
■ Facial or digital edema
■ Evidence of domestic violence
• Laboratory tests (some tests performed at subsequent visits as noted)
• Complete blood count; hemoglobin and hematocrit; blood type to
determine ABO incompatibility; Rh factor (if indicated, antibody titer
test and/or indirect Coombs test) to determine potential hemolytic
condition)
• Tuberculosis; Tay-Sachs, particularly for Jewish women; sickle cell,
particularly for African American women
• Pap test for cancer; wet prep for bacterial vaginosis (linked to preterm
labor)
• Serologic test for syphilis, repeated at 32 weeks; cervical smears for
gonorrhea and Chlamydia
• Rubella titer: titer of 1:8 considered immune
• Cytomegalovirus, hepatitis B, HIV, parvovirus, toxoplasmosis (found in
cat feces), varicella-zoster virus
• Herpes culture: first visit, at 36 weeks, if woman or partner has history
of genital herpes
• At all visits: urinalysis for ketones, albumin, and glucose
• Alpha-fetoprotein (AFP): at 14 to 16 weeks; screening test to determine
neural tube defects, Down syndrome, and some other congenital
anomalies
• Routine sonogram: at 18 to 20 weeks; confirms gestational age; assesses
placenta, fetus, amniotic fluid
• Chorionic villi sampling (CVS) or amniocentesis: determines
chromosomal or other abnormalities for women at risk (35 years or
older; CVS is performed ideally between 10 and 13 weeks of gestation;
amniocentesis is performed after week 15 of gestation) (see Chapter 5
for additional information)
• Serum glucose level: at 26 to 28 weeks for gestational diabetes
• Group B streptococcus culture: after 36 weeks
Application and review
3. A client tells the nurse that the first day of her last menstrual period was
July 22, 2015. What is the estimated date of delivery?
1. May 7, 2016
2. April 29, 2016
3. April 22, 2016
4. March 6, 2016
4. At her first prenatal visit, a client says to the nurse, “I guess I’ll be having
an internal examination today.” What is the nurse’s best response?
1. “Yes, an internal examination is done at the mother’s first visit.”
2. “Are you fearful of having an internal examination done?”
3. “Have you ever had an internal examination done before?”
4. “Yes, a slightly uncomfortable internal examination must be done.”
5. While caring for a pregnant client and her partner, a nurse suspects
domestic violence. Which assessments support this suspicion? Select all
that apply.
1. Woman has injuries to the breasts and abdomen.
2. Partner refuses to come into the examination room.
3. Partner answers questions that are asked of the woman.
4. Woman has visited the clinic several times in the last month.
5. Partner is excessively attentive while the health history is being
taken.
6. A pregnant client is making her first antepartum visit. She has a 2-year-old
son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-yearold twin daughters born at 35 weeks. She had a spontaneous abortion 3
years ago at 10 weeks. Using the GTPAL format, what does the nurse
document about the client’s obstetric history?
1. G4 T3 P2 A1 L4
2. G5 T2 P2 A1 L4
3. G5 T2 P1 A1 L4
4. G4 T3 P1 A1 L4
7. The nurse reads the history of a neonate admitted to the nursery and
discovers that the infant’s mother was listed as gravida 1, para 1 before the
baby was born. How should the nurse use these data to gather more
information?
1. Determine whether there were fetal losses
2. Determine whether there are twins at home
3. Consider that someone recorded the gravida and para incorrectly
4. Consider that the current birth means that there were two
pregnancies
8. A client who is visiting the prenatal clinic for the first time has a serology
test for toxoplasmosis. What information in the client’s history indicates
to the nurse that there is a need for this test?
1. Taking care of a cat
2. Working as a dog trainer
3. Using chemical cleaners
4. Consuming raw vegetables
9. A 36-year-old multigravida who is at 14 weeks’ gestation is scheduled for
an alpha-fetoprotein test. She asks the nurse, “What does the alphafetoprotein test indicate?” The nurse bases a response on the knowledge
that this test can indicate an increased risk for what?
1. Kidney defects
2. Cardiac anomalies
3. Neural tube defects
4. Urinary tract anomalies
10. A client has several tests during pregnancy. Place the tests in the order
they should be performed during pregnancy.
1. Routine ultrasound
2. Sickle cell screening
3. Group B streptococcus culture
4. Serum glucose for gestational diabetes
5. Alpha-fetoprotein testing for neural tube defects
See Answers on pages 34-36.
Follow-up visits
• Interval health history
• New events
• General psychologic well-being
• Problems or physical symptoms
• Questions
• Third trimester: reassess understanding
■ Warning signs or emergencies
■ Signs of preterm labor
■ Methods to assess fetal well-being
• Maternal physical assessment
• Vital signs including blood pressure; weight
• Urinalysis for ketones, albumin, and glucose
• Abdominal palpation
• Presence and degree of edema; facial or digital edema
• Evidence of domestic violence
Fetal assessment
• Fundal height and size
• Leopold maneuvers: assess position and presentation
■ What is in fundus
■ Location of the fetal back
■ What part of fetus is above symphysis pubis
■ Position of the cephalic prominence
• Auscultation of fetal heartbeat
• Fetal activity
Nursing interventions
• Patient teaching
• Teach expectant mother or parents
■ Anatomy and physiology of pregnancy, labor, and birth
■ Physiologic changes and related discomforts occurring during
pregnancy
■ Signs and symptoms to anticipate
■ Common discomforts: fatigue, nasal stuffiness, nausea, vomiting,
heartburn, constipation, hemorrhoids, vaginal discharge, backache,
varicose veins, leg cramps, edema of the lower extremities
■ How to self-manage: elevation of lower extremities (raising feet)
several times each day for dependent edema, staying hydrated and
eating fiber for constipation, lifting properly to prevent backache,
moving regularly to improve circulation, etc.
■ To avoid lying on her back (supine) because it can decrease
placental perfusion and lead to hypotension (see Fig. 2.2)
■ Changes in nutritional needs and how to meet them (see Chapter 4);
consider cultural and personal preferences
■ To avoid alcohol, tobacco, contact with secondhand smoke (causes
maternal and fetal vasoconstriction resulting in intrauterine growth
restriction)
■ To check with health care provider before taking OTC medications
(eg, nonsteroidal antiinflammatory drugs [NSAIDs] considered
harmless may be teratogenic to fetus), prescription drugs,
supplements, herbs
■ Pregnancy affects the metabolism of medications
■ Parenteral medications may be absorbed more rapidly due to
increased cardiac output
■ Drugs can cross the placenta, can be passed through breast milk
■ Importance of adequate fluid intake, moderate exercise to promote
circulation and prevent stasis
■ Importance of continuing breast self-examination throughout
pregnancy
■ To notify health care provider when membranes rupture and/or
regular contractions are 5 to 10 minutes apart
• Woman should be given written instructions at the level (and in the
language) she can read, listing important signs to report to the health
care provider
• Teach expectant mother and/or parents to monitor for and report
complications
• Visual disturbances; edema of face, fingers, or feet; persistent, severe
headaches; epigastric pain; seizures (eclampsia)
• Persistent, severe vomiting (eg, hyperemesis gravidarum)
• Signs of infection (eg, burning on urination)
• Unusual vaginal discharge, including blood (eg, placenta previa)
• Abdominal pain (eg, abruptio placentae)
• Absence of or decrease in fetal movements after initial presence
(nonreassuring fetal sign)
• Signs and symptoms of preterm labor (eg, rupture of membranes)
• Respond to questions (eg, bathing, douching, work, sex, exercise, travel)
■ Bathing
■ Showering is safer due to ease of access
■ Hot tubs, Jacuzzi, saunas are contraindicated because they increase
body temperature
■ Tub baths contraindicated when amniotic membranes have
ruptured
■ Douching
■ Changes vaginal pH and alters normal vaginal flora
■ Only perform if ordered by health care provider
■ Work
■ Typically no reason for the woman not to continue working
■ Exceptions include occupational hazards, such as exposure to
chemicals
■ Take frequent rest periods and avoid heavy lifting
■ If woman’s job involves heavy lifting, see if modifications can be
made
■ Proper body mechanics should be used for lifting
■ If in a sedentary job, should not stand or sit for a long time
■ Movement is important, but avoid activities requiring balance or
coordination
■ Sexual counseling
■ Should not engage in activity if amniotic sac (“bag of waters”) has
ruptured or labor has begun
■ Other than amniotic sac rupture, in a healthy pregnancy, no valid
reason to limit
■ Alternative positions may be needed
■ Increased uterine activity sometimes noted after intercourse
■ Exercise during pregnancy
■ Maternal cardiac status and fetoplacental reserve serve as the basis
for determining exercise levels during all trimesters of pregnancy
■ It is important to assess the exercise practices of the individual
■ Moderate exercise has many benefits: more positive self-image, a
decrease in musculoskeletal discomfort during pregnancy, and a
more rapid return to prepregnant weight after delivery
■ Guidance
○ Discontinue if discomfort experienced
○ Do not exceed American College of Obstetricians and
Gynecologists (ACOG) recommendations for moderate exercise;
intensity of exercise should be modified based on the “talk test”
(perceived moderate intensity)
○ Recommend eating 2 to 3 hours before exercise or immediately
after
○ Avoid marked changes in depth of water (such as scuba diving)
and/or altitude (skydiving/ mountain climbing)
○ Avoid becoming overheated; be sure to increase fluid intake
■ Travel tips during pregnancy
■ Air travel generally safe, but avoid sitting for extended periods;
walk every hour; wear compression stockings to minimize risk
■ Use seatbelt and headrest properly
■ Avoid locations that increase the risk of exposure to infectious
diseases
■ Bring a copy of obstetric records
■ Obtain information about nearest health care facility
■ Use hand hygiene and take dietary precautions
■ Reinforce importance of hydration
• Psychosocial support: help expectant parents discuss and explore
feelings related to childbearing and childrearing
• Identify expectant parents’ support systems
• Prepare expectant father or significant other for coaching and
supportive role during pregnancy, labor, and birth
• Prepare expectant mother for physical work of labor through relaxation
and breathing exercises for various phases of labor
• Discuss various breathing techniques (eg, slow paced, modified paced,
pattern paced)
• Refer to preparatory classes, if appropriate
• Encourage monthly and final weekly visits
• Explore findings that indicate domestic violence; follow up to prevent
damage to mother and fetus
Evaluation/outcomes
• Expectant mother
• Keeps weight gain within recommended limits
• Abstains from alcohol, drugs, and tobacco
• Adjusts to physiologic changes associated with pregnancy
• Identifies signs of complications
• Attends childbirth classes with partner/coach (if appropriate)
• Fetus
• Survives intrauterine period
• Maintains growth and development within acceptable parameters
Collaborative care
• Health care providers
• Obtain consent from the patient to access records of her primary care or
other health care providers, such as medical specialists; this
information (medications, diagnoses, etc.) may aid in providing
prenatal care
■ Primary care provider
■ Source of information about concurrent medical conditions
■ Foster collaborative care through communication if patient has
given written permission for exchange of records
■ Provider of obstetric care for previous pregnancies
• Mental health professionals and social workers
■ Psychologists can help patients with emotional responses outside of
the norm for pregnancy, or if patient requests a referral
■ Social workers can help direct patients to resources; for example, for
help with nutritional services, such as WIC (nutritional support for
pregnant women and small children; see Chapter 4), or housing if
woman is escaping an abusive relationship
Application and review
11. A pregnant client is being prepared for a pelvic examination. She states
that she is always tired and feels sick to her stomach, especially in the
morning. What is the nurse’s best response?
1. “Tell me about how you feel the rest of the day.”
2. “Let’s discuss ways to resolve these common problems.”
3. “Perhaps you should ask your health care provider about it.”
4. “There is no need to worry about these expected problems.”
12. A client at her first prenatal clinic visit is at 6 weeks’ gestation. She asks
how long she may continue to work and when she should plan to quit.
How should the nurse respond?
1. “What activities does your job entail?”
2. “How do you feel about continuing to work?”
3. “Most women work throughout their pregnancy.”
4. “Usually women quit work at the start of their third trimester.”
13. What recommendation should a nurse give to clients who have fluid
retention during pregnancy?
1. Decrease fluid intake.
2. Maintain a low-sodium diet.
3. Elevate the lower extremities.
4. Ask the health care provider for a diuretic.
14. A nurse teaches a pregnant woman to avoid lying on her back during
labor. What information about the result of lying in the supine position is
the basis for the nurse’s teaching?
1. Labor may take longer.
2. Placental perfusion is decreased.
3. Movement of the coccyx is obstructed.
4. Transient episodes of hypertension may occur.
See Answers on pages 34-36.
Variations in prenatal care
Cultural influences
• Nursing considerations
• Awareness of, acceptance of, and respect for beliefs, values, traditions,
and practices that are different from one’s own is cultural competency
• Adapting health care so it does not violate the culture or religion of the
patient shows respect
• Achieving cultural competence is aided by knowledge, skills, and
encounters with others of different cultures
• Exploring a woman’s beliefs and perceptions about pregnancy and
childbearing can help the nurse understand how to positively influence
the maternal role and the mother’s relationship with her partner
• Cultural differences may influence emotional responses, physical
activity and rest, clothing, and sexual activity, as well as diet during
pregnancy
Age differences
• Adolescent
• The nurse must assess the adolescent mother’s developmental and
educational level, as well as her support system to best provide care for
her
• Consider the priorities typical of her age and whether peer pressure is a
substantial influence
• Pregnant adolescents must cope with two of life’s most stressful
transitions at the same time: adolescence and parenthood
• Adolescents have a higher risk of delayed prenatal care; the nurse’s role
is to encourage early and continued prenatal care
• Mothers older than 35 years
• Can be primiparas or multiparas
• Tend to adjust to the pregnancy because they are more likely well
educated, have achieved life experiences that enable them to better
cope with realities of parenthood
• May face being older than peers who are having children
Multifetal pregnancy
• Risks
• Mother and fetuses are at increased risk for adverse outcomes
■ Mothers are at higher risk for developing certain conditions and are
more likely to have severe manifestations of those conditions, such as
preeclampsia, hypertension, and anemia
• Multifetal pregnancies are more likely to end in premature delivery
• Spontaneous rupture of membranes before term is more common
• Fetuses in multifetal pregnancies are at increased risk for anatomic
abnormalities
• Counseling needs to be provided for these topics
• Risk of preterm labor
• Modification of weight gain and nutritional intake (see Chapter 4)
• Selective reduction
■ An ethical dilemma arises when considering the risks of a multifetal
pregnancy
■ The risk for pregnancy loss, preterm delivery, and long-term
morbidity for children of multiple gestations increases proportionally
to the number of fetuses carried
■ Perinatal morbility and mortality are improved when pregnancies
with quadruplets or greater are reduced to smaller numbers
• Lifestyle changes
■ Can place a strain on finances, space, workload, and the woman’s and
family’s coping capabilities
Perinatal and childbirth education
Classes for expectant parents
• Goal is to help individuals and family members make informed and safe
decisions about pregnancy, birth, infant care, and early parenthood
• Education programs consist of a menu of class series and activities from
preconception through the early months of parenting
• May include techniques for coping with labor, such as relaxation and
breathing techniques
• Classes available for specific needs: women with special needs, older and
adolescent mothers, single mothers, adoptive parents, planned cesarean
births, parents of multiples
Perinatal care choices
Provider choices
• Physicians (obstetricians, family practice physicians, osteopathic
physicians) attend 92% of hospital births
• Obstetricians see low-risk and high-risk pregnant women, whereas
family practice and osteopathic physicians primarily provide care to
low-risk pregnant women
• Certified nurse midwives (CNMs) and certified midwives (CMs)
• Attend 7% to 8% of hospital births; ∼30% out-of-hospital births
• Model of care emphasizes minimal intervention; usually see low-risk
pregnant women; increases the likelihood of a spontaneous vaginal
birth
• Reduced use of epidurals, fewer episiotomies and instrument-assisted
births
• Services provided depend on licensure
• Other
• Doulas are trained to provide support during labor and birth
• A doula is used in addition to another health care provider; they do not
replace the health care provider
■ Continuous support provided by doulas decreases the use of pain
medication, increases the likelihood of a spontaneous vaginal birth
■ No risk factors associated with doula support
• Note: Although nurse practitioners are trained to deliver babies, they
generally do not do so unless they are also nurse-midwives
Birth plans
• Written plan that serves as a tool where parents can explore childbirth
options, communicate preferences to health care provider
• Must be understood that the plan is tentative, based on circumstances
during actual labor and birth
• Usually planned to be used upon admission to hospital
• Nurse can use a template to develop a simple birth plan by asking about
preferences
Birth setting choices
• Hospital
• Traditional labor and delivery rooms with separate postpartum and
newborn units
• Labor, delivery, recovery rooms (LDRs) and labor, delivery, recovery,
postpartum rooms (LDRPs)
■ Continuity of nursing staff from admission through discharge
■ Comfortable, private space
■ Outfitted with all needed equipment, although it may be stored out of
sight
• Birth centers
• Usually separate, but nearby a hospital
• Safe management of low-risk pregnancy women
• Ambulance service and emergency procedures readily available
• Homelike accommodations
• Home birth
• In developing countries, facilities often unavailable to most pregnant
women
• Remains a controversial topic in U.S. health care
■ ACOG and American Medical Association (AMA): safest setting is
hospital or birthing center that meets standards set by American
Academy of Pediatrics (AAP) and ACOG
■ Safe for healthy low-risk women attended by certified nurse midwives
when transfer to a hospital is available
■ Benefits: mother more relaxed in her own home; contact with
newborn is immediate and sustained; less expensive
Answer key: Review questions
1. 2 Expected periods of marked change and adjustment are called
developmental crises.
1 Mood changes during pregnancy are transient; they are similar to
previous mood changes and should not affect the client’s ability to
cope. 3 Hormonal and physiologic changes occur throughout the life
cycle of a mature woman and should not now be classified as a crisis. 4
Pregnancy becomes a crisis if the client’s partner withdraws support.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
2. 2 Cigarette smoking or continued exposure to secondary smoke causes
both maternal and fetal vasoconstriction, resulting in fetal growth
restriction and increased fetal and infant mortality.
1 There is no clinical evidence that smoking relieves tension or that the
fetus is more relaxed. 3 Smoking causes vasoconstriction; permeability
of the placenta to smoke is irrelevant. 4 Although the fetal and
maternal circulations are separate, vasoconstriction occurs in both
mother and fetus.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
3. 2 April 29, 2017. The Naegele rule is an indirect, noninvasive method for
estimating the date of delivery: EDD = last menstrual period + 1 year – 3
months + 7 days.
1 May 7, 2016, is beyond the expected date of birth. 3 April 22, 2016, is
before the expected date of birth. Remember to add 7 days after you
subtract 3 months. 4 March 6, 2016, is before the expected date of birth.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
4. 3 Before health teaching is instituted, the nurse should ascertain the
client’s past experiences; they will influence the teaching plan.
1 Just stating that an examination will be performed does not give the
client a chance to discuss her feelings about the examination. 2 Asking
about a client’s fear presupposes that the client is fearful and does not
address the client’s question. 4 A response about discomfort does not
give the client a chance to discuss her feelings about the examination;
the nurse is assuming that the client’s concerns are related to
discomfort.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring;
Communication/Documentation; Nursing Process:
Planning/Implementation
5. Answer: 1, 3, 4. 1 During pregnancy, batterers may concentrate their anger
at the pregnancy itself and focus their assaults on the breasts, buttocks,
and abdomen. 3 It is common for the abuser to control the conversation
by answering for the client. 4 Women who are battered are at risk for
stress illnesses such as gastrointestinal (GI) distress and chest pain. They
are more likely to suffer from frequent headaches and depression.
2 Control is a primary concern of the abuser, so it would be highly
unlikely for him to leave the client alone with the care provider. 5
Excessive attentiveness is not typical behavior of an abusive person.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis
6. 3 The acronym GTPAL reflects G, gravidity; T, term birth; P, preterm
birth; A, abortions; and L, living children; G5 T2 P1 A1 L4 indicates that
there were 5 pregnancies, twins count as 1 pregnancy, and the present
pregnancy counts as 1; 2 term births; twins count as 1 preterm birth; 1
abortion; 4 living children.
1 G4 T3 P2 A1 L4 indicates that there were 4, not 5, pregnancies; 3, not 2,
term births; twins count as 1, not 2, preterm births; 1 abortion; 4 living
children. 2 G5 T2 P2 A1 L4 indicates that there were 5 pregnancies; 2
term births; twins count as 1, not 2, preterm births; 1 abortion; 4 living
children. 4 G4 T3 P1 A1 L4 indicates that there were 4, not 5,
pregnancies; 3, not 2, term births; twins count as 1 preterm birth; 1
abortion; 4 living children.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Communication/Documentation; Nursing
Process: Assessment/Analysis
7. 3 Gravida refers to pregnancies, and para refers to pregnancies terminated
(by whatever means) after the age of viability. If this is the client’s only
pregnancy (gravida 1), she could not have had a previous pregnancy that
terminated after the age of viability.
1 Gravida refers to the number of pregnancies, including this pregnancy.
Para will not exceed gravida. 2 One pregnancy is gravida 1. A twin
pregnancy is still one pregnancy terminated after the age of viability. 4
Because the documentation of the client is gravida 1, it cannot be
assumed that it is the woman’s second pregnancy.
Client Needs: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Communication/Documentation; Nursing
Process: Assessment/Analysis
8. 1 Toxoplasmosis is caused by a protozoan parasite; cats acquire the
organism by ingesting infected mice or birds, and the cysts are found in
their feces.
2 Working with cats, not dogs, poses a potential problem with
toxoplasmosis. 3 Chemical cleaners may be teratogenic, but they do not
cause toxoplasmosis. 4 Eating raw vegetables of any kind does not
cause toxoplasmosis.
Client Needs: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
9. 3 The alpha-fetoprotein test can indicate an increased risk for neural tube
defects, Down syndrome, and some other congenital anomalies. It is a
screening test that indicates a need for further follow up; confirmation
requires more definitive testing.
1 Kidney defects are not detected by the alpha-fetoprotein test. 2 Cardiac
anomalies are not detected by the alpha-fetoprotein test. 4 Urinary tract
anomalies are not detected by the alpha-fetoprotein test.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation
10. Answer: 2, 5, 1, 4, 3.
2 Sickle cell screening, particularly for black women, should be done on
the initial visit. 5 Alpha-fetoprotein (AFP) testing for neural tube
defects should be done between 14 and 16 weeks. 1 Routine sonogram
is performed at 18 to 20 weeks. 4 Serum glucose testing for gestational
diabetes should be done between 26 and 28 weeks. 3 Group B
streptococcus culture should be done between 36 and 38 weeks.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
11. 2 Focusing on solutions allows the client to discuss her feelings and
participate in her care.
1 This is not relevant at this time; the client needs help with the
alterations that occur in early pregnancy. 3 Suggesting she talk with the
health care provider cuts off communication and does not address the
client’s concerns. 4 Discounting her concerns cuts off communication;
also it may cause the client to worry that something is seriously wrong.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Caring; Communication/Documentation; Nursing
Process: Planning/Implementation
12. 1 More information is needed before the nurse can give a professional
response.
2 Although the client’s feelings are important, at this time she is seeking
information. 3 Although most women do work through pregnancy,
more information is needed before the nurse should respond. 4 Saying
that women usually quit work at the start of the third trimester is
misinformation.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Assessment/Analysis
13. 3 Elevation of the extremities several times daily is recommended to
decrease the dependent edema.
1 Fluid intake should be encouraged because adequate hydration
maintains fluid and electrolyte balance. 2 Sodium intake should not be
restricted because it is needed to balance the increased fluid volume
during pregnancy. 4 Diuretics can be harmful and are not used during a
healthy pregnancy.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
14. 2 The supine position results in pressure on the vena cava by the gravid
uterus; this impedes venous return, causing hypotension and decreased
systemic perfusion.
1 A lengthened labor may or may not happen. 3 Even if placental
perfusion is decreased, it is not the reason for discouraging the supine
position. 4 The supine position can lead to hypotension, not
hypertension.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
C H AP T E R 4
Maternal and fetal nutrition
Nutrient needs before conception
• A healthy diet ensures adequate nutrients for the developing fetus
• The first trimester is critical in terms of embryonic and fetal development
• Many women do not realize they are pregnant for the first 8 weeks
• Healthy eating patterns are appropriate for any woman of childbearing
age
• Desirable body weight reduces maternal and fetal risks
• For overweight or obese women, their pregnancies will be healthier if
they lose weight before pregnancy; weight loss during pregnancy is not
advised.
• Folic acid intake
• Neural tube defects can occur with poor intake
• Take 400 mcg/day of supplemental folic acid = 0.4 mg/day per Centers
for Disease Control and Prevention (CDC) if planning to become
pregnant
■ During pregnancy, recommendation rises to 0.6 mg/day (= 600
mcg/day) for women who have no previously affected child with
neural tube disorder (NTD) such as spina bifida
■ For women with a previously affected child, the CDC
recommendation is 4 mg/day (= 4000 mcg/day) from 4 weeks before
conception through the first 3 months of pregnancy. She should take
this supplement even if she is not planning to become pregnant.
Note this is 10 times the usual preconception dose: 4 mg/day (instead
of the usual 0.4 mg/day).
■ Note that long-term use of oral contraceptives inhibits folate
absorption and enhances its degradation by the liver. Folate stores
may be more rapidly depleted in women who have used oral
contraceptives, which may lead to higher incidence of deficiency in
these women if they become pregnant.
• Alcohol use is contraindicated in women who may become pregnant
• Alcohol is a teratogen. There is no safe level established.
• Medical conditions affecting nutrition
• Screening for anemia should take place before pregnancy
■ Anemia should ideally be resolved before pregnancy begins
• Diabetes should ideally be under control before pregnancy (See also
gestational diabetes mellitus).
• Discussions of treatment of other chronic conditions (such as kidney
disease, liver disease, cystic fibrosis, and seizures) should occur before
pregnancy so that medication use can be altered if necessary
Nutrient needs during pregnancy
Energy needs
• Exact amount depends on mother’s prepregnancy weight, health status,
and activity level
• Active, large, teenage, and underweight women may require more
energy than the standard guidelines
• Pregnant women are encouraged to participate in an exercise program
that leads to an eventual goal of moderate-intensity exercise for at least
20 to 30 minutes per day on most or all days of the week (total ∼150
minutes/week)
• Purpose of increased calories
• Meet increased basal metabolic needs for both the mother and the
fetus, including growth needs
• Spare protein for tissue building
• Additional energy needs per trimester
• First trimester: energy needs are about the same as prepregnancy needs
• Second trimester: increased need of 340 kcal/day
• Third trimester: increased need of 452 kcal/day
• Average increase over all three trimesters is ∼300 kcal/day
• Mother should be counseled with 300-kcal examples, such as one snack
of 300 kcals
• Mother is not “eating for two”!
• Preferred sources of increased energy are increased carbohydrates,
monounsaturated fats and polyunsaturated fats, especially during late
pregnancy and lactation
Weight gain (table 4.1)
Weight gain (table 4.1)
• Rationale: sufficient weight gain is necessary for successful pregnancy
• Hazards of restricting adequate weight gain: small weight gain increases
risk for premature birth, low birthweight/small-for-gestational-age
infant, low Apgar scores, and morbidity
• Average weight gain distribution during a normal pregnancy shows that
the fetus is the largest component
• Fetus: 7 to 8.5 lb
• Placenta: 2 to 2.5 lb
• Amniotic fluid: 2 lb
• Uterine tissue increase: 2 lb
• Breast tissue: 2 lb
• Blood volume increase: 4 to 5 lb
• Increased tissue fluid: 3 to 5 lb
• Increased stores (fat): 4 to 6 lb
• Body mass index (BMI) helps to individualize appropriate weight gain
• Determines a prepregnancy weight category: normal, underweight,
overweight, obese
• Women of normal weight should gain
■ 25 to 35 lb (11.5 to 16 kg); about 4 lb every month after an initial 2- to
4-lb gain in first trimester
■ First trimester: 2 to 4 lb (1 to kg)
■ Second and third trimesters: ∼1 lb (0.45 kg) per week
• Underweight women need to gain more: 28 to 40 pounds (12.5 to 18 kg)
• Overweight women should gain less, but still gain 15 to 25 pounds (7 to
11.5 kg)
• Obese women still need to gain 11 to 20 pounds (5 to 9 kg) in order to
ingest enough nutrients for the fetus’s health
• Multifetal pregnancy: twins—woman should gain 4 to 6 pounds in first
trimester, 1½ pounds per week in second and third trimesters, for a
total of 37 to 54 pounds (16.5 to 24.5 kg)
• Pregnant adolescent: weight gain based on BMI as for adults
• Pattern/rate of weight gain important (see Table 4.1)
■ Sudden increased weight gain after the 20th week can be a sign of
edema and risk for hypertension
• Excessive weight gain
■ Has both short- and long-term complications for the mother and fetus
■ Mother’s weight gain is a predictor of birthweight and is associated
with infant’s BMI later in life
TABLE 4.1
Recommendations for Total Weight Gain and Rate of Weight Gain During
Pregnancy, by Prepregnancy BMI
*
Calculations assume a 0.5–2 kg (1.1–4.4 lb) weight gain in the first trimester.
†
Normal-weight women carrying twins: 37–54 lb.
From Rasmussen, K.M. & Yaktine, A.L., (Eds.). (2009). Weight gain during pregnancy: Reexamining the
guidelines, Washington, DC: National Academies Press.
Protein
• Rationale for increased need: provides for fetal growth demands of new
body tissues as well as placental development, growth of the fetus and
maternal tissues, and increased maternal blood volume and amniotic
fluid
• Daily recommended intake is 71 g/day (compared with 46 g/day in a
nonpregnant woman); increase is 25 g/day for pregnancy
• However, in the United States, the average woman’s (age 20 to 39 years)
nonpregnant diet already contains 74 grams of protein daily—so an increase
from the woman’s usual diet may not be needed; a personalized dietary
plan is best to determine any change in protein recommendation.
• Complete protein sources = animal products (milk, eggs, beef, poultry,
fish, pork, cheese, etc.) and soy products
• Incomplete proteins from plant sources (eg, beans and grains)
• Protein-rich foods contain other important nutrients (eg, milk also has
calcium)
Omega-3 fatty acids
• Omega-3 fatty acids are critical for fetal neurodevelopment
• Studies show that adequate intake decreases the chance of preterm
delivery
• Fish, although an excellent source of omega-3 fatty acids, may contain
mercury contamination and should therefore be limited to two 6-ounce,
low-mercury seafood servings per week, such as shrimp, salmon, pollock,
catfish, scallops, and sardines
• Other sources are vegetable oils and supplements, but there are no
guidelines for supplements at this time
Fluids
• 2.3 L (2300 mL = 78 oz/day or eight 10-oz glasses/day)
• Water, milk, decaffeinated teas are sources
• Promotes regular bowel function, helps resolve constipation
• Dehydration increases the risk of preterm labor, so fluid intake should
be encouraged
• Fluid intake before, during, and after exercise should be encouraged
Minerals
• Iron
• The daily recommended intake (DRI) for pregnant women rises to 27
mg/day (instead of 18 mg/day for nonpregnant women ages 19 to 50)
• Pregnant women are at risk of deficiency because of higher
requirements during pregnancy for fetal needs (liver storage) and
increasing maternal blood volume
• Iron-deficiency anemia increases the risk of maternal and infant death,
preterm delivery, and low birthweight. It also negatively affects infant
brain development and function.
• Relatively high plasma volume during pregnancy produces a
physiologic anemia because of the relatively lower hemoglobin
concentration and hematocrit
■ Screening for anemia should take place before pregnancy, as well as
during each trimester of pregnancy
• The National Academy of Sciences recommends 30 mg/day as an iron
supplement during pregnancy for women with normal preconception
hemoglobin measurements. The supplement can be delayed until the
12th week if nausea in the first trimester prevents starting it sooner.
■ For women with poor preconception hemoglobin measurements or
who are carrying more than one fetus, a supplement of 60 to 100
mg/day is recommended until hemoglobin levels are normal.
• Certain foods taken with iron can help absorption (eg, foods high in
vitamin C, such as citrus fruits and juices)
• Antacids should not be taken concurrently with iron supplements, as
they interfere with the absorption of iron
• Iron needs in the pregnant adolescent are higher than for adult women
to support enlarging muscle mass as well as increasing blood volume;
the DRI for pregnant women younger than 19 years also rises (from
nonpregnant level of 15 mg/day) to 27 mg/day; the 30 mg/day
supplement is still recommended in this age group
• Calcium
• Calcium promotes fetal bone and tooth development, prevents maternal
bone loss
• The DRI for calcium during pregnancy is 1000 mg/day for women 19 or
older, the same as for nonpregnant women of the same age
• The DRI for calcium for women younger than 19 years is 1300 mg/day
• Inadequate maternal calcium intake during pregnancy is associated
with preterm delivery
• Although the DRI for calcium is easily reached with a diet that includes
at least three servings of dairy products (at least four for women
younger than 19 years), not all women consume dairy products
• If a pregnant woman is lactose intolerant or does not drink milk,
alternative sources of calcium are available from fish, beans, tofu,
greens, and other sources. Note that yogurt, cheese, and buttermilk
may be tolerated even if fluid milk is not.
• Calcium supplements may be needed for women who do not ingest the
DRI and for women carrying more than one fetus
• Magnesium
• The DRI for magnesium during pregnancy is 400 mg/day
• As many as half of pregnant and lactating women may have inadequate
magnesium intakes
• Good sources include dairy products, nuts, whole grains, and leafy
green vegetables
• Sodium
• Needs for sodium increase just slightly during pregnancy because of
expanded blood volume
• Sodium restriction is not recommended
• Sodium restriction does not affect the rate of preeclampsia
• Sodium restriction can stress the kidneys and adrenal gland
• Moderate peripheral edema is normal during pregnancy
• Potassium
• Adequate potassium intake is associated with reduced risk for
hypertension
• A diet of 8 to 10 servings of unprocessed fruit and vegetables daily
provides adequate potassium
• Zinc
• DRI for pregnant women is 11 mg/day, but vegetarians may need more
because the phytates from whole grains and beans bind with zinc and
may reduce absorption
• Deficiency is associated with central nervous system malformations, low
birthweight, and preterm birth
• Large amounts of iron and folic acid (such as those in supplements
during pregnancy) can inhibit the absorption of zinc—so zinc
consumption from food sources should be encouraged. For women
receiving iron supplements of 60 mg/day or higher, zinc (and copper)
supplementation is recommended.
• Good sources include liver, shellfish, meats, whole grains, and milk
Vitamins
• DRIs for most vitamins are higher for pregnant women than nonpregnant
women. As energy intake increases, so do the amounts of nutrients in the
foods ingested; thus most vitamins do not require supplementation
during pregnancy.
• Fat-soluble vitamins
• Stored in body tissues; although toxicity from food sources is highly
unlikely, it is possible to ingest an overdose from supplements
• Vitamin A
■ Low levels of maternal vitamin A (retinol) are associated with lowerbirthweight infants; excessive levels from supplements of the
preformed vitamin A (beyond standard prenatal supplements) can
result in congenital malformations
■ Good food sources of the precursor, β-carotene, are dark green and
deep yellow vegetables (leafy greens and carrots), plus fruits such as
cantaloupes and apricots (note orange color)
• Vitamin D
■ Important in calcium absorption and bone health, as well as fetal
bone development and mineralization
■ Deficiency is associated with increased chance of having a primary
cesarean section, decreased birthweight, and may be associated with
preeclampsia and preterm birth
■ DRI is 15 mcg/day (600 IU) during pregnancy. This need can be met
with at least 3 cups/day of vitamin D−fortified milk, which contains
about 10 mcg (400 IU) per quart.
■ Additional vitamin D is derived from synthesis after sun exposure
■ Use of sunscreen can reduce skin production by as much as 99%,
making ingestion of fortified foods even more important
■ Evidence does not support the need for vitamin D supplementation
during pregnancy, unless the mother has low serum levels, is a strict
vegetarian, or avoids sunlight or dairy foods
■ For women who do not consume cow’s milk (vegans or lactose
intolerant), vitamin D− fortified soy milk or rice milk products are
sources
• Vitamin E
■ Combats oxidative stress; it has antioxidant functions
■ Good sources are vegetable oils and nuts
• Water-soluble vitamins
• Body stores are minimal, so daily ingestion is important. Toxicity from
overdose is much less likely than for fat-soluble vitamins.
• Folate (and folic acid)
■ Vital for neural tube formation and hemoglobin synthesis; also
involved in synthesis of nucleic acids and several amino acids
■ Prevents NTDs (such as spina bifida and anencephaly), although the
mechanism is unknown
■ DRI of 600 mcg/day of folic acid (0.6 mg/day) by the CDC for pregnant
women is most easily attained with a supplement. If a mother has a
previous child affected by NTD, the amount recommended rises to 4
mg/day (see also NUTRIENT NEEDS BEFORE CONCEPTION)
■ Folate’s function in hemoglobin synthesis also means that it is
involved in preventing anemia
■ Good sources include enriched flour and grain products, fortified
cereals, liver, legumes such as beans, orange juice, asparagus, and
broccoli
• Vitamin C
■ Plays a role in tissue formation and enhances iron absorption
■ DRI of 85 mg/day can be met by including one to two daily servings of
citrus fruit or juice or other good sources, such as kiwi, strawberries,
and fresh tomatoes
■ Women who smoke have an increased need for vitamin C
• Vitamin B6
■ Has roles in metabolism of all macronutrients, as well as the
synthesis of red blood cells, antibodies, and neurotransmitters
■ DRI of 1.9 mg/day; larger amounts may help reduce nausea and
vomiting
■ Good sources include meats, dark green vegetables, whole grains
• Vitamin B12
■ Especially important in neural growth and functioning
■ DRI during pregnancy is 2.6 mcg/day
■ Deficiency is associated with developmental anomalies, spontaneous
abortions, preeclampsia, and low birthweight
■ Sources only include animal products (meat, milk, eggs, fish, poultry);
some vegan products are fortified with it
■ A supplement is indicated for women who do not include sources of
vitamin B12 in their diet (vegans)
Multivitamin-multimineral supplements during
pregnancy
• Supplementation with iron (30 mg/day) and folic acid (600 mcg/day) is
supported with evidence for improved outcomes
• Micronutrient supplementation of other nutrients does not have sufficient
evidence for support, except for the special circumstances for calcium,
zinc, vitamin D, and vitamin B12 as noted earlier
• Still, most health care providers prescribe a prenatal supplement because
many women do not ingest sufficient nutrients to meet nutritional needs
during the first trimester, especially for folic acid and iron
• Even when a pregnant woman is taking a vitamin–mineral supplement, it does
not decrease the need to ingest a nutritious diet
Additional considerations
• Alcohol
• Alcohol is a teratogen; there is no safe level of consumption established
for pregnant women
• Any use is contraindicated throughout pregnancy
• Fetal alcohol syndrome can result from maternal consumption during
pregnancy
■ Fetal alcohol syndrome features include central nervous system
abnormalities, growth restriction, and facial dysmorphism
• Caffeine intake
• Caffeine crosses the placenta and is distributed to all fetal tissues
• Caffeine is a diuretic, so it increases the frequency of urination
• Caffeine is a stimulant, increases heart rate and blood pressure, and
interferes with sleep
• Studies connecting caffeine intake with miscarriage are conflicting
• The March of Dimes recommends limiting caffeine consumption to less
than 200 mg/day, which is about the amount in one 12-oz cup of coffee
• Pica
• Pica is the ingestion of nonfood substances or excessive amounts of lownutrient substances, such as cornstarch or ice
• Risks
■ Nonfood substances may be contaminated with heavy metals or other
harmful ingredients
■ Nonfood substances may displace nutritious food needed for fetal
growth
■ Nonfood substances can interfere with the absorption of nutrients
• Women who have pica should be tested for iron-deficiency anemia
• Substances consumed can be influenced by cultural background
• Cravings
• There is no evidence to support the idea that cravings are caused by
missing nutrients in the diet
• Nurses can suggest healthy alternatives for unhealthy cravings, eating
small amounts of craved foods, eating regularly to avoid hypoglycemia,
using other techniques to curb the craving
• Artificial sweeteners
• These artificial sweeteners have been approved by the Food and Drug
Administration (FDA) for use during pregnancy: aspartame,
acesulfame potassium, and sucralose
■ Aspartame (which contains phenylalanine) should be avoided by
women with phenylketonuria (PKU)
• No acceptable intake has been established for stevia or agave in
pregnant women
• Sodium intake (see “Sodium” in Minerals section)
• Lactose intolerance (see also discussions of calcium and vitamin D)
• Lactose-intolerant individuals do not have enough of the enzyme lactase
to digest milk sugar (lactose)
• If the pregnant woman does not ingest fortified cow milk, she will need
another source for sufficient calcium and vitamin D
• Lactase supplements can be used
• Gestational diabetes mellitus (GDM)
• Referral to a registered dietician for counseling is recommended
• GDM is usually controlled by a standard diet for women with diabetes,
with 30 kcal/kg/day based on prepregnancy weight
• Carbohydrate intake is restricted; complex carbohydrates are favored
over simple carbohydrates
• Surveillance of blood glucose is needed to ensure glycemic control has
been established
• Insulin is required in some women
• Moderate exercise is recommended to improve blood sugar control
• See also Chapter 6
• Vegetarianism
• Protein can be supplied from plant and other nonmeat sources
■ Complete proteins supply all essential amino acids; incomplete
proteins do not. Animal products supply complete protein; so does
soy.
■ Consuming a variety of different plant proteins—grains, dried beans
and peas, nuts, and seeds—can provide complementary proteins,
which provide all of the essential amino acids (some from one food,
the rest from another).
■ Milk and eggs can provide complete protein and other vital nutrients
for lacto-, ovo-, and lacto-ovo vegetarians
• Vegans consume no animal products (no meat, eggs, milk, or other
dairy foods)
■ Need a source of vitamin B12 in their diets, such as a supplement or
fortified food
■ May also need a supplement of vitamin D
■ Referral to a dietician is warranted for a thorough diet history to
ensure adequate intake of vital nutrients during pregnancy
• Cultural preferences
• Nurse should be aware of what constitutes a typical diet for each
cultural or ethnic group; different cultural groups’ diets favor different
essential nutrients
Daily intake
• A food plan will ideally be developed on an individual basis
• Recommended fiber intake is 28 g/day (compared with 25 g/day for
nonpregnant women)
• A nutrient-rich diet as shown in Table 4.2 should be eaten by the pregnant
woman, including grains, vegetables, fruits, milk, meat, and beans, as well
as healthy oils. Vegetables should include various colors and types.
• Protein—71 g/day (1.1 g/kg/day) should be supplied daily
• Calcium—1200 mg/day should be included daily
• Iron—30 mg/day as a supplement
• Folic acid—600 mcg/day as a supplement
TABLE 4.2
Daily Food Plan for Pregnant Women *,
†
*
This particular food plan is based on the average needs of a pregnant woman who is 30 years old, who is 5
feet, 5 inches tall, whose prepregnancy weight was 125 pounds, and who is physically active between 30
and 60 minutes each day. Plans provided by the MyPlate.gov site are specific to each individual woman;
however, this is an example for a woman of the described stature and activity level.
†
These plans are based on 2200-, 2400-, and 2600-calorie food-intake patterns. The recommended nutrient
intake increases throughout the pregnancy to meet changing nutritional needs.
1
Make half of the grains be whole grains.
2
Vary your veggies.
Data from U.S. Department of Agriculture, Center for Nutrition Policy and Promotion (2016). USDA’s
MyPlate home page, www.choosemyplate.gov.
Application and review
1. During her first visit to the prenatal clinic, it is determined that a client is
obese. During the ensuing 5 months, the client has not been successful in
adhering to her nutritional plan. Which finding indicates to the nurse that
she has been successful during the sixth month?
1. Weight loss of 1 pound
2. Weight gain of 2 pounds
3. Same weight this month as last month
4. Statement that she lost weight last week
2. A client who is pregnant for the first time attends the prenatal clinic. She
tells the nurse, “I’m worried about gaining too much weight because I
have heard that it is bad for me.” How should the nurse respond?
1. “Yes, too much weight gain causes complications during
pregnancy.”
2. “You’ll have to follow a low-calorie diet if you gain more than 15
pounds.”
3. “We’re more concerned if you don’t gain enough weight to ensure
adequate growth of your baby.”
4. “A 25-pound weight gain is recommended, but the pattern of weight
gain is more important than the total amount.”
3. A nurse teaches a pregnant woman about the need to increase her intake
of complete proteins. Which foods identified by the client indicate that the
teaching is effective? Select all that apply.
1. Nuts
2. Milk
3. Eggs
4. Bread
5. Beans
6. Cheese
4. A pregnant client with iron-deficiency anemia is prescribed iron
supplements daily. To increase iron absorption, the nurse should suggest
that the client eat foods high in what?
1. Vitamin C
2. Fat content
3. Water content
4. Vitamin B complex
5. A nurse caring for a pregnant woman determines that she is engaging in
the practice of pica. Why should the nurse prepare a teaching plan for this
client?
1. Inedible items are being ingested.
2. There is a need for a particular food.
3. Many foods cause nausea and vomiting.
4. There is a dislike for an essential group of foods.
6. A pregnant woman tells a nurse in the prenatal clinic that she knows folic
acid is very important during pregnancy and she is taking a prescribed
supplement. She asks the nurse what foods contain folic acid (folate) so
she can add them to her diet in its natural form. Which foods should the
nurse recommend? Select all that apply.
1. Beef and fish
2. Milk and cheese
3. Chicken and turkey
4. Black and pinto beans
5. Enriched bread and pasta
7. During a client’s first visit to the prenatal clinic, a nurse discusses a
pregnancy diet. The client states that her mother told her she should
restrict her salt intake. What is the nurse’s best response?
1. “Your mother is correct. You should use less salt to prevent
swelling.”
2. “Because you need salt to maintain body water balance, it is not
restricted. Just eat a well-balanced diet.”
3. “Salt is an essential nutrient that is naturally reduced by the body’s
estrogen. There is no reason to restrict salt in your diet.”
4. “We no longer recommend that salt intake be as restricted as much
as in the past. However, you shouldn’t add salt to your food.”
8. A client is concerned about gaining weight during pregnancy. What should
the nurse explain is the cause of the largest amount of weight gain during
pregnancy?
1. Fetal growth
2. Fluid retention
3. Metabolic alterations
4. Increased blood volume
See Answers on pages 52-54.
Nutrient needs during lactation
Food plan
• The core diet recommended for pregnancy, including any supplements,
should be continued through lactation
• Nutrient needs during lactation are generally higher than for nonpregnant
women; some are even higher than during pregnancy (eg, vitamin C, zinc,
protein)
• Fiber needs remain higher (29 g/day) than those of nonpregnant women
• MyPlate food guide system provides specific information
• Goal: double the infant’s birthweight in about 5 months
Energy
• Lactation requires additional energy because energy is stored in the milk
produced, and energy is used in making the milk
• Recommended increases over nonpregnant energy needs are 330 kcal/day
for the first 6 months of lactation and 400 kcal/day thereafter
• Additional energy comes from maternal stores, which translates into
weight loss for the mother
• Discuss appropriate weight-loss goals during lactation, ∼1 kg/month
Fluid
• Breastfeeding mothers need ample fluids for adequate milk production
• Fluid intake should be about 3 L/day
• Sources include water, juices, milk, and soup
• Beverages that contain alcohol and caffeine should be avoided, because
they pass into the breast milk
■ Breastfed babies of women who drink large amounts (more than 2 to
3 cups/day) of caffeinated beverages may be unusually active and
have difficulty sleeping
■ Caffeine intake can result in a reduced iron content of the milk and
contribute to anemia in the infant
■ Alcohol use may impair the milk-ejection reflex
Protein
• Protein needs are 25 g/day higher than for the nonpregnant woman, or ∼71
g/day
Minerals and vitamins
• Iron and folic acid needs decrease compared with pregnancy because the
mother is no longer making an expanded blood supply
• Vitamins and minerals involved in energy have higher requirements than
nonpregnant needs
• Recommendations for vitamins A and C and for zinc are higher than in
pregnancy to allow for nutrients given to the infant in milk
• Calcium requirements remain just as high as during pregnancy, and
vitamin B12 requirements are slightly higher
• Similar cautions apply to lactating women who do not consume milk. A
fortified supplement should be included in the diet to supply the
requirements of calcium as well as vitamins D and B12.
Care management
Assessment
• Advise that nutritional status can affect the pregnancy outcome
• Considerations
• Age and parity: frequent births may mean maternal nutrient stores are
depleted
■ Adolescence
■ Social and economic factors
■ Dual demands of pregnancy and adolescence
■ Tend to eat more “junk food,” which does not contain needed
nutrients for adequate fetal growth
• Previous obstetric history: history of preterm births, low-birthweight
infant, or small-for-gestational-age infant can indicate inadequate
dietary intake
• Contraceptive methods
■ Blood loss from recent intrauterine device placement
■ Low folate and high iron stores from oral contraceptive use
• Health history
• Current and past medical conditions
■ Chronic illnesses, such as diabetes, high blood pressure, renal or liver
disease, malabsorption syndromes, cystic fibrosis, seizure history can
all affect pregnancy
■ Previous iron-deficiency anemia
■ Pattern of inadequate or excessive weight gain
■ Current medications and supplements (see Chapter 3)
■ Refer patient to registered dietitian for detailed counseling if she will
need medical nutrition therapy during pregnancy
• Exercise pattern will affect energy requirements
• Review of systems
■ Gastrointestinal: appetite, digestion, elimination
■ Cardiovascular: history of heart or vascular problems
■ Respiratory: inquire about smoking history and any chronic
conditions
■ Endocrine: metabolic syndrome, thyroid conditions, etc.
• Previous maternal diet
• Use a food intake or diet history questionnaire to establish eating
patterns
• Inquire about
■ Food categories that seem to be missing from the diet (missing
animal products that may signal vegetarianism, dairy intake,
vegetable intake)
■ Food allergies or intolerances (eg, lactose intolerance)
■ Cultural practices related to food, such as pica
■ Any evidence of eating disorders
• Assess food habits and preferences
• Inquire about current gastrointestinal discomforts: nausea/vomiting,
constipation, pyrosis (heartburn)
• Assess the woman’s financial ability to afford nutritious food versus the
need for assistance, as well as access to refrigeration and cooking
implements
• Assess the woman’s understanding of sound nutrition and nutrition
education needs
• When concerns are noted, notify the health care provider; a nutritional
consultation may be needed
Physical examination
• Measurements: height, weight, BMI
• Serial weight measurements crucial to establishing pattern of weight
gain
• BMI important to determine energy requirements
• Physical signs of malnutrition
• Caution is advised when interpreting physical signs because some
symptoms of pregnancy, such as peripheral edema, could be
misinterpreted as signs of malnutrition
■ Interpret any physical findings with information from the history and
laboratory tests
• Vital signs: be alert for disturbances of heart rate or rhythm, breathing
difficulties, blood pressure abnormalities
• General appearance, hair, skin, face, eyes, oral cavity, and skeleton all
assessed by observation
• Palpation for swelling (thyroid, extremities, abdomen) and texture
(muscle tone)
• Percussion for enlargement of abdominal organs, lung excursion
• Auscultation of heart for murmurs
Laboratory testing
• Hematocrit or hemoglobin used to screen for anemia
• Normal values adjusted to reflect physiologic anemia of pregnancy
• Lower limit for normal is 11 g/dL in first and third trimesters, 10.5 g/dL
in second trimester (versus 12 g/dL in nonpregnant women)
Nutritional care and patient education
• Physical and psychologic
• Teach the woman about nutritional needs during pregnancy and what
constitutes an adequate diet during pregnancy (see Table 4.2). Work
with her to accommodate all circumstances—cultural, personal,
financial, health—and yet follow a food plan that is good for her and
the fetus.
• Emphasize nutrient-dense foods and reading food labels.
• Explain that avoiding nutrient-poor foods gives room calorically for
nutrient-dense foods
• Use the ChooseMyPlate pregnancy weight gain calculator to
individualize energy needs: http://www.choosemyplate.gov/pregnancyweight-gain-calculator
■ Women must be educated that they are not “eating for two”
• Use the ChooseMyPlate “My Plate Daily Checklist” to help her plan an
individualized daily food plan: http://www.choosemyplate.gov/momsdaily-food-plan
• Discuss alterations for gestational diabetes or other medical conditions
and any needed referral to a dietitian
• Explain the need for iron and folate supplements
• Limit caffeine to less than 200 mg/day
• No level of alcohol consumption is safe during pregnancy; alcohol is a
teratogen. (see also “Alcohol” earlier)
• Discuss food safety (see later)
• Adolescence
■ Important to include adolescent and person who purchases and
prepares food (if it is not the pregnant adolescent) in nutrition
teaching
■ Focus on improving the adolescent’s understanding and behaviors in
the following categories:
■ Nutrition knowledge
■ Meal planning
■ Food preparation
• Cultural
• Review ways to incorporate cultural traditions within a healthy food
plan during pregnancy
• Discuss how various cultural foods fit into the MyPlate food groups
• Explain the risks of pica (if needed; see earlier)
• Economic
• Offer information about the Supplemental Nutrition Assistance
Program (SNAP) and Women, Infants, and Children (WIC) if needed
• SNAP: offers nutrition assistance to eligible, low-income individuals
and families and provides economic benefits to communities. The Food
and Nutrition Service works with state agencies, nutrition educators,
and neighborhood and faith-based organizations to ensure that those
eligible for nutrition assistance can make informed decisions about
applying for the program and can access benefits. Information is
available at www.fns.usda.gov/snap
• WIC: provides federal grants to states for supplemental foods, health
care referrals, and nutrition education for low-income pregnant,
breastfeeding, and nonbreastfeeding postpartum women and to infants
and children up to age 5 who are found to be at nutritional risk.
Information is available at www.fns.usda.gov/wic
• Management of common nutrition-related problems
• Nausea and vomiting; heartburn and indigestion
■ Instruct to eat small, low-fat meals and snacks; to eat dry crackers in
the morning; to eat slowly and frequently; to avoid strong food odors
and spicy foods; to wait 1 to 2 hours after eating a meal before lying
down; to limit fluids with meals and instead drink fluids between
meals; to restrict fat; to be sure to eat all grains in daily food plan; to
eat a protein snack at bedtime; to wear loose-fitting clothes; to avoid
skipping meals and thus becoming very hungry
■ Instruct patient to consult with health care practitioner if nausea and
vomiting are severe or if weight loss occurs. Some providers
prescribe a combination of vitamin B6 and doxylamine.
■ Do not take any medication without consulting health care provider.
■ Ask health care provider whether iron supplementation can be
postponed to start in the 12th week of pregnancy if it is contributing
to nausea
• Constipation
■ Advise patient to increase fluid intake; increase daily fiber intake,
including additional fruits, vegetables, and whole grains; participate
in moderate physical activity; add a psyllium fiber supplement; set
aside a specific time of day for bowel movement; and ask health care
provider about the use of stool softener if taking iron supplements
• Food safety (see FoodSafety.gov)
• Pregnant women have altered immune and hormonal function that puts
them more at risk for food poisoning
• Food poisoning
■ Illness from food can have maternal and fetal effects
■ Wash vegetables and fruits well; cook all meats; avoid foods listed
later; only consume dairy products that have been pasteurized
■ Wash hands often
■ Refrigerate foods promptly: “keep hot foods hot; cold foods cold”
■ Wash all surfaces that come into contact with raw meat, fish, or
poultry with hot soapy water. Keep foods that will not be cooked
(such as fresh salad ingredients) on separate surfaces from those of
raw meats.
■ Peel vegetables or wash well with soap and water to remove mercury
• Food restrictions: limit seafood
■ Limit to no more than 12 ounces per week these low-mercury fish:
shrimp, salmon, pollock, catfish, canned light tuna, pangasius,
tilapia, cod, clams, crab
■ Limit to no more than 6 ounces in 1 week of albacore white tuna and
tuna steaks
■ Privately caught fish: check with local health department before
eating
• Foods to avoid
■ Raw or undercooked fish and shellfish; smoked seafood
■ Highly carnivorous fish (likely high in mercury): tuna, shark, tilefish
(includes golden and white snapper), swordfish, mackerel/king
mackerel
■ Soft-scrambled eggs; foods made with raw or lightly cooked eggs,
including eggnog
■ Unpasteurized juices, cider, and milk
■ Soft cheeses and foods made from soft cheeses (Brie, feta,
Camembert, Roquefort, queso blanco, and queso fresco)
■ Raw sprouts, such as alfalfa sprouts
■ Raw or undercooked meats, poultry (and stuffing), seafood, hot dogs
■ Deli meats (eg, ham, bologna): can cause food poisoning; must be
reheated before eating
■ Meat spreads or paté
■ Homemade ice cream; raw cookie and cake batter (because of the raw
eggs in them)
■ Herbal supplements and teas
Application and review
9. A pregnant client complains of constipation. Which strategies should the
nurse recommend? Select all that apply.
1. Exercise regularly.
2. Take a mild laxative before breakfast.
3. Drink at least one caffeinated beverage daily.
4. Add a few tablespoons of wheat bran to cereal at breakfast.
5. Plan to have a bowel movement at the same time every day.
10. When discussing dietary needs during pregnancy, a client tells the nurse,
“I do not like to drink milk because it makes me constipated.” What
should the nurse recommend?
1. Replace nonfat milk with whole milk.
2. Substitute a variety of cheeses for the milk.
3. Treat constipation in some way other than omitting milk.
4. Increase the number of prenatal capsules so the milk can be
omitted.
11. A primigravida tells the nurse that she has morning sickness. What
suggestion should the nurse make to help relieve the nausea?
1. Eat three small meals a day.
2. Increase dietary calcium.
3. Avoid long periods without food.
4. Drink 2 quarts or more of fluid a day.
12. During a prenatal interview at 20 weeks’ gestation, the nurse determines
that the client has a history of pica. What is the most appropriate nursing
action?
1. Seek a psychologic referral for the client.
2. Ensure that the client’s diet is nutritionally adequate.
3. Inform the client of the danger this poses to her fetus.
4. Obtain an order for multivitamin supplements for the client.
13. A nurse is providing dietary counseling to a client who is at 14 weeks’
gestation. The client is a recent immigrant from Asia, and the nurse
explores the foods the client usually eats. Which foods does the nurse
counsel her to avoid during pregnancy? Select all that apply.
1. Yogurt
2. Oily fish
3. Apricots
4. Raw shellfish
5. Herbal supplements
6. Soft-scrambled eggs
14. Why is it important for a nurse in the prenatal clinic to provide
nutritional counseling to all newly pregnant women?
1. Most weight gain is caused by fluid retention.
2. Different cultural groups favor different essential nutrients.
3. Dietary allowances should not increase throughout pregnancy.
4. Pregnant women must adhere to a specific pregnancy dietary
regimen.
15. A primigravida in her 10th week of gestation is concerned because she
has read that nutrition during pregnancy is important for the growth and
development of the fetus. She wants to know something about the foods
she should eat. What should be the nurse’s initial response?
1. Instruct her to continue eating her regular diet.
2. Ask her what she has eaten over the last 3 days.
3. Give her a list of foods to help her plan her meals more efficiently.
4. Emphasize to her the importance of limiting highly seasoned foods.
16. What should a nurse include in nutritional planning for a newly pregnant
woman of average height weighing 145 pounds?
1. A decrease of 100 calories per day
2. A decrease of 200 calories per day
3. An increase of 300 calories per day
4. An increase of 500 calories per day
17. A pregnant adolescent at 10 weeks’ gestation visits the prenatal clinic for
the first time. The nutrition interview indicates that her dietary intake
consists mainly of soft drinks, candy, French fries, and potato chips. Why
does the nurse consider this diet inadequate?
1. Caloric content will result in too great a weight gain.
2. Ingredients in soft drinks and candy can be teratogenic in early
pregnancy.
3. Salt in this diet will contribute to the development of gestational
hypertension.
4. Nutritional composition of the diet places her at risk for a lowbirthweight infant.
18. What should a nurse suggest to a pregnant client that might help
overcome first-trimester morning sickness?
1. “Eat protein before bedtime.”
2. “Take an antacid before breakfast.”
3. “Drink water until the nausea subsides.”
4. “Request a prescription for an antiemetic.”
See Answers on pages 52-54.
Answer key: Review questions
1. 2 Although obese, the client must gain weight to meet the fetus’s
nutritional needs; a weight gain of 2 pounds is appropriate.
1 Losing weight is contraindicated during pregnancy because it may
interfere with fetal growth and development. 3 The same weight month
to month may indicate that the nutritional needs of the fetus are not
being met. Weight gain is necessary even for the obese pregnant
woman. 4 Statements from the client are not objective measurements.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
2. 4 A sudden, sharp increase in weight may indicate fluid retention related
to preeclampsia.
1 Weight gain is necessary to ensure adequate nutrition for the fetus. The
term “too much” is vague; there rarely are complications when weight
gain is over 25 to 30 pounds in an uncomplicated pregnancy. 2 There is
no specific number of pounds that the client should gain, but lowcalorie diets are contraindicated. 3 “We’re more concerned if you don’t
gain enough weight to ensure adequate growth of your baby” closes off
communication; it does not allow the client to ask more questions
about weight gain.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis; Integrated Process:
Teaching/Learning
3. Answers: 2, 3, 6.
2 Milk contains animal proteins, which are complete proteins that
contain all the essential amino acids. 3 Eggs contain animal
proteins, which are complete proteins that contain all the essential
amino acids. 6 Cheese contains milk, which is a complete protein
that consists of all the essential amino acids.
1 Nuts are incomplete proteins; animal products (eg, milk, eggs, cheese,
meat, fish, and fowl) and soy are complete proteins. 4 Bread is not a
complete protein. 5 Beans are not complete proteins unless eaten in a
specific combination with soy products.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes; Integrated Process:
Teaching/Learning
4. 1 Vitamin C aids in the absorption of iron.
2, 3, 4. Fat content, water content, and vitamin B complex are unrelated to
the absorption of iron.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes; Integrated Process:
Teaching/Learning
5. 1 Pica is the eating of inedibles, such as starch and dirt; there is a cultural
influence on this practice. However, it may be related to malnutrition or
anemia.
2 A need for a particular food is a food craving that frequently occurs in
pregnant women. 3 Foods that cause nausea and vomiting describe
morning sickness. If it continues past the first trimester, it may be
hyperemesis gravidarum. 4 A dislike for an essential group of foods
does not describe the practice of pica.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
6. Answer: 4, 5.
4 Legumes contain large amounts of folate. 5 Enriched grain products
contain large amounts of folate.
1 Beef and fish do not contain an adequate amount of folate. 2 Milk and
cheese do not contain an adequate amount of folate. 3 Fowl does not
contain an adequate amount of folate.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
7. 2 Sodium is needed to maintain body water balance; sodium requirements
increase slightly during pregnancy to accommodate the increased blood
volume. A healthy pregnant woman should not limit her sodium intake.
1 Using salt to prevent swelling could be detrimental to the client’s
health. 3 Sodium, although essential, is not a nutrient but a mineral. 4
There are no restrictions on salt intake during pregnancy.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
8. 1 The average weight gain during pregnancy is 25 to 35 lb (11.3 to 15.8 kg);
of this, the fetus accounts for 7 to 8 lb (3.2 to 3.6 kg), or approximately
30% of weight gain.
2 Fluid retention accounts for about 20% to 25% of weight gain. 3
Metabolic alterations do not cause a weight gain. 4 Increased blood
volume accounts for about 12% to 16% of weight gain.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
9. Answer: 1, 4, 5.
1 One of the benefits of regular exercise is that it promotes peristalsis. 4
High-fiber foods promote peristalsis. 5 Setting aside a specific time of
day helps establish regular bowel habits.
2 Medications should not be recommended or taken during pregnancy
without a prescription. 3 Caffeinated beverages do not relieve
constipation and may be harmful. Staying hydrated by drinking 8 to 10
glasses of fluid per day may relieve the constipation. Water, milk, and
fruit juices are recommended.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
10. 3 Unless a lactose intolerance is present, the client should drink milk;
eating dried fruits and high-fiber foods and increasing fluids and activity
will aid in lessening constipation.
1 Nonfat milk is not as beneficial as whole milk and will cause
constipation as well. 2 Cheeses can cause constipation. 4 Megadoses of
prenatal vitamins and supplements can be harmful and are not a
substitute for milk.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
11. 3 Fasting results in hypoglycemia, which can cause nausea; in addition,
the developing fetus should not be deprived of nutrients for any length of
time; dry toast, crackers, and small, frequent meals may alleviate morning
sickness.
1 Three small meals a day are not sufficient to meet the nutritional needs
of the mother and fetus. 2 Additional calcium intake will not relieve the
nausea. 4 Fluids need not be increased, but should be consumed
between meals.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
12. 2 The primary concern when a pregnant woman practices pica is that
other intake will be nutritionally inadequate to meet both fetal and
maternal needs.
1 Pica does not necessarily indicate a psychologic/emotional disturbance;
more often it is related to the client’s culture. 3 If not toxic to the
mother, generally it is not fetotoxic. 4 Multivitamin supplements are
not necessary if other nutritional intake is adequate.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
13. Answers: 4, 5, 6.
4 The March of Dimes has included this food on its list of foods to avoid
during pregnancy; raw shellfish may be contaminated with hepatitis or
typhoid. 5 Herbal supplements and teas often have ingredients that are
medicinal and should not be taken during pregnancy without
consulting a health care provider as to safety. 6 The March of Dimes
has included soft-scrambled eggs on its list of foods to avoid during
pregnancy because they may be contaminated with salmonella.
1 Yogurt is an excellent source of calcium and is safe to eat during
pregnancy. 2 Oily fish has a high level of omega-3 oils and is safe to eat
in limited amounts during pregnancy. 3 Apricots are a source of
potassium and are safe to eat during pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
14. 2 The nurse should become informed about the cultural eating patterns
of clients so that foods containing the essential nutrients that are part of
these dietary patterns will be included in the diet.
1 Fluid retention is only one component of weight gain; growth of the
fetus, placenta, breasts, and uterus also contributes to weight gain. 3
Calories and nutrients are increased during pregnancy. 4 Pregnancy
diets are not specific; they are composed of the essential nutrients.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
15. 2 Asking what she usually eats enables the nurse to assess the woman’s
level of nutritional knowledge and gain clues for appropriate methods of
counseling.
1 A “regular” diet does not indicate that the client is eating a nutritious
diet; also, the client will need increased protein and calories. 3 These
foods may be too expensive and different from her usual choices,
leading to nonadherence to a healthy diet. 4 If the client’s diet includes
highly seasoned foods and they are well tolerated, they need not be
excluded.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
16. 3 An increase of 300 calories per day is the recommended caloric increase
for adult women to meet the increased metabolic demands of pregnancy.
1, 2 A decrease of 100 to 200 calories per day will not meet the metabolic
demands of pregnancy and may harm the fetus. 4 An increase of 500
calories per day is the recommended caloric increase for breastfeeding
mothers.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Knowledge; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
17. 4 The diet does not reflect a healthy diet with a variety of foods,
especially protein; adequate nutrition is necessary for the birth of a
healthy full-term infant whose weight is appropriate for gestational age.
1 The caloric content of these foods is not high if small amounts are
consumed; in addition, this client’s weight gain may not be reflective of
an adequate weight gain in the developing fetus. 2 No data are available
to support that ingredients in soft drinks and candy can be teratogenic
in early pregnancy. 3 Unrestricted salt intake does not contribute to the
development of gestational hypertension.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
18. 1 Nausea and vomiting in early pregnancy can be relieved with a small
snack of protein before bedtime to slow digestion.
2 An antacid may affect electrolyte balance; also this will not help
morning sickness. 3 Drinking only water is contraindicated because
both fetus and mother need nourishment. 4 Medications in the first
trimester are contraindicated because this is the period of
organogenesis, and congenital anomalies could result.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
C H AP T E R 5
Assessment of high-risk pregnancy
Assessment of risk factors
• Biophysical factors: maternal and fetal factors that affect fetal
development or functioning or maternal functioning
• Psychosocial factors: maternal behaviors that negatively affect the health
of the mother or fetus, such as emotional distress and inadequate social
support
• Sociodemographic factors: factors about the mother and the family, such
as low income and lack of prenatal care
• Environmental factors: examples include workplace hazards and exposure
to chemicals
Antepartum testing
• Goals: (1) identify fetuses at risk for injury to prevent injury and death; (2)
identify fetuses receiving appropriate levels of oxygen to avoid
unnecessary intervention
• Common indications for antepartum testing are shown in Box 5.1
• Usually begins by 32 to 34 weeks
• Results must be interpreted within the complete clinical picture, as the
rates of false-positive findings can be high
BOX 5.1
C om m on M a t e rna l a nd F e t a l I ndica t ions for
A nt e pa rt um T e st ing
Maternal indications
• Diabetes
• Chronic hypertension
• Chronic renal disease
• Preeclampsia
• Systemic lupus erythematosus
Pregnancy-related indications
• Fetal growth restriction
• Multiple gestation
• Oligohydramnios, polyhydramnios
• Preterm premature rupture of membranes
• Late term or postterm gestation
• Previous stillbirth
• Decreased fetal movement
• Cholestasis of pregnancy
Modified from Miller, L., Miller, D., & Tucker, S. (2013). Mosby’s pocket guide to fetal monitoring: A
multidisciplinary approach (7th ed.). St. Louis: Mosby and O’Neill, E. & Thorp, J. (2012). Antepartum
evaluation of the fetus and fetal well being. Clinical Obstetrics and Gynecology 55(3), 722–730.
Biophysical assessment
• Daily fetal movement count (DFMC)/maternal assessment of fetal activity
• Client counts number of fetal movements in specified period; reflects
vitality of fetus; also called kick count
• Used to monitor conditions that can affect fetal oxygenation
• Advantages: noninvasive, inexpensive, does not interfere with daily
routine
• Nursing care: teach how to monitor movements; report fewer than 3
movements in 8 hours, fewer than 10 movements in 12 hours, or no
movements in morning
• Zero movements in 12 hours warrants a nonstress test (NST; see later)
• Note that movements are not usually detectable during the fetal sleep
cycle and that obesity decreases the mother’s perception of movements
• Ultrasonography
• Uses sound energy to create an image; can produce two- or threedimensional image; if the image is across time (recorded in real time), it
is called four-dimensional
• Can be performed abdominally or transvaginally
• Guides chorionic villus sampling (CVS), amniocentesis, and
percutaneous umbilical blood sampling
• Used to assess amniotic fluid volume, called amniotic fluid index: the
sum of the deepest cordfree amniotic fluid pocket in each abdominal
quadrant
• Identifies multiple pregnancy, placental location, and gestational age by
measurement of biparietal diameters (can detect cephalopelvic
disproportion); visualizes organ formation
• Used to measure nuchal translucency (NT) between 10 and 14 weeks of
gestation to identify possible fetal abnormalities, in combination with
maternal serum marker levels; when abnormal, diagnostic genetic
testing is recommended
• Can also be used for Doppler blood flow analysis, helps determine fetal
well-being. The motion and velocity of the red blood cells are
detectable.
• Also used in biophysical profile (BPP; see later)
• Three levels:
■ Standard/basic: evaluate fetal presentation and amniotic fluid, cardiac
activity, placenta, fetal growth
■ Limited: for specific indications such as fetal presentation
■ Specialized/targeted: to view a particular anatomic part or get specific
information about physical anomaly
• Some patients look forward to ultrasound because they can learn sex of
fetus, see fetus and movement, and hear the heartbeat
• Nursing care: counseling and educating women; encourage fluids and
teach to refrain from voiding before test, when performed during first
20 weeks’ gestation, to improve visualization
• BPP
• Combines fetal heart rate (FHR; normal between 110 and 160 beats/min)
monitoring with four parameters observed from fetal ultrasound
• Assesses five categories: fetal breathing movements, gross body
movements, tone, amniotic fluid volume, FHR reactivity during NST;
each category is assigned a score of 2; used for fetus who may be
compromised
• Score of 8 to 10 indicates healthy fetus
• Nursing care: initiate care related to amniocentesis (if needed); provide
emotional support; evaluate response
• Modified biophysical profile (mBPP)
• Combines the NST (see later) with the amniotic fluid index
• Shortens testing time versus the BPP
• Magnetic resonance imaging
• Provides excellent images of soft tissue; fetal and maternal structures
can be examined
• Can be used to quantify amniotic fluid
Biochemical assessment
• CVS
• Done at 10 to 12 weeks’ gestation; sonogram before and during test to
determine placental location, uterine position, and relative placement
of neighboring organs (bowel, blood vessels)
• Advantages: earlier diagnosis and rapid results compared with
amniocentesis; relatively safe procedure; risks no higher than in the
general population
• Removes a small tissue specimen from the placenta, which has the same
genetic composition as the fetus
• Can be performed transcervically or transabdominally (Fig. 5.1)
• Supplies chromosomal data (such as Down syndrome or Tay-Sachs
disease)
• Nursing care: instruct to drink fluid to fill bladder (because of the
concurrent ultrasound); after test monitor for uterine contractions and
vaginal discharge; teach to monitor for infection
• Amniocentesis
• Done as early as the beginning of week 15 of pregnancy; complications
occur in less than 1% of cases
• Sonogram performed before and during to locate placenta, fetus, and
area of amniotic fluid suitable for aspiration
• Amniotic fluid indicates an increased risk for gender, chromosomal
(such as Down syndrome or Tay-Sachs disease) or biochemical defects
(alpha-fetoprotein [AFP] is elevated in amniotic fluid in the presence of
neural tube defects [NTDs]), fetal age; reveals lecithin to
sphingomyelin (L/S) ratio (2:1 ratio indicates lung maturity);
phosphatidylglycerol (PG) after 35th week (indicates fetal lung
maturity); increased bilirubin level (for Rh incompatibility); amniotic
fluid index; biophysical profile of fetus
• Nursing care: instruct to void; assess FHR during and after test; after
test monitor for uterine contractions, vaginal discharge; teach to rest
and monitor for infection
• Discovery of serious fetal problems may prompt woman to decide to
terminate pregnancy; nurse should provide an opportunity for woman
to express her feelings.
• Percutaneous umbilical blood sampling (PUBS; cordocentesis)
• Similar to amniocentesis, except the object is to retrieve blood from the
fetus instead of amniotic fluid
• An ultrasound-guided needle biopsy of cord blood; can be used as a
follow-up to amniocentesis or CVS
• Can be used to detect certain genetic disorders, blood conditions, and
infections
• Complications can occur
• Nursing care: FHR monitoring for 1 to 2 hours; teach woman to count
fetal movements at home
• Maternal assays
• AFP enzyme blood test
■ Done at 15 to 20 weeks’ gestation as a maternal serum test (“maternal
serum AFP [MSAFP]”; 16 to 18 weeks is ideal), comparing levels
based with normal for the specific week of gestation
■ Increase identifies fetus with increased risk for NTDs (eg, spina
bifida and anencephaly); may indicate multiple pregnancy; followed
by targeted ultrasonography when increased
■ Nursing care: food or fluid restrictions are not required
• Multiple marker screens
■ Performed as early as 11 to 14 weeks of gestation
■ Tests include
■ Human chorionic gonadotropin (hCG) or the free beta-hCG
■ Pregnancy-associated placental protein (PAPP-A)
■ Combined with fetal NT (see ultrasonography earlier) to identify
genetic abnormalities
■ Triple screen (at 16 to 18 weeks of gestation) is MSAFP (see earlier),
unconjugated estriol, and hCG can identify an increased risk for
trisomies 21 and 18
■ Quad screen (optimally at 16 to 18 weeks of gestation) is the triple
screen plus a placental hormone, inhibin A, which increases the
accuracy of screening for trisomy 21 in women younger than 35
years
■ In trisomy 21, hCG levels are higher than normal in the first
trimester, whereas PAPP-A levels are lower than normal
■ The accuracy of multiple marker tests relies on the accuracy of
gestational age assessment because the levels of these markers
change throughout pregnancy
FIG. 5.1 Chorionic villus sampling. Two types of chorionic tissue sampling are
illustrated. One is obtained by aspiration with a catheter through the cervix. Another
method uses a needle inserted through the mother’s abdominal and uterine walls.
Both methods use concurrent ultrasound guidance. Source: (From Leonard, P.C. [2015].
Building a medical vocabulary with Spanish translations [9th ed.]. St. Louis: Saunders.)
Assessment and review
1. During a routine visit to the prenatal clinic, a client listens to the fetal
heartbeat for the first time. The client, commenting on how rapid it is,
appears frightened and asks whether this is normal. How should the nurse
respond?
1. “The heart rate is usually rapid and is in the expected range.”
2. “The heart rate is usually rapid and twice the mother’s pulse rate.”
3. “The heart rate is rapid, but I’d be more concerned if it were slow.”
4. “The heart rate is rapid, but it accommodates the fetus’s nutritional
needs.”
2. A couple who recently emigrated from Israel tells a nurse in the prenatal
clinic that they are concerned about a genetic disease that is prevalent
among Jewish people. Which genetic test should the nurse recommend to
determine the possibility of their child inheriting the disease?
1. Cystic fibrosis
2. Phenylketonuria
3. Turner syndrome
4. Tay-Sachs disease
3. A client is scheduled for a nonstress test in the 37th week of gestation. A
nurse explains the procedure. Which statement demonstrates that the
client understands the teaching?
1. “An IV will be needed to inject the medication.”
2. “My baby may get very restless after this procedure.”
3. “I hope this test does not cause my labor to begin early.”
4. “If the heart reacts well, my baby should do okay when I give birth.”
4. A client in the 18th week of pregnancy is scheduled for ultrasonography.
What instruction should the nurse give the client?
1. “Don’t eat for 4 hours after the test.”
2. “Give yourself an enema the night before.”
3. “Don’t urinate for at least 3 hours before the test.”
4. “You will be monitored closely afterward for signs of labor.”
5. A 42-year-old client has an amniocentesis during the 16th week of
gestation because of concern about Down syndrome. What additional
information about the fetus will examination of the amniotic fluid reveal
at this time?
1. Lung maturity
2. Type 1 diabetes
3. Cardiac anomaly
4. Neural tube defect
6. A client at 9 weeks’ gestation asks the nurse in the prenatal clinic if she can
have her chorionic villi sampling (CVS) done at this visit. At what week
gestation should the nurse respond is the best time for this test?
1. 8 weeks and less than 10 weeks
2. 10 weeks and less than 12 weeks
3. 12 weeks and less than 14 weeks
4. 14 weeks and less than 16 weeks
7. A nurse suspects that there is cephalopelvic disproportion in a client who
is having a difficult labor. For which test should the nurse prepare the
client?
1. Ultrasound
2. Fetal scalp pH
3. Amniocentesis
4. Digital pelvimetry
8. A client who is scheduled for an amniocentesis states, “I’m glad this test
will be able to tell whether my baby is well or not.” How should the nurse
respond?
1. “Research has shown that this is an excellent test.”
2. “A normal amniocentesis is a reliable indicator of a healthy baby.”
3. “This test is useful in detecting potential defects due to
chromosomal errors.”
4. “An amniocentesis is a valuable tool for detecting congenital defects
in the developing fetus.”
9. A client in preterm labor at 35 weeks’ gestation asks the nurse, “What
determines whether my baby’s lungs will be okay?” The nurse explains
that a test of the amniotic fluid obtained through an amniocentesis will
reflect fetal lung maturity. Which test should the nurse include in the
discussion?
1. Amniotic fluid index (AFI)
2. Phosphatidylglycerol (PG) test
3. Alpha-fetoprotein levels (AFP)
4. Lecithin-sphingomyelin (L/S) ratio
10. A 38-year-old client attends the prenatal clinic for the first time. A nurse
explains that several tests will be performed, one of which is the serum
alpha-fetoprotein test. The client asks what the test will reveal. What
should the nurse include in the reply?
1. Trisomy 21
2. Turner syndrome
3. Open neural tube defects
4. Chromosomal aberrations
See Answers on pages 62-63.
Antepartum assessment using electronic fetal
monitoring
• Indications
• In third trimester, to determine whether the intrauterine environment
still supports the fetus
• Women at risk for uteroplacental insufficiency, to determine the timing
of childbirth
■ If the placenta is insufficient, leads to intrauterine growth restriction
(IUGR)
• No ideal test or strategy of testing for all high-risk pregnancies exists
• Most indications for testing in high-risk pregnancy are also indications
for electronic fetal monitoring (see Box 5.1).
• NST (see later) and mBPP most commonly used. Complete BPP is a
follow-up for nonreactive NST or mBPP.
■ Testing usually begins at 32 to 34 weeks of gestation and occurs once
or twice a week
• NST
• The NST test evaluates the response of the fetus to movement and
activity
• Monitors accelerations of FHR in response to fetal movement over 30- to
40-minute period
• However, absence of FHR accelerations may indicate fetal sleep state
• Classification of results
■ Reactive: indicates fetal well-being; baseline FHR 110 to 160
beats/min; two accelerations in 10 minutes, each increasing FHR by
15 beats/min and lasting 15 seconds
■ Nonreactive: indicates nonreassuring prognosis: criteria not met (see
earlier)
■ Unsatisfactory: result cannot be interpreted; test repeated in 24 hours
■ Nursing care: explain test; explain why fasting is unnecessary;
document fetal monitor recordings; evaluate physiologic and
emotional responses to test and its results
• Vibroacoustic stimulation
• Buzzing (fetal acoustic stimulation test [FAST]) or vibration (VST)
created over head of fetus through maternal abdomen for 1-second and
1-minute intervals for 5 minutes
• Reactive test: FHR accelerates; indicates fetal well-being
• Nonreactive test: does not demonstrate at least two qualifying
accelerations
• Nursing care: explain test is noninvasive; obtain baseline FHR before
test
• Contraction stress test (CST)
• Also called oxytocin challenge test
• Demonstrates if fetus can withstand decreased oxygen during a
contraction (uteroplacental sufficiency); contraction produced by
exogenous oxytocin, manual stimulation of nipples, or moist heat
• Provides early warning of fetal compromise
• Should not be performed on women who cannot give birth vaginally
when the test is done
• Additional contraindications: preterm labor, placenta previa, vasa
previa, premature rupture of membranes, presence of incompetent
cervix, multiple gestations, previous classic incision for cesarean birth
• Classification of results
■ Negative: indicates fetus should survive labor; no late decelerations
with minimum of three contractions in 10 minutes
■ Positive: repetitive late decelerations with more than half of
contractions indicating nonreassuring prognosis because of
uteroplacental insufficiency; consideration of early intervention
■ Suspicious: late decelerations occurring in less than half of
contractions; repeat in 24 hours
■ Equivocal-hyperstimulatory: decelerations with frequent contractions
(more than one every 2 minutes) or contractions lasting longer than
90 seconds; repeat in 24 hours
■ Unsatisfactory: Unable to produce three contractions in 10 minutes or
inability to trace FHR; repeat in 24 hours
• Nursing care: explain procedure; obtain signed consent if needed;
instruct to void before test; monitor FHR for 30 minutes before;
monitor after for possible initiation of labor; evaluate physiologic and
emotional responses to test and its results
Psychologic considerations related to high-risk
pregnancy
• All women who undergo these assessments are at risk for problems
• Women and their partners may be experiencing anxiety, fear, or other
psychologic responses to the high-risk diagnosis and testing
• Parents may not be full participants in preparation for the infant because
of the physical demands or psychologic response to the diagnosis
Nurses’ role in assessment and management of the
high-risk pregnancy
• Education and planning: provide information about the diagnosis and its
management as well as the accompanying testing
• Counseling: provide support and encouragement throughout testing and
pregnancy
• Mothers may be experiencing loss and grief (see Chapter 20) over a lessthan-perfect pregnancy or anticipated outcome
• Allow time for the woman to ask questions and receive answers about
information and process
• May assist health care provider with testing
• May perform tests such as NST (provided they have additional training)
• Coordinate care from multiple providers; facilitate communication and
collaboration
Assessment and review
11. A health care provider orders a contraction stress test (CST) for a client
whose nonstress test (NST) was nonreactive. Which maternal
complications should alert the nurse to question the order? Select all that
apply.
1. Hypertension
2. Preterm labor
3. Drug addiction
4. Incompetent cervix
5. Premature rupture of membranes
12. When caring for a woman who had a positive contraction stress test
(CST), what complication does the nurse suspect?
1. Preeclampsia
2. Placenta previa
3. Imminent preterm birth
4. Uteroplacental insufficiency
See Answers on pages 62-63.
Answer key
1. 1 With spontaneous or stimulated activity, the fetal heart rate (FHR) is
usually between 110 and 160 beats/min. This is to be expected, and the
client should be made aware of this.
2 The heart rate for a fetus is 110 to 160 beats/min, not twice the mother’s
heart rate. 3 “The heart rate is rapid, but I’d be more concerned if it
were slow” implies that the heart rate is too rapid; this is
misinformation that may cause more concerns. 4 The heart rate is rapid
to accommodate the metabolic, not nutritional, needs of the fetus.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
2. 4 Tay-Sachs disease is a genetic disorder transmitted as an autosomalrecessive trait that occurs primarily among Ashkenazi Jews.
1, 2, 3 Cystic fibrosis, phenylketonuria, and Turner syndrome do not have
a higher prevalence in the Jewish population.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
3. 4 The nonstress test evaluates the response of the fetus to movement and
activity. A reactive test indicates that the fetus is healthy.
1 No injections of any kind are used during a nonstress test; this test
involves only the use of a fetal monitor to record the fetal heart rate
during periods of activity. 2 This test will not influence the activity of
the fetus because no exogenous stimulus is used. 3 It is unlikely that a
nonstress test will cause labor to begin early because it is a noninvasive
test.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
4. 3 A full bladder is required for effective visualization of the uterus in
early pregnancy.
1 The gastrointestinal (GI) tract is not involved; ultrasonography is a
noninvasive procedure. 2 The procedure is not done via the colon and
will not cause fecal contamination. 4 This procedure is noninvasive; it
cannot irritate the uterus and initiate labor.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
5. 4 Alpha-fetoprotein in amniotic fluid is elevated in the presence of a
neural tube defect.
1 Lung maturity cannot be determined until after 35 weeks’ gestation. 2
Diabetes cannot be detected via an amniocentesis. 3 Cardiac disorders
cannot be detected via an amniocentesis.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
6. 2 10 weeks and less than 12 weeks is the ideal time for chorionic villi
sampling (CVS); this allows the client time to consider other options if a
problem is discovered.
1 CVS is no longer done at 8 weeks and less than 10 weeks because it has
been associated with digit reduction. 3 12 weeks and less than 14 weeks
is too late for CVS. 4 14 weeks and less than 16 weeks is when a genetic
amniocentesis is done.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
7. 1 A sonogram of the pelvis is an accurate and safe test for cephalopelvic
disproportion.
2 Fetal scalp pH is done to assess fetal well-being. 3 Amniocentesis is a
test of the components of the amniotic fluid; it does not reveal the size
of the fetus or the diameters of the pelvis. 4 Digital pelvimetry is an
external measurement obtained by the health care provider; it is an
estimate, not an accurate assessment.
Clinical Area: Childbearing and Women’s Health Nursing; Client Need:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Planning/Implementation
8. 3 Amniocentesis has proved useful in detecting potential defects resulting
from chromosomal and metabolic errors, such as Down syndrome, TaySachs disease, hemophilia, thalassemia, and neural tube defects.
1 “Research has shown that this is an excellent test” is false reassurance,
and it may stop further communication. 2 An amniocentesis can
identify many fetal defects, but even if none are detected, this does not
guarantee a healthy newborn because other factors can influence a
positive outcome. 4 An amniocentesis does not detect congenital
defects; the test can detect chromosomal anomalies, inherited errors of
metabolism, and other disorders for which marker genes are known.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Planning/Implementation; Integrated Process:
Communication/Documentation
9. 2 The phosphatidylglycerol (PG) is a phospholipid that, if present in the
amniotic fluid, indicates that the fetus’s lungs are mature.
1 The amniotic fluid index is a noninvasive measurement of the amount
of amniotic fluid in the four quadrants of the uterus; it is done via
ultrasonography. 3 The amount of alpha-fetoprotein in the amniotic
fluid determines whether there is a neural tube defect. 4 Lecithin and
sphingomyelin are surfactants, and by 36 weeks’ gestation, the L/S ratio
should be approximately 2:1 and should indicate fetal lung maturity;
however, the L/S ratio is not as accurate as the PG test.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Comprehension; Nursing
Process: Planning/Implementation; Integrated Process:
Teaching/Learning
10. 3 Elevated levels of alpha-fetoprotein (AFP), a fetal serum protein, have
been found to reflect an increased risk for open neural tube defects, such
as spina bifida and anencephaly.
1 Trisomy 21 is revealed by genetic testing of fetal cells. 2 Genetic studies
will reveal the presence of just one X chromosome in a female child. 4
Genetic testing, not AFP testing, will reveal chromosomal aberrations.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Planning/Implementation; Integrated Process:
Communication/Documentation
11. Answers: 2, 4, 5.
2 The CST could trigger a preterm birth in a woman who is in preterm
labor or has a history of preterm births. 4 The CST could trigger a
preterm birth in a woman who has had the Shirodkar procedure for an
incompetent cervical os because it would exert pressure on the sutures
and may cause them to rupture. 5 The CST could trigger a preterm
birth in a woman whose membranes have ruptured prematurely; the
woman is at risk for a preterm birth already.
1 The contraction stress test (CST) is indicated to assess the influence of
hypertension on the placental circulation. 3 The CST is indicated to
determine the response of the compromised fetus to labor.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
12. 4 A positive contraction stress test (CST) indicates a compromised fetus
with late decelerations during contractions; this is associated with
uteroplacental insufficiency.
1 Preeclampsia does not cause a positive CST unless the fetus is
compromised. 2 Ultrasonography demonstrates placenta previa; a CST
is contraindicated because it may induce labor. 3 A CST is
contraindicated for a woman with a suspected preterm birth or a
pregnancy of less than 33 weeks’ gestation because it may induce labor.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
C H AP T E R 6
High-risk complications of pregnancy
Hypertensive disorders
Classification of hypertensive states
• Gestational hypertension
• Hypertension during pregnancy beginning in second trimester (20 to 24
weeks); disappears 6 weeks after birth
• Transient hypertension
• Gestational hypertension without preeclampsia
• Resolves by 12 weeks’ postpartum
• Preeclampsia
• Mild: blood pressure (BP) 140/90 mm Hg on two readings taken 6 hours
apart; systolic BP increase of 30 mm Hg or diastolic BP increase of 15
mm Hg; proteinuria +1 (30 mg/dL) or more
• Severe:
■ Objective: BP 160/110 mm Hg or higher on two readings taken 6 hours
apart after bed rest; proteinuria +3 to +4; hyperreflexia; oliguria;
hemoconcentration
■ Subjective: blurred vision; epigastric pain; irritability; persistent
headache
• Blood chemistry: elevated hematocrit and hemoglobin; increased uric
acid, liver enzymes, and blood urea nitrogen (BUN); decreased carbon
dioxide combining power (may indicate worsening preeclampsia)
• Qualitative urinalysis: increased albumin output (proteinuria) and/or
decreased urinary output indicates worsening preeclampsia
• Eclampsia
• Seizure and/or coma; seizure may be preceded by rolling of eyes to one
side while staring
• Occurs after intractable, severe preeclampsia
• Chronic hypertension: preexisting
• Preeclampsia superimposed on chronic hypertension
• Previously controlled BP becomes elevated; proteinuria
• Blood chemistry: thrombocytopenia, elevated creatinine; other clinical
manifestations of severe preeclampsia
Risk factors
• First pregnancy at younger than 17 years of age
• Over 35 years of age; obesity
• Numerous pregnancies
• Chronic hypertension
• Diabetes mellitus
• Severe nutritional deficiencies
• Multifetal pregnancy
• Trophoblastic disease
HELLP syndrome
• Hemolysis, Elevated Liver enzymes, Low Platelet count
• Preeclampsia with hepatic dysfunction
• Sudden onset; may not have previous signs of preeclampsia; 2% to 12%
incidence in women with severe preeclampsia; occurs after 24 weeks’
gestation or after birth
• Right upper quadrant pain in 90% of affected women; may have
proteinuria
• Blood smear reveals broken red blood cells (RBCs; schistocytes or burr
cells)
• Increased uric acid, liver enzymes, and BUN
Guidelines for prevention
• Reduction of risk factors if possible
• Adherence to prenatal recommendations (eg, diet, exercise, rest, regular
prenatal examinations)
• Prophylactic treatment is not available
• Sodium restriction and diuretics are contraindicated
Therapeutic interventions
• Gestational hypertension
• Frequent rest periods
• Dietary management with increased fluid intake
• Treated symptomatically
• Mild preeclampsia
• High-protein diet
• Ambulatory care; frequent visits to health care provider
• Frequent rest periods with feet elevated; side-lying position to enhance
renal and placental perfusion
• Severe preeclampsia or eclampsia
• Hospitalization and complete bed rest
• Magnesium sulfate administered intravenously via infusion pump; if
respiratory depression caused by magnesium sulfate occurs, calcium
gluconate for mother and levallorphan for newborn
• Antihypertensives: hydralazine, nifedipine, methyldopa, labetalol
• Indwelling catheter for output assessment
• Labor induction or cesarean birth
• Betamethasone for preterm birth less than 34 weeks’ gestation
(stimulates fetal surfactant production)
• HELLP syndrome
• Same as severe preeclampsia or eclampsia
• Blood or blood product replacement if necessary
Nursing care of women with hypertensive disorders
of pregnancy
• Assessment/analysis
• Clinical indications of cerebral involvement (eg, persistent headache,
visual disturbances, irritability, confusion)
• Vital signs for hypertension
• Urinary status for proteinuria, oliguria
• Extremities for edema, increasing daily weight
• Epigastric pain
• Planning/implementation
• Monitor BP every 15 minutes during critical phase; every 1 to 4 hours as
condition improves
• Insert indwelling catheter; monitor urine for output and proteinuria
• Monitor edema, daily weights, input and output (I&O)
• Administer magnesium sulfate as prescribed (check for sufficient
urinary output before starting); assess for therapeutic response (eg, +2
deep tendon reflexes, increased urinary output, absence of seizures)
• Monitor for magnesium toxicity
■ Assess for depressed or absent deep tendon reflexes (eg, patellar,
brachial)
■ Observe for depressed respirations (fewer than 12 to 14 breaths/min),
flushed face
■ Assess magnesium blood levels every 6 hours; therapeutic range is 4
to 8 mg/dL
■ Have calcium gluconate available for magnesium sulfate toxicity
• Observe for indications of seizure activity (eg, may be preceded by
rolling of eyes to one side with a stare); maintain seizure precautions;
monitor vital signs and fetal heart rate (FHR) after seizure
• Monitor FHR
• Monitor hematologic studies
• Maintain on bed rest in side-lying position; maintain quiet, dark
environment; limit visitors
• Offer high-protein diet with adequate sodium intake
• Explore anxieties and concerns
• Observe for signs of bleeding and labor
• Be prepared for induced birth or emergency cesarean birth
• Continue to monitor for 48 hours after birth during diuresis (seizures
[eclampsia] may occur several weeks postpartum)
• Evaluation/outcomes
• Maintains (mother and fetus) vital signs within acceptable range
• Remains free from seizures
• Maintains fluid balance
Application and review
1. A patient is receiving magnesium sulfate therapy for severe preeclampsia.
What initial sign of toxicity should alert the nurse to intervene?
1. Hyperactive sensorium
2. Increase in respiratory rate
3. Lack of the knee-jerk reflex
4. Development of a cardiac dysrhythmia
2. A nurse is monitoring a patient with severe preeclampsia who is receiving
an infusion of magnesium sulfate. Assessment reveals a pulse rate of
55/minute, respirations of 12/minute, and a flushed face. What is the next
nursing action?
1. Continue the infusion and notify the health care provider.
2. Stop the infusion and start an infusion of dextrose and water.
3. Continue the infusion and document the findings on the clinical
record.
4. Decrease the rate of the infusion and obtain blood for a magnesium
level.
3. A patient admitted with preeclampsia is receiving magnesium sulfate.
Which assessment indicates that a therapeutic level of the medication has
been reached?
1. Respiratory rate of 12
2. Increased fetal activity
3. Decreased urine output
4. Deep tendon reflexes of +2
4. Which woman should the nurse identify is at risk for developing a
hypertensive disorder of pregnancy?
1. Primigravida who is obese
2. Multipara who is 31 years old
3. Multipara who had more than six previous pregnancies
4. Primigravida who took oral contraceptives within 3 months of
conception
5. A patient in the prenatal clinic is diagnosed with preeclampsia. What
clinical findings support this diagnosis?
1. Elevated blood pressure of 150/100 mm Hg
2. Elevated blood pressure that is accompanied by a headache
3. Blood pressure above the baseline while fluctuating at each reading
4. Blood pressure more than 140 mm Hg systolic accompanied by
proteinuria
6. A patient is admitted to the birthing suite with a blood pressure of 150/90
mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of
severe preeclampsia is made. What other clinical findings support this
diagnosis? Select all that apply.
1. Headache
2. Constipation
3. Abdominal pain
4. Vaginal bleeding
5. Visual disturbances
7. A nurse is monitoring a patient with severe preeclampsia for the onset of
eclampsia. What clinical finding indicates an impending seizure?
1. Persistent headache with blurred vision
2. Epigastric pain with nausea and vomiting
3. Spots with flashes of light before the eyes
4. Rolling of the eyes to one side with a fixed stare
8. A patient with the diagnosis of severe preeclampsia is admitted to the
hospital from the emergency department. What precaution should the
nurse initiate?
1. Pad the side rails on the bed.
2. Place the call button next to the patient.
3. Have oxygen with face mask available.
4. Assign a nursing assistant to stay with the patient.
9. When does a nurse caring for a patient with eclampsia determine that the
risk for another seizure has subsided?
1. After birth occurs
2. After labor begins
3. 48 hours postpartum
4. 24 hours postpartum
See Answers on pages 109-116.
Hemorrhagic disorders
Early pregnancy bleeding
• Miscarriage (spontaneous abortion)
• Complete or partial expulsion (incomplete) of products of conception
before viability; gestational age 20 weeks or less; weight less than 500
grams; length less than 16.5 cm
• Incidence: 10% to 20% of confirmed pregnancies
• Risk factors: embryonic defects, maternal hormone imbalances,
immunologic factors, infections, genetic factors, systemic disorders,
external mechanical force, trauma
• Types/clinical findings
■ Threatened abortion: cervix closed, bleeding, cramping, backache;
pregnancy may continue uninterrupted
■ Imminent or inevitable abortion: cervix dilates, bleeding, severe
cramping, membranes may rupture
■ Incomplete abortion: all products of conception not expelled after
cervical os has dilated
■ Complete abortion: all products of conception expelled within 24 to
48 hours
■ Missed abortion: fetus dies in utero but not expelled; risk for
developing disseminated intravascular coagulopathy (DIC)
■ Habitual abortions: three consecutive pregnancies that terminate
spontaneously
• Therapeutic interventions
■ Maintenance of complete bed rest
■ Diagnostic/therapeutic blood studies: complete blood count (CBC),
blood typing, and Rh factor; crossmatching if blood is available;
serum progesterone or serial beta human chorionic gonadotropin (βhCG)
■ Dilation and curettage or vacuum aspiration to remove retained
products of conception
• Nursing care of women experiencing spontaneous abortion
■ Assessment/analysis
■ Vital signs; amount of bleeding
■ Level of pain
■ Emotional response to loss
■ Planning/implementation
■ Institute measures to alleviate fear and anxiety
■ Monitor and document amount and type bleeding
○ Save and count number of perineal pads
○ Distinguish between dark clotted blood and frank bleeding
(bright red)
■ Monitor vital signs for hypovolemia, shock, and infection
■ Monitor fundus for firmness after products of conception are
expelled
■ Check laboratory reports (eg, CBC, hemoglobin, hematocrit) in
preparation for blood transfusion
■ Administer oxygen if necessary
■ Maintain fluid and electrolyte balance
■ Administer RhoGAM if prescribed
■ Assist with grieving process
○ Discuss physiologic reality, but encourage to work through
feelings
○ Expect that grieving may continue for 24 months
○ Encourage participation with thanatology services and
bereavement/support groups when appropriate
■ Educate about necessity for follow-up care
■ Evaluation/outcomes
■ Remains free from complications (eg, hemorrhage, infection)
■ Expresses feelings
• Incompetent cervix
• Cervical effacement and dilation in early second trimester; expulsion of
products of conception; recurrent miscarriages, each one earlier in
pregnancy
• Risk factors: previous forceful/excessive dilation and curettage; previous
difficult birth; congenitally short cervix
• Clinical findings
■ Painless contractions in second trimester
■ Preterm birth of nonviable fetus
• Therapeutic interventions
■ Conservative: bed rest; adequate hydration; tocolytic therapy to
inhibit uterine contractions
■ Cerclage procedure: during 10 to 14 weeks’ gestation; suture or
ribbon placed beneath cervical mucosa to close cervix
■ Activity restrictions (eg, no intercourse, heavy lifting, standing for
more than 90 minutes)
■ Cesarean birth or cutting of suture for vaginal birth at term
• Nursing care of women with an incompetent cervix
■ Assessment/analysis
■ Number of weeks gestation
■ Obstetric history
■ Knowledge of treatment options (eg, cerclage procedure)
■ Planning/implementation (after cerclage procedure)
■ Maintain bed rest for 24 hours
■ Monitor vital signs and FHR
■ Monitor for rupture of membranes or bleeding
■ Teach which activities are restricted and importance of adherence
to restrictions
■ Evaluation/outcomes
■ Continues pregnancy to term
■ Describes signs of labor
■ States will notify health care provider when labor begins
• Ectopic pregnancy
• Implantation of fertilized ovum outside uterus; most frequently (95%)
in middle portion of fallopian tube; other sites in abdomen, ovaries,
and cervix
• Incidence; rising; 20 in 1000 pregnancies
• Risk factors: pelvic inflammatory disease (PID), tubal surgery,
endometriosis
• Diagnosis: ultrasonography, radioimmunoassay for β-hCG
• Tubal pregnancy pattern
■ Asymptomatic
■ Spotting after one or two missed menstrual periods; localized
tenderness (before rupture)
■ Sudden, sharp, knifelike lower right or left abdominal pain radiating
to shoulder after rupture
■ Concealed bleeding from site of rupture leads to sudden shock
• Therapeutic interventions
■ Diagnosis confirmed by ultrasound examination, laparoscopy, or
culdocentesis
■ Immediate blood replacement if blood loss is severe
■ Removal or surgical repair of ruptured fallopian tube
■ Pharmacologic therapy: methotrexate to salvage fallopian tube
• Nursing care of women with an ectopic pregnancy
■ Assessment/analysis
■ Vital signs, signs of shock
■ Bleeding; rigid, tender abdomen
■ Character and location of pain
■ Level of anxiety
■ Planning/implementation
■ Monitor for signs of shock
■ Administer blood transfusion if ordered
■ Administer prescribed analgesics for pain
■ Provide emotional support
■ Provide preoperative and postoperative care
■ Administer RhoGAM if appropriate
■ Evaluation/outcomes
■ Remains free from complications
■ States implications for future childbearing
■ Expresses feelings
• Hydatidiform mole or trophoblastic disease
• Abnormal proliferation of trophoblastic cells covering chorionic villi;
associated with high hCG levels
• Categories: hydatidiform mole; complete or partial mole; gestational
trophoblastic neoplasia (GTN); metastatic trophoblastic neoplasia (low,
intermediate, or high risk); choriocarcinoma may develop with
metastasis to lungs
• Incidence: one in 1200 pregnancies; more common in Asian women
• Risk factors unknown; may be related to malnutrition or ovular defect;
previous miscarriages; age (early teens, past 40 years); women who have
taken clomiphene to stimulate ovulation
• Clinical findings
■ Types
■ Molar pregnancy—no fetus or amnion
■ Partial molar pregnancy—fetus and/or amniotic sac
■ Uterus: larger for period of gestation; fetal parts not palpable;
doughlike consistency; contains mass resembling bunch of grapes
■ Manifestation of gestational hypertension and hyperemesis
gravidarum
■ Potential for uterine perforation, hemorrhage, infection
■ Confirmation by ultrasonography
• Therapeutic interventions
■ Evacuation by dilation and curettage or hysterotomy if no
spontaneous evacuation
■ Continued follow-up of serum gonadotropin levels for 1 year to rule
out choriocarcinoma (increased gonadotropin levels require
chemotherapy)
■ Chemotherapy when malignant
• Nursing care of women with hydatidiform mole or trophoblastic disease
■ Assessment/analysis
■ Vaginal bleeding (brownish, prune juice) containing grapelike
tissue
■ Uterine enlargement; fundal height greater than expected for
length of pregnancy
■ Vomiting
■ Elevated BP earlier than 24 weeks’ gestation
■ Absence of fetal heart tones or activity
■ Planning/implementation
■ See Nursing Care under Spontaneous Abortion
■ Teach importance of follow-up care for at least 1 year, especially for
serum gonadotropin testing
■ Teach importance of preventing pregnancy for 1 year
■ Evaluation/outcome
■ Continues follow-up care
■ Uses measures to prevent pregnancy for 1 year
Late pregnancy bleeding
• Placenta previa
• Placental implantation in lower uterine segment
• Incidence: 0.5% of births; more common in African and Asian woman
• Risk factors: maternal age older than 35 years; history of placenta previa,
cesarean births, multiple gestations, and closely spaced pregnancies;
endometrial scarring
• Types
■ Type I—low-lying: placenta in lower uterine segment next to internal
cervical os; as uterus stretches with gestation, placenta moves away
from os
■ Type II—marginal: placental edge at os, but does not cover it
■ Type III—partial: placental edge partially covers os
■ Type IV—complete: placenta is centered over os
• Clinical findings
■ Painless, bright red bleeding; hemorrhage in third trimester
■ Soft uterus in latter part of pregnancy
■ May have signs of infection
• Therapeutic interventions
■ Ultrasonography to confirm placenta previa
■ Depend on location of placenta, amount of bleeding, status of fetus
■ Avoidance of vaginal examinations
■ Measures to control bleeding
■ Replacement of blood loss if necessary
■ Home monitoring with repeated ultrasounds for type I—low-lying
■ Cesarean birth, if necessary
• Nursing care of women with placenta previa
■ Assessment/analysis
■ Painless bright red bleeding; absence of pain
■ Clinical manifestations of shock (hypovolemic)
■ Changes in or absence of FHR
■ Level of anxiety (usually increases)
■ Planning/implementation
■ Monitor and document amount of bleeding; count number of
perineal pads and extent of saturation to determine blood loss
■ Monitor FHR using electronic device
■ Monitor maternal vital signs using electronic equipment
■ Observe color for pallor or cyanosis; administer oxygen if necessary
■ Emphasize to other health care providers that vaginal examinations
are contraindicated
■ Maintain bed rest in semi-Fowler position
■ Monitor hemoglobin and hematocrit, administer IV therapy and/or
blood replacement if needed
■ If ultrasound is unavailable and a vaginal examination is necessary,
prepare a double setup for vaginal or cesarean birth (rarely done)
■ Prepare for cesarean birth if bleeding persists
■ Evaluation/outcomes
■ Birth of viable, stable newborn
■ Demonstrates hemodynamic stability
• Premature separation of placenta (abruptio placentae; placental
abruption)
• Partial, marginal, or complete premature separation of placenta in third
trimester; degrees of separation: mild, moderate, severe (grade 1, 2, 3,
respectively)
• Risk factors: preexisting hypertension; preeclampsia; eclampsia; cocaine
use; abdominal trauma; previous abruption; multiple gestations
• Clinical findings
■ Vaginal bleeding; concealed if center of placenta separates and
margins are intact; overt if placenta separates at margin
■ Moderate to agonizing abdominal pain
■ Persistent uterine contraction; firm to boardlike abdomen
■ Fetal hyperactivity, then cessation of fetal movements
■ Hemorrhage, DIC, hypofibrinogenemia may occur
• Therapeutic interventions
■ Replacement of blood loss
■ Administration of oxygen if necessary
■ Maintenance of fluid and electrolyte balance
■ Induction of labor for mild separation with reassuring fetal signs and
some cervical effacement and dilation
■ Emergency cesarean birth for moderate or severe separation,
maternal distress, fetal compromise
• Nursing care of women with abruptio placentae
■ Assessment/analysis
■ Pain with or without dark red bleeding
■ Tonicity of abdominal wall
■ Clinical manifestations of shock
■ Changes in or absence of FHR
■ Levels of increasing anxiety
■ Planning/implementation
■ Maintain bed rest in lateral recumbent position
■ Monitor FHR with electronic device
■ Monitor maternal vital signs using electronic equipment
■ Determine abdominal pain and tonicity of abdomen
■ Observe color for pallor or cyanosis; administer oxygen if necessary
■ Obtain blood for typing and crossmatching, coagulation studies,
hemoglobin, hematocrit
■ Administer IV therapy and/or blood replacement
■ Prepare for Kleihauer-Betke test to assess fetal bleeding into
maternal circulation
■ Observe perineal pads for bleeding
■ Prepare for cesarean birth if abruptio is moderate or severe
■ Observe for signs of DIC (eg, see page of blood from IV site or
incisional areas)
■ Evaluation/outcomes
■ Birth of a viable, stable newborn
■ Demonstrates hemodynamic stability
• Cord insertion and placental variations
• Rare anomaly of the placenta in which the fetal vessels lie over the
cervical os and are at risk for compression or rupture
• Variations:
■ Succenturiate placenta
■ Placenta divides into two or more separate lobes, each with distinct
circulation; blood vessels joining the lobes may tear in labor, birth,
or placental expulsion; lobes may not detach during placental
expulsion, increasing risk for postpartum hemorrhage
■ Velamentous insertion of the cord
■ Cord vessels begin to branch at membranes and then course on to
the placenta; range of motion or tension on the cord can tear the
vessels, resulting in rapid fetal hemorrhage and death
• Traction on the cord may tear one of the vessels, causing the fetus to
bleed rapidly, resulting in fetal death
• Risk factors
■ Placenta previa
■ Multiple gestation
■ Pregnancies resulting from assisted reproductive technology
• Clotting disorders in pregnancy
• DIC
■ Response to overstimulation of clotting and anticlotting processes
■ Massive amounts of microthrombi affect microcirculation
■ Complicated by hemorrhage at various sites as a result of fibrinolytic
response
■ Multiple system failure may occur (eg, circulatory, respiratory,
gastrointestinal [GI], renal, neurologic) from bleeding or thrombosis
■ In pregnancy, most commonly as a result of placental abruption,
retained dead fetus syndrome, and amniotic fluid embolus
■ Usually resolves with birth and resolution of coagulation
abnormalities
■ Clinical findings
■ Subjective: restlessness, anxiety
■ Objective
○ Low fibrinogen level; prolonged prothrombin and partial
thromboplastin times; reduced platelets; positive D-dimer assay
○ Hemorrhage, both subcutaneous and internal; petechiae; signs of
organ failure
■ Therapeutic interventions
■ Treatment of underlying cause
■ Heparin to prevent formation of thrombi
■ Transfusion of blood products
■ Antifibrinolytic therapy to prevent bleeding if necessary
■ Nursing care of women with DIC
■ Assessment/analysis
○ History of causative factors
○ Bleeding; abnormal coagulation profile
■ Planning/implementation
○ Observe for bleeding; replace fluids as ordered
○ Minimize skin punctures; prevent injury
○ Monitor for renal, cerebral, and respiratory complications
○ Assess vital signs regularly
○ Positioning: maintain a side-lying tilt position to maximize blood
flow to uterus
○ Provide oxygen as needed
○ Provide emotional support
■ Evaluation/outcomes
○ Maintains circulation to all tissues and fetus
○ Verbalizes a decrease in anxiety
○ Maintains adequate cardiac output
Application and review
10. What assessment finding of a pregnant patient should alert the nurse to
notify the health care provider?
1. Dependent edema at 38 weeks’ gestation
2. Fundal height at the umbilicus at 16 weeks’ gestation
3. Fetal heart rate of 150 beats/min at 24 weeks’ gestation
4. Maternal heart rate of 92 beats/min at 28 weeks’ gestation
11. A nurse is assessing a patient with a tentative diagnosis of hydatidiform
mole. Which clinical finding should the nurse anticipate?
1. Hypotension
2. Decreased fetal heart rate
3. Unusual uterine enlargement
4. Painless, heavy vaginal bleeding
12. A nurse is obtaining the health history from a patient with a diagnosis of
a ruptured tubal pregnancy. At what point in the pregnancy does the
nurse expect the patient to state when the low abdominal pain and vaginal
bleeding started?
1. At the end of the first trimester
2. About the sixth week of pregnancy
3. Midway through the second trimester
4. When the first menstrual period was missed
13. Which sign or symptom leads a nurse to suspect that a patient has a tubal
pregnancy?
1. A painful mass centered in the abdomen
2. Lower abdominal cramping for 1 week
3. A sharp lower right or left abdominal pain radiating to the shoulder
4. Leukorrhea or dysuria a few days after the first missed menstrual
period
14. A nurse is caring for a patient who had a spontaneous abortion. For what
complication should the nurse assess this patient?
1. Hemorrhage
2. Dehydration
3. Hypertension
4. Subinvolution
15. A nurse is caring for a patient who had a spontaneous abortion. The
patient asks why spontaneous abortions occur. The nurse responds that
they are most commonly caused by what?
1. Physical trauma
2. Unresolved stress
3. Congenital defects
4. Embryonic defects
16. A patient tells a nurse in the prenatal clinic that she has vaginal staining
but no pain. Her history reveals amenorrhea for the last 2 months and
pregnancy confirmation after her first missed period. She is admitted to
the high-risk unit because she may be having a spontaneous abortion.
What type of abortion is suspected?
1. Missed
2. Inevitable
3. Threatened
4. Incomplete
17. A few hours after being admitted to the hospital with a diagnosis of
inevitable abortion, a patient at 16 weeks’ gestation begins to experience
bearing-down sensations and suddenly expels the products of conception
in bed. What should the nurse do first?
1. Notify the health care provider.
2. Administer the prescribed sedative.
3. Take the patient to the operating room.
4. Check the patient’s fundus for firmness.
18. After an incomplete abortion, a patient tells a nurse that although her
health care provider explained what an incomplete abortion was, she did
not understand. What is the nurse’s best response?
1. “I don’t think you should focus on this anymore.”
2. “This is when the fetus dies but is retained in the uterus for at least
2 months.”
3. “I think it is best if you asked your health care provider for the
answer to that question.”
4. “This is when the fetus is expelled but other parts of the pregnancy
remain in the uterus.”
19. A patient at 28 weeks’ gestation has a sonogram. The results reveal a
small-for-gestational-age (SGA) fetus and a low-lying placenta. For what
complication should the nurse assess this patient during the last trimester
of pregnancy?
1. Preterm labor
2. Placenta previa
3. Premature separation of the placenta
4. Premature rupture of the membranes
20. A patient is scheduled for a sonogram at 36 weeks’ gestation. Shortly
before the test she tells the nurse that she has severe abdominal pain.
Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and
an increased pulse rate. What complication does the nurse suspect?
1. Hydatidiform mole
2. Vena caval syndrome
3. Marginal placenta previa
4. Complete abruptio placentae
21. A patient at 37 weeks’ gestation arrives at the emergency department
stating that she has abdominal pain but no vaginal bleeding. The health
care provider diagnoses abruptio placentae. The patient asks the nurse
why it is so painful. What should the nurse consider is the initial cause of
the abdominal pain before responding in language the patient will
understand?
1. Hemorrhagic shock
2. Concealed hemorrhage
3. Blood in the myometrium
4. Disseminated intravascular coagulation
22. A patient at 37 weeks’ gestation is admitted to the birthing unit from the
emergency department. She had arrived by ambulance after a motor
vehicle accident. Her vital signs are BP: 90/60; P: 108; R: 24. She is reporting
sharp abdominal pain. What is the priority nursing intervention at this
time?
1. Apply an electronic fetal monitor.
2. Prepare for a possible cesarean birth.
3. Draw blood for a type and crossmatch.
4. Assess the amount of vaginal bleeding.
23. A patient who had a severe abruptio placentae asks the nurse why there
was so much bleeding. What should the nurse consider is the cause of the
heavy bleeding before responding in language the patient will
understand?
1. Polycythemia
2. Thrombocytopenia
3. Hyperglobulinemia
4. Hypofibrinogenemia
24. A nurse is reviewing the obstetric history of a patient who had an
abruptio placentae. What prenatal condition does the nurse expect the
patient to have had?
1. Cardiac disease
2. Hyperthyroidism
3. Gestational hypertension
4. Cephalopelvic disproportion
25. A patient arrives at the hospital at 38 weeks’ gestation with profuse
vaginal bleeding. She states that it occurred suddenly without any
contractions. Which condition may the patient be experiencing that
requires immediate notification of the health care provider?
1. Placenta previa
2. Placenta accreta
3. Ruptured uterus
4. Concealed abruptio
26. What nursing intervention should be included when caring for a patient
with placenta previa?
1. Vital signs at least once per shift
2. Tap water enema before the birth
3. Documentation of the amount of bleeding
4. Limited ambulation until the bleeding stops
27. A nurse notifies the health care provider that a patient has been admitted
to the high-risk unit in her 36th week of gestation. She is bleeding, has
severe abdominal pain and a rigid fundus, and is demonstrating signs of
shock. For what intervention should the nurse prepare?
1. A high-forceps birth
2. An immediate cesarean birth
3. The insertion of an internal fetal monitor
4. The administration of an oxytocin infusion
See Answers on pages 109-116.
Endocrine and metabolic disorders
Diabetes mellitus
• Diabetes mellitus during pregnancy
• Pregestational
■ Type 1: complications include retinopathy, neuropathy, and coronary
artery disease
■ Type 2: complications may include retinopathy, neuropathy, and
coronary artery disease; women with type 1 diabetes are at greater
risk
• Gestational diabetes mellitus (GDM)
■ Controlled by diet
■ Insulin required in 20% of women
• Physiology of pregnancy that affects woman with diabetes
• Vomiting, especially in first trimester, decreases carbohydrate intake,
which reduces insulin need; may result in acidosis
• Progression of hormonal influences
■ Insulin production increases, but resistance to insulin occurs
■ Insulin need increases
■ Exogenous insulin is required to maintain serum glucose level within
acceptable range, especially in latter part of pregnancy
• Basal metabolic rate increases; carbon dioxide combining power
decreases; acidosis may result
• Renal threshold for glucose decreases, glycosuria may result
• During labor: muscular activity depletes glycogen; insulin need
decreases
• Postpartum period: involution and lactation further reduce insulin
need; hypoglycemia may result
• Hazards of diabetes during pregnancy
• Increased incidence of fetal deaths, stillbirths, newborn anomalies
• Neonatal deaths from hypoxia, hypoglycemia, congenital anomalies,
preterm labor
• Excessively large newborn; weight over 4000 g (macrosomia) with
inadequate diabetic control
• Hypertensive disorders, hydramnios
• Frequent adjustments of insulin dosage because insulin needs vary
throughout pregnancy
• Frequent hospitalizations may be necessary
• Cesarean birth may be necessary
• Nursing care of pregnant women with diabetes mellitus
• Assessment/analysis
■ Number of years with disorder; type 1 or type 2
■ Dietary patterns
■ Signs of infection
■ Results of tests (eg, blood glucose level, glucose tolerance,
glycosylated hemoglobin)
■ Understanding of disorder in relation to pregnancy
■ Support system
• Planning/implementation
■ Care of mother
■ Encourage preconception counseling; early, sustained prenatal
supervision
■ Teach
○ Dietary and insulin regimens; encourage adherence
○ Clinical manifestation of hyperglycemia (acidosis), hypoglycemia
(insulin reaction)
○ Blood glucose testing, insulin administration, record keeping
○ Reason for multiple tests to determine fetal well-being (eg,
ultrasound, stress/nonstress tests, biophysical profile,
amniocentesis for phosphatidylglycerol levels and lecithin–
sphingomyelin [L/S] ratio)
■ Prepare for hospitalization, induction of labor, or cesarean birth if
indicated
■ Monitor fluid and electrolyte balance for signs of ketoacidosis
during prenatal, intrapartum, and postpartum periods
■ Monitor glucose levels for first 48 hours postpartum; may not
remain diabetic if gestational diabetic
■ Care of neonate—infant of diabetic mother (IDM)
■ Perform newborn assessment; inspect for congenital anomalies
related to increased incidence in IDM
■ Admit to neonatal intensive care unit (NICU) if necessary
■ Keep warm (inadequate temperature control mechanisms)
■ Observe respirations (distended stomach may impinge on
diaphragmatic movement)
■ Perform heel-stick blood specimen for glucose level; assess for
hypoglycemia caused by excessive insulin production (blood
glucose level 30 to 45 mg/dL)
■ Observe for signs of hypoglycemia (eg, lethargy, poor sucking,
irritability cyanosis, tremors, hypotonia, cyanosis); hypocalcemia
(eg, muscular twitching, tremors, seizure triggered by minor
stimulus)
■ Offer prescribed glucose water feedings to prevent acidosis;
administer prescribed parenteral glucose if newborn has poor
sucking reflex
■ Promote early parent–infant interaction
• Evaluation/outcomes
■ Maintains serum glucose levels within acceptable limits
■ Gives birth to healthy newborn
■ Remains free from complications
Hyperemesis gravidarum
• Vomiting that continues past first 10 weeks of pregnancy; excessive, with
5% weight loss
• Incidence: varies from 3 to 10 per 1000 births
• Risk factors: nulliparity, obesity, history of migraine headaches, multifetal
pregnancy, may be related to transient hyperthyroidism, may have
psychologic component
• Clinical findings: significant weight loss, dehydration (eg, decreased BP,
increased pulse rate, inadequate tissue turgor) cannot retain even clear
fluids, electrolyte imbalances
• Therapeutic interventions
• Laboratory tests (eg, urine for ketones [acidosis], CBC, electrolytes, liver
enzymes, bilirubin level, thyroid studies); psychosocial assessment
• IV therapy to correct fluid and electrolyte imbalance; nothing by mouth
(NPO) for 48 hours after vomiting ceases; antiemetic medications;
corticosteroids for intractable vomiting; total parenteral nutrition
(TPN) if necessary; psychotherapy if indicated
• Nursing care of women with hyperemesis gravidarum
• Assessment/analysis
■ History for possible causes of vomiting, precipitating factors,
■ Nature of vomitus: frequency, severity, duration of episodes, amount
and color
■ Physical examination: vital signs, weight loss, nutritional status, other
signs of dehydration
■ Emotional status
• Planning/implementation
■ Monitor patient
■ IV therapy, I&O
■ Frequency, amount, and characteristics of vomiting
■ Vital signs, hydration and nutritional status
■ Maintain NPO as ordered
■ Administer prescribed medications and nutritional supplements
■ Provide quiet, restful environment; attempt to eliminate odors
■ Offer prescribed diet: usually small, low-fat, high-protein, bland
feedings; document response to oral intake
■ Encourage ventilation of feelings
■ Arrange for continuing care at home
• Evaluation/outcomes
■ Nausea and vomiting do not recur
■ Consumes nutritional meals
■ Gains weight
■ Pregnancy continues to term
■ Newborn is healthy
Thyroid disorders
• Hyperthyroidism
• Excessive concentration of thyroid hormones in blood as a result of
thyroid disease or increased levels of thyroid-stimulating hormone
(TSH); leads to hypermetabolic state
• Rare in pregnancy; typically associated with Graves disease
• If untreated, moderate-to-severe hyperthyroidism increases risks for
severe preeclampsia, maternal heart failure, preterm birth, miscarriage,
giving birth to infants who are stillborn, giving birth to infants who
have thyroid disease
• Clinical findings
■ Subjective: polyphagia, emotional lability, apprehension, heat
intolerance
■ Objective
■ Weight loss, loose stools, tremors, hyperactive reflexes,
restlessness, diaphoresis, insomnia, exophthalmos, corneal
ulceration, increased systolic BP, temperature, pulse rate, and
respiration
■ Decreased TSH levels if thyroid disorder; increased TSH levels if
secondary to a pituitary disorder
■ Graves disease generally involves hyperthyroidism, goiter, and
exophthalmos
■ Increased T3, T4, radioactive iodine uptake (RAI) test, long-acting
thyroid stimulator (LATS)
■ Thyrotoxic crisis (thyroid storm): hypermetabolism that may lead to
heart failure; usually precipitated by a severe physiologic or
psychologic stress (eg, labor, preeclampsia, surgery, infection, etc.)
that releases thyroid hormone into bloodstream
• Therapeutic interventions
■ Antithyroid medication for pregnancy: propylthiouracil (PTU)
■ Readily crosses placental barrier; may cause hypothyroidism of
fetus
■ Does not concentrate in breast milk, and breastfeeding does not
have a negative impact on the thyroid of the infant
■ Radioactive iodine: 131I (atomic cocktail)
■ Destroys thyroid gland cells, thereby decreasing production of
thyroid hormone
■ Not used in pregnant women because of likelihood of destroying
thyroid tissue of fetus
■ Medications to relieve clinical findings related to increased metabolic
rate: adrenergic blocking agents
■ Long-term use during pregnancy is discouraged because of fetal
side effects
■ Surgical intervention: subtotal or total thyroidectomy
■ Used only with women for whom PTU is not an effective option
■ Ideally performed in second trimester
■ Well-balanced, high-calorie diet with vitamin and mineral
supplements
• Nursing care of women with hyperthyroidism
■ Assessment/analysis
■ History of weight loss, diarrhea, insomnia, emotional lability,
palpitations, heat intolerance
■ Eyes for exophthalmos, tearing, sensitivity to light (photophobia)
■ Neck palpation for enlarged thyroid gland
■ Weight and vital signs to establish baseline
■ Planning/implementation
■ Establish climate for uninterrupted rest (eg, decreased stimulation,
back rub, prescribed medications); provide relaxing, calm
environment
■ Protect from stress-producing situations
■ Keep room cool
■ Provide diet high in calories, proteins, and carbohydrates with
supplemental feedings between meals and at bedtime; vitamin and
mineral supplements as prescribed
■ Understand that woman is upset by lability of mood and
exaggerated response to environmental stimuli; explain disease
processes involved; avoid rushing and surprises; prepare patient
for procedures
■ Protect eyes (eg, eye drops, patches, tinted eyeglasses, elevation of
head of bed, cool compresses to eyes)
■ Provide care before thyroidectomy
○ Teach importance of taking prescribed antithyroid medications
to achieve euthyroid state
○ Teach deep-breathing exercises and use of hands to support neck
to avoid strain on suture line after surgery
■ Provide care after thyroidectomy
○ Observe for clinical findings of respiratory distress and laryngeal
stridor caused by tracheal edema; explain a sore throat when
swallowing is expected; keep tracheotomy set available
○ Assess for hoarseness, which may result from endotracheal
intubation or laryngeal nerve damage
○ Maintain in semi-Fowler position to reduce edema at surgical site
○ Observe for hemorrhage at operative site and back of neck and
shoulders
○ Observe for thyrotoxicosis (eg, high temperature, tachycardia,
irritability, delirium, coma)
○ Notify health care provider immediately if clinical findings of
thyrotoxicosis occur; administer propranolol, iodine, PTU, and
steroids as prescribed
○ Observe for signs of tetany (eg, numbness or twitching of
extremities, spasm of glottis, positive Chvostek and Trousseau
signs) because hypocalcemia can occur after accidental trauma or
removal of parathyroid glands; give calcium gluconate or calcium
chloride (IV) as prescribed if tetany occurs
■ Teach importance of taking antithyroid medications regularly and
to observe for adverse effects
○ Hypothyroidism as a result of treatment
○ Hyperthyroidism as a result of thyrotoxicosis or overmedication
with thyroid hormone replacement therapy
■ Instruct woman to comply with periodic T3, T4, TSH studies to
monitor hormone levels
■ Evaluation/outcomes
■ Maintains ideal body weight
■ Establishes regular routine of activity and rest
• Hypothyroidism
• Deficient hormone synthesis
• Decreased levels of thyroid hormones (T3 and T4) slow basal metabolic
rate (BMR); decreased BMR affects lipid metabolism, increases
cholesterol and triglyceride levels, and affects RBC production, leading
to anemia and folate deficiency
• In severe cases, infertility and increased risk of miscarriage
• Myxedema coma is most severe degree of hypothyroidism; exhibited by
hypothermia, bradycardia, hypoventilation, progressive loss of
consciousness; precipitated by severe physiologic stress; potentially
fatal endocrine emergency
• In adults, usually caused by autoimmune diseases (eg, Hashimoto
disease, sarcoidosis)
• If untreated in pregnancy can increase risk of miscarriage, gestational
hypertension, preeclampsia, placental abruption, preterm delivery, low
birthweight, and stillbirth
• Fetus is dependent on maternal production of thyroid hormones during
first trimester; hypothyroidism during the first trimester can cause
long-term neuropsychologic damage in the child
• Clinical findings
■ Subjective: dull mental processes, apathy, lethargy, loss of libido,
intolerance to cold, anorexia
■ Objective
■ Lack of facial expression; weight gain; constipation; subnormal
temperature and pulse rate; dry, brittle hair and nails; pale, dry,
coarse skin; enlarged tongue; drooling; hoarseness; thinning of
lateral eyebrows; loss of scalp, axilla, and pubic hair; diminished
hearing; anemia; periorbital edema
■ Decreased T3 and T4 levels
■ TSH stimulation test: increased in primary hypothyroidism;
delayed or poor response with secondary hypothyroidism
■ Decreased BMR and radioactive iodine uptake
• Therapeutic interventions
■ Thyroid hormones: levothyroxine; liothyronine; liotrix
■ Increased doses of hormones needed to achieve same effect as
pregnancy progresses
• Nursing care of women with hypothyroidism
■ Assessment/analysis
■ History that may have contributed to condition
■ Activity tolerance, bowel elimination, sleeping patterns, sexual
function, and intolerance to cold
■ Skin and hair for characteristic changes
■ Weight and vital signs to establish baseline
■ Clinical findings of anemia, atherosclerosis, or arthritis
■ Planning/implementation
■ Have patience with lethargic patient
■ Explain that activity tolerance and mental functioning will improve
with therapy; explain importance of continued hormone
replacement throughout life
■ Review clinical findings of hypothyroidism and hyperthyroidism to
help patient identify clinical findings of undermedication or
overmedication
■ Instruct patient
○ Avoid over-the-counter (OTC) drugs unless approved by health
care provider; have medical supervision when taking opioid
analgesics and tranquilizers
○ Modify outdoor activities in cold weather; wear adequate clothing
because of sensitivity to cold environments
○ Use moisturizers for dry skin
○ Restrict calories, cholesterol, and fat in diet to prevent weight
gain
○ Avoid constipation (eg, increase fluid intake and fiber in diet)
■ Teach to seek medical supervision regularly and when clinical
findings of illness develop; teach patient and family clinical
findings of complications
○ Angina pectoris: chest pain, indigestion
○ Cardiac failure: dyspnea, palpitations
○ Myxedema coma: weakness, syncope, slow pulse rate, subnormal
temperature, slow respirations, lethargy
■ Evaluation/outcomes
■ Completes activities of daily living (ADLs) without fatigue
■ Adheres to dietary, exercise, and medication regimen
■ Establishes regular pattern of bowel elimination
Maternal phenylketonuria (PKU)
• Lack of enzyme phenylalanine hydroxylase; changes phenylalanine
(essential amino acid) into tyrosine for metabolism
• Goal is identification and dietary management of women who have PKU
during childbearing years
• Screening should be considered if woman exhibits symptoms, has a
family history, or has given birth to microcephalic infant previously
• Guthrie blood test: performed after protein ingestion; if tested during
initial 24 hours, repeat test at 2 weeks of age; tandem mass
spectrometry now used to detect PKU
• Dietary changes should be permanent, but at least preconception
through delivery
• Clinical findings if untreated
• Growth failure, frequent vomiting, irritability
• Cognitive impairment; damage to nervous system by accumulation of
phenylalanine
■ Altered mental processes apparent by 4 months of age
■ Intelligence quotient usually below 50, most frequently under 20
• Urine has strong, musty odor from phenylacetic acid
• Blond hair and blue eyes; absence of tyrosine reduces production of
melanin
• Fair skin susceptible to eczema
• Therapeutic interventions
• Early detection essential; newborn testing is mandatory throughout
United States
• Dietary: low-phenylalanine diet calculated to allow 20 to 30 mg of
phenylalanine per kg of body weight
■ Dietary restrictions of phenylalanine recommended throughout life
■ Low-phenylalanine diet for women with PKU who are planning
pregnancy or who are pregnant
■ Breastfeeding: discouraged because of high concentrations of
phenylalanine in breast milk
Application and review
28. The nurse is counseling a pregnant patient with type 1 diabetes about
medication changes as the pregnancy progresses. Which medication will
be needed in increased dosages during the second half of her pregnancy?
1. Insulin
2. Antihypertensives
3. Pancreatic enzymes
4. Estrogenic hormones
29. What should a nurse anticipate about the insulin requirements of a
woman with diabetes on her first postpartum day?
1. A rapid increase
2. Will remain unchanged
3. A sharp and sudden decrease
4. Will decrease slowly and steadily
30. How should a nurse screen a newborn of a diabetic mother for
hypoglycemia?
1. Test for glucose tolerance.
2. Draw blood for a serum glucose level.
3. Arrange for a fasting blood glucose level.
4. Test heel blood with a glucose-oxidase strip.
31. What does a nurse anticipate will be provided for a newborn of a mother
with a history of long-standing diabetes?
1. Fast-acting insulin
2. Special high-risk care
3. Routine newborn care
4. Limited glucose intake
32. A nurse anticipates that newborns of mothers who have diabetes often
have tremors, periods of apnea, cyanosis, and poor sucking ability. With
what complication are these signs associated?
1. Hypoglycemia
2. Hypercalcemia
3. Central nervous system edema
4. Congenital depression of the islets of Langerhans
See Answers on pages 109-116.
Medical-surgical disorders
Cardiovascular disorders
• 1% of pregnancies complicated by serious heart disease.
• Adverse effects of hemodynamics during pregnancy
• Oxygen consumption increased 10% to 20%; related to needs of growing
fetus
• Plasma level and blood volume increase; RBCs remain same
(physiologic anemia)
• Peak cardiac output at about 28 weeks
• After birth, extravascular fluid shifts into intravascular compartment
with increased workload of heart
• Functional (therapeutic) classification of heart disease during pregnancy
• Class I: no limitation of physical activity; no clinical manifestations of
cardiac insufficiency or angina
• Class II: slight limitation of physical activity; may experience excessive
fatigue, palpitation, angina, or dyspnea; slight limitations as indicated
• Class III: moderate to marked limitation of physical activity; dyspnea,
angina, and fatigue with slight activity; bed rest during most of
pregnancy
• Class IV: marked limitation of physical activity; angina, dyspnea, and
discomfort at rest; indication for termination of pregnancy
• Nursing care of pregnant women with cardiovascular disorders
• Assessment/analysis
■ Prenatal period: vital signs, weight gain, dietary patterns, emotional
outlook, knowledge about self-care, clinical findings of heart failure,
stress factors (eg, work, household responsibilities), medication
regimen
■ Intrapartum period: vital signs (heart rate increases), respiratory
changes (dyspnea, coughing, or crackles), FHR patterns
■ Postpartum period: clinical manifestations of heart failure or
hemorrhage related to fluid shifts; I&O
• Planning/implementation
■ Prenatal
■ Administer prescribed medications: heparin; furosemide, digoxin,
beta blockers, antidysrhythmics
■ Monitor for heart failure (eg, respiratory distress, tachycardia); may
be precipitated by severe anemia; accelerated maternal heart rate
in latter half of pregnancy results in increased cardiac workload
■ Teach patient
○ Balance activity and rest, avoid stress
○ Wear elastic stockings, elevate legs periodically
○ Continue supervision by health care provider specializing in
cardiology
○ Maintain appropriate dietary intake: adequate calories to ensure
appropriate, but not excessive, weight gain; limited, not
restricted, sodium intake (2.5 g/day)
■ Intrapartum
■ Observe progress of labor via clinical findings and electronic
fetal/uterine monitoring
■ Maintain continuous cardiac monitoring
○ Monitor for heart failure
○ Monitor for sudden tachycardia during birth, which may cause
cardiac arrest
■ Encourage to remain in semi-Fowler or left-lateral position
■ Assist to cope with discomfort; regional analgesia usually used
■ Assist with birth (eg, forceps or vacuum extraction) to avoid work
of pushing
■ Postpartum: most critical because of increased circulating blood
volume after birth of placenta
■ Monitor for heart failure (increased cardiac output after birth of
placenta may cause sudden bradycardia with cardiac arrest)
■ Administer prescribed prophylactic antibiotics if history of
rheumatic fever
■ Encourage adequate rest (increased oxygen consumption during
labor can deplete energy reserves)
■ Institute early ambulation schedule; apply elastic stockings
■ Determine newborn risks (eg, intrauterine growth restriction,
preterm birth, hypoxia)
■ Plan for discharge; refer to agencies for family support if needed
• Evaluation/outcomes
■ Gives birth to healthy infant
■ Maintains cardiac status within acceptable limits
■ Uses resources to obtain help in the home
Pulmonary disorders
• Asthma
• Recurrent lower respiratory tract bronchospasms with airway
inflammation and bronchoconstriction
• Clinical findings: nonproductive cough, chest tightness, dyspnea,
wheezing, shortness of breath
• Impact on pregnancy: elevation of uterus in abdominal cavity impinges
on thoracic cavity; maternal hypoxia causes impaired fetal gas exchange
• Therapeutic interventions
■ Identification of triggers for attacks; limitation of exposure to
respiratory tract pathogens
■ Allergy desensitization if necessary
■ Yearly influenza vaccination recommended by Centers for Disease
Control and Prevention (CDC); may be administered during
pregnancy because it does not contain live organisms
■ Inhaled bronchodilators during exacerbations (eg, albuterol and
metaproterenol)
■ Glucocorticoids when bronchodilators are ineffective to decrease
inflammation and mucus secretions
• Nursing care of pregnant women with asthma
■ Assessment/analysis
■ Health history to identify past record of respiratory disease,
exposure to tuberculosis, clinical manifestations of tuberculosis
■ Results of purified protein derivative (PPD) test, sputum cultures,
and chest x-ray film if findings indicate possible infection
■ Case finding to limit spread of infection to family and community
■ Planning/implementation
■ Teach patient to
○ Adhere to pharmacologic protocol
○ Maintain pregnancy diet and adequate fluid intake
○ Balance activity and rest
○ Continue prenatal supervision for both maternal and fetal wellbeing
■ Monitor FHR
■ Ensure collaboration between pulmonary and obstetric health care
providers
■ Evaluation/outcomes
■ Maintains pharmacologic regimen throughout pregnancy
■ Modifies activities to maintain optimum oxygenation
■ Fetus exhibits expected growth and reactivity
• Cystic fibrosis (CF)
• Men with CF are usually infertile, but women with CF are often fertile
with a mean survival age in the mid- to late 20s
• In women with mild respiratory involvement and good nutrition,
pregnancy may be well tolerated; in women with more severe
respiratory involvement, pregnancy may be complicated
• Autosomal-recessive disorder affecting exocrine (mucus-producing)
glands
■ Reduces ability of epithelial cells in airways and pancreas to transport
chloride; abnormal transport of sodium and chloride across
epithelium leads to increased viscosity of airway mucus, abnormal
mucociliary clearance, and lung disease
■ Elevation in sweat electrolytes; sodium and chloride levels are three
to five times higher than expected; sweat chloride levels more than 60
mEq/L are diagnostic
• Organs affected by increased viscosity of mucous gland secretions
■ Pancreas: becomes fibrotic; decreased production of pancreatic
enzymes (lipase, trypsin, chymotrypsin, amylase) that affect
digestion and absorption of foods
■ Respiratory system: viscous mucus in trachea, bronchi, and
bronchioles interferes with expiration, predisposing to emphysema
■ Liver: possible cirrhosis from biliary obstruction, malnutrition, or
infection; portal hypertension predisposes to esophageal varices
■ Rectum: may prolapse
■ Sexual organs: may become infertile (common in males)
• Incidence: most common lethal genetic disease of childhood
■ About 1 in 29 Caucasian children are symptom-free carriers
■ Thirty-five percent of adults with CF between ages 20 and 29 have
diabetes resulting from pancreatic involvement
• Clinical findings
■ Respiratory involvement
■ Frequent pulmonary infections
■ Barrel-shaped chest (hyperaeration of functioning alveoli),
cyanosis, clubbing of fingers
■ Chronic obstructive pulmonary disease
■ Cardiac involvement: enlargement of heart (right ventricular
hypertrophy [cor pulmonale])
■ Nutrition status significantly affects fetal development
■ During labor, increased cardiac stress can lead to cardiopulmonary
failure, right-sided heart failure
• Therapeutic interventions
■ Ideally, woman should be 90% of her ideal body weight before
becoming pregnant and should gain 11 to 12 kg (24 to 26 lb)
throughout pregnancy
■ Nighttime tube feedings may help women to achieve necessary
weight
■ Parenteral hyperalimentation if needed
■ Vaginal birth recommended, with epidural or local analgesia
• Nursing care of women with CF
■ Assessment/analysis
■ Respiratory status; baseline pulmonary function tests
■ GI status
■ Body mass index
■ Planning/implementation
■ Prevent respiratory tract infections
■ Promote optimum nutrition
○ Monitor weight, blood glucose, hemoglobin, total protein, serum
albumin, prothrombin time, and fat-soluble vitamins A and E
○ Pancreatic enzymes adjusted as needed
○ Administer prescribed vitamin supplements; fat-soluble
vitamins in water-miscible form
○ Encourage high-protein, moderate-fat, high-calorie diet
■ Inhaled recombinant human deoxyribonuclease I or saline 7% to
reduce sputum viscosity
■ Monitor for any signs of infection
■ Fetal assessment
○ Fundal height, ultrasound measured/performed regularly
○ Fetal movements counted
■ Testing of sodium content of breast milk; if determined to be
normal, infant can be breastfed
○ Breast milk should be tested regularly for sodium, chloride, and
fat
○ Infant’s growth pattern should be monitored
■ Evaluation/outcomes
■ Achieves acceptable body weight for pregnancy
■ Gains appropriate weight to sustain pregnancy
■ Remains free from infection
■ Normal fetal development
■ Delivery free from cardiopulmonary complications
■ Able to breastfeed, as desired
• Acute respiratory distress syndrome (ARDS)
• Acute lung injury precipitated by trauma; aspiration; prolonged
mechanical ventilation; severe infection; prolonged cardiopulmonary
bypass; fat, air, or amniotic fluid emboli; shock, smoke inhalation, DIC,
pyelonephritis, preeclampsia, eclampsia, severe hemorrhage, blood
transfusion reactions, or peripartum cardiomyopathy
• Postpartum incidence does not depend on type of birth but instead on
amount of trauma involved; may occur with miscarriage or spontaneous
abortion
• Mortality rates are relatively high in pregnant women with ARDS; for
survivors, long-term prognosis is good, even with severe lung injury
• Involves
■ Alveolar capillary damage with loss of fluid and pulmonary edema
■ Impaired alveolar gas exchange causing V/Q mismatch and shunting;
tissue hypoxia results
■ Alteration in surfactant production; decreased lung compliance
■ Atelectasis, resulting in labored and inefficient respiration
• Clinical findings
■ Subjective: restlessness; anxiety; dyspnea
■ Objective
■ Tachycardia; grunting respirations; intercostal retractions; cyanosis
■ Pco2 initially decreased and later increased; decreased Po2; chest xray study shows pulmonary edema
• Therapeutic interventions
■ Treatment of underlying cause
■ Early intubation and mechanical ventilation
■ In severe injury, positive end-expiratory pressure (PEEP) may be
necessary: PEEP maintains positive pressure within lungs at end of
expiration; increases residual capacity, reducing hypoxia
■ Sedative or neuromuscular blocking agents may be needed to
facilitate mechanical ventilation
■ Surfactant replacement therapy may be necessary
■ Maintenance of fluid volume and nutrition
■ Administration of blood may help maintain cardiac output
• Nursing care of women with ARDS
■ Assessment/analysis
■ Vital signs, especially characteristics of respirations
■ Breath sounds, oxygen saturation, electrocardiogram (ECG)
■ Pain that increases on inspiration
■ Planning/implementation
■ Maintain a patent airway
■ Monitor oxygen saturation and arterial blood gases per protocol
■ Observe behavioral changes and obtain vital signs because
confusion and hypertension may indicate cerebral hypoxia
■ Schedule frequent rest periods between therapeutic interventions
■ Establish system for communication when intubated
■ Provide tranquil, supportive environment; sedation is
contraindicated because of its depressant effect on respirations
unless receiving mechanical ventilation
■ Provide care for patient receiving mechanical ventilation
■ Auscultate lungs for absent breath sounds that indicates
pneumothorax (when on PEEP, frail lung tissue may not withstand
increased intrathoracic pressure and a pneumothorax results)
■ Evaluation/outcomes
■ Maintains adequate gas exchange
■ Communicates reduction in anxiety
■ Performs activities without respiratory distress or fatigue
Integumentary disorders
• Pruritus gravidarum
• Generalized itching, usually of the abdomen, without a rash present
• Symptom of pregnancy-related skin disease, likely resulting from skin
distention
• No relation to poor perinatal outcomes
• Therapeutic interventions
■ Treated with topical antipruritics, oral antihistamines
■ Sunlight, ultraviolet light exposure may decrease itching sensation
■ Resolves with birth, but likely to recur in subsequent pregnancies
• Pruritic urticarial papules and plaques of pregnancy (PUPPP)
• Small, usually pruritic, lesions on the abdomen that may spread to the
arms, thighs, back, and buttocks, often with severe itching
• Usually occurs in the third trimester
• Not associated with poor maternal or fetal outcomes
• Therapeutic interventions
■ Focus is on maternal comfort
■ Treated with topical antipruritics, oral antihistamines, topical
steroids; oral prednisone if the case is severe enough
■ Usually resolves within a few weeks of birth; does not usually recur
• Intrahepatic cholestasis of pregnancy (ICP)
• A pregnancy-related liver disorder characterized by generalized
pruritus without skin lesions and itching on the palms of the hands and
soles of the feet
• Cause is unknown, but there is often a familial history
• Major risks include preterm delivery, stillbirth, likely related to elevated
fetal serum bile levels
• Clinical findings
■ Elevated liver enzymes and serum bile acid
■ May present with jaundice, light-colored stools, dark urine
• Therapeutic interventions
■ Ursodeoxycholic acid
■ Monitoring of liver function and bile acids
■ Antepartum fetal testing; labor may be induced at 36 to 37 weeks if
liver function does not improve and fetal lungs are mature
■ Usually resolves 2 to 4 weeks postpartum, but can recur with
subsequent pregnancies or use of oral contraceptives
Neurologic disorders
• Epilepsy (seizure disorder)
• Abnormal discharge of electric impulses by nerve cells in brain from
idiopathic or secondary causes, resulting in loss of consciousness;
seizures; motor, sensory, behavioral changes
• Onset of idiopathic epilepsy generally before age 30; seizures can be
associated with brain tumor, brain attack, Alzheimer disease,
hypoglycemia, head trauma, fluid shifts in the brain
• The majority of women with epilepsy have uneventful pregnancies with
good outcomes; however, congenital anomalies associated with
anticonvulsant medications include cleft lip and palate, congenital
heart disease, and neural tube defects
• Types of seizures
■ Partial seizures (seizures beginning locally)
■ Simple: focal motor or sensory effect; no loss of consciousness
■ Complex: cognitive, psychosensory, psychomotor, or affective
effect; brief loss of consciousness
■ Generalized seizures (bilaterally symmetric and without local onset)
■ Absence (petit mal): brief transient loss of consciousness, with or
without minor motor movements of eyes, head, or extremities;
most common in childhood and adolescence
■ Myoclonic: brief, transient rigidity or jerking of extremities, singly
or in groups
■ Tonic-clonic (grand mal): aura, loss of consciousness, rigidity
followed by tonic-clonic movements, interruption of respirations,
loss of bladder and bowel control; may last 2 to 5 minutes
■ Atonic: loss of muscle control; loss of consciousness may be brief
■ Status epilepticus: prolonged repetitive seizures without recovery
between attacks; may result in complete exhaustion, cerebral injury,
or death
• Clinical findings (tonic-clonic seizures)
■ Subjective: often preceded by an aura or warning sensation such as
seeing spots or feeling dizzy; lethargy following return to
consciousness (postictal phase)
■ Objective
■ Shrill cry as seizure begins and air is forcefully exhaled
■ Loss of consciousness during seizure
■ Tonic-clonic movement of muscles
■ Incontinence
■ Abnormal electroencephalogram (EEG), magnetic resonance
imaging (MRI)
• Therapeutic interventions
■ Anticonvulsant therapy usually continued throughout life; seizure
control is unlikely to change during pregnancy, so it is important to
achieve preconception if possible
■ Ideally, only a single anticonvulsant should be taken during
pregnancy
■ Diazepam or lorazepam given IV to treat status epilepticus
■ Sedatives used to reduce emotional stress
■ Neurosurgery is sometimes indicated if source of seizures is
localized; vagal nerve stimulation, which involves implantation of an
electrical impulse generator, is a palliative treatment if therapy has
been unsuccessful
■ Folic acid may be given to reduce incidence of neural tube defects
■ Vitamin D may be given because anticonvulsant medications can
interfere with vitamin production
• Nursing care of women with epilepsy
■ Assessment/analysis
■ Preconception counseling; determine medication use and seizure
frequency
■ History of type, frequency, and duration of seizures; precipitating
factors
■ As soon as possible, determine an accurate gestational age
■ Planning/implementation
■ Teach patient regarding the importance of seizure prevention
during pregnancy
■ Blood levels of medications should be checked regularly, and
medications adjusted as necessary
■ Maternal serum testing at 16 weeks; ultrasound at 18 to 22 weeks
for determination of neural tube defects or other fetal conditions
■ Vaginal birth is preferred; medication should be oral during
prolonged labor if possible
■ Monitor and adjust anticonvulsant medication levels postpartum
■ Teach patient that all major anticonvulsants are found in breast
milk, but this does not contraindicate breastfeeding
■ Encourage expression of feelings about illness and necessary
changes in lifestyle
■ Evaluation/outcomes
■ Remains free from injury
■ Adheres to medical regimen
■ Seizure-free pregnancy
• Multiple sclerosis
• Destruction of myelin in the central nervous system (CNS) by sensitized
T and B lymphocytes, causing randomly scattered plaques of sclerotic
tissue on demyelinated axons; frequently affected areas include optic
nerves, cerebrum, brainstem, cerebellum, and spinal cord
• Considered a chronic, debilitating, progressive disease with periods of
remission and exacerbation
• Types
■ Relapsing-remitting (RR): acute episodes with almost a complete
recovery between attacks
■ Primary progressive (PP): steady degenerative progression without
exacerbation
■ Secondary progressive (SP): initially RR followed by steady
deterioration later in disease process
■ Progressive-relapsing (PR); progressive but with periodic acute
exacerbations
• Cause unknown; viral, environmental, and immunologic causes are
implicated
• Onset in early adult life (20 to 40 years); higher incidence in females,
Caucasians, those living in temperate climates, and those with
trigeminal neuralgia
• Fatigue, stress, and heat tend to increase symptoms
• Clinical findings
■ Subjective
■ Numbness; altered position sense
■ Difficulty swallowing (dysphagia)
■ Weakness; fatigue
■ Blurred vision; diplopia
■ Emotional lability (eg, depression, apathy, euphoria)
■ Objective
■ Charcot triad: intention tremor; nystagmus; scanning (clipped)
speech
■ Ataxia; shuffling gait; increased deep tendon reflexes; spastic
paralysis
■ Impaired bowel and bladder function
■ Cognitive loss in advanced stage
■ Pallor of optic discs; blindness
■ Increased immunoglobulin G (IgG) levels in the cerebrospinal fluid
(CSF)
■ MRI indicates demyelination and presence of multiple sclerosis
plaques
• Therapeutic interventions
■ Generally palliative
■ Disease-modifying therapy
■ Interferon beta-1a (given either IM or SC)
■ Interferon beta-1b given SC
■ Glatiramer acetate given SC
■ Mitoxantrone given IV every 3 months
■ Additional drugs: corticosteroids to shorten duration of relapses,
baclofen for spasticity, carbamazepine for trigeminal neuralgia,
ascorbic acid to acidify urine, immunosuppressive agents
■ Physical therapy and psychotherapy
• Nursing care of women with multiple sclerosis
■ Assessment/analysis
■ History of onset and progression of motor and sensory loss
■ Factors that intensify symptoms
■ Neurologic status
■ Planning/implementation
■ Explain disease process to both patient and family
■ Explain that pregnancy does not seem to worsen the disease, and
remission during pregnancy is common
■ Spend time listening to both patient and family; encourage
expression of feelings
■ Explain to patient and family that mood swings and emotional
alterations are part of the disease
■ Teach to take medications as prescribed; reinforce injection
technique; explain interferon beta-1a may cause flulike symptoms
■ If patient is paraplegic or has lumbosacral lesions, explain that she
may have difficulty determining when labor begins
■ Teach patient that breastfeeding is encouraged
■ Evaluation/outcomes
■ Remains free from injury
■ Establishes exercise/activity and rest/sleep routine that avoids
fatigue
■ Maintains bowel and bladder function
■ Remains free from urinary tract infection (UTI)
• Bell palsy
• Paralysis occurring on one side of face resulting from an inflamed
seventh cranial (facial) nerve; lasts about 2 to 8 weeks but may last
longer in older adults
• Cause unknown; possibly viral, ischemic, or autoimmune link
• Most common between ages 20 and 50 years
• More common in women than in men, and three to four times more
likely in pregnant women, and linked with an increased risk for
gestational hypertension
• Most common in third trimester
• Infants are unaffected, and maternal outcome is generally positive,
although maternal recovery from Bell palsy is significantly slower (>1
year in half of the cases) than it is for others
• Clinical findings
■ Subjective: facial pain; altered taste; impaired ability to chew and
swallow
■ Objective: distortion of face; drooping of mouth on affected side;
difficulty with articulation; diminished blink reflex; inability to close
eye; increased or decreased lacrimation
• Therapeutic interventions
■ Diagnostic evaluation to rule out (eliminate) brain attack as the cause
■ Corticosteroids (eg, prednisone), antiviral (eg, acyclovir), and/or
anticonvulsant (eg, gabapentin) therapy within first 5 to 6 days of
onset
■ Heat, massage, and electric stimulation to maintain circulation and
muscle tone
■ Prevention of corneal irritation with eye drops and protective eye
shield
• Nursing care of women with Bell palsy
■ Assessment/analysis
■ Presence or absence of blink reflex and ability to close eye
■ Facial pain; extent of facial paralysis and altered sensation
■ Nutritional intake; ability to chew and swallow
■ Planning/implementation
■ Teach prevention of corneal irritation (eg, using artificial tears,
manually closing eye, applying an eye shield, wearing wraparound
sunglasses)
■ Teach importance of keeping face warm
■ Teach gentle massage of face; simple exercises such as blowing
through pursed lips when acute phase is over
■ Encourage expression of feelings
■ Teach importance of small, frequent feedings; encourage favoring
unaffected side while eating
■ Evaluation/outcomes
■ Maintains corneal integrity
■ Expresses a positive body image
■ States pain is reduced
■ Understands may face a longer recovery time than is typical
Autoimmune disorders
• Systemic lupus erythematosus (SLE)
• Necrosis of glomerular capillaries, inflammation of cerebral and ocular
blood vessels, necrosis of lymph nodes, vasculitis of GI tract and
pleura, and degeneration of basal layer of skin
• Immune complex deposits in blood vessels, among collagen fibers, and
on organs
• Affects connective tissue and is thought to result from defect in body’s
immunologic mechanisms, genetic predisposition, or environmental
stimuli; actual cause unknown
• More common in females ages 15 to 40
• Disease follows a pattern of flares and remissions; women with SLE who
wish to become pregnant are advised to wait until they have been in
remission 6 months
• Flares are common during pregnancy and can cause increased severity
of symptoms and increased risk of miscarriage, stillbirth, nephritis,
preeclampsia, possible need to give birth at a preterm gestation,
intrauterine growth restriction, and an increased risk of cesarean birth
• Clinical findings
■ Subjective: malaise, photosensitivity, joint pain
■ Objective
■ Fever; butterfly erythema on face and palms; Raynaud
phenomenon; weight loss, and evidence of impaired renal, GI,
cardiac, respiratory, and neurologic functions
■ Positive lupus erythematosus preparation (LE prep); increased
antinuclear antibodies (ANAs) in blood
• Therapeutic interventions
■ Corticosteroids and analgesics are usually used to reduce
inflammation and pain, but they are not recommended in pregnancy
■ Supportive therapy as major organs become affected
■ Antimalarial drugs: hydroxychloroquine to treat fatigue, joint pain,
skin rashes, and lung inflammation can be continued during
pregnancy
■ Immunosuppressives should be discontinued before conception
■ Plasmapheresis to remove autoantibodies and immune complexes
from the blood
■ Life-threatening SLE may be treated with stem cell transplants
• Nursing care of women with SLE
■ Assessment/analysis
■ Progression of clinical findings from the history
■ Presence of skin lesions
■ Sensitivity to light (photosensitivity)
■ Vital signs for baseline data
■ Heart and lung sounds
■ Abdomen for enlargement of liver and spleen
■ Neurologic status
■ Renal function (review BUN and creatinine analysis results)
■ Planning/implementation
■ Monitor for pregnancy complications
■ Frequent ultrasound examinations
■ Fetal assessment tests to begin at 30 weeks (including fetal
movement counts, nonstress testing, amniotic fluid volume, etc.)
■ Testing needs to be performed more frequently if the patient
experiences a flare
■ Teach patient that a flare is very likely during labor or postpartum
■ Immediately postpartum, any medications that were discontinued
for pregnancy should resume
■ Explain to patient that if she receives chronic steroid treatment, she
will need to be on a stress dose for 1 year postpartum
■ Help to establish program of exercise balanced by rest periods to
avoid fatigue
■ Instruct to alter consistency and frequency of meals if dysphagia
and anorexia exist
■ Encourage diet rich in nutrient-dense foods such as fruits,
vegetables, whole grains, and legumes to improve and maintain
nutritional status and compensate for nutrient interactions of
corticosteroid and other therapeutic medications; emphasize need
for vitamin C-enriched foods because it is essential in biosynthesis
of collagen, and large doses are found to increase total collagen
synthesis
■ Teach to prevent infection (eg, hand hygiene, avoidance of
individuals with infections)
■ Emphasize need for continued medical supervision
■ Discuss with patient the dangers of pregnancy and the need to
limit the number of pregnancies because of the increased maternal
and fetal risks
○ Estrogen-containing oral contraceptives may increase the risk of
thromboembolism
○ Progestin-only implants and injections have no currently known
effects on SLE flares
○ Barrier methods of contraception are the least risky in women
with SLE
○ Tubal sterilization may be best performed postpartum or while
patient is in remission
■ Evaluation/outcomes
■ Remains in remission through pregnancy
■ Verbalizes understanding of postpartum care
■ Understands risk of pregnancy and need for frequent monitoring
and follow-up care
• Myasthenia gravis (MG)
• Chronic, progressive, neuromuscular disorder with remissions and
exacerbations; disturbance in transmission of impulses at myoneural
junction, resulting in profound weakness
• Dysfunction caused by reduced acetylcholine receptors (AChR) and
altered postsynaptic membrane of muscle end plates
• Autoimmune theory: antibodies to AChR cause accelerated destruction
and blockage of AChR
• Highest incidence in young adult women ages 20 to 40; peak incidence
in men ages 60 to 70
• Greatest period of risk is in the first year postdiagnosis; if possible,
pregnancy should be delayed after this time
• Response to pregnancy is unpredictable, but does not affect the overall
course of the disease
• Fatigue of pregnancy may be poorly tolerated; respirations may be
limited by enlargement of uterus
• Vaginal birth is preferred, and women usually tolerate labor well
• Some infants will develop neonatal myasthenia; the disease is transient
and usually resolves within 6 weeks of birth
• Myasthenic crisis
■ Sudden, severe exacerbation of signs and symptoms of myasthenia
gravis; precipitated by conditions such as disease exacerbation,
infection, and inadequate amount of anticholinesterase drugs
■ Signs and symptoms: increased pulse, respirations, and blood
pressure; respiratory distress with cyanosis; loss of cough and
swallowing reflexes; increased respiratory secretions; diaphoresis;
increased lacrimation; dysarthria; restlessness; bowel and bladder
incontinence
• Cholinergic crisis
■ Overmedication of anticholinesterase medication; sudden onset
■ Signs and symptoms: drooping eyelids (ptosis); weakness; difficulty
swallowing, chewing, speaking, and breathing; abdominal cramps
and diarrhea; increased respiratory secretions; diaphoresis, increased
lacrimation; fasciculations; blurred vision
• Clinical findings
■ Subjective: extreme muscle weakness; becomes progressively worse
with use, but improves with rest; dyspnea; transient respiratory
insufficiency; dysphagia (difficulty chewing and swallowing);
dysarthria (difficulty speaking); diplopia
■ Objective
■ Physical: ptosis; strabismus; weak voice (dysphonia); myasthenic
smile (snarling, nasal smile); ineffective cough; enlarged thymus
■ Diagnostic measures: spontaneous relief of symptoms with IV
administration of edrophonium; edrophonium also used to
distinguish myasthenic crisis from cholinergic crisis (toxic effects
of excessive neostigmine)
• Therapeutic interventions
■ Treatment is the same as it is for nonpregnant women
■ Medications that block cholinesterase at myoneural junction
■ Radiation therapy or surgical removal of thymus gland may cause
partial remission by producing antigen-specific immunosuppression
■ Corticosteroids to suppress antibody production
■ Intubation with mechanical ventilation as necessary in myasthenic
crisis
■ Plasmapheresis and immunosuppressives to reduce circulating
antibody titer
■ Tube feedings if experiencing dysphagia
• Nursing care of women with MG
■ Assessment/analysis
■ History of onset and progression of motor and sensory loss
■ Neurologic status
■ Respiratory status: vital signs, depth of respirations, breath sounds,
oxygen saturation, arterial blood gases
■ Planning/implementation
■ Administer medications on strict time schedule to prevent onset of
symptoms; medication may need to be administered during night
■ Monitor for signs and symptoms of myasthenic and cholinergic
crises; administer short-acting cholinesterase inhibitor per protocol
to distinguish between the two; signs and symptoms will
temporarily improve with myasthenic crisis and intensify with
cholinergic crisis
■ Monitor blood glucose regularly
■ Thymectomy, if indicated, should be performed before or after
pregnancy if possible
■ Plan activity to avoid fatigue based on tolerance; collaborate with
patient to develop individualized energy-saving strategies
■ Teach patient and family to wash hands frequently and to avoid
people with upper respiratory tract infections because pneumonia
may develop as a result of respiratory impairment
■ Encourage carrying medical alert information
■ Avoid administering morphine to patients receiving cholinesterase
inhibitors; these drugs potentiate effects of morphine and may
cause increased respiratory depression
■ Provide emotional support
■ Schedule meals to coincide with peak drug action; administer tube
feedings as ordered
■ Tape eyelids closed for short periods and administer artificial tears
to keep cornea moist if patient has difficulty closing eyes
■ Encourage patient and family to participate in planning care
■ Teach patient and family signs and symptoms of myasthenic crisis
and cholinergic crisis
■ Maintain a patent airway; suction patient’s secretions as necessary;
maintain mechanical ventilation as ordered
■ Anticipate all needs during exacerbations because patient is too
weak to turn, drink, or even request assistance
■ Evaluation/outcomes
■ Maintains a balance between activity and rest
■ Maintains effective respiratory function
■ Identifies signs and symptoms of crises
Gastrointestinal disorders
• Inflammatory bowel disease
• Flare occurrence is not increased during pregnancy, although a flare in
the early part of the pregnancy can increase the risk of a poor outcome
• Outcomes of pregnancy for women with inflammatory bowel disease
are similar to those of the general population
• Therapeutic interventions
■ Treatment is unchanged in pregnancy
■ NPO and TPN when inflammatory episodes are severe
■ Pharmacologic management: sulfasalazine, 5-aminosalicylate drugs,
and corticosteroids
■ Fat-soluble vitamin, calcium, and folic acid supplements very
important
■ Parenteral nutrition may be necessary
■ Maintenance of fluid and electrolyte balance
■ Surgical intervention indicated when medical management is
unsuccessful or for specific complications such as hemorrhage
Hematologic disorders
• Anemia
• Reduction in concentration of erythrocytes (RBCs) or hemoglobin
■ Iron-deficiency anemia: most common causes are GI bleeding,
menstruation, malignancy; other causes include inadequate dietary
intake, malabsorption, and increased demand (eg, pregnancy)
■ Associated with preterm delivery and low-birthweight infants
■ Fetus usually receives adequate iron, further depleting mother’s
iron levels
■ Megaloblastic anemia
■ Rarely occurs in third trimester
■ Folate deficiency: insufficient amount of folic acid absorbed or
ingested to synthesize DNA, RNA, and proteins; associated with
alcoholism, malabsorption, pregnancy, lactation
○ Improves rapidly with folic acid treatment
○ Not a significant cause of perinatal morbidity
■ Pernicious anemia: lack of intrinsic factor in the stomach prevents
absorption of vitamin B12, reducing the formation of adequate
numbers of erythrocytes
■ Hemolytic anemia: excessive or premature destruction of RBCs;
causes include sickle cell anemia, thalassemia, glucose-6-phosphate
dehydrogenase (G6PD) deficiency, antibody reactions, infection, and
toxins
■ Sickle cell trait: women usually tolerate pregnancy well, but are at
increased risk for UTIs, preeclampsia, miscarriage, preterm
delivery, low-birthweight infants, and endometriosis
■ Sickle cell anemia: all children will be affected; women at
significant risk for miscarriage, stillbirth, intrauterine growth
restriction, maternal death, preeclampsia, UTI, pulmonary
infection, sickle cell crisis during pregnancy
■ Beta thalassemia minor: women usually asymptomatic; no adverse
effect associated with pregnancy
■ Thalassemia major: infertility is common in women; pregnancy
usually leads to severe anemia, congestive heart failure in mother
• Clinical findings
■ Subjective: fatigue, headache, paresthesias, dyspnea; sore mouth with
pernicious anemia; bleeding gums and epistaxis with
thrombocytopenic purpura
■ Objective
■ Ankle edema
■ Dry, pale mucous membranes
■ Pallor, except with hemolytic anemia
■ Iron-deficiency anemia: decreased levels of hemoglobin,
erythrocytes, ferritin; increased iron-binding capacity;
megaloblastic condition of blood
■ Pernicious anemia: beefy red tongue, lack of intrinsic factor,
positive Romberg test (loss of balance with eyes closed)
■ Hemolytic anemia: increased reticulocytes and unconjugated
bilirubin levels; jaundice
• Therapeutic interventions
■ Improvement of diet: include ascorbic acid, which enhances iron
uptake
■ Supplements: iron, vitamin B12, folic acid
■ Blood transfusions (except for polycythemia vera)
■ Oxygen as needed
■ Epoetin to stimulate bone marrow function
■ Hemolytic anemia: splenectomy if indicated
• Nursing care of women with anemias
■ Assessment/analysis
■ History of dietary habits, symptoms, and causative agents
■ Status of skin, mucous membranes, and sclera
■ Baseline vital signs
■ Planning/implementation
■ Provide genetic counseling for women with sickle cell anemia
■ Teach dietary modifications and medication administration;
emphasize foods high in iron (eg, spinach, raisins, liver)
■ Help to balance rest and activity
■ Provide postoperative care if splenectomy is performed; encourage
deep breathing and coughing; assess for abdominal distention that
may reflect hemorrhage
■ Evaluation/outcomes
■ States/selects dietary sources of iron, folic acid, and vitamin B12
■ Verbalizes need for and continues long-term therapeutic
supervision
■ Performs ADLs
■ Remains afebrile and injury free
Genitourinary disorders
Genitourinary disorders
• Asymptomatic bacteriuria
• Presence of bacteria in women who experience no symptoms of
infection
• If untreated, many women will become symptomatic
• Associated with preterm labor and birth; low birthweight
• Clinical findings
■ Clean catch urine sample >100,000 colonies/mL
• Therapeutic interventions
■ Treatment with course of antibiotics
• Nursing care of women with asymptomatic bacteriuria
■ Assessment/analysis
■ Prescreening at first prenatal visit
■ Planning/implementation
■ Full course of amoxicillin, ampicillin, cephalexin, ciprofloxacin,
levofloxacin, nitrofurantoin, and trimethoprim-sulfamethoxazole
■ Suppressive therapy for women who experience recurrence
■ Evaluation/outcomes
■ Negative repeat urine culture
■ Describes methods to prevent recurrence of infection
• Cystitis: inflammation of bladder wall usually caused by ascending
bacterial infection (Escherichia coli most common)
• More common in females because of shorter urethra, childbirth,
anatomic proximity of urethra to rectum
• Clinical findings
■ Subjective: urgency; frequency; pain when initiating, during, and
completion of urination; males—prostate tenderness with rectal
examination
■ Objective: nocturia, hematuria, pyuria, cloudy urine, positive urine
culture; males—prostate enlargement with rental examination
• Therapeutic interventions
■ Urine culture: to identify causative organism
■ Pharmacologic therapy: antibiotics, urinary antiseptics,
antispasmodics
■ Diet: directed toward altering properties of urine (eg, cranberry juice
—contributes to hostile environment for bacterial growth;
elimination of caffeine, which causes bladder irritability)
■ Additional fluids: dilute urine
■ Warm sitz baths: provides comfort
■ Antiseptic solution: installation via urethral catheter
■ Urosepsis: IV therapy with aminoglycosides; beta-lactam antibiotics,
aztreonam; used with probenecid to increase therapeutic level of
drug
• Nursing care of women with cystitis
■ Assessment/analysis
■ Urine for color, clarity, odor, blood, or mucus; dysuria; burning;
discharge
■ Suprapubic area for bladder distention
■ Planning/implementation
■ Obtain urine specimen for culture and sensitivity before
administering prescribed antibiotics; refrigerate specimen if it
cannot be sent to laboratory immediately
■ Administer aminoglycoside medication; monitor for nephrotoxicity
and respiratory paralysis; encourage increased fluid intake to avoid
nephrotoxicity, neurotoxicity, and ototoxicity.
■ Teach to seek medical attention at first sign of clinical findings and
to take medications as directed
■ Encourage intake of additional fluids
■ Teach preventive measures (eg, perineal care, avoiding tub baths,
voiding after intercourse, wearing cotton underwear)
■ Teach those at risk for recurrent UTIs that frequent follow-up care
with culture and sensitivity testing of urine if indicated
■ Evaluation/outcomes
■ Expresses relief of pain on urination
■ Resumes expected urinary patterns
■ Describes methods to prevent recurrence of infection
• Pyelonephritis
• Renal infection that may affect one kidney (most often right kidney in
pregnant women) or both
• Many women have symptoms of cystitis before developing
pyelonephritis
• Most often develops in second trimester and is a common cause of
hospitalization
• Complications: anemia, septicemia, transient renal dysfunction,
pulmonary insufficiency, urosepsis, sepsis syndrome, and renal
dysfunction
• Associated with preterm labor; recurrent infections can cause death of
fetus
• Usually caused by E. coli
• Recurrent infections are common
• Clinical findings
■ Abrupt onset
■ Fever, shaking chills
■ Pain in lower back
■ Anorexia, nausea and vomiting
■ Costovertebral angles likely sensitive to palpation
• Therapeutic interventions
■ Immediate hospitalization
■ Broad-spectrum IV antibiotic treatment (may be changed once
causative organism is identified)
■ Ultrasound for possible obstruction
■ Follow-up with oral antibiotic
• Nursing care of women with pyelonephritis
■ Assessment/analysis
■ Urine and blood samples for culture and sensitivity
■ Planning/implementation
■ Monitor for development of sepsis
■ Monitor vital signs for response to therapy
■ Teach to seek medical attention at first sign of clinical findings and
to take medications as directed
■ Encourage intake of additional fluids
■ Teach preventive measures (eg, perineal care, avoiding tub baths,
voiding after intercourse, wearing cotton underwear)
■ Teach importance of follow-up care with culture and sensitivity
testing each trimester
■ Explain importance of prophylactic antibiotic course, as indicated
■ Evaluation/outcomes
■ Resolution of infection
■ Resumes expected urinary patterns
■ Describes methods to prevent recurrence of infection
Application and review
33. A nurse in the prenatal clinic is caring for a patient with heart disease
who is in the second trimester. What hemodynamic of pregnancy may
affect the patient at this time?
1. Decrease in the number of RBCs
2. Gradually increasing size of the uterus
3. Heart rate acceleration in the last half of pregnancy
4. Increase in cardiac output during the third trimester
34. A pregnant patient with class II heart disease is concerned that her
pregnancy will be an added burden on her already compromised heart. A
nurse explains that during pregnancy the cardiac system is most
compromised during the what?
1. First trimester
2. Third trimester
3. Transitional phase of labor
4. First 2 days after the birth
35. A pregnant patient with a history of rheumatic heart disease since
childhood is concerned about the birth of her baby and asks what to
expect. What should a nurse explain about the birth? Select all that apply.
1. Labor may be induced.
2. Birth may be midforceps assisted.
3. Birth may be vacuum extraction assisted.
4. Regional anesthesia may be administered.
5. Inhalation anesthesia may be administered.
36. A patient with class I heart disease is admitted to the birthing suite in
active labor. In what position should the nurse place the patient?
1. High Fowler
2. Semi Fowler
3. Left lateral with head elevated
4. Right lateral with head elevated
37. What nursing intervention is specific for patients with cardiac problems
who are in active labor?
1. Encouraging frequent voiding
2. Monitoring the blood pressure hourly
3. Auscultating the lungs for crackles every 30 minutes
4. Helping to turn from side to side at 15-minute intervals
See Answers on pages 109-116.
Cancer
• Moral dilemma for childbearing woman, family, and health team
Risk factors
• Increase with age, postponement of pregnancy
Incidence
• Breast most common; cervical, ovarian, melanoma, leukemia, lymphomas,
and tubal and thyroid cancers
Therapeutic interventions
• Staging without exposing fetus to radiation: ultrasound, MRI
• Laparoscopy used for node sampling; surgical procedures increase risk for
preterm labor, intrauterine growth restriction (IUGR), fetal demise
• Contraindicated therapies
• Chemotherapy: teratogenic, especially in first trimester
• Radiotherapy: increases risk of fetal abnormalities, low birthweight,
cancer later in life, possible genetic effects on future generations of
fetus
Care of pregnant women with cancer
• Assessment/analysis
• Results of blood studies related to organ functioning
• Review of tumor markers (may be influenced by oncofetal proteins
found in maternal blood)
• Planning/implementation
• Explain treatment choices and plan
• Assess understanding of condition and its effects on client and the
pregnancy
• Encourage client and family to express feelings
• Refer to health care providers, agencies, and clergy as needed
• Evaluation/outcomes
• Maintains emotional and physiologic well-being
• Verbalizes concerns
• Arrives at decisions through problem solving
• Uses support systems
Surgical emergencies during pregnancy
Appendicitis
• Most common nonobstetric surgical emergency
• Rupture and subsequent peritonitis more common in pregnant women
because
• Diagnosis may be delayed (symptoms are similar to normal changes of
pregnancy)
• Appendix position is shifted
• Compromised circulation and inflammation of vermiform appendix;
inflammation may be followed by edema, necrosis, rupture, peritonitis
• Causes: obstruction by a fecalith, foreign body, or kinking
• Clinical findings
• Subjective: anorexia, nausea, right lower quadrant pain (McBurney
point), rebound tenderness
• Objective: vomiting; fever; leukocytosis; abdominal distention and
paralytic ileus if appendix has ruptured
• Therapeutic interventions
• Laparoscopic surgical removal of appendix immediately to decrease risk
of rupture and peritonitis
• Prophylactic antibiotics
• Maintenance of fluid and electrolyte balance
• Analgesics for pain
• Nursing care of women with appendicitis
• Assessment/analysis
■ History of characteristics of pain, nausea, vomiting
■ Presence of anorexia or urge to pass flatus
■ Presence of rebound tenderness when palpating abdomen
■ Presence of tenderness/rigidity when palpating McBurney point
(Rovsing sign); located between the anterior iliac crest and the
umbilicus in the right lower quadrant of the abdomen
■ Temperature for baseline data
■ Presence and extent of bowel sounds
• Planning/implementation
■ Provide emotional support because this condition is unanticipated
and the patient needs to voice concerns
■ Monitor fluid and electrolyte balance
■ Assess for signs of infection; maintain semi-Fowler position to help
localize infection in lower abdominal cavity if appendix ruptures
■ Assess for return of bowel function (eg, bowel sounds, flatus, bowel
movement); encourage ambulation
• Evaluation/outcomes
■ States pain is alleviated
■ Remains free from infection
Cholelithiasis/cholecystitis
• Inflammation of gallbladder; usually caused by infection or stones
(cholelithiasis), which are composed of cholesterol, bile pigments, and
calcium; may be related to hepatic Helicobacter bacteria; cannot contract in
response to fatty foods entering duodenum because of obstruction by
calculi or edema
• Obstructed common bile duct: bile cannot pass into duodenum and is
absorbed into blood, leading to hyperbilirubinemia and jaundice
• Incidence: highest in obese women in fourth decade; people with
cirrhosis, portal hypertension, sickle cell disease, or diabetes;
transplantation candidates; incidence increases in pregnant women
• Clinical findings
• Subjective: indigestion after eating fatty or fried foods; pain, usually in
right upper quadrant of abdomen, which may radiate to back; nausea;
itchy skin
• Objective
■ Vomiting; increased temperature and white blood cell (WBC) count;
clay-colored stool; dark urine; jaundice may be present
■ Rebound tenderness in abdomen increasing on inspiration,
indicating peritoneal inflammation
• Diagnostic tests
■ Serum bilirubin and alkaline phosphatase levels are increased
■ Ultrasonography determines presence of gallstones
■ Endoscopic retrograde cholangiopancreatography (ERCP) reveals
location of gallstones
• Therapeutic interventions
• Medical management
■ Nasogastric tube suctioning to reduce nausea and eliminate vomiting
■ Opioids (drug of choice) to decrease pain by relaxing smooth muscles
■ Antispasmodics and anticholinergics to reduce gallbladder spasms
and contractions
■ Antibiotic therapy if infection is suspected
■ Vitamin K to prevent bleeding (vitamin K is fat soluble and is not
absorbed in absence of bile and a deficiency may result in bleeding)
■ When the surgical risk is high or radiolucent cholesterol stones are
small, chenodeoxycholic acid or ursodiol administered for 6 to 12
months to dissolve stones
■ Dissolution of stones by infusing a solvent such as methyl tertiary
terbutyl ether (MTBE) into the gallbladder through ERCP
■ Endoscopic papillotomy via ERCP to retrieve stones in common bile
duct
■ Electrohydraulic shock wave lithotripsy (ESWL): fragmentation of
stones by ultrasonic sound waves enables their passage without
surgical intervention
■ Low-fat diet to avoid stimulating gallbladder, which contracts to
excrete bile with subsequent pain; calories principally from
carbohydrate foods in acute phases; postoperatively a fat-restricted
diet is initiated and progresses to a regular diet
• Surgical intervention
■ If possible, delayed until puerperium, but surgery can be performed
throughout pregnancy
■ Abdominal cholecystectomy: removal of gallbladder through an
abdominal incision
■ Laparoscopic cholecystectomy: removal of gallbladder through
endoscope inserted through abdominal wall; also called endoscopic
laser cholecystectomy; not used if infection is present
Application and review
38. Which clinical indicator should the nurse identify before scheduling a
patient for an endoscopic retrograde cholangiopancreatography (ERCP)?
1. Urine output
2. Bilirubin level
3. Blood pressure
4. Serum glucose
39. A patient is discharged the same day after ambulatory surgery for a
laparoscopic cholecystectomy. The nurse is providing discharge teaching
about how many days the patient should wait to engage in certain
activities. Place in order the activities from the first to the last in which the
patient may engage.
1. _____ Showering
2. _____ Driving a car
3. _____ Performing light exercise
4. _____ Getting out of bed in a chair
5. _____ Lifting objects of more than 10 pounds
40. A nurse is preparing a teaching plan for a pregnant patient with a history
of cholelithiasis. Which information about why the ingestion of fatty foods
will cause discomfort should the nurse include in the teaching plan?
1. Fatty foods are hard to digest.
2. Bile flow into the intestine is obstructed.
3. The liver is manufacturing inadequate bile.
4. There is inadequate closure of the ampulla of Vater.
41. A nurse is caring for a woman with cholelithiasis and obstructive
jaundice. When assessing this patient, the nurse should be alert for which
common clinical indicators associated with these conditions? Select all
that apply.
1. Ecchymosis
2. Yellow sclera
3. Dark brown stool
4. Straw-colored urine
5. Pain in right upper quadrant
42. An 18-year-old pregnant woman in her first trimester is admitted with an
acute onset of right lower quadrant pain at the McBurney point.
Appendicitis is suspected. For which clinical indicator should the nurse
assess the patient to determine whether the pain is secondary to
appendicitis?
1. Urinary retention
2. Gastric hyperacidity
3. Rebound tenderness
4. Increased lower bowel motility
See Answers on pages 109-116.
Trauma
• Leading nonobstetric cause of mortality
• Over half of all incidents of maternal trauma are related to motor vehicle
collisions
• Maternal trauma accounts for roughly half of all fetal deaths; usually
related to motor vehicle collisions
• Maternal adaptations to pregnancy change clinical responses to trauma
(Table 6.1)
• Electronic fetal monitoring can reveal changes to maternal status before
they are otherwise apparent
• Priority is maternal stabilization; improves fetus’s chances of survival
TABLE 6.1
Maternal Adaptations during Pregnancy and Relation to Trauma
System
Alteration
Clinical Responses
Respiratory
Increased oxygen consumption
Increased tidal volume
Decreased functional residual capacity
Chronic compensated alkalosis
Decreased Paco2
Decreased serum bicarbonate
Increased risk of acidosis
Increased risk of respiratory mismanagement
Decreased blood-buffering capacity
Cardiovascular
Increased circulating volume, 1600 mL
Increased CO
Increased heart rate
Decreased SVR
Decreased arterial blood pressure
Heart displaced upward to left
Can lose 1000 mL blood
No signs of shock until blood loss >30% total blood
volume
Decreased placental perfusion in supine position
Point of maximal impulse, fourth intercostal space
Renal
Increased renal plasma flow
Dilation of ureters and urethra
Bladder displaced forward
Increased risk of stasis, infection
Increased risk of bladder trauma
Gastrointestinal Decreased gastric motility
Increased hydrochloric acid production
Decreased competency of
gastroesophageal sphincter
Increased risk of aspiration
Passive regurgitation of stomach acids if head
lower than stomach
Reproductive
Increased blood flow to organs
Uterine enlargement
Increased source of blood loss
Vena caval compression in supine position
Musculoskeletal
Displacement of abdominal viscera
Pelvic venous congestion
Cartilage softened
Fetal head in pelvis
Increased risk of injury, altered rebound response
Altered pain referral
Increased risk of pelvic fracture
Center of gravity changed
Increased risk of fetal injury
Hematologic
Increased clotting factors
Decreased fibrinolytic activity
Increased risk of thrombus formation
From Lowdermilk, D.L., Perry, S.E., Cashion, K., & Alden, K.R. (2016). Maternity and women’s health care
(11th ed.). St Louis: Elsevier.
CO, Cardiac output; Paco2, arterial partial pressure of carbon dioxide; SVR, systemic vascular resistance.
Immediate stabilization
• Priorities should be same as for nonpregnant patient
• All women of childbearing age should be assumed to be pregnant
• Primary survey
• Airway
■ Assume cervical spinal injury; use jaw thrust
■ Oxygen needs are greater in pregnant women
■ For a pregnant woman past 20 weeks of gestation, position uterus to
one side (lateral position, manual deflection, wedges)
• Breathing
■ Observe chest wall
■ Watch for movement of breathing
■ Rapid, labored, uncoordinated, and/or unsymmetric movement of
flail chest
■ Ventilate and intubate patient as needed
■ Supplemental oxygen provided via nonrebreather at 10 to 12 L/min
• Circulation
■ Check carotid pulse
■ If no pulse is detected, begin compressions; on pregnant woman,
compressions may be higher on sternum
■ If patient seriously injured, place two 14- to 16-gauge IV lines
■ If providing crystalloids or blood volume expanders, adjust
replacement to account for increased pregnancy blood volume
■ Draw blood to test for possible necessary transfusion
■ If possible, avoid vasopressors; however, these should be
administered if necessary for successful resuscitation
• Defibrillation
■ Heart is displaced upward; move paddles up one intercostal space
• Determine baseline neurologic status
• Secondary survey
• Physical assessment of all body systems (Box 6.1)
• Outwards signs (pain, bruises, wounds) can indicate internal damage
• Assume patient has full stomach; can be emptied via a nasogastric tube
• Assess for placental abruption
■ Very common
■ Can result from relatively minor injuries
■ Ultrasound cannot confirm or rule out
• Penetrating wounds
■ Locate all wounds; if appropriate, find all exit wounds
■ Ultrasound and computed tomography can aid with finding internal
bleeding
■ If wound is a gunshot, exploratory laparotomy
• After stabilization, provide hemodynamic monitoring
BOX 6.1
P hysica l E x a m ina t ion of t he P re gna nt T ra um a V ict im
Head
• Check scalp for signs of cuts, bruises, or edema. Examine skull for
deformities, depressions, or lumps. Examine eyes and eyelids. Evaluate
pupils for size, equality, and reaction to light. If contact lenses are
present, remove them. Examine nose and ears, and observe for serous or
bloody fluid. Open the mouth and look for blood, vomitus, loose teeth,
and dentures.
• Neurologic function should be evaluated frequently because the most
frequent cause of death in women not using seat belts is head trauma. If
neurologic checks show a possible head trauma, a complete neurologic
consultation and examination should be obtained quickly, including skull
films and computed tomographic examination.
Neck
• Palpate for tenderness over the cervical spine area. Immobilize with a
cervical collar and backboard if complaints of tenderness are present or
any injury is suspected. Tilt backboard to side as soon as the pregnant
woman is placed on backboard.
Chest
• Observe for lacerations, contusions, wounds, or impaled objects. Observe
chest wall movement for symmetry and equal expansion. Assess breath
sounds and quality and rate of respirations. Observe for deviated trachea,
sounds of sucking wounds, and flail chest. Palpate ribs, sternum, and
clavicles.
Abdomen
• Observe for lacerations, contusions, wounds, or impaled objects. Perform
light and then deep palpation. Apply electronic fetal monitoring (EFM)
devices—ultrasound Doppler and tocodynamometer. Palpate for
intensity of uterine contractions and determine uterine resting tone.
Observe fetal heart rate tracing for normal (reassuring) or abnormal
(nonreassuring) characteristics.
Lower back
• Palpate for tenderness. Observe for contusions, deformities, or other
signs of injury.
Extremities
• Examine for deformities, edema, dislocation, bleeding, contusions, and
fractures. Palpate for tenderness. Assess radial and pedal pulses. Ask
pregnant woman to move extremities; observe response.
Vagina
• Use digital examination for term gestation without vaginal bleeding; use
sterile speculum examination for preterm gestation or if vaginal bleeding
is present. Assess for signs of labor, injuries to tissues, or evidence of
ruptured membranes.
Urinary tract
• Observe for the presence of blood in the urine. Trauma to the lower
urinary tract is usually accompanied by a fractured pelvis, requiring use
of a Foley catheter. Rupture of the bladder may occur in late pregnancy
without a pelvic fracture because the full bladder becomes an abdominal
organ. Maintain accurate documentation of intake and output and
observe color of urine.
From Lowdermilk, D.L., Perry, S.E., Cashion, K., & Alden, K.R. (2016). Maternity and women’s health
care (11th ed.). St Louis: Elsevier.
Cardiopulmonary resuscitation (CPR) of the
pregnant woman
• See “Primary survey” (earlier)
• Chest compressions produce less output than in nonpregnant women
• If CPR is not effective within 4 minutes, perimortem caesarean birth may
be considered in third trimester
• Maternal complications include liver laceration, splenic rupture, uterine
rupture, hemothorax, hemopericardium
• Fetal complications include cardiac arrhythmia, asystole, CNS depression,
fetal hypoxemia, and fetal academia
• If CPR is successful, continued maternal and fetal monitoring are
imperative
Nursing care of pregnant women with special
needs
The pregnant adolescent
• Reasons for high-risk pregnancy
• Physical development: not yet completed; bone growth may be
incomplete; increased levels of estrogen may close epiphyses
• Preeclampsia: common complication because of poorly developed
vascular system in placenta; possible inadequate adolescent nutrition
• Developmental tasks of adolescence not yet achieved
• Emotional immaturity
• Factors contributing to incidence of adolescent pregnancy
• Inadequate coping mechanisms
• Need to enhance self-concept
• Belief in own invulnerability
• Need for immediate gratification: focus on present, not future; lack of
concern for long-term consequences
• Need for attention, closeness, and/or idealized or idolized love
• Lack of knowledge about conception or contraception
• Indulgence in risk-taking behavior; sexual acting out
• Change in concepts of morality; variety of family configurations;
increase in dysfunctional families
• Nursing care of pregnant adolescents
• Assessment/analysis
■ Personal and family health; menstrual history
■ Nutritional status
■ Drug/alcohol abuse
■ Developmental level
■ Support system; financial status
■ Potential role of infant’s father
■ Attitude about pregnancy (eg, denial, ambivalence); understanding of
responsibility of pregnancy and motherhood
• Planning/implementation
■ Establish a trusting relationship
■ Refer to appropriate agencies and resources
■ Promote problem-solving abilities
■ Involve father, if desired
■ Provide prenatal education; encourage consistent prenatal care
• Evaluation/outcomes
■ Arrives at decisions regarding pregnancy
■ Keeps prenatal appointments and attends childcare classes
■ Involves significant others in planning during pregnancy and for the
future
The older pregnant woman (35 years of age or
older)
• Reasons for high-risk pregnancy
• Increased chance of chromosomal abnormalities
• Preexisting illness
• Increased incidence of multiple gestation secondary to fertility
medications
• Increased risk for spontaneous abortions and preterm labor
• Emotional concerns related to changes in role, job, income, and
childcare issues
• Nursing care of older pregnant women
• Assessment/analysis
■ Health history; gynecologic/obstetric history (fibroids; nulliparous;
grand multipara); family health history
■ Genetic history, counseling, and testing
■ Nutritional status
■ Prescribed/OTC medications and supplements
• Planning/implementation
■ Refer for genetic counseling
■ Provide prenatal care with emphasis on preexisting conditions and
immunizations
■ Allow for verbalization of plans regarding work, changing
responsibilities, and altered lifestyle
• Evaluation/outcomes
■ Expresses feelings regarding expectations of body changes
■ Uses appropriate agencies for risk assessment
■ Makes appropriate plans for role change during pregnancy and after
birth
The woman with a multifetal pregnancy
• Frequency increasing; related to higher incidence of fertility drug use
• Increasing rate of elective fetal reduction to decrease risk of fetal death;
greater incidence of twin births; lower incidence of triplet and higherorder births
• High probability for developing preterm labor, gestational hypertension,
hyperemesis gravidarum, iron or folate anemia, dystocia, twin-to-twin
transfusion, postpartum uterine atony
• High risk for fetuses being born with congenital anomalies and IUGR
• Monozygotic (identical) twins: develop from one fertilized ovum and are
of same gender, race, heredity, parity; maternal age has no influence on
incidence
• Dizygotic (fraternal) twins: develop from two ova, each of which is
fertilized by a different sperm; may be same or different genders; familial
predisposition; increased incidence in women who are African American,
multiparous, and younger than 35 years of age
The pregnant woman with human
immunodeficiency virus (HIV)
• Risk for transmission to infant before or around time of birth; increased
with low CD4+ T-cell count, prolonged rupture of membranes, and high
plasma RNA concentrations
• Reduced risk for transmission: antiretroviral (ARV) therapy for mother;
caesarian birth; ARV therapy for newborn
• Nursing care of women with HIV
• Assess for prenatal ARV therapy; offer ARV when in labor to decrease
risk of transmission
• Avoid procedures that may increase risk of transmission (eg, fetal scalp
sampling, artificial rupture of membranes)
• Teach importance of formula feeding rather than breastfeeding (may
not be an option for mothers in developing countries)
Application and review
43. A 16-year-old adolescent visits the prenatal clinic because she has missed
three menstrual periods. Before her physical examination she says, “I
don’t know what the problem is, but I can’t be pregnant.” What is the
nurse’s most therapeutic response?
1. “Many young women are irregular at your age.”
2. “You probably are pregnant if you had intercourse.”
3. “Why did you decide to come to the prenatal clinic?”
4. “Should I ask the health care provider to talk to you?”
44. A teenager at 32 weeks’ gestation is hospitalized with preeclampsia. She
is anorexic and appears depressed. Which comment indicates to the nurse
that further exploration of the client’s emotional status is indicated?
1. “I’m tired of feeling so clumsy.”
2. “I’ll be glad when I can sleep all night.”
3. “I dreamed my baby had only one arm.”
4. “I was really happy before I got pregnant.”
45. A client visiting the prenatal clinic for the first time asks a nurse about
the probability of having twins because her husband is one of a pair of
fraternal twins. What is the appropriate response by the nurse?
1. “A sonogram will confirm if there is a twin pregnancy.”
2. “There is a 25% probability of having twins.”
3. “The husband’s history of being a twin increases the chance of
having twins.”
4. “There is no greater probability of having twins than in the general
population.”
46. Women who become pregnant for the first time at a later reproductive
age (35 years of age or older) are at risk for what complications? Select all
that apply.
1. Preterm labor
2. Multiple gestation
3. Development of seizures
4. Chromosomal anomalies
5. Bleeding in the first trimester
47. What is the initial responsibility of a nurse when teaching the pregnant
adolescent?
1. Instructing her about the care of an infant
2. Informing her of the benefits of breastfeeding
3. Advising her to watch for danger signs of preeclampsia
4. Encouraging her to continue regularly scheduled prenatal care
48. A nurse is counseling a woman who was just diagnosed with a multiple
gestation. Why does the nurse consider this pregnancy high risk?
1. Postpartum hemorrhage is an expected complication.
2. Perinatal mortality is two to three times greater in multiple than in
single births.
3. Maternal mortality is higher during the prenatal period with a
multiple gestation.
4. Optimum adjustment after a multiple birth requires 6 months to 1
year.
49. A nurse in the birthing unit is caring for several clients. Which factor
should the nurse anticipate will increase the risk for hypotonic uterine
dystocia?
1. Twin gestation
2. Gestational anemia
3. Hypertonic contractions
4. Gestational hypertension
50. Sonography of a primigravida who is at 15 weeks’ gestation reveals a twin
pregnancy. The nurse reviews with the client the risks of a multiple
pregnancy that were explained by the health care provider. Which
condition does the client identify that indicates the need for further
instruction about complications associated with a multiple gestation?
1. Preterm birth
2. Down syndrome
3. Twin-to-twin transfusion
4. Gestational hypertension
51. A client pregnant with twins is told by the health care provider that she is
at risk for postpartum hemorrhage. Later, the client asks the nurse why
she is at risk for hemorrhage. What should the nurse consider is the cause
of the postpartum hemorrhage before responding in language the client
will understand?
1. Uterine atony
2. Mediolateral episiotomy
3. Lacerations of the cervix
4. Retained placental fragments
See Answers on pages 109-116.
Answer key: Review questions
1. 3 Magnesium sulfate has a CNS depressant effect; therefore, toxic levels
will be reflected by the loss of the knee-jerk reflex.
1​​ The level of consciousness is decreased with excessive magnesium
sulfate. 2 There is a deceleration in the respiratory rate with magnesium
sulfate toxicity. 4 Development of a cardiac dysrhythmia may be caused
by increased potassium, not magnesium sulfate.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes
2. 2 The patient’s slow pulse and respirations and the flushed face are signs
of magnesium sulfate toxicity. The infusion should be stopped and the IV
site should be maintained with an infusion of D5W because an antagonist
(calcium gluconate) may be prescribed.
1 Continuing the infusion will make the CNS depression more severe;
this is unsafe. The health care provider should be notified after the
infusion has been stopped. 3 These actions are unsafe. The patient’s
clinical manifestations indicate a life-threatening condition. 4 It is
unsafe to decrease the rate of the infusion because the CNS depression
will worsen. The magnesium level should be obtained, but not before
stopping the infusion.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Planning/Implementation
3. 4 Hyperreflexia of severe preeclampsia is 3+ to 4+; therefore, a deep
tendon reflex of 2+, which is an active, expected reflex, indicates that a
therapeutic level of the drug has been reached. A diminished or absent
reflex indicates that the serum magnesium level is too high.
1 Because magnesium sulfate is a CNS depressant, a respiratory rate of 12
indicates that the serum magnesium level is too high. 2 Alterations in
fetal activity are not indicators of a therapeutic magnesium sulfate
level. 3 Oliguria is a sign of severe preeclampsia; diuresis is a
therapeutic effect of magnesium sulfate administration.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes
4. 1 A first pregnancy and obesity are both documented risk factors for a
hypertensive disorder of pregnancy.
2 The risk for a hypertensive disorder of pregnancy increases when the
patient is younger than 20 years of age and older than 35 years of age. 3,
4 Multipara who had more than six previous pregnancies and
primigravida who took oral contraceptives within 3 months of
conception are not documented risk factors.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
5. 4 A blood pressure more than 140 mm Hg systolic and 90 mm Hg diastolic
along with proteinuria is diagnostic of preeclampsia; assessments should
be done twice 4 to 6 hours apart.
1 Hypertension alone does not support a diagnosis of preeclampsia. 2
Hypertension accompanied by a headache is not necessarily indicative
of preeclampsia. 3 Blood pressure above the baseline while fluctuating
at each reading can occur at any time, not specifically in patients with
gestational hypertension.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
6. Answers: 1, 3, 5
1 Headache in severe preeclampsia is related to cerebral edema. 3
Abdominal pain in severe preeclampsia is related to decreased
circulating blood volume and generalized edema. 5 Visual disturbances
in severe preeclampsia are related to retinal edema.
2 Constipation is not related to preeclampsia. 4 Vaginal bleeding is not
associated with preeclampsia.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
7. 4 Rolling of the eyes to one side with a fixed stare is a sign of CNS
involvement that the nurse can observe without obtaining subjective data
from the patient. It is a sign of an impending seizure.
1, 2, 3 Persistent headache with blurred vision, epigastric pain with
nausea and vomiting, and spots of flashes of light are clinical
manifestations of severe preeclampsia, not eclampsia.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
8. 1 Padded side rails prevent injury during the clonic-tonic phase of a
seizure. The patient must be protected from injury if there is a seizure.
2 Although some patients have an aura before a seizure, there is not
enough time to use a call button and wait for help. 3 Oxygen is useless
during a seizure when the patient is not breathing and/or is thrashing
about. 4 Assigning a staff member to stay with the patient in
anticipation of a seizure is impractical and unproductive.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Nursing Process: Planning/Implementation
9. 3 The danger of a seizure in a woman with eclampsia subsides when
postpartum diuresis has occurred, usually 48 hours after birth; however,
the risk for seizures may remain for up to 2 weeks postpartum.
1, 2, 4 Anything 24 hours and before is too soon.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
10. 2 Fundal height at the umbilicus at 16 weeks’ gestation indicates a
hydatidiform mole, a multiple gestation, or a fetal congenital anomaly; at
16 weeks’ gestation the fundus is below the umbilicus. It does not rise to
the umbilicus until 20 to 22 weeks.
1 Foot and ankle edema is common as pregnancy reaches term; the
enlarged uterus presses on the femoral veins, impeding the flow of
venous blood from the extremities. 3, 4 Fetal heart rate of 150 beats/min
at 24 weeks’ gestation and maternal heart rate of 92 beats/min at 28
weeks’ gestation are within the expected range during pregnancy.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
11. 3 The proliferation of trophoblastic tissue filled with fluid causes the
uterus to enlarge more quickly than if a fetus were in the uterus.
1 Hypertension, not hypotension, often occurs with a molar pregnancy. 2
There is no fetus within a hydatidiform mole. 4 There may be slight
painless vaginal bleeding.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
12. 2 At this time the products of conception are too large for the tube to
accommodate them, and rupture occurs.
1, 3 Tubal pregnancies cannot advance to this stage because of the tube’s
inability to expand to accommodate a pregnancy of this size. 4 The
embryo is recognizable at this time (about 2 weeks after fertilization),
but it is too small to cause the tube to rupture.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Nursing Process: Assessment/Analysis
13. 3 A fallopian tube is unable to contain and sustain a pregnancy to term;
as the fertilized ovum grows, there is excessive stretching or rupture of
the affected fallopian tube, causing pain.
1 At this stage the products of conception are too small to form a mass;
the pain is lateral, not centered. 2 The pain is sudden, intense, and
knifelike, not prolonged or cramping. 4 Leukorrhea and dysuria may be
indicative of a vaginal or bladder infection.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
14. 1 Hemorrhage may result from retained placental tissue or uterine atony.
2 There is no indication that the patient has been deprived of fluids. 3
Hypotension, not hypertension, may occur with postabortion
hemorrhage. 4 Subinvolution is more likely to occur after a full-term
birth.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
15. 4 About 75% of all spontaneous abortions take place between 8 and 12
weeks’ gestation and show embryonic defects.
1 Although possible, physical trauma rarely causes an abortion. 2
Unresolved stress is rarely associated with spontaneous abortions. 3
Congenital defects are asymptomatic during pregnancy and do not
usually cause an abortion.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
16. 3 Spotting in the first trimester may indicate that the patient is having a
threatened abortion; any patient with the possibility of hemorrhage
should not be left alone; therefore, her admission to the hospital ensures
her safety.
1 A missed abortion may not cause any outward signs or symptoms,
except that the signs of pregnancy disappear. 2 An inevitable abortion
can be confirmed only if vaginal examination reveals cervical dilation. 4
With an incomplete abortion, some, but not all, of the products of
conception have been expelled.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis
17. 4 After a spontaneous abortion, the uterine fundus should be palpated
for firmness, which indicates effective uterine tone. If the uterus is not
firm or appears to be hypotonic, hemorrhage may occur; a soft or boggy
uterus also may indicate retained placental tissue.
1 The nurse would notify a health care provider if necessary after
checking for fundal firmness. 2 Administering a prescribed sedative is
not the priority; the potential for hemorrhage must be monitored. 3 It is
unnecessary to take the patient to the operating room; fetal and
placental contents are small and expelled easily.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
18. 4 A correct and simple definition answers the question and fulfills the
patient’s need to know.
1 “I don’t think you should focus on this anymore” denies the patient’s
right to know. 2 “This is when the fetus dies but is retained in the
uterus for at least 2 months” is the definition of a missed abortion. 3 “I
think it is best if you asked your health care provider for the answer to
that question” abdicates the nurse’s responsibility; the nurse can
independently reinforce information and correct misconceptions.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
19. 2 Placenta previa is defined as an abnormally implanted placenta in the
thin, lower-uterine segment (ie, low-lying, partially covering, or
completely covering the cervical os).
1 Preterm labor can occur at any time; it is not specific to a low-lying
placenta. 3 Premature separation of the placenta can occur with a
normally implanted placenta. 4 Premature rupture of the membranes
can occur at any time with or without a low-lying placenta.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
20. 4 Severe pain accompanied by bleeding at term or close to it is
symptomatic of complete premature detachment of the placenta (abruptio
placentae).
1 A hydatidiform mole is diagnosed before 36 weeks’ gestation; it is not
accompanied by severe pain. 2 There is no bleeding with vena caval
syndrome. 3 Bleeding caused by placenta previa should not be painful.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
21. 2 The blood cannot escape from behind the placenta; thus, the abdomen
becomes boardlike and painful because of the entrapment of blood.
1 Signs and symptoms of hemorrhagic shock do not include pain. 3 Blood
in the myometrium is not related to the initial pain of abruptio
placentae; eventually blood at the site of placental separation may seep
into the uterine muscle (Couvelaire uterus). 4 Disseminated
intravascular coagulation is not related to the initial pain of abruptio
placentae; it is a life-threatening complication.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
22. 1 The patient’s clinical manifestations suggest abruptio placentae, and
her vital signs indicate that shock may be occurring; the priority is to
determine fetal viability so that appropriate treatment may be instituted
immediately.
2 Preparing for a cesarean birth is premature until fetal viability is
determined. 3 Obtaining a blood sample before assessing the status of
the fetus is unsafe. 4 The amount of vaginal bleeding is not relevant
because there may be hidden bleeding.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
23. 4 Clotting defects are common in moderate and severe abruptio placentae
because of the loss of fibrinogen caused by copious internal bleeding.
1 An excessive amount of RBCs is not related to the depletion of
fibrinogen. 2 The bleeding with abruptio placentae is caused by
depletion of fibrinogen, not thrombocytes (platelets). 3 Excessive
globulin in the blood is unrelated to clotting.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
24. 3 Hypertension during pregnancy leads to vasospasms; this in turn
causes the placenta to tear away from the uterine wall (abruptio
placentae).
1 Generally cardiac disease does not cause abruptio placentae. 2
Hyperthyroidism may cause an endocrine disturbance in the infant but
does not affect the blood supply to the uterus. 4 Cephalopelvic
disproportion may affect the birth of the fetus but does not affect the
placenta.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
25. 1 Placenta previa is classically painless bleeding; the placenta partially or
completely covers the cervical os, and as the cervix dilates, the placenta
separates and bleeds.
2 Placenta accreta is an abnormally adherent placenta; the placenta
attaches through the endometrium to the myometrium. 3 A ruptured
uterus is a painful occurrence; the fetus may be expelled from the
uterus into the abdomen. 4 There is no visible bleeding if the abruptio
is concealed; abruptio placentae is painful because the blood
accumulates between the placenta and the uterine muscle.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
26. 3 Observation and documentation of bleeding are necessary for
implementing safe care because hemorrhage and shock can be life
threatening.
1 Vital signs should be checked more often while there is bleeding. 2 Tap
water enema before the birth is contraindicated because it may cause
further separation of the placenta. 4 The patient should be restricted to
complete bed rest until bleeding stops.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing Process:
Planning/Implementation
27. 2 This is the treatment of choice for complete placental separation
(abruptio placentae). The risk for fetal and maternal mortality is too high
to delay action.
1 A high-forceps birth rarely is used because the forceps may further
complicate the situation by tearing the cervix. 3, 4 The fetus would
probably expire if this course of action were taken.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
28. 1 Usually as pregnancy progresses, there are alterations in glucose
tolerance and in the metabolism and utilization of insulin. The result is an
increased need for exogenous insulin.
2 Antihypertensives are administered only to patients with severe
hypertensive preeclampsia. 3 Pancreatic enzymes or hormones other
than insulin are not taken by pregnant women with diabetes. 4
Estrogenic hormones are not administered during pregnancy.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Planning/Implementation
29. 3 Insulin requirements may fall suddenly during the first 24 to 48
postpartum hours because the endocrine changes of pregnancy are
reversed.
1 Insulin requirements do not suddenly increase at this time. 2 Insulin
requirements do not remain unchanged at this time. 4 Insulin
requirements do not slowly and steadily decrease at this time.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Nursing Process: Evaluation/Outcomes
30. 4 Glucose-oxidase strips are used by nurses to screen infants for
hypoglycemia.
1, 2 A test for glucose tolerance and serum glucose levels are not used to
screen for hypoglycemia. 3 Fasting blood glucose levels are not used
routinely to screen newborns for hypoglycemia.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Planning/Implementation
31. 2 The infant of a diabetic mother (IDM) is a newborn at risk because of
the interaction between the maternal disease and the developing fetus.
1 A newborn of a mother with type 1 diabetes generally is hypoglycemic
because of oversecretion of insulin by the newborn’s hypertrophied
pancreas. 3 A newborn of a mother with type 1 diabetes is at high risk
and requires intensive care. 4 The newborn of a mother with type 1
diabetes is prone to hypoglycemia and probably will need increased
glucose.
Client Need: Management of Care; Cognitive Level: Application; Nursing
Process: Planning/Implementation
32. 1 The pancreas of a fetus of a diabetic mother responds to the mother’s
hyperglycemia by secreting large amounts of insulin; this leads to
hypoglycemia after birth.
2 Hypocalcemia, not hypercalcemia, occurs. 3 Edema may be generalized,
not specific to the CNS. 4 In response to the increased glucose received
from the mother, the islets of Langerhans in the fetus may have become
hypertrophied; they are not congenitally depressed.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
33. 3 The heart rate increases by about 10 beats/min in the last half of
pregnancy; this increase, plus the increase in total blood volume, can
strain a damaged heart beyond the point at which it can efficiently
compensate.
1 The number of RBCs does not decrease during pregnancy. 2 The
increased size of the uterus is related to the growth of the fetus, not to
any hemodynamic change. 4 Cardiac output begins to decrease by the
34th week of gestation.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
34. 4 This is the most critical period because of the rapid shift of
extravascular fluid as it returns to the bloodstream; this mobilization of
fluid can compromise the heart and lead to cardiac decompensation.
1 During the first trimester the increased amount of circulating blood
volume is minimal and occurs gradually; thus, it does not place an
unusual burden on the heart. 2 The risk for cardiac decompensation
increases as pregnancy progresses; however, the increase in blood
volume occurs gradually, and the mother is monitored closely. 3 There
is an increased risk for stress on the heart during labor; however, close
monitoring and the use of agents to provide rest and pain relief have
decreased these risks.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
35. Answers: 1, 3, 4
1 An oxytocin infusion is carefully monitored for the gentle induction or
augmentation of labor. 3 The health care provider may prefer a
vacuum extraction–assisted birth to reduce the need to push and to
conserve energy. 4 Regional anesthesia relieves the stress of pain, and
it does not compromise cardiovascular function.
2 A midforceps-assisted birth is not needed. A low or outlet forceps may
be used to reduce the need to push and to conserve energy. 5 Inhalation
anesthesia is contraindicated because it could compromise
cardiovascular function.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
36. 3 Elevating the patient’s head facilitates easier oxygen exchange, and the
left side-lying position promotes venous return.
1 High Fowler is too uncomfortable; the gravid uterus will impede venous
return from the legs. 2 Although the semi-Fowler position is
comfortable, the gravid uterus may inhibit venous return and result in
placental congestion and supine hypotension. 4 At full term, the left
side-lying position is preferred to the right side-lying position to
enhance venous return.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
37. 3 Patients with cardiac problems are prone to heart failure during active
labor; crackles indicate the presence of pulmonary edema.
1, 2 Encouraging frequent voiding and monitoring the blood pressure
hourly is done for all patients who are in labor. 4 It is not necessary to
turn from side to side at 15-minute intervals; although patients who are
in labor are maintained on the side to facilitate venous return, the sides
do not have to be alternated every 15 minutes.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Planning/Implementation
38. 2 ERCP involves the insertion of a cannula into the pancreatic and
common bile ducts during an endoscopy. The test is not performed if the
patient’s bilirubin level is more than 3 to 5 mg/dL because cannulation
may cause edema, which will increase obstruction of bile flow.
1, 3, 4 Urine output, blood pressure, and serum glucose are not directly
related to this test.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
39. Answers: 4, 3, 1, 2, 5
4 Getting out of bed is the activity that should be implemented first. It
allows the patient to adjust to the upright position before ambulating. 3
Light exercise such as walking can begin after tolerating sitting in a
chair. 1 A patient may shower or bathe 1 to 2 days after surgery. 2 A
patient may drive 3 to 4 days after surgery. 5 Objects exceeding 10 lb
may be lifted 1 week after surgery.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation
40. 2 When bile does not mix with foods in the intestine, emulsification of
fats cannot occur and fat digestion is impaired. Stomach motility is also
reduced because increased stomach peristalsis depends on fat digestion in
the small intestine.
1 Once emulsified by bile, fatty foods are readily broken down by
digestive enzymes. 3 The production of bile is unaffected. 4
Obstruction, not inadequate closure, of the ampulla of Vater causes
discomfort. Bile and pancreatic secretions enter the duodenum through
the ampulla of Vater. With obstruction, edema and spasms occur,
blocking the flow of enzymes and causing pain.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
41. Answers: 1, 2, 5
1 Inadequate bile flow interferes with vitamin K absorption, contributing
to ecchymosis, hematuria, and other bleeding. 2 Yellow sclera results
from failure of bile to enter the intestines, with subsequent backup
into the biliary system and diffusion into the blood. The bilirubin is
carried to all body regions, including the skin and mucous membranes.
5 Pain in the right upper quadrant occurs especially after eating foods
high in fat and is characteristic of acute cholecystitis and biliary colic.
3 With obstructive jaundice the stool is clay colored, not dark brown; the
presence of bile causes stool to be brown. 4 When bile levels in the
bloodstream are high, as in obstructive jaundice, there is bile in the
urine, causing it to have a dark color.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
42. 3 Rebound tenderness is a classic subjective sign of appendicitis.
1 Urinary retention does not cause acute lower right quadrant pain. 2
Hyperacidity causes epigastric, not lower right quadrant pain. 4 There
generally is decreased bowel motility distal to an inflamed appendix.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
43. 3 Why did you decide to come to the prenatal clinic?” response points out
reality and allows the client to elaborate.
1 Although it is true that many women are irregular at 16 years of age, it
does not allow for further communication. 2 “You probably are
pregnant if you had intercourse” implies that the nurse does not
believe the client; it would probably cut off further communication. 4
“Should I ask the health care provider to talk to you?” abdicates the
nurse’s responsibility; also, it may cut off further communication
Client Need: Management of Care; Cognitive Level: Analysis; Integrated
Process: Communication/Documentation; Nursing Process:
Assessment/Analysis
44. 4 “I was really happy before I got pregnant” indicates failure to resolve
conflicting feelings about pregnancy that should have been resolved in
the first trimester.
1 “I’m tired of feeling so clumsy” is an expected feeling in the third
trimester. 2 “I’ll be glad when I can sleep all night” is expected in the
third trimester as the enlarging uterus limits the number of
comfortable positions that can be assumed during sleep. 3 Concerns
about the expected infant having physical abnormalities are common in
the third trimester.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Assessment/Analysis
45. 4 Fraternal twins may occur as a result of a hereditary trait, but it is
related to the ovaries releasing two eggs during one ovulation; the fact
that the father is a fraternal twin would not influence the female’s ovaries
to release two eggs during one ovulation.
1 Although a sonogram will confirm a twin pregnancy, it does not answer
the client’s question. 2, 3 If there is no maternal family history of twin
pregnancies, it would be a chance occurrence that is equal to the
probability found in the general population.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation
46. Answers: 1, 2, 4, 5
1 Increased risk for developing preterm labor is age associated; it occurs
more commonly in older primigravidas and adolescents. 2 Mature
women have an increased incidence of multiple gestation secondary to
fertility drug use and in vitro fertilization. 4 After 35 years of age,
mature women have an increased risk of having children with
chromosomal abnormalities. 5 Bleeding in the first trimester as a result
of spontaneous abortion occurs more frequently in mature gravidas.
3 Development of seizures is not seen more frequently in mature
gravidas.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
47. 4 It is not uncommon for adolescents to avoid prenatal care; many do not
recognize the deleterious effect that lack of prenatal care can have on
them and their infants.
1 Instructing on infant care can be done in the later part of pregnancy and
reinforced during the postpartum period. 2 Information concerning the
benefits of breastfeeding should come later in pregnancy, but not
before ascertaining the client’s feelings about breastfeeding. 3 Advising
her to watch for danger signs of preeclampsia will have to be done, but
it is not the priority intervention at this time.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
48. 2 Perinatal morbidity and mortality rates are higher with a multiplegestation pregnancy because the greater metabolic demands and the
possibility of malpositioning of one or more fetuses increases the risk for
complications.
1 Although postpartum hemorrhage does occur more frequently after
multiple births, it is not an expected occurrence. 3 Maternal mortality
during the prenatal period is not increased in the presence of a
multiple gestation. 4 Adjustment to a multiple gestation and birth is
individual; the time needed for adjustment does not place the
pregnancy at high risk.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
49. 1 A multiple gestation thins the uterine wall by overstretching; thus, the
efficiency of contractions is reduced.
2 Gestational anemia is physiologic anemia that is benign; although
anemia may cause fatigue during labor, it does not affect uterine
contractility. 3 Hypertonic contractions will cause increased discomfort,
fatigue, dehydration, and increased emotional distress, not hypotonic
uterine dystocia. Therapeutic interventions include rest and sedation. 4
Gestational hypertension may trigger preterm labor; it does not cause
hypotonic uterine dysfunction.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
50. 2 Chromosomal anomalies are not associated with a multiple gestation;
therefore, the client needs further instruction.
1 Preterm birth with multiple gestation occurs for a variety of reasons
such as spontaneous rupture of the membranes, abruptio placentae,
and marked uterine distention. 3 Shunting of blood between placentas
can occur with a multiple gestation if there are multiple placentas. 4
The increased blood volume and metabolism necessary to sustain a
multiple gestation predispose the client to hypertension.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
51. 1 Uterine atony often results from an overdistended uterus; uterine
contractions do not occur readily and the uterus fills with blood.
2 Mediolateral episiotomy might cause a hematoma to form, but not a
hemorrhage. 3 Lacerations of the cervix is unusual; it may cause some
bleeding, but not a hemorrhage. 4 Retained placental fragments can
occur in single, not just multiple, births if the placenta has not been
carefully inspected for tears.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
C H AP T E R 7
Mental health disorders and
substance abuse
Mental health disorders during pregnancy
Overview
• Women with mental illness who give birth have more complications;
however, treatment lowers these risks; recognition of mental illness
permits intervention
• Women may have a history of mental illness before they become
pregnant, or it may develop during pregnancy or in the postpartum
period
• Referral to a mental health professional is recommended if a woman has a
history of mental illness or shows symptoms
• Mental illness affects the pregnant woman, the newborn, and the family
Perinatal mood disorders
• Can include depression, anxiety, obsessive-compulsive disorder,
posttraumatic stress disorder (PTSD), and postpartum psychosis
• Depression and anxiety are the most common mood disorders during
pregnancy
• Depression during pregnancy is a risk factor for postpartum depression
• Untreated maternal depression negatively affects the infant’s
development and children’s mental health
Major depression
• Diagnosis
• Thyroid disorders and anemia need to be ruled out because they can
both cause signs/symptoms similar to depression
• At least five of these signs/symptoms must be present for at least 2
weeks: depressed mood, often with spontaneous crying; substantially
diminished interest in activities; insomnia or hypersomnia; weight
changes (up or down); psychomotor retardation or agitation; fatigue or
loss of energy; feelings of worthlessness or inappropriate guilt,
diminished ability to concentrate; suicidal ideation with or without a
plan
• Etiologic factors
• Neurotransmitter dysregulation includes serotonin, norepinephrine,
dopamine, acetylcholine, and gamma-aminobutyric acid (GABA)
systems; altered neuropeptides include corticotropin-releasing
hormones
• Individuals with chronic or severe medical conditions are at increased
risk
• Psychosocial stressors associated with a major loss play a significant
role in first or second depressive onset
• Familial history among close biologic relatives increases risk for
disorder
• Onset usually in late 20s, but may occur across life span
• Victims of domestic violence are more likely to suffer from depression
• Behavioral/clinical findings
• Recurrent pessimistic thoughts; suicidal ideation with or without a plan
• Interruption in thinking and concentration that may interfere with
occupational and social functioning; difficulty making decisions
• Diminished interest or pleasure in all activities (anhedonia); apathy
• Decreased appetite with weight loss or overeating with weight gain
• Psychomotor retardation; anergia; constipation
• Anxiety, somatic ailments, tearfulness, fearfulness, and hopelessness
• Insomnia or hypersomnia
• Feelings of worthlessness and/or inappropriate guilt
• Therapeutic interventions
• For mild depression during pregnancy, psychotherapy is first
intervention
• Main treatment: combination of antidepressants and cognitivebehavioral therapy
■ Antidepressant medications that increase the level of norepinephrine
and serotonin
■ There is no agreement on safety of antidepressants during
pregnancy
■ Because many women are unaware they are pregnant for the first 1
to 2 months, they may be taking these medications during the time
of greatest risk to the embryo/fetus
■ Selective serotonin reuptake inhibitors (SSRIs) are considered safer
than tricyclic antidepressants; however, neonates show signs of
withdrawal from SSRIs that can include respiratory failure
■ Dose requirements often increase in the second half of pregnancy
to offset increased metabolism
■ Risk–benefit analysis of treatment options should be performed;
some studies show increased rates of birth defects with maternal
use of SSRIs
■ Note that untreated depression also has negative consequences for
the fetus, including preterm birth
■ Cognitive and behavioral psychotherapy can be delivered by
psychiatrists and nonphysician professionals, including
psychologists, psychiatric nurse clinical specialists or practitioners, or
licensed clinical social workers
■ Additional strategies include exercise and self-help groups
• Care management
• Planning/implementation
■ Educate woman about depression and about the plan of care
■ Suggest alternative treatments if woman refuses medication
■ Maintain a caring relationship; convey an attitude of concern that is
not intrusive
• Evaluation/outcomes
■ Verbalizes feelings
■ Verbalizes increased feelings of self-worth
■ Continues prescribed treatment regimen
■ Returns to preillness level of functioning
Application and review
1. A client in a psychiatric hospital with the diagnosis of major depression is
tearful and refuses to eat dinner after a visit with a friend. What is the
most therapeutic nursing action?
1. Allow the client to skip the meal.
2. Offer an opportunity to discuss the visit.
3. Reinforce the importance of adequate nutrition.
4. Provide the client with adequate quiet thinking time.
2. A client with major depression is admitted to the hospital. What is the
most therapeutic initial nursing intervention?
1. Introducing the client to one other client
2. Requiring participation in therapy sessions
3. Encouraging interaction with others in small groups
4. Conveying an attitude of concern that is not intrusive
See Answers on pages 137-140.
Anxiety disorders
Overview
• Anxiety disorders are the most common psychiatric disorders
• Symptoms of anxiety impair functioning
• Postpartum women are at an increased risk for anxiety disorders and
mood disorders
• A risk–benefit analysis of treatment with medication is appropriate for
each pregnant woman with an anxiety disorder
• Panic attack description
• Occurs in many anxiety disorders
• Functions as a marker that influences prognosis of the severity of
disorders in which it can occur
• Behavioral/clinical findings
■ Brief (5- to 15-minute) periods of overwhelming, intense discomfort;
can be either expected or unexpected
■ Signs/symptoms: palpitations or accelerated heart rate; sweating;
trembling or shaking; shortness of breath; feelings of choking, chest
pain, or discomfort; nausea or abdominal distress; depersonalization;
fear of losing control; fear of dying; paresthesias; and chills or hot
flashes
Panic disorder
• Etiologic factors
• Biochemical and genetic theories are most often cited as the underlying
cause; no one gene or biochemical dysfunction has been identified
• Onset varies, most often noted between late adolescence and mid-30s;
thus, it can begin during pregnancy; infrequently may begin in
childhood or after age 45; early life rigid and orderly
• Discrete periods of intense discomfort for more than 1 month in
duration
• Recurrent attacks of severe anxiety may be associated with a stimulus or
can occur spontaneously
• Pressures of decision making regarding lifestyle that occur in early
adult years act as precipitating factors
• Functions to permit some measure of social adjustment
• Behavioral/clinical findings
• Brief (5- to 15-minute) attacks (panic attacks) of overwhelming, intense
discomfort
• Attack must be accompanied by four or more of the following
symptoms: palpitations or accelerated heart rate; sweating; trembling
or shaking; shortness of breath; feelings of choking, chest pain, or
discomfort; nausea or abdominal distress; depersonalization; fear of
losing control; fear of dying; paresthesias; and chills or hot flashes
• Therapeutic interventions
• Complete diagnostic workup to rule out physical illness
• Psychotherapy, family therapy, group therapy, cognitive-behavioral
therapies
• Antidepressants are the firstline medications for panic disorder
• Maternal benzodiazepine has risks to fetus
• Nursing care of clients with panic disorder
• Assessment/analysis
■ Progression of somatic symptoms
■ Interference in activities of daily living (ADLs) and social and
occupational functioning
■ Situational triggers that may precipitate the onset of an attack
■ Determination whether panic symptoms are related to a phobia
• Planning/implementation
■ See “General nursing care of clients with anxiety disorders” (later)
■ Remain with client during an attack; maintain safety
■ Remain calm and in control of the situation
■ Assign to a private room if hospitalized because it decreases
environmental stimuli
■ Administer prescribed medications
• Evaluation/Outcomes
■ Identifies situations that increase anxiety
■ Demonstrates increased use of anxiety-reducing behaviors
■ Follows prescribed treatment regimen
■ Reports a decreased number of panic attacks
Agoraphobia
• Diagnosis/Behavioral and Clinical Findings
• A separate diagnosis from panic attack in Diagnostic and Statistical
Manual of Mental Disorders, fifth edition (DSM-V)
• Anxiety out of proportion to threat or situation; Fear of at least two
situations (“two” distinguishes it from other phobias); these often
include fear of crowds, open spaces, being alone, and public places
where help would not be available immediately if needed (eg, tunnels,
bridges, crowds, buses, trains); has lasted at least 6 months.
• The person realizes the fear is out of proportion to the stimulus.
• The person avoids the situation (avoidance behavior) or endures it with
significant distress; this avoidance or the distress interferes with
normal functioning, routine or relationships.
• May be accompanied by physical symptoms similar to a panic attack.
• Therapeutic Interventions
• Same as those listed under Panic Disorder
• Behavior modification: a counterconditioning technique to overcome
fears by gradually increasing exposure to feared object, situation, or
animal (desensitization) or by continuous exposure to the feared
stimulus until anxiety is extinguished (flooding)
• Cognitive therapies, with risk-benefit analysis of pharmacologic
therapy.
• Nursing Care of Clients with Agoraphobia
• Assessment/Analysis
■ Presence and duration
■ Avoidance behaviors to prevent exposure to stress-producing
situation
■ Interference in activities of daily living (ADLs) and social and
occupational functioning
■ Situational triggers that may precipitate the onset of the anxiety
■ Any accompanying somatic symptoms
• Planning/Implementation
■ See “General nursing care of clients with anxiety disorders”
■ Identify and accept client’s feelings about triggering situations
■ Provide constant support if exposure to situations cannot be avoided
■ Assist with relaxation and cognitive-behavioral techniques to control
or diminish anxiety levels
• Evaluation/outcomes
■ Uses relaxation techniques to diminish anxiety
■ Follows prescribed treatment regimen
■ Copes with triggering situations effectively
Generalized anxiety disorder
• Etiologic factors
• Psychologic, behavioral, and neurobiologic theories are postulated; the
latter is most promising
• Functions to permit some measure of social adjustment
• Commonly begins in early adulthood as a result of environmental
factors and pressures of decision making; early life is rigid and orderly
• Excessive anxiety and worry involve at least two life situations
• Unrelated to physiologic effects of substances or a medical condition
• Behavioral/clinical findings
• Persistent anxiety (longer than 6 months) and excessive worry
associated with three or more of the following symptoms: restlessness
(akathisia) or feeling on edge, becomes easily fatigued, difficulty
concentrating, irritability, muscle tension, and sleep disturbance
• Inability to control the anxiety
• Impairment in social or occupational relationships
• Symptoms of autonomic hyperarousal (eg, tachycardia, tachypnea,
dizziness, and dilated pupils); however, they are less prominent than in
other anxiety disorders
• Additional physical symptoms correlate with muscle tension and worry:
headaches, fatigue, nausea, diarrhea, and abdominal pain
• Therapeutic interventions: same as those listed under “Panic Disorder”
(earlier)
• Nursing care of clients with generalized anxiety disorder: see “General
nursing care of clients with anxiety disorders” and “Nursing care of
clients with panic disorders” (earlier)
• Recognition of anxiety or symptoms of increasing anxiety is an
indication that the client is improving
Obsessive-compulsive disorder
• Etiologic factors
• Chronic anxiety disorder with decreased levels of serotonin
• Control of anxiety with obsessions (intrusive recurring thoughts) or
compulsions (repetitive ritualistic behaviors)
• Compulsive behavior precedes obsessive thinking
• Symptoms worsen with stress
• Adults recognize behavior is excessive and interferes with daily
activities but cannot be controlled
• Pressures of decision making regarding lifestyle that occur in the early
adult years act as precipitating factors; some evidence that early life
patterns were rigid and orderly
• Behavioral/clinical findings
• Major defensive mechanisms are isolation, undoing, and reaction
formation; intellectual and verbal defenses are used
• Thoughts persist and become repetitive and obsessive
• Demonstrates indecisiveness and a striving for perfection and
superiority
• Anxiety and depression present in various degrees, particularly if rituals
are prevented
• Obsessions or compulsions consume most of client’s waking hours (at
minimum more than 1 hour per day) and interfere with ADLs,
occupation, social activities, or relationships
• Limiting or interrupting a ritual increases anxiety
• Therapeutic interventions
• Same as those listed under “Panic Disorder”
• Behavior modification to attempt to limit length and/or frequency of
ritual
• Cognitive therapy is effective.
• SSRIs may be prescribed, although risk–benefit analysis during
pregnancy is key
• Nursing care of clients with obsessive-compulsive disorders
• Assessment/analysis
■ Type and use of ritual or obsession
■ Level of anxiety (eg, mild, moderate, severe, panic)
■ Level of interference in lifestyle
■ Extent of danger inherent in ritual or obsession
■ Behaviors associated with other anxiety disorders
• Planning/implementation
■ See “General nursing care of clients with anxiety disorders”
■ Allow performance of the ritual initially unless ritual causes harm
and must be stopped (eg, excessive handwashing causing skin
damage); eventually attempt to limit length and frequency of the
ritual
■ Support attempts to reduce dependency on the ritual
■ Role model appropriate behavior and discuss adaptive responses
• Evaluation/outcomes
■ Decreases obsessive thoughts and length and frequency of ritual
■ Follows prescribed treatment regimen
■ Learns new adaptive coping responses
Posttraumatic stress disorder
• Etiologic factors
• Follows a devastating event that is outside the range of usual human
experience (eg, rape, assault [including intimate partner violence],
military combat, hostage situations, natural or precipitated disasters)
• Neurobiology of PTSD does not follow the usual fight-or-flight stress
response; studies indicate a complex interaction of neuroendocrinology,
neuroanatomy, genetics, and traumatic stress
• Adult’s response involves intense fear, helplessness, or horror; child’s
response involves disorganized or agitated behaviors
• Traumatic event is persistently reexperienced as flashbacks, distressing
dreams, sense of reliving the experience, or exposure to situations
(including anniversaries) that foster recall of the event
• Behavioral/clinical findings
• Exposure to a traumatic event resulting in death, threatened death, or
serious injury to others or self
• Responds to traumatic event with intense fear, confusion, helplessness,
horror, or denial
• Symptoms include mentally reexperiencing the trauma
• Interrupted concentration; difficulty sleeping
• Hypervigilance; hyperarousal; exaggerated startle reflex; avoidance of
associated stimuli
• Feelings of isolation and detachment; depression
• Violent outbursts of anger
• Risk-taking behaviors; substance abuse in attempt to control symptoms
• If pregnancy is the result of rape, examinations and birth can trigger
memories/flashbacks of the traumatic event
• Therapeutic interventions
• Same as those listed under “Panic Disorder”
• Behavior modification to provide controlled exposure to recall of event
• Use of eye movement, desensitization, reprocessing techniques (EMDR)
• Imagery, relaxation, and meditation
• Cognitive restructuring and reframing
• Nursing care of clients with posttraumatic stress disorder
• Assessment/analysis
■ History of traumatic experience
■ Sleep-pattern disturbances, outbursts of anger, and decreased
concentration
■ Screening for symptoms of major depression, phobias, and substance
abuse
■ Behaviors associated with other anxiety disorders
• Planning/implementation
■ See “General nursing care of clients with anxiety disorders”
■ Stay with client when memory of event returns to conscious level
■ Protect from acting out violently with disregard for safety of self or
other
• Evaluation/outcomes
■ Uses positive coping mechanisms to manage anxiety and reactions to
the traumatic event and its flashbacks
■ Verbalizes a decrease in dreams or flashbacks regarding the
traumatic event
■ Follows prescribed treatment regimen
General care management
• General nursing care of clients with anxiety disorders
• Provide an environment that limits demands and permits attention to
resolution of conflicts; establish a trusting relationship
• Identify precipitating stressors and limit them if possible
• Intervene to protect from acting out on impulses that may be harmful to
self or others
• Accept symptoms as real to client; do not emphasize or call attention to
them
• Attempt to limit client’s use of negative defenses, but do not try to stop
them until client is ready to give them up
• Help to develop appropriate ways of managing anxiety-producing
situations through problem solving and cognitive/behavioral therapies;
assist to expand supportive network; assist significant others to
understand the client’s situation
• Plan a routine schedule of activities
• Manage aggressive behavior progressively (eg, diversion, limit setting,
medication administration, seclusion, restraints)
• Collect and document information to assist with determining presence
of both an anxiety disorder and depression (comorbidity)
• Encourage to develop a balance between work and relaxation
• Medication during pregnancy
• General rule: avoid medications during first trimester
• Decisions to use medications during pregnancy should be made by the
woman, her partner, and her health care providers
• Lowest therapeutic doses are advised
• Administering medications at or near birth can cause the infant to
require respiratory support at birth or be dependent on the drug and
exhibit withdrawal syndrome (see Chapter 19).
Application and review
3. A client is diagnosed with generalized anxiety disorder. For what behavior
should the nurse assess a client to determine the effectiveness of therapy?
1. Participates in activities
2. Learns how to avoid anxiety
3. Takes medication as prescribed
4. Identifies when anxiety is developing
4. A client who uses ritualistic behavior taps other clients on the shoulders
three times while going through the ritual. The nurse infers that this client
has a what?
1. Blurred personal identity
2. Poor control of sudden urges
3. Disturbance in spatial boundaries
4. Reduced ability to adapt to life’s stresses
5. A 20-year-old college student comes to the college health clinic reporting
increasing anxiety, loss of appetite, and an inability to concentrate. What is
the most appropriate response by the nurse?
1. “With whom have you shared your feelings of anxiety?”
2. “What have you identified as the cause of your anxiety?”
3. “It has been difficult for you. How long has this been going on?”
4. “Let’s talk about your problems. Are you having difficulty
adjusting?”
6. A nursing assistant interrupts the performance of a ritual by a client with
obsessive-compulsive disorder. What is the most likely client reaction?
1. Anxiety
2. Hostility
3. Aggression
4. Withdrawal
7. A client’s severe anxiety and panic are often considered to be
“contagious.” What action should be taken when a nurse’s personal
feelings of anxiety are increasing?
1. Refocus the conversation on some pleasant topics.
2. Say to the client, “Calm down. You are making me anxious, too.”
3. Say, “Another staff member is coming in. I will leave and return
later.”
4. Remain quiet so that personal feelings of anxiety do not become
apparent to the client.
8. A client with mild preeclampsia is told that she must restrict her activities
and rest in bed several times a day. The client starts to cry and tells the
nurse that she has two small children at home who need her. How should
the nurse respond?
1. “You’ll need someone to help you care for the children.”
2. “You are worried about how you will be able to manage.”
3. “You can get a neighbor to help out, and your husband can do the
housework.”
4. “You’ll be able to fix light meals, and the children can go to day care
a few hours each day.”
9. A nurse is caring for a client with a generalized anxiety disorder. Which
factor should be assessed to determine the client’s present status?
1. Memory
2. Behavior
3. Judgment
4. Responsiveness
10. A newly admitted client with an obsessive-compulsive personality
disorder frequently performs a hand-washing ritual. When attempts are
made to set limits on the frequency or length of the ritual, the client’s
anxiety escalates and the client becomes verbally aggressive. What is most
important for the nurse to do when the client performs the ritual?
1. Allow the client sufficient time to carry out the ritual.
2. Promote reality by showing that the ritual serves little purpose.
3. Try to ascertain the meaning of the ritual by discussing it with the
client.
4. Interrupt the ritual to demonstrate that the ritual does not control
what happens.
See Answers on pages 137-140.
Postpartum mood disorders
Paternal postpartum depression
• Incidence up to 50%
• Risk factor is having a partner with postpartum depression
• Symptoms include fatigue, anger, irritability, withdrawal
Postpartum blues/maternal blues
• Transient; begins in the first postpartum week; rarely lasts more than 10
to 14 days
• Up to 85% of women experience this transient mild depression after
delivery
• Mild depression lasting beyond 2 weeks after delivery is more serious
than postpartum blues
• Characterized by mood swings, feeling overwhelmed, and unable to cope;
she may be oversensitive with periods of unexplained tearfulness, have
difficulty sleeping, and have decreased appetite
• Does not affect woman’s ability to care for the infant
• Nursing care
• Explain to the woman that these feelings are normal and will likely
resolve within 2 weeks
• Explain that if the depression lasts beyond 2 weeks, if it becomes severe,
if the woman is unable to cope with daily activities, or if she has any
thoughts about harming herself or the baby, then the woman should
call the health care provider
• Treatment consists of rest, anticipatory guidance, reassurance, support,
and assistance
Postpartum (also called peripartum) depression
without psychotic features
• Description and behavioral/clinical findings
• Onset during pregnancy or within 4 weeks through the first year after
delivery; is the most common complication of childbirth; affects 10% to
15%, but is underdiagnosed
• Characterized by depressed mood, feelings of hopelessness, and loss of
interest in almost all activities
• It also includes at least four of the following: changes in appetite or
weight, sleep, and psychomotor activity; decreased energy; feelings of
worthlessness or guilt (may even feel guilty about being depressed
when she thinks she should be happy about having an infant); difficulty
thinking, concentrating, or making decisions; recurrent thoughts of
death or suicide; or death or suicide plans or attempts
• Lasts at least 2 weeks
• Not the same as mood swings; is a persistent, depressed mood
• Irritability as a symptom is strong feature
• Mother may reject the infant or feel jealous of partner’s affection for the
infant
• Affects woman’s ability to care for herself and the infant
• Affects women of all cultures, although symptoms vary
• Not a separate diagnosis in DSM-V from major depression; diagnosis
requires criteria for a major depressive episode (MDE) and uses the
peripartum-onset specifier
• Etiology
■ Risk factors are shown in Box 7.1.
■ Poor nutrition a contributing factor; folate and vitamin B12 are needed
to synthesize serotonin; low folate levels affect response to
antidepressant medications
• Therapeutic interventions
■ Usually improves over 6 months postpartum, but supportive
interventions are not sufficient for major postpartum depression
■ Psychotherapy
■ Antidepressant medication; usually SSRI initially prescribed
■ Alternative therapies may be helpful
■ Possible role for estradiol treatment is being investigated
• Nursing care management of postpartum depression
■ Listen to what the woman is saying, verbally and nonverbally, to help
recognize symptoms
■ Demonstrate caring
■ If nurse assesses that mother is depressed, must ask whether woman
has had thoughts about hurting self or infant
■ Provide support and anticipatory guidance
■ Encourage woman to express feelings, provide validation, address
personal conflicts, and reinforce personal power and autonomy
■ Understand that a woman’s culture, experiences, and coping
strategies influence her adjustment to becoming a mother
■ If safety of mother or children is threatened, refer women with
moderate to severe cases of postpartum depression to mental health
professional such as a psychiatric nurse practitioner or psychiatrist
for evaluation and therapy
BOX 7.1
R isk F a ct ors for P ost pa rt um D e pre ssion
• Depression during pregnancy or previous postpartum depression (strong
predictors), history of major depression or prenatal anxiety
• First pregnancy
• Hormonal fluctuations that follow childbirth
• Medical problems during pregnancy or after birth, including
preeclampsia, diabetes mellitus, anemia, or postpartum thyroid
dysfunction
• Personal or family history of depression, mental illness, or alcoholism
• Personality characteristics, such as immaturity and low self-esteem
• Difficult relationship with the significant other, resulting in lack of
support
• Victims of intimate partner violence
• Anger or ambivalence about the pregnancy
• Unwanted or unplanned pregnancy
• Multifetal pregnancy
• Single status
• Young maternal age
• Feelings of isolation or lack of support
• Fatigue, lack of sleep
• Mothers who have undergone infertility treatment
• Preterm or ill infant
• Life stress
• Financial worries/low socioeconomic status
• Child care stress (infant who is ill, has anomalies, or has a difficult
temperament)
• Chronic stressors
• Major life stress, such as moving or job change
Data from Murray, S.S., McKinney, E.S. (2014). Foundations of Maternal-Newborn & Women’s Health
Nursing (ed. 6). St. Louis: Elsevier; Beck, C. (2002). Revision of the postpartum depression predictors
inventory. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(4), 394–402; Beck, C. (2001).
Predictors of postpartum depression: An update. Nurse Researcher, 50(5), 275–282; Postpartum
Support International. (2014). Depression during pregnancy and postpartum. Retrieved from
www.postpartum.net/get-the-facts/depression-during-pregnancy-postpartum.aspx.
Screening for postpartum depression
• When recognized early, postpartum depression is treatable
• Widely used tool = Edinburgh Postnatal Depression Scale: brief (takes 5–
10 minutes), self-reported questionnaire of 10 statements with graded
responses
• If screening results or self-report indicate woman is depressed, a full
screening is needed with likely referral to mental health or other provider
• Assess family in case they can offer information or need to explain their
response to woman’s condition
• Screening can begin before discharge after delivery on the postpartum
unit
• Women may be discharged before the blues or depression occurs
• Routine instructions should be given to whomever takes the woman
home
• See Box 7.2 for signs of postpartum blues, depression, and psychosis
BOX 7.2
S igns of P ost pa rt um B lue s, D e pre ssion, a nd
P sychosis
Baby blues (these should go away in a few days or a week)
• Sad, anxious, or overwhelmed feelings
• Crying spells
• Loss of appetite
• Difficulty sleeping
Postpartum depression (can begin any time in the first year)
• Same signs as baby blues, but they last longer and are more severe
• Thoughts of harming yourself or your baby
• Not having any interest in the baby
Postpartum psychosis
• Seeing or hearing things that are not there
• Feelings of confusion
• Rapid mood swings
• Trying to hurt yourself or your baby
When to call your health care provider
• The baby blues continue for more than 2 weeks
• Signs/symptoms of depression get worse
• Difficulty performing tasks at home or at work
• Inability to care for yourself or your baby
• Thoughts of harming yourself or your baby
Data from U.S. Department of Health and Human Services, Office of Women’s Health. (2016).
Depression during and after pregnancy fact sheet. Retrieved from
www.womenshealth.gov/publications/our-publications/fact-sheet/depression-pregnancy.html
Postpartum depression with psychotic features
• Description and behavioral/clinical findings
• Begins by second week after birth; may have history of psychiatric
disorder (eg, bipolar disorder)
• Rare, less than 0.2%
• Features include delusions, hallucinations, disorientation,
suspiciousness, confusion with or without symptoms of depression;
may also occur with bipolar symptoms (mania and depressive episodes)
• Psychiatric emergency; safety of woman and her newborn are at risk;
woman will likely need inpatient psychiatric care
• Therapeutic interventions
• Medications include mood stabilizers and antipsychotics
• Informed consent necessary because it can be harmful to infant to be
around mother and because medications in breast milk can be harmful
to infant
• Good prognosis with early recognition and treatment
Application and review
11. After giving birth to her third child, a client tearfully says to the nurse,
“How much more can I give of myself?” What should the nurse consider
when applying mental health principles to the care of any person with
children?
1. It is easier to adjust to the first child than to later ones.
2. It is pathologic to feel anger and resentment toward a child.
3. Some parents experience feelings of resentment toward their
children.
4. Parents usually have inborn feelings of love and acceptance of their
children.
12. A nurse is assessing a client with depression without psychotic features.
Which clinical manifestation reflects a disturbance in affect related to
depression?
1. Echolalia
2. Delusions
3. Confusion
4. Hopelessness
See Answers on pages 137-140.
Perinatal substance abuse
Perinatal considerations
• Use of illegal drugs, tobacco, and alcohol can cause serious complications
in the developing fetus
• Up to 15% of pregnant women have a substance abuse problem; abuse is
not confined to poor, young, or minority women
• Intravenous and intranasal administration crosses the placenta more
often than other methods
• Prenatal care may not occur until late into pregnancy, if at all, in women
who abuse drugs
Substance abuse definitions
• Substance refers to any mind-altering chemical
• Substance abuse: maladaptive pattern of drug use leading to impairment
or distress, as manifested by two or more of the following occurring
within a 12-month period:
• Failure to fulfill major roles
• Use in hazardous situations
• Craving or strong desire or urge to use a substance
• Continued use despite social or interpersonal problems
• Substance intoxication: a reversible substance-specific syndrome caused
by recent ingestion of, or exposure to, a substance resulting in
maladaptive behavior or psychologic changes from effect on the central
nervous system (CNS)
• Substance withdrawal: development of a substance-specific syndrome
resulting from cessation or reduction in substance use that has been
heavy or prolonged
• Impairment in role functioning (eg, social, school, or occupational)
• Symptoms are not associated with another mental disorder
• Substance withdrawal is more risky with drugs that are CNS
depressants or that have a short half-life (eg, alcohol) than those with a
long half-life (eg, marijuana); withdrawal is not lethal with some (eg,
cocaine)
• Withdrawal may cause more problems in older adults because they
possess lower physiologic reserves
• Substance tolerance: the need for greatly increased amounts of the
substance to achieve the desired effects or a markedly diminished effect
with the continued use of the same amount of the substance; substance
tolerance does not occur with all substances
• Polysubstance abuse: abuse of three or more drugs or of alcohol and drug
• Potentiation: two or more substances interact in the body to produce an
effect greater than the sum of the effects of each substance taken alone
• Substance dependence: the continued use of a substance despite
significant related problems in cognitive, physiologic, and behavioral
components; spending more time in getting, taking, and recovering from
the substance; continuous abuse despite knowledge of physical or
psychologic problems or awareness of complications resulting from
continued use of the substance; dependency can be both psychologic
(needed to enhance coping) and physiologic (discontinuance results in
withdrawal signs and symptoms)
• Dual diagnosis: diagnosis of substance abuse and another mental health
disorder
Barriers to treatment
• Negative attitudes of health care workers; it is vital that nurses exhibit a
nonjudgmental attitude
• Self-review of attitudes and prejudices is encouraged
• Social attitudes/stigma against substance abuse
• User’s guilt
• Limited knowledge of health care workers
• Barriers within the drug treatment system, such as lack of concurrent
obstetric care and child care, long waiting lists
• Lack of health insurance
• Insufficient knowledge to manage comorbidities, such as mental health
disorders
Commonly abused drugs: Tobacco and alcohol
• Alcohol and tobacco are the most commonly abused drugs, followed by
marijuana, prescription drug abuse, and others. Also see “Commonly
Abused Drugs: Other” (later)
• Tobacco
• Fetal exposure to tobacco is a risk factor for spontaneous abortion,
intrauterine growth restriction (IUGR), and perinatal mortality, as well
as increased neonatal risks for sudden infant death syndrome and
asthma
• Components of the smoke interfere with oxygen supply to fetus
• Women are more likely to quit smoking while pregnant than at any
other time in their lives; smoking cessation programs during pregnancy
are effective
• Interferes with the let-down reflex during breastfeeding;
contraindicated during pregnancy and breastfeeding
• American College of Obstetricians and Gynecologists recommends
intervention called the “5 A’s”: Ask about tobacco use, Advise to quit,
Assess willingness to make a quit attempt; Assist in quit attempt;
Arrange follow-up. Use of brief counseling session and pregnancyspecific materials doubles or triples quit rates
• Alcohol
• Background
■ Twenty percent to 30% of women drink at some time during their
pregnancy
■ Alcohol is a known teratogen that crosses the placenta
■ Alcohol is the leading cause of birth defects, including facial
anomalies and microcephaly
■ Alcohol alters brain development and is the most common
preventable cause of cognitive disability in United States
■ Causes fetal alcohol spectrum disorders, including fetal alcohol
syndrome
■ No safe level during pregnancy has been established; abstinence is
advised
• Behavioral/clinical findings
■ Warning signs of alcoholism: frequent drinking sprees, increased
intake, drinking alone or in the early morning, blackouts
■ Intoxication: state in which coordination or speech is impaired and
behavior is altered
■ Defense mechanisms of rationalization and denial are often used;
may fill in gaps in memory with fabricated information
(confabulation)
■ Alcohol dependence: cessation of drinking results in signs and
symptoms of withdrawal (eg, nausea; vomiting; tremor; paroxysmal
sweats; anxiety; agitation; headache; impaired orientation/clouding of
sensorium; and tactile, auditory, and visual disturbances)
■ Alcohol withdrawal delirium: occurs on days 2 and 3 but may appear
as late as 14 days after the last drink; confusion, disorientation,
hallucinations, tachycardia, hypertension/hypotension, tremors,
agitation, diaphoresis, fever
• Therapeutic interventions
■ Withdrawal therapy performed as inpatient management
■ During pregnancy, withdrawal treatment uses benzodiazepines
■ Antabuse is teratogenic and contraindicated
■ Thiamine is used to support neurologic functioning and limit
peripheral neuropathies
■ Should be multifaceted (social and medical); involves psychotherapy
(eg, group, family, and individual counseling); clients can be assisted
only when they admit they need help
■ Self-help groups such as Women for Sobriety or Alcoholics
Anonymous provide support; they are the most effective intervention
to change destructive behaviors
■ Physical needs must be met because of prolonged malnutrition
■ Referral of significant others to self-help groups such as Al-Anon and
Adult Children of Alcoholics to assist with the understanding of the
effects of alcoholism and issues of codependency and enabling
• Nursing care of clients who abuse alcohol: assessment/analysis
■ History of alcohol use, abuse, and dependence from client and family
if available (eg, type, amount, and frequency)
■ Use of the CAGE questionnaire
(http://pubs.niaaa.nih.gov/publications/inscage.htm)
■ Blood alcohol level (BAL) also called blood alcohol concentration (BAC);
people with high tolerance to alcohol will appear less intoxicated
despite having elevated BALs (Table 7.1)
■ Data pertaining to substance dependence and psychiatric impairment
■ Client’s perception of the problem and sleep patterns
■ Use of the Clinical Institute Withdrawal Assessment for Alcohol
(CIWA-Ar) Scale to assess withdrawal and evaluate medication used
to limit withdrawal symptoms (Table 7.2)
■ Physical and emotional status in relation to nutrition, fluid and
electrolytes, and safety
■ Factors influencing the client’s decision to seek treatment at this time
• Nursing care of clients who abuse alcohol: planning/implementation
■ Advise total abstinence during pregnancy; there is no safe level
■ Accept that the most important factor in rehabilitation is the client’s
intrinsic motivational readiness
■ Supervise and prevent injury; institute seizure precautions during
withdrawal
■ Monitor for CNS and respiratory depression if intoxicated
■ Provide support without criticism or judgment; accept the smooth
facade presented while approaching the lonely and fearful individual
inside
■ Administer prescribed medications that support nutritional status
and limit signs and symptoms of withdrawal
■ Provide support during alcohol withdrawal delirium; provide support
if hallucinations and illusions occur; stay with client; point out reality
■ Monitor visitors because they may supply the client with alcohol
■ Encourage increased fluid intake, well-balanced diet, and no caffeine
■ Provide a well-controlled, alcohol-free environment; explain unit
routines
■ Plan a full program of activities but provide for adequate rest;
environment should be well lit and quiet
■ Avoid attempting to talk client out of the problem or making client
feel guilty
■ Accept hostility and acting-out behaviors without criticism or
retaliation; set appropriate limits if hostility is physical or escalates
■ Recognize ambivalence and limit the need for decision making
■ Maintain the client’s interest in a therapy program
■ Provide education on alcohol as a disease with negative effects on
physical and mental health
■ Refer to an appropriate 12-step group such as Women for Sobriety or
Alcoholics Anonymous
■ Expect and accept lapses as client is changing a long-term habit;
accept failures without judgment or punishment; teach how to
handle relapses
■ Provide family counseling and refer to self-help groups to address
effects of drinking and sobriety on the family
• Nursing care of clients who abuse alcohol: evaluation/outcomes
■ Recognizes, accepts, and seeks treatment for problem
■ Accepts responsibility for problem without blaming others
■ Achieves optimal physiologic and nutritional status
■ Learns new, more self-preserving coping mechanisms
■ Verbalizes feelings and situations that pose increased risk for alcohol
use
■ Enters into and continues with community-based self-help program
■ Maintains abstinence from alcohol and chemical substances
■ Demonstrates responsibility in meeting own health care needs
TABLE 7.1
Effects of Blood Alcohol Levels
Blood Alcohol Level Effect on Body
0.02
Slight mood changes
0.06
Lowered inhibition, impaired judgment, decreased rational decision-making abilities
0.08
Legally drunk, deterioration of reaction time and control
0.15
Impaired balance, movement, and coordination
Difficulty standing, walking, talking
0.20
Decreased pain and sensation
Erratic emotions
0.30
Diminished reflexes
Semiconsciousness
0.40
Loss of consciousness
Very limited reflexes
Anesthetic effects
0.50
Death
TABLE 7.2
Clinical Institute Withdrawal Assessment for Alcohol [CIWA-Ar] Scale
Nausea and vomiting
None to constant nausea
Frequent dry heaves
Vomiting
Tremors
None to severe
Paroxysmal sweats
Anxiety
None to drenching sweats
None to equivalent to acute panic states
Agitation
None to pacing back and forth constantly
Thrashing about
Tactile disturbances
None to continuous tactile hallucinations (itching, burning, numbness)
Auditory disturbances None to continuous auditory hallucinations
Visual disturbances
None to continuous visual hallucinations
Headache
None to extremely severe
Orientation
Oriented or disoriented to place and/or person
Modified from Sullivan, J.T., Sykora, K., Schneiderman, J., Naranjo, C.A., Sellers, E.M. (1989). Assessment
of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar).
British Journal of Addiction, 84(11), 1353–1357.
Commonly abused drugs: Other
• Marijuana (hashish; from cannabis plant)
• Some states in the United States have laws allowing marijuana for
certain medical conditions; some have legalized it for recreational use
• Results in euphoria, anxiety, paranoia, restlessness, talkativeness,
increased appetite
• Overdose: hallucinations.
• Withdrawal: restlessness, irritability, decreased appetite, insomnia
• Adverse effects on fetus include altered responses to visual stimuli,
tremulousness and exaggerated startle response, high-pitched cries
• Contraindicated during breastfeeding and pregnancy; continued
exposure in breastfeeding decreases motor capability
• See also “General considerations” (later)
• Prescription drug abuse
• Definition: the intentional use of a medication without a prescription in
a way other than as prescribed or for the experience or feelings elicited
• In addition to illegal drugs, many prescription drugs such as narcotic
analgesics, stimulants, sleeping pills, and antianxiety agents are
abused; prescription drug abuse rate is second in incidence to
marijuana
• Misuse can produce dependency
• Contraindicated during breastfeeding as well as pregnancy
• Characteristics of abuse, overdose, and withdrawal vary with type of
medication
• See also “General considerations” (later)
• Cocaine (from coca plant; “crack”)
• Powerfully addictive stimulant
• Teratogen
• Increased incidence of miscarriage, preterm labor, and abruptio
placentae in pregnant cocaine users
• Infants of pregnant cocaine users may be small for gestational age;
stillbirth is an additional risk
• Use results in hypervigilance, increased sexual activity, hyperactivity,
dilated pupils, euphoria, anorexia and thirst; snorting leads to nasal
septum destruction, hoarseness, and throat infections
• Overdose: cardiac dysrhythmias, seizures, hypertension, paranoid
ideation, psychosis with hallucinations
• Withdrawal: marked emotional and physical letdown with progression
to severe depression and paranoia
• Contraindicated during breastfeeding as well as pregnancy
• See also “General considerations” (later)
• Methamphetamine
• Addictive stimulant; can be prescribed for attention deficit
hyperactivity disorder (ADHD)
• Maternal adverse effects include mood disturbance, psychotic
symptoms, cardiovascular problems, and convulsions
• Maternal risks: preterm birth, abruptio placentae
• Fetal effects: small for gestational age, lethargy, brain and heart
abnormalities
• Results of use, characteristics of overdose are similar to cocaine (earlier)
• For acute intoxication, careful use of benzodiazepines and antipsychotic
medication can calm an agitated combative patient
• There is no effective treatment other than supportive care for
withdrawal
• Contraindicated during breastfeeding as well as pregnancy
• See also “General considerations” (later)
• Opioids: heroin, morphine, oxycodone, hydrocodone, fentanyl
• Results of use: constricted pupils, drowsiness, euphoria, slurred speech,
psychomotor retardation; needle marks (track marks), particularly on
limbs or between toes, which can lead to infections (eg, endocarditis,
hepatitis, or HIV); wearing long-sleeved shirts, even in warm weather
• Overdose: respiratory depression, bradycardia, death
• Withdrawal: yawning, lacrimation, rhinorrhea, and perspiration appear
10 to 15 hours after last opioid injection; unrealistic high; pronounced
depression; severe abdominal cramps, nausea, and vomiting if too
much time has elapsed between doses
• Contraindicated during breastfeeding as well as pregnancy; however,
methadone use is not contraindicated during breastfeeding (see later)
• Therapeutic interventions
■ Naloxone, an opioid antagonist, improves respiratory rate, although it
may not affect level of consciousness; respiratory depression can
recur when the drug is metabolized before the opioid has been
metabolized to a safe level
■ Completely or partially reverses opioid depression and may
produce an acute abstinence (withdrawal) syndrome by blocking
effects of the opioid
■ Gastric lavage may be necessary if substance was taken orally within the
past several hours
■ Treatment for withdrawal symptoms
■ Antidepressants seem to block the “high” from stimulant abuse and
diminish the craving for the substance
■ Methadone maintenance for opioid dependence: programs change
the dependence from an illegal drug to a legal drug, which is
administered under supervision; has proven successful in individuals
with long-standing addictions
○ Reduction in dosage can cause withdrawal signs and symptoms
○ Withdrawal signs and symptoms begin to develop in 8 hours and
may last as long as 2 weeks
○ Approved for treatment of pregnant and breastfeeding opioid
addicts
• General considerations
• General etiologic factors
■ Addictive capacity depends on the drug, from lowest potential to
highest potential (eg, progressing from codeine, alcohol, and
barbiturates to heroin); concurrent use of multiple drugs
(polysubstance use), including alcohol
• General behavioral/clinical findings
■ Physical examination reflects type of drug used and route of delivery
■ Poor reality testing; personality change
■ History of violent acting out with disregard for human life or
suffering
■ History of stealing, selling drugs, and prostitution
■ Inability to maintain ADLs or fulfill role obligations
■ Marked tolerance for some drugs such as opioids and cocaine with a
progressive need for higher doses to achieve desired effect
• General therapeutic interventions
■ Treatment for drug overdose
■ High-calorie, high-protein diet with vitamin supplements
■ Treatment in groups led by former addicts
■ Therapeutic community setting
■ Psychotherapy and family therapy on an outpatient basis
■ Vocational counseling
Care management: Nursing care of clients who
abuse drugs
• Assessment/analysis/screening
• History of drugs being used (eg, types, amount, and frequency)
• Informed consent for urine toxicology screen, HIV testing, drug abuse
screening tests
• Full history, including length and pattern of drug dependence; time
since last dose
• Physical status of the client for signs and symptoms of drug
dependence; nutritional status
• Signs of drug overdose or withdrawal; use of established scales (eg,
Clinical Institute Narcotic Assessment [CINA] Scale or Clinical Opiate
Withdrawal Scale [COWS]) to help with completeness and consistency
of assessment
• Degree of difficulty sustaining role in relation to family members, job,
school, etc.
• Why client is seeking treatment at this time
• Potential for violence toward others or self
• Presence of hallucinations, paranoid ideation, and depression
• Relationship between substance use and psychiatric disorders (known
as dual diagnosis)
• Potential for recurrence of drug abuse after period of withdrawal
• Planning/implementation
• Treatment for substance abuse and advice about breastfeeding must be
individualized
• Maintain drug-free environment when hospitalized
• Keep atmosphere pleasant and cheerful but not overly stimulating
• Contribute to the client’s self-confidence, self-respect, and security in a
realistic manner; focus on feelings; help the woman identify her own
strengths
• Expect and accept evasion, manipulative behavior, and negativism, but
require the maintenance of standards of responsibility; set realistic
limits
• Accept client without approving the behavior
• Do not permit client to become isolated; introduce to group activities as
soon as possible; evaluate response to group interaction
• Protect client from self and others
• Refer to appropriate 12-step group such as Women for Sobriety, Cocaine
Anonymous, and Narcotics Anonymous
• Treat physical effects of substance abuse
• Provide education related to the disease process and health effects on
mother and infant
• Evaluation/outcomes
• Recognizes, accepts, and seeks treatment for problem
• Accepts responsibility for problem without blaming others
• Achieves optimal physiologic and nutritional status
• Learns new, more self-preserving coping mechanisms
• Verbalizes feelings and emotions
• Enters into and continues with community-based self-help program
• Abstains from all mood-altering chemicals
• Follow-up care
• Home situation must be assessed to determine whether someone can
meet the infant’s needs; usually done by social services
• Home care or public health nurse may visit
• If serious concerns remain, case can be referred to the state child
protection services
Application and review
13. What should a nurse identify as the most important factor in
rehabilitation of a client addicted to alcohol?
1. Motivational readiness
2. Availability of community resources
3. Accepting attitude of the client’s family
4. Qualitative level of the client’s physical state
14. Clients addicted to alcohol often use the defense mechanism of denial.
What is the reason why this defense is so often used?
1. Reduces their feelings of guilt
2. Creates the appearance of independence
3. Helps them live up to others’ expectations
4. Makes them look better in the eyes of others
15. While a client is attending an Alcoholics Anonymous (AA) meeting, a
nurse talks with the client’s spouse about the purpose of AA. What is the
priority goal of this self-help group?
1. Change destructive behavior.
2. Develop functional relationships.
3. Identify how they present themselves to others.
4. Understand their patterns of interacting within the group.
16. A client with a history of alcohol abuse says to the nurse, “Drinking is a
way out of my depression.” Which strategy probably is most effective for
the client at this time?
1. A self-help group
2. Psychoanalytic therapy
3. A visit with a religious advisor
4. Talking with an alcoholic friend
17. A client who has participated in caring for her infant in the neonatal
intensive care unit (NICU) for several days in preparation for the infant’s
discharge comes to the unit on the last hospital day with an alcohol odor
on her breath and slurred speech. What action should the nurse take?
1. Talk with the mother about her condition and assess her willingness
to participate in an alternate discharge plan.
2. Request that the mother wait in the hospital lobby and call the
health care provider to cancel the discharge order.
3. Speak to the mother about her condition and have her see a social
worker about the infant’s discharge to a foster home.
4. Continue with the discharge procedure and alert the home health
nurse that the mother needs an immediate follow-up visit.
18. A pregnant woman who is in the third trimester arrives in the emergency
department with vaginal bleeding. She states that she snorted cocaine
approximately 2 hours ago. Which complication does the nurse suspect is
the cause of the bleeding?
1. Placenta previa
2. Tubal pregnancy
3. Abruptio placentae
4. Spontaneous abortion
19. A nurse is planning for the discharge of a crack-addicted 17-year-old
mother and her newborn. What is the most appropriate referral to meet
the mother’s and the infant’s needs?
1. Legal aid
2. Family court
3. Foster parent care
4. Home health nurse
See Answers on pages 137-140.
Answer key: Review questions
1. 2 Offering an opportunity to discuss the visit provides the client with an
opportunity to discuss feelings.
1​ Allowing the client to skip the meal does not address the client’s
depression. 3 Teaching is inappropriate when a client is emotionally
distressed. 4 Providing the client with quiet thinking time limits further
communication and may imply rejection.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
2. 4 This approach allows the client to control the pace of development of the
nurse–client relationship.
1 Depressed clients are unable to move into relationships with other
clients. 2 It is too early for therapy sessions; the first thing that must be
established is a trusting nurse–client relationship. 3 Depressed clients
are unable to move into group situations.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
3. 4 Recognition of anxiety or symptoms of increasing anxiety is an
indication that the client is improving.
1 Participating in activities does not indicate improvement or recognition
of feelings; the client may be doing what others expect. 2 Avoidance of
anxiety is not a good indication of improvement; there is no guarantee
that anxiety can always be avoided. 3 Taking medication as prescribed
does not indicate improvement or recognition of feelings; the client
may be doing what others expect.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcome
4. 4 Ineffective coping is the impairment of a person‘s adaptive behaviors
and problem-solving abilities in meeting life’s demands; ritualistic
behavior is an impaired type of coping.
1 Not enough information is available to lead to the conclusion that the
client has a blurred personal identity. 2 Not enough information is
available to lead to the conclusion that the client has poor control of
sudden urges. 3 Not enough information is available to lead to the
conclusion that the person has a disturbance in spatial boundaries.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
5. 3 “It has been difficult for you. How long has this been going on?”
acknowledges feelings and attempts to collect more data.
1 “With whom have you shared your feelings of anxiety?” will not
facilitate data collection about the extent of anxiety. 2 Anxiety is most
often a response to a vague, nonspecific threat; the client will not be
able to answer “What have you identified as the cause of your anxiety?”
4 It is too early to try to identify the cause of the anxiety; crisis
intervention with anxious clients requires a more structured approach
than “Let’s talk.”
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
6. 1 Because the compulsive ritual is used to control anxiety, any attempt to
prevent the action will increase anxiety.
2 Underlying hostility is considered to be part of the disorder itself, not a
reaction to an interruption of the ritual. 3 Aggression is possible only if
the anxiety reached panic levels and caused the person to express anger
overtly. 4 Withdrawal is not a pattern of behavior associated with
obsessive-compulsive disorder.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
7. 3 The nurse who is anxious should leave the situation after providing for
continuity of care; the client will be aware of the nurse‘s anxiety, and the
nurse’s presence will be nonproductive and nontherapeutic.
1 Refocusing the conversation on some pleasant topics meets the nurse’s
need, but it may make the client feel guilty that something was said
that upset the nurse. The client will be aware of the nurse’s anxiety,
which will increase the client’s own anxiety. 2 If the nurse tells the
client to calm down and that the client is making the nurse anxious,
that meets the nurse’s need, but it may make the client feel guilty that
something was said that upset the nurse. The client will be aware of the
nurse’s anxiety, which will increase the client’s own anxiety. 4 If the
nurse remains quiet so that personal feelings of anxiety do not become
apparent to the client, the client will probably sense the nurse’s anxiety
through nonverbal channels, if not through verbal responses.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Integrated
Process: Communication/Documentation; Nursing Process:
Planning/Implementation
8. 2 “You are worried about how you will be able to manage” explores
feelings so that the client’s anxiety can be reduced before solutions are
discussed.
1 Suggesting that she will need someone to help care for the children is
giving solutions rather than exploring the situation with the client. 3
Suggesting that a neighbor can help out and that the husband can do
the housework is giving solutions rather than exploring the situation
with the client. 4 The nurse’s suggestion about fixing light meals and
sending the children to day care assumes that the client is able to afford
day care.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Caring
9. 2 The client’s current behavior is the best indicator of the client’s current
level of functioning; all behavior has meaning.
1 Memory is important and should be assessed, but it is not the best
indicator of the client’s current level of functioning. 3 Judgment is
important and should be assessed, but it is not the best indicator of the
client’s current level of functioning. 4 Responsiveness is important and
should be assessed, but it is not the best indicator of the client’s
current level of functioning.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
10. 1 Rituals provide a means for the individual to control anxiety. If not
permitted to carry out the ritual, the client probably will experience
unbearable anxiety. The client has exhibited verbally aggressive behavior
in the past, and this behavior may escalate. Safety of the client and others
becomes an issue.
2 The client probably understands this already but is unable to stop the
activity. 3 Clients with obsessive-compulsive disorder have no idea
what the ritual means, only that they must continue the ritual. 4
Interrupting the ritual will have the effect of increasing anxiety,
possibly to panic levels.
Clinical Area: Comprehensive Examination; Client Needs: Safe and
Infection Control; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Caring
11. 3 Parents’ feelings of resentment toward their children is a normal
response. To relieve feelings of guilt and shame, it is vital to help parents
realize this.
1 The first child causes the greatest amount of adjustment in one’s life. 2
Anger and resentment toward a child are expected feelings. 4 The idea
that parents usually have inborn feelings of love and acceptance of their
children is an untrue generalization.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Comprehension; Nursing
Process: Assessment/Analysis; Integrated Process: Caring
12. 4 Feelings of hopelessness are symptomatic of depression; the individual
feels unable to find any solution to problems and thus feels
overwhelmed.
1 Echolalia is the pathologic meaningless repetition of another’s words or
phrases and is associated with schizophrenia, not with depression. 2
Delusions are associated with psychotic disorders such as
schizophrenia or depression with psychotic features. 3 Confusion is not
common because these individuals are in contact with reality, unlike
depression with psychotic features.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Comprehension; Nursing
Process: Assessment/Analysis; Integrated Process: Caring
13. 1 Intrinsic motivation, stimulated from within the learner, is essential if
rehabilitation is to be successful. Often clients are most emotionally ready
for help when they have “hit bottom.” Only then are they motivationally
ready to face reality and put forth the necessary energy and effort to
change behavior.
2 Availability of community resources is important, but not the most
important factor. 3 An accepting attitude of the client’s family is an
important factor and a helpful one, but not the most important one. 4
The qualitative level of the client’s physical state is an important factor,
but not the most important one.
Client Need: Psychosocial Integrity; Cognitive Level: Comprehension;
Nursing Process: Assessment/Analysis
14. 1 Clients addicted to alcohol often use denial as a defense against
feelings of guilt; this will reduce anxiety and protect the self.
2 Denial may make a client seem more stable to others, not independent.
3 Denial deals more with a client’s own expectations. 4 Denial that
makes the client look better in the eyes of others may be part of the
reason, but the bigger motivating factor is to decrease guilt feelings.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
15. 1 The purpose of a self-help group is for individuals to develop their
strengths and new, constructive patterns of coping.
2 To develop functional relationships is just one of the purposes of group
therapy. 3 To identify how they present themselves to others is just one
of the purposes of group therapy. 4 To understand their patterns of
interacting within the group is just one of the purposes of group
therapy.
Client Need: Psychosocial Integrity; Cognitive Level: Comprehension;
Integrated Process: Communication/Documentation; Nursing Process:
Planning/Implementation
16. 1 Members of self-help groups, particularly Alcoholics Anonymous, are
living with the problem themselves; therefore, problem identification and
self-responsibility are emphasized, and manipulation is limited.
2 Long-term therapy tends to increase anxiety until resolution occurs;
level of commitment and duration of therapy render it a less desirable
choice for substance abusers. 3 Depending on the client’s feelings
about religion, a visit with a religious advisor may or may not be
helpful. 4 Depending on the friend’s drinking status, talking with an
alcoholic friend may be helpful or harmful. These variables negate the
effectiveness of this choice.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Management of Care; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process:
Communication/Documentation
17. 1 Confrontation about the active substance abuse and the mother’s
diminished ability to care for the infant safely at this time is necessary to
support the mother get help and to protect the infant.
2 Decisions should not be made without input from the mother. 3
Decisions should not be made without input from the mother. 4 To
continue with the discharge procedure and alert the home health nurse
that the mother needs an immediate follow-up visit is unsafe; the
mother may not be capable of caring for the infant.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Management of Care; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process:
Communication/Documentation
18. 3 Abruptio placentae is associated with cocaine use; it occurs in the third
trimester.
1 Placenta previa is seen in the third trimester but is not associated with
cocaine use. 2 A tubal pregnancy is identified in the first trimester. 4
Spontaneous abortion occurs in the first two trimesters.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
19. 4 By going into the home, a nurse will be able to monitor both the
mother’s and the infant’s health, as well as the mother’s parenting skills
and evidence of drug abuse or rehabilitation.
1 Legal aid is not the most appropriate referral because the court system
already is involved due to the infant’s positive toxicologic screen. 2
Family court is not the most appropriate referral because the court
system already is involved due to the infant’s positive toxicologic
screen. 3 Foster care is not automatic if it has been determined that the
mother is able to care for the infant.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Management of Care; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process:
Communication/Documentation
C H AP T E R 8
Labor and birth processes
Factors affecting labor
Labor: involuntary physiologic process whereby contents of gravid uterus are
expelled through birth canal into external environment
Passenger
• Fetal head
• The size of the fetal head affects the ability of the fetus to travel the
birth canal
• The location of the fetal head helps determine the fetal presentation
• The fetal skull bones are connected by membranous sutures, but are not
fused, allowing them to mold or shift to help permit the fetus’ passage
through the birth canal. Where the sutures connect are membranous
fontanels:
■ Anterior fontanel is largest; at the junction of the sagittal, coronal,
and frontal sutures
■ Posterior fontanel at the junction of the two parietal bones with the
occipital bone
• Measurements: fetal head measurements include the anteroposterior
measurement (suboccipitobregmatic) and the transverse (biparietal)
diameter
• Fetal presentation: body part of fetus that engages in pelvic inlet first
• Cephalic (head): vertex, brow, or face
• Breech: frank, complete, single, or double footling
• Shoulder: fetus cannot travel through birth canal
• Presenting part: the part of the fetus that is closest to the inside of the
maternal cervix
• Fetal lie: relationship of long axis of fetus to long axis of mother
• Most common are longitudinal/vertical and horizontal/transverse;
longitudinal means that a vaginal birth is possible
• Fetal attitude: relationship of fetal parts to each other
• Usually in general flexion
• As head becomes more extended, the anteroposterior diameter of the
fetal head widens, which may prevent the head from moving into the
true pelvis
• Fetal position: relationship of presenting parts to four quadrants of
mother’s pelvis (left [L] or right[R]; anterior [A] or posterior [P]; occiput
[O]; mentum or face [M]; sacrum [S]):
• Vertex: occiput, LOA, LOP, ROA, ROP (Fig. 8.1)
• Face: mentum (chin), LMA, LMP, RMA, RMP
• Breech: sacrum, LSA, LSP, RSA, RSP
• Station is the relationship of the presenting part to the imaginary line
between ischial spines (how far fetal presenting part has descended into
mother’s pelvis); measured as −5, through −1, 0, +1 through +5
• Floating: presenting part movable above pelvic inlet; fetus is high in the
pelvis
• Engaged: biparietal plane of the fetus has passed maternal pelvic inlet
■ Engagement: when the biparietal diameter of fetal head reaches level
of ischial spines of mother’s pelvis; usually corresponds to station
“0”
• Station 0: presenting part at level of the ischial spines; levels above
spines −1, −2, −3; levels below spines +1, +2, +3 (Fig. 8.2)
FIG. 8.1 Fetal position.The right occipitoanterior (ROA) or left occipitoanterior
(LOA) is most favorable for normal labor. Source: (From Matteson, P.S. [2001]. Women’s
health during the childbearing years: A community-based approach. St Louis: Mosby.)
FIG. 8.2 Stations of presenting part. Source: (From Matteson, P.S. [2001]. Women’s health
during the childbearing years: A community-based approach. St Louis: Mosby.)
Passageway
• Bony pelvis
• Classification of pelvis: gynecoid (female-shaped pelvis; most common),
android (male-shaped pelvis), anthropoid (similar to male-shaped
pelvis), platypelloid (flat pelvis; least common)
• True pelvis: bony inner pelvis through which fetus must pass (true
conjugate, cannot be measured directly); accurate measurement
determined with computerized tomography, ultrasonography
• False pelvis is above the brim that forms the inlet to the true pelvis
• Pelvic inlet = upper border of true pelvis; pelvic outlet = lower border of
true pelvis
• Soft tissues: lower uterine segment, cervix, muscles of the pelvic floor, and
vagina
• Upper muscular uterine segment is marked by a ring during labor
dividing it from the lower uterine segment, which stretches; because
the upper portion contracts and the lower portion stretches, the uterine
contents are moved downward
• Cervix thins (effaces) and opens (dilates) during labor
• If previous delivery, will yield more readily to contractions and pushing
efforts
• May not yield as readily in primiparas or older women
Powers
• Powers determine the effectiveness of contractions
• Involuntary powers are primary powers = uterine contractions
• Responsible for effacement (shortening and thinning of cervix in first
stage of labor)
• Voluntary powers are secondary powers = bearing down by woman
• Compress the uterus and add to the force of the uterine contraction
Position of the laboring woman
• Position changes can help woman adapt to labor
• Position can influence frequency and strength of contractions, but must
accommodate health care provider to assist the birth
• Side-lying is better than supine to help oxygenation of the fetus
Process of labor
Clinical findings preceding labor
• Physiologic
• Lightening: fetus drops into pelvis
• Preparatory contractions (formerly called Braxton Hicks): irregular mild
contractions in preparation for true labor; contractions subside when
walking
■ False labor does not result in cervical changes, whereas true labor
causes changes in cervical dilation and effacement
• Increased vaginal secretions
• Softening of cervix (ripening)
• Bloody show: mucous plug expelled; accompanied by small blood loss;
can occur before or during labor
• Psychologic: mother shows signs of nesting (increased activity) caused by
sudden rise in energy level (spurt of energy)
Clinical findings of true labor
• Regular uterine contractions (5–8 minutes apart; counted from the
beginning of one contraction to the beginning of the next contraction)
that increase in frequency, strength, and duration and do not disappear
when lying down or walking
• Effacement (shortening or thinning of cervix) and progressive dilation of
cervix
Stages of labor and maternal changes
• First stage: from onset of true labor to complete effacement and dilation
of cervix
• Latent phase: mild, short contractions, cervix dilated 0 to 3 cm; client
excited that labor has started, some apprehension; follows directions
readily; walking assists labor process
• Active phase: moderate to strong contractions about 5 minutes apart,
cervix dilates from 4 to 7 cm, bloody show, membranes may rupture;
slow, deep-breathing techniques help with relaxation; increasing
difficulty in following directions; analgesic may be needed for
discomfort; need for supportive measures (eg, encouragement, praise,
reassurance, back pressure or back rubs); client/significant other seeks
information regarding progress of labor
■ If rupture of membranes occurs before labor, it warrants evaluation
of the pregnant woman at the health care facility, in particular
because the risk of infection increases
■ Rupture of membranes (whether spontaneous or performed [called
an amniotomy; see Chapter 12] by health care provider) allows more
effective pressure of the fetal head on the cervix, enhancing dilation
and effacement
• Transition phase: strong contractions 1 to 2 minutes apart (lasting 45–60
seconds or more with little rest in between); cervix dilates from 8 to 10
cm with increased bloody show; becomes irritable, restless, agitated,
emotional, belches, has leg tremors, perspires, develops pale white ring
around mouth (circumoral pallor), flushed face, sudden nausea, may
vomit; feels need to have bowel movement because of pressure on
anus; may be unable to communicate or follow directions; requires
focused emotional support
• Second stage: begins with full dilation of cervix and ends with birth
• Latent phase: may last up to 1 hour with decrease in strength and
frequency of contractions and without urge to push; passive fetal
descent
• Active phase: urge to push; contractions stronger with increased
frequency; fetal head arrives at perineum; perineum bulges when
pushing with contractions; client makes grunting sounds; behavior
changes from irritability to involvement with birth process; sleep and
relaxation between contractions; leg cramps are common
• Mechanisms of second-stage labor: rotation and descent of fetus in
vertex presentation through pelvis; these cardinal movements are a
series of actions that reflect changes in the posture of the fetus as it
adapts to the birth canal; these are called the mechanisms of labor:
■ Engagement
■ Descent with flexion: at onset of second stage, head descends and
chin flexes on chest
■ Internal rotation: as labor contractions and uterine forces move fetus
downward, head internally rotates to pass through ischial spines
■ Extension: occiput emerges under symphysis pubis and head is born
by extension
■ External rotation: rotation of shoulders to an anteroposterior position
■ Expulsion: remainder of fetus’s body is born
• Third stage: begins after birth of infant through expulsion of placenta
• Placental separation (5–30 minutes) heralded by globular shape of
uterus, lengthening of umbilical cord, and gush of blood
• May have alteration in perineal structure either from episiotomy
(prophylactic incision into perineum to allow for birth of head; see
Chapter 16) or from lacerations caused by expulsion of presenting part
• Fourth stage: follows expulsion of placenta to 2-4 hours after birth
• Fundus firm in midline, at or slightly above the umbilicus
• Bloody vaginal discharge (lochia rubra)
• Fatigue, thirst, chills, nausea; excitement and intermittent dozing
Application and review
1. A nurse is teaching a primigravida about how she can identify the onset of
labor. What clinical indicator of labor would necessitate the client to call
her health care provider?
1. Bloody show and back pressure occur.
2. Contractions become regular or get stronger.
3. Membranes rupture or contractions are 5 to 8 minutes apart.
4. Contractions are 10 to 12 minutes apart and last about 30 seconds.
2. At a prenatal visit a client who is at 36 weeks’ gestation states that she is
having uncomfortable irregular contractions. What should the nurse
recommend?
1. “Lie down until they stop.”
2. “Walk around until they subside.”
3. “Time the contractions for 30 minutes.”
4. “Take 2 extra-strength aspirins if the discomfort persists.”
3. How does the nurse identify true labor as opposed to false labor?
1. Cervical dilation is progressive.
2. Contractions stop when the client walks around.
3. Client’s contractions progress only in a side-lying position.
4. Contractions occur immediately after the membranes rupture.
4. A primigravida is admitted to the birthing unit in early labor. A pelvic
examination reveals that her cervix is 100% effaced and 3 cm dilated. The
fetal head is at +1 station. In what area of the client’s pelvis is the fetal
occiput?
1. Not yet engaged
2. Below the ischial spines
3. Entering the pelvic inlet
4. Visible at the vaginal opening
5. A client in the active phase of the first stage of labor begins to tremble,
becomes very tense during contractions, and is quite irritable. She
frequently states, “I cannot stand this a minute longer.” What does this
behavior indicate to the nurse caring for her?
1. There was no preparation for labor.
2. She should receive an analgesic for pain.
3. She is entering the transition phase of labor.
4. Hypertonic uterine contractions are developing.
6. A nurse assesses the frequency of a client’s contractions by timing them
from the beginning of a contraction until when?
1. Until the uterus starts to relax
2. To the end of a second contraction
3. Until the uterus completely relaxes
4. To the beginning of the next contraction
7. A client is admitted to the birthing unit in active labor. What should the
nurse expect after an amniotomy is performed?
1. Diminished bloody show
2. Increased and more variable fetal heart rate
3. Less discomfort with contractions
4. Progressive dilation and effacement
8. A nurse is caring for a primigravida during labor. What does the nurse
observe that indicates birth is about to take place?
1. Bloody discharge from the vagina increases.
2. Perineum begins to bulge with each contraction.
3. Client becomes irritable and stops following instructions.
4. Contractions occur more frequently, are stronger, and last longer.
9. A nurse is caring for a client in labor. What client response indicates that
the transition phase of labor probably has begun?
1. Assumes the lithotomy position
2. Perspires and has a flushed face
3. Indicates back and perineal pain
4. Exhibits decrease in frequency of contractions
10. A woman in labor hears the health care provider tell the nurse that the
fetal lie is longitudinal. The mother asks the nurse what this means in
relation to her labor and birth of the baby. How should the nurse respond?
1. “A vaginal birth is possible.”
2. “A cesarean birth is anticipated.”
3. “This has no relevance to the labor and impending birth.”
4. “Labor probably will be long and you might have back pain.”
11. The fetus of a client in labor is assessed to be at −1 station. Where did the
nurse locate the fetus’s head?
1. On the perineum
2. High in the pelvis
3. Just below the ischial spines
4. Slightly above the ischial spines
12. A client in active labor is admitted to the birthing room. A vaginal
examination reveals the cervix to be 7 cm dilated. On the basis of this
finding, what does the nurse expect the client to exhibit?
1. Nausea and vomiting
2. Bloody and profuse show
3. Inability to control her shaking legs
4. Strong contractions with intervals of several minutes
13. A nurse on the birth unit is assessing a primigravida who states that labor
has begun. How does the nurse know that this client is in true labor?
1. Cervix is dilated.
2. Fetal head is engaged.
3. Membranes have ruptured.
4. Uterine contractions are occurring.
14. A few hours after being admitted in early labor, a primigravida perspires
profusely and becomes restless, flushed, and irritable. The client states
that she is going to vomit. What phase of the first stage of labor does the
nurse suspect the client has entered?
1. Latent
2. Transition
3. Late active
4. Early active
See Answers on pages 147-149.
Answer key: Review questions
1. 3 When the membranes rupture, the potential for infection is increased,
and when the contractions are 5 to 8 minutes apart, they are usually of
sufficient force to warrant professional supervision.
1 Bloody show and back pressure may be early signs of labor or signs of
posterior fetal position; it is too early to notify the health care provider.
2 When contractions become regular or get stronger is too early; the
client should remain with her family and keep moving around at home.
4 When contractions are 10 to 12 minutes apart, lasting about 30
seconds, is too early; the client should remain with her family and keep
moving around at home.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
2. 2 Ambulation relieves the discomfort of preparatory contractions.
1 Preparatory contractions will increase when the client is resting. 3
Preparatory contractions are not indicative of true labor and need not
be timed. 4 Aspirin may be harmful to the fetus because it can
hemolyze red blood cells.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
3. 1 Progressive cervical dilation is the most accurate indication of true labor.
2 With true labor, contractions will increase with activity. 3 Contractions
of true labor persist in any position. 4 Contractions may not begin until
24 to 48 hours later.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
4. 2 A station of +1 indicates that the fetal head is 1 cm below the ischial
spines.
1 The head is now past the points of engagement, which are the ischial
spines. 3 Entering the pelvic inlet is designated as 0 station. 4 The head
must be at +3 to +4 station to be visible at the vaginal opening.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
5. 3 The contractions become stronger, last longer, and are erratic during this
stage; the intervals between contractions become shorter than the
contractions themselves; the client needs to apply a great deal of
concentration and effort to pace her breathing with each contraction.
1 Even clients who have been adequately prepared will experience these
behaviors (will tremble and become tense and irritable) during the
transition phase of the first stage of labor. 2 Administration of an
analgesic at this time may reduce the effectiveness of labor and depress
the fetus. 4 There is no indication that the contractions are hypertonic.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
6. 4 Counting from the beginning of one contraction to the beginning of the
next contraction is the accepted way to determine the frequency of the
contractions.
1 When the uterus starts to relax does not determine the length of a
contraction. 2 Counting to the end of a second contraction does not
indicate the frequency of contractions. 3 Counting until the uterus
completely relaxes identifies the end of a contraction, but it is not the
accepted way of timing the frequency of contractions.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Knowledge; Nursing Process: Assessment/Analysis
7. 4 Artificial rupture of the membranes (amniotomy) allows for more
effective pressure of the fetal head on the cervix, enhancing dilation and
effacement.
1 Vaginal bleeding may increase because of the progression of labor. 2 An
amniotomy does not directly affect the fetal heart rate. 3 Discomfort
may become greater because contractions usually increase after an
amniotomy.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes
8. 2 The bulging perineum indicates that the fetal head is on the pelvic floor
and birth is imminent.
1 Bloody discharge from the vagina increases during the transition phase
or at the beginning of the second stage. 3 The client becomes irritable
and stops following instructions during the transition phase or at the
beginning of the second stage. 4 Contractions occurring more
frequently, becoming stronger, and lasting longer describe the progress
of labor; it is not a sign that birth is imminent.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
9. 2 As cervical dilation nears completion, labor is intensified, causing an
increase in energy expenditure; these result in perspiration and a flushed
face.
1 The client usually is restless and thrashes about during transition,
assuming no particular position. 3 Back pain usually indicates a
posterior-lying position of the fetus’s head. Perineal pain starts during
the second stage of labor. 4 Pain is increased because contractions are
more frequent and intense, and they last longer.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
10. 1 A longitudinal lie means that the fetus is parallel to the woman’s spine;
therefore, a vaginal birth is possible.
2 A transverse, not longitudinal, lie might indicate that a vaginal birth is
unlikely, and a cesarean birth is anticipated. 3 The fetal lie will
influence the labor and birth of the fetus. 4 A longitudinal lie does not
indicate that the labor will be prolonged; however, if the fetal head is in
the posterior occiput position, second-stage labor may be prolonged,
accompanied by back pain.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Communication/Documentation
11. 4 The term station is used to indicate the location of the presenting part.
The level of the tip of the ischial spines is considered to be zero. The
position of the bony prominence of the fetal head is described in
centimeters, minus (above the spines) or plus (below the spines). Minus
one indicates that the head is just below the ischial spines.
1 The fetal head on the perineum is referred to as crowning and is
designated as +5. 2 The fetal head high in the pelvis is designated by
the term floating, which means that the presenting part has not yet
engaged in the pelvis. 3 The term station is used to indicate the location
of the presenting part. The level of the tip of the ischial spines is
considered to be zero. The position of the bony prominence of the fetal
head is described in centimeters, minus (above the spines) or plus
(below the spines). Plus one indicates just below the ischial spines.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
12. 4 Strong contractions with intervals of several minutes is a description of
the contractions that occur during the active portion of the first stage of
labor.
1 Nausea and vomiting occur in the transition phase of the first stage of
labor (8–10 cm cervical dilation). 2 Bloody and profuse show occurs in
the transition phase of the first stage of labor (8–10 cm cervical
dilation). 3 Inability to control shaking legs occurs in the transition
phase of the first stage of labor (8–10 cm cervical dilation).
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
13. 1 False labor does not produce cervical dilation; true labor does.
2 The fetal head may enter the pelvic cavity up to 1 month before true
labor begins, especially in primigravidas. 3 It may be a premature
rupture of membranes, which can occur before uterine contractions and
cervical dilation start. 4 Irregular preparatory contractions may occur
and are not a sign of true labor.
Clinical Area: Childbearing; Client Needs: Health Promotion and
Maintenance; Cognitive Level: Comprehension; Nursing Process:
Assessment/Analysis
14. 2 The physiologic intensification of labor that occurs during transition
(8–10 cm cervical dilation) is caused by greater energy expenditure and
increased pressure on the abdomen; this results in feelings of fatigue,
discouragement, and nausea.
1 The latent phase is the earliest phase of labor. It is characterized by
cervical dilation and effacement (0–3 cm). 3 There are three phases in
the first stage of labor. The active phase lasts from 4 to 7 cm dilation.
There is no distinction between early and late active phases. 4 There are
three phases in the first stage of labor. The active phase lasts from 4 to
7 cm dilation. There is no distinction between early and late active
phases.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
C H AP T E R 9
Maximizing comfort for the laboring
woman
Pain during labor and birth
Definition and description
• Pain is a universally unpleasant emotional and sensory experience that
occurs in response to actual or potential tissue trauma or inflammation;
during birth, both the psychologic and physiologic components are
important
• Subjective: pain is whatever client says it is
• Perception of client’s pain is influenced by multiple factors (eg, previous
pain experience and emotional, physical, and psychologic status)
• Differences in labor pain compared with other pain:
• Can prepare for it
• Usually intermittent; self-limited
• Normal part of labor; not associated with injury or disease
• Concludes with birth of infant
Neurologic origins
• Ischemia in uterus: uterine contraction results from arterial compression
• Cervical effacement and dilation produces pain carried by T10 to L1 spinal
levels
• Pressure and tension on pelvic structures: visceral pain, including
pressure against bladder and rectum, traction on supportive tissues
• Stretching of vagina and perineum produces somatic pain, which can
include lacerations, transmitted by the pudendal nerve (S2–4 spinal
levels)
Perception of pain
Perception of pain
• Pain threshold (minimum amount of stimulus required to cause sensation
of pain) is similar in all people, but perception of pain and responses to
pain vary
• Pain tolerance: maximum pain a client is willing or able to endure; when
exceeded, the laboring woman will seek pain relief
• Factors affecting pain tolerance include preparation for childbirth, desire
for natural childbirth, anxiety, support during labor, and participation in
nonpharmacologic comfort measures
Expression of pain
• Physiologic expressions include increased catecholamine levels, increased
blood pressure and heart rate, changes in respiratory patterns, and
nausea and vomiting, as well as diminished uterine activity that may
prolong labor
• Emotional expressions include anxiety, vocalizations, gesturing, muscular
excitability
The joint commission standards
• All patients have the right to pain assessment and management
• Staff must be competent in pain assessment and management
• Policies, procedures, and patient/family education, including discharge
planning, must support pain management
Factors influencing pain response
Physiologic factors
• High anxiety and fear produce catecholamines, increase muscle tension,
hasten fatigue; fatigue influences the need for pain medication
• Nurses should teach pregnant women the importance of conserving the
“spurt of energy” common before labor so that they are not fatigued
when labor begins
• Uterine contractions, cervical dilation, and effacement are sources of pain,
as well as vaginal and perineal stretching
• Fetal size, position, and speed of descent affect the woman’s pain
• Maternal position and mobility during labor, as well as the interval
between and duration of contractions, affect pain
• Endogenous endorphins increase during pregnancy and birth, which may
help raise the woman’s pain threshold
Culture
• Although cultures vary in their approach to pain, each woman is an
individual, who may or may not have adopted her culture’s approach;
interpretation of pain sensations is highly individual and is based on past
experiences, which include cultural values
• Cultural influences may include expectations of a variety of behaviors,
from stoicism to vocal expressions of pain
Anxiety
• Excessive anxiety and fear magnify pain perception, in part by increasing
muscle tension, which speeds fatigue, which also increases pain
• Excessive anxiety can decrease a woman’s confidence in her ability to
manage pain, which can reduce the effectiveness of pain management
techniques
Previous experience
• Learning that pain during labor does not indicate injury can help
• Negative previous experiences can heighten pain; positive ones can reduce
anxiety and pain; it is important for nurses to understand the influence of
previous experience
• Past experience may also include cultural values; it may be past experience
of relatives or friends; it does not have to be the woman’s own past
experience
Gate-control theory of pain
• Suggests that stimulation of large-diameter fibers can block transmission
of painful impulses through the dorsal horn of the spinal cord
• Types of stimulation that travel on the large-diameter fibers include tactile
input (hydrotherapy, massage, heat) and visual and auditory stimulation
• Cognitive work, such as focusing on breathing and relaxation, also
interferes with pain transmission
Support
• Meeting needs and desires provides comfort
• Anxious support providers can magnify the woman’s anxiety
• Having a person supportive of the woman during labor decreases the need
for pain medication and analgesia
• Encouragement and support, helping the woman to maintain control, is
especially important during the transition phase
• Offering comfort measures and giving the woman choices about comfort
measures are appropriate nursing actions to show support
Environment
• Environment includes individuals and physical place
• Ideally the environment is safe and private, with room for position
changes and ambulation, and containing equipment that facilitates
nonpharmacologic pain management
• Relaxation can be enhanced with variations in light, noise/music, and
temperature per the woman’s preferences
Application and review
1. Why should a nurse teach pregnant women the importance of conserving
the “spurt of energy” before labor?
1. Energy helps to increase the progesterone level.
2. Fatigue may influence the need for pain medication.
3. Energy is needed to push during the first stage of labor.
4. Fatigue will increase the intensity of the uterine contractions.
2. What does a nurse consider the most significant influence on many clients’
perception of pain when interpreting findings from a pain assessment?
1. Age and sex
2. Physical and physiologic status
3. Intelligence and economic status
4. Previous experience and cultural values
3. A primigravida who is at 40 weeks’ gestation arrives at the birthing center
with abdominal cramping and a bloody show. Her membranes ruptured
30 minutes before arrival. A vaginal examination reveals 1 cm dilation and
the presenting part at −1 station. After obtaining the fetal heart rate (FHR)
and maternal vital signs, what should the nurse do next?
1. Teach the client how to push with each contraction.
2. Encourage the client to perform pattern-paced breathing.
3. Provide the client with comfort measures used for women in labor.
4. Prepare to have the client’s blood typed and crossmatched for a
possible transfusion.
4. How should a nurse direct care for a client in the transition phase of the
first stage of labor?
1. Decrease IV fluid intake.
2. Help the client to maintain control.
3. Reduce the client’s discomfort with medications.
4. Institute simple breathing patterns during contractions.
5. A nurse is caring for a client who is having a prolonged labor. The client is
annoyed and very concerned because her labor is deviating from what she
perceives as normal. After the nurse has acknowledged the client’s
feelings, what is the next best intervention?
1. “I’ll leave so you can talk to your partner.”
2. “I’ll rub your back, and you tell me if it helps.”
3. “Let’s talk some more about what’s really bothering you.”
4. “Women usually become weary and frustrated during labor.”
See Answers on pages 161-164.
Nonpharmacologic pain management
Advantages
• Less invasive, does not slow labor, safer for mother and baby
• Has little risk of allergy and few, if any, adverse effects
• Can fill the time gap between request for analgesia and administration
• Can help fill the gap to manage residual pain remaining after
pharmacologic pain management
• May be the only option if woman arrives at the facility in advanced, rapid
labor
Disadvantages
• Some methods require practice
• May not eliminate enough pain
• Even if well prepared, woman may still need analgesia or anesthesia
Childbirth preparation
• Knowledge and understanding reduce anxiety and fear of the unknown,
but do not eliminate all pain
• Allows rehearsal of skills; various methods are available
Positional changes
• Low back pain is increased with the woman in the supine position; sitting,
side-lying, and Sims position can help back pain during labor; see also
“Effleurage and Counterpressure” (later).
Relaxation and breathing techniques
• Providing the client with comfort measures used for women in labor, such
as aids to relaxation, helps promote effective labor
• Sequential muscle relaxation: promotes relaxation and decreases anxiety,
thereby reducing pain perception
• Promotes uterine blood flow and therefore effective contractions and
fetal oxygenation
• Reduces tension that can affect pain perception and inhibit fetal descent
• Breathing patterns should be complex and require a high level of
concentration to distract the client
• Slow, deep breathing expands the spaces between the ribs and raises
the abdominal muscles, allowing room for the uterus to expand and
preventing painful pressure of the uterus against the abdominal wall; it
is most helpful when active labor begins; it is impossible to maintain
during a second-stage labor contraction
• Pattern-paced breathing technique (pant-blow) is used during the
transition phase
• Blowing forcefully through the mouth controls the strong urge to push
and allows for a controlled birth of the head
• Panting is used to halt or delay the expulsion of the infant’s head before
complete dilation
• Avoid prolonged breath-holding during pushing to promote fetal
oxygenation
• The order of breathing patterns to be used as labor progresses is:
1. Cleansing breaths: breathing in through the nose and out
through the mouth; used at the beginning and end of each
contraction
2. Slow, deep breaths: used early in the first stage of labor to
promote relaxation of abdominal muscles; performed at about
½ the normal breathing rate
3. Modified-paced breathing: may be used when the woman can no
longer walk or talk through contractions; it requires
concentration and promotes relaxation and oxygenation;
performed at about twice the normal breathing rate; as
contractions increase in frequency and intensity, more
complex breathing techniques require enhanced
concentration and therefore block painful stimuli more
effectively
4. Patterned-paced breathing, such as pant-blow: used during the
transition phase
5. Slow, exhalation pushing: used during the second stage to
facilitate a controlled birth, minimizing maternal trauma
and/or the need for an episiotomy
Effleurage and counterpressure
• Effleurage is light stroking in rhythm with breathing during contractions
• Sacral counterpressure with a fist or solid object is especially useful if
woman is experiencing back pain; pelvic rocking is also effective for back
pressure during labor
Touch and massage
• Therapeutic touch: use of hands near body to improve energy imbalances
• Nonclinical touch is a powerful tool as well, indicating caring
• Massage: stimulates large-diameter fibers, blocking pain transmission
• Can be self-massage or provided by others
• Type of massage determines amount of pressure; method of strokes
used; whether fingertips, hands, or forearms are used
• Promotes blood flow, loosening tight muscles and connective tissue
• Reflexology: pressure applied to areas on feet, hands, or ears that
correspond to specific body organ; may have calming effect through
release of endorphins
• Contraindications
• Skin rash or disease; or over wounds, tumors, or bruises
• Some circulatory problems
• If pressure produces pain
Application of heat and cold
• Diminishes pain by stimulation of large sensory fibers (See “Gate-Control
Theory of Pain” earlier)
• Cold promotes vasoconstriction, which helps reduce edema and promote
local anesthesia
• Heat promotes vasodilation, which enhances healing; can include
blankets, compresses, and heat from a shower
• Heat and cold can be alternated
• Contraindications: ischemic areas, anesthetized areas
• Precaution: hot and cold packs need one to two layers of cloth between
them and skin to prevent skin damage
Acupressure and acupuncture
• Acupressure: finger pressure applied over meridians or acupuncture
points; less invasive than acupuncture
• Hundreds of sensitive acupoints along meridians (energy pathways) can
be used to trigger the body to release natural pain-killing compounds
• Acupuncture: insertion of disposable needles into meridians to change
energy flow; may use heat or electric stimulation; stimulation of these
points thought to influence positive-negative energy (chi)
• Can trigger the body to release natural pain-killing substances called
endorphins, which blunt the perception of pain
• Can reduce nausea and vomiting during pregnancy
• Contraindications: easy bruising or bleeding; on blood thinners; avoid
needle insertion on abdomen in pregnant women
• Infection is possible if needles are not sterile before application
• If not performed by a skilled and reputable practitioner, can cause
injury
Transcutaneous electrical nerve stimulation
• Stimulation of peripheral sensory nerve fibers blocks transmission of pain
impulse
• Small electronic unit sends pulsed currents with electrodes applied to skin
• In labor, electrodes are placed on either side of thoracic and sacral spine;
woman or nurse increases the stimulation during contractions by turning
control knob on device
• Contraindication: do not use on persons with implanted medical devices
Hydrotherapy (water therapy)
• Includes bathing, showering, whirlpool baths
• Reduces anxiety, triggers release of endorphins to lessen pain sensation
during labor; warm water allows local vasodilation and muscle relaxation
• Decreases use of pharmacologic pain relief measures
• Can be used to stimulate nipples, triggering more oxytocin production,
which stimulates labor
• Bath precautions: if woman’s temperature and FHR increase, or if labor
slows, woman can get out of bath and return later; water temperature
should be at body temperature, with the water covering the woman’s
abdomen; shoulders remain out of the water to disperse heat; be sure to
assist woman into and out of tub in case she becomes dizzy, and preserve
modesty
• Agency policy to be consulted before beginning hydrotherapy
Intradermal water block
• Injection of sterile water into the low back; can be repeated
• May work by gate-control method
Aromatherapy
• Aroma therapy: plant oils applied topically or misted (eg, ginger for
arthritis or headaches, lavender to reduce anxiety associated with pain)
have shown benefit
• Improvement derived from emotional response to pleasing scents rather
than any physiologic effects
• Can be used for inhalation (such as in bath water) or as massage oils
Music
• Enhances relaxation, cheers woman and attendants
• Woman should choose familiar music associated with pleasant memories
• Headphones can help shut out other noises
Hypnosis
• Altered state of consciousness in which concentration is focused; believed
that pain stimuli in brain are prevented from penetrating the conscious
mind; also, may cause release of natural morphinelike substances (eg,
endorphins and enkephalins)
• Helps woman become relaxed; offers positive suggestions in that state
Biofeedback
• Relaxation technique applicable to labor that allows individual to gain
control over physiologic reactions that are ordinarily subconscious;
requires intensive focused concentration as one learns to control
autonomic function
• Application of noninvasive sensors to various points on body (such as
heat sensors with audio cues) used to teach mental and physical exercises
to address the situation (such as tension or vasoconstriction) causing the
problem
• Once individual has learned pattern of actions, can assert control without
the aid of the feedback device to reduce tension, anxiety, or fatigue
• Contraindication: implanted medical device
Application and review
6. A client and her partner are working together during the woman’s labor.
The client’s cervix is now dilated 7 cm, and the presenting part is low in
the midpelvis. What should the nurse instruct the partner to do that
would alleviate the client’s discomfort during contractions?
1. Deep-breathe slowly.
2. Perform pelvic rocking.
3. Use the panting technique.
4. Begin pattern-paced breathing.
7. Which breathing technique should the nurse instruct the client to use as
the head of the fetus is crowning?
1. Shallow
2. Blowing
3. Slow chest
4. Modified paced
8. A laboring client reports low back pain. What should a nurse recommend
to the client’s coach that will promote comfort?
1. Instruct her to flex her knees.
2. Place her in the supine position.
3. Apply pressure to her back during contractions.
4. Perform neuromuscular control exercises with her.
9. What position should a nurse teach a client to avoid when the client is
experiencing back pain during labor?
1. Sims
2. Sitting
3. Supine
4. Side-lying
10. A client arrives in the birthing room with the fetal caput emerging. What
should the nurse tell the client to do during a contraction?
1. “Push hard.”
2. “Hold your breath.”
3. “Take slow, deep breaths.”
4. “Use the panting-breathing pattern.”
11. In childbirth classes, the nurse is teaching paced-breathing techniques to
use during labor. In which order should the breathing techniques be used
as labor progresses?
1. Cleansing breaths
2. Slow, deep breaths
3. Pant-blow breathing
4. Slow, exhalation pushing
5. Modified-paced breathing
12. A client with an inflamed sciatic nerve is to have a conventional
transcutaneous electrical nerve stimulation (TENS) device applied to the
painful nerve pathway. When operating the TENS unit, which nursing
action is appropriate?
1. Maintain the settings programmed by the health care provider.
2. Turn the machine on several times a day for 10 to 20 minutes.
3. Adjust the dial on the unit until the client states the pain is relieved.
4. Apply the color-coded electrodes on the client where they are most
comfortable.
13. A nurse applies an ice pack to a client’s back for 20 minutes. What clinical
indicator helps the nurse determine the effectiveness of the treatment?
1. Local anesthesia
2. Peripheral vasodilation
3. Depression of vital signs
4. Decreased viscosity of blood
See Answers on pages 161-164.
Pharmacologic pain management
Overview
• Pharmacologic management should be begun before catecholamines
prolong labor
• Any medication given to the woman is likely to affect the fetus
• Combination of nonpharmacologic with pharmacologic is optimal
• Complications may limit the choice of pain management options
• Pharmacologic measures more common in hospitals than in birthing
centers
• Medication is chosen in part by the stage of labor and the planned method
of birth
Sedatives
• Functions
• Relieve anxiety
• Depress central nervous system (CNS); produce sedation in small
dosages and sleep in larger dosages; useful for prolonged latent phase
when woman is fatigued
• Types
• Barbiturates: depress CNS starting with diencephalon (eg, secobarbital
sodium); respiratory and vasomotor depression
• Benzodiazepines(eg, lorazepam, diazepam): act on many levels of CNS;
when given with opioid analgesic, enhance pain relief
• Major side effects
• Drowsiness (depression of CNS)
• Hypotension (depression of cardiovascular system)
• Benzodiazepines hurt thermoregulation in newborns
Analgesia and anesthesia
• Definitions: analgesia is pain relief; anesthesia includes pain relief as well
as amnesia and lack of sensation
• Systemic analgesia
• Administered via intravenous (IV), intramuscular (IM), or patientcontrolled analgesia (PCA)
• Provide sedation and euphoria; pain relief is incomplete
• Avoid within 1 hour of birth because of respiratory depression of
newborn
• Maternal adverse effects: nausea, vomiting, dizziness, risk of aspiration,
depression of cardiovascular and respiratory functions
• Types:
■ Opioid analgesics (meperidine hydrochloride; fentanyl citrate)
■ No amnesic effect, but enhance rest; can cause CNS depression in
mother and infant
■ Can inhibit uterine contractions, so should not be given until labor
is established
■ Use of meperidine hydrochloride becoming more controversial
because it causes prolonged neonatal sedation, and the effects
cannot be reversed with naloxone
■ Fentanyl is faster onset, but shorter acting than meperidine, so it
has fewer neonatal side effects
■ Opioid (narcotic) agonist-antagonist analgesics (butorphanol;
nalbuphine)
■ Agonist means the drug stimulates a receptor to act; antagonist
means it blocks the receptor or blocks the medicine from activating
a receptor; opioid agonist-antagonist analgesics are agonists at
some opioid receptors and antagonists at other types of opioid
receptors; they act on these receptors to reduce pain
■ Advantages: give analgesia with little risk of respiratory depression
in mother or infant
■ Routes: IV preferred, but can also be IM or subcutaneous
■ Contraindication: not for women with opioid addiction because can
cause withdrawal symptoms
■ Opioid (narcotic) antagonists (naloxone)
■ Can reverse the effects of opioid agonists, but not of meperidine’s
metabolite, normeperidine
■ Counters stress-induced endorphins
■ Pain returns as effects of opioid agonist are undone
■ Contraindication: not for women with opioid addiction because can
cause withdrawal symptoms
■ Adjunctive medications given to prevent/relieve nausea or pruritus
caused by opioids; also promote sleep and decrease anxiety
■ Promethazine and hydroxyzine; to prevent/relieve nausea
■ Diphenhydramine; for pruritus
• Nerve block analgesia and anesthesia
• Local perineal infiltration anesthesia: before episiotomy or repair of
lacerations
■ Used in woman who does not have regional anesthesia
■ Administered via injection; can be repeated as needed
■ Adverse effects are rare; allergy to local anesthetics possible
contraindication
• Pudendal nerve block: during late second stage of labor
■ Two nerves are injected with local anesthetic 10 to 20 minutes before
anesthesia is needed
■ Used for vaginal delivery to numb the vagina and perineum; also
used for episiotomy
■ Few adverse effects because it acts locally
■ Does not relieve pain of uterine contractions
• Spinal anesthesia (block)
■ Injection of local anesthetic + opioid agonist analgesic in lower back
into subarachnoid space around spinal cord given in a single dose;
may wear off before procedure is complete; epidural route more
common; positioning involves forward flexion of the woman’s spine
to increase space between lumbar vertebrae
■ Medication mixes with cerebrospinal fluid; after injection, woman is
moved to upright position so medication affects lower spinal nerves;
for cesarean, woman is positioned supine (with pelvis tipped laterally
to prevent hypotension)
■ Used mainly for cesarean birth (lower levels used for vaginal birth,
but not appropriate for labor)
■ May cause hypotension, ineffective breathing, and postspinal
headache (triggered by upright position)
■ Woman is unable to sense contractions; must be instructed to bear
down
• Epidural anesthesia/analgesia (block)
■ Used during labor, during cesarean birth, and postcesarean when
abdomen is being closed; preferred for obese patients and
recommended for women with heart disease
■ Injection of anesthetic, opioid, or both into the epidural space around
the spinal cord; positioning similar to spinal block; early placement
can be ideal because woman is better able to cooperate
■ Maternal hypotension is a common complication of epidural
anesthesia during labor, and nausea is one of the first clues that this
has occurred; turning the client onto her side will deflect the uterus
from putting pressure on the inferior vena cava, which causes a
decrease in blood flow
■ Baseline vaginal examination and explanation of epidural anesthesia
to the woman are needed before proceeding
■ Check risk factors/contraindications before beginning epidural
anesthesia: antepartum hemorrhage, a bleeding disorder, or an
allergy to the medication
■ Possible adverse effects include hypotension and urinary retention
■ Fetal complications are rare
• Combined spinal-epidural analgesia (intrathecal)
■ Dose lower than for epidural, but risk of fetal bradycardia higher
• Nitrous oxide for analgesia
• Mixed with oxygen (50%/50%) to be inhaled; face mask used for selfadministration
• Promotes relaxation, reduces pain perception
• Adverse effects include nausea, vomiting, dizziness, drowsiness
• Advantages: ease of use, rapid onset, no adverse effects in
fetus/newborn
• General anesthesia
• Rarely used in uncomplicated vaginal births; sometimes used for
cesarean sections
• Used for emergency procedures; preceded by 100% oxygen to avoid
hypoxemia
• Goal is loss of consciousness, pain relief, and reduced maternal recall
• Many adverse effects possible, including respiratory depression in
newborn, aspiration of gastric contents in woman
• Respiratory and cardiovascular function are priorities
Care management
Assessment/analysis
• Part of the interview process is to determine what the woman is
anticipating in terms of analgesia; helping her clarify her choices is part of
patient education
• Assess for allergies
• Provide patient education to allow informed consent
Nursing care during nonpharmacologic
interventions
• Provide support and assistance with nonpharmacologic interventions;
promote relaxation; reduce sources of discomfort; reduce anxiety and fear
• Evaluate pain management
• Vital signs and FHR measurement
Nursing care of clients receiving
analgesic/anesthetic agents
• Vital signs and FHR measurement
• Provide feedback about labor progress
• Administer ordered medications
• Explain and prepare for procedures; monitor for side effects
• Keep naloxone available to counteract respiratory depression if it occurs
• Observe client and newborn for respiratory depression; monitor mother
for hypotension
• Epidural: monitor client for hypotension; if hypotension occurs,
position on left side, increase IV infusion, administer oxygen, assess
FHR
• Pudendal: explain that it eliminates discomfort during an episiotomy
and its repair; assess for vaginal wall or perineal hematoma
• Spinal: monitor for headache that increases with head elevation; usually
in first 24 to 72 hours; keep client supine
• General anesthesia: assessment and documentation of oral intake and
medication administration; monitor respiratory status
Application and review
14. A nurse has just finished reviewing how anesthesia will be used during a
vaginal birth for a client with class I heart disease. What type of anesthesia
does the client discuss that indicates to the nurse that the teaching was
effective?
1. Spinal
2. Inhalation
3. Epidural regional
4. Local perineal filtration
15. A nurse is caring for an adolescent in labor an hour after she was
admitted to the birthing unit. The adolescent is anxious and tense. She
cries during contractions and asks the nurse for epidural anesthesia. The
nurse obtains the adolescent’s current vital signs and reviews her history
and admission information. What nursing interventions are essential
before epidural anesthesia is administered? Select all that apply.
1. Perform a baseline vaginal examination.
2. Tell the adolescent what to expect with each procedure.
3. Identify risk factors that contraindicate epidural anesthesia.
4. Have the parents sign a consent form for the epidural anesthesia.
5. Explain the need to stay in one position while the epidural catheter
is in place.
16. A nurse is caring for an obese client in early labor. The anesthesiologist
discussed several types of analgesia/anesthesia with the client and
recommended one. The client requests clarification before signing the
consent form. Which type did the anesthesiologist recommend?
1. Epidural anesthesia
2. Oral opioid analgesia
3. Pudendal nerve anesthesia
4. IV infusion of opioid analgesia
17. During labor a client who has been receiving epidural anesthesia has a
sudden episode of severe nausea, and her skin becomes pale and clammy.
What is the nurse’s immediate reaction?
1. Turn the client on her side.
2. Notify the health care provider.
3. Check the vaginal area for bleeding.
4. Monitor the fetal heart rate every 3 minutes.
18. A nurse is caring for a primigravida during labor. At 7 cm dilation a
prescribed pain medication is administered. Which medication requires
monitoring of the newborn for the side effect of respiratory depression?
1. Meperidine hydrochloride
2. Hydroxyzine
3. Promethazine
4. Diphenhydramine
19. A client in active labor becomes very uncomfortable and asks a nurse for
pain medication. Nalbuphine is prescribed. How does this medication
relieve pain?
1. Produces amnesia
2. Acts as a preliminary anesthetic
3. Induces sleep until the time of birth
4. Acts on opioid receptors to reduce pain
20. A pregnant client is now in the third trimester. The client tells the nurse,
“I want to be knocked out for the birth.” How should the nurse respond?
1. “You are worried about too much pain.”
2. “You don’t want to be awake during the birth.”
3. “I can understand that because labor is uncomfortable.”
4. “I will tell your health care provider about this request.”
See Answers on pages 161-164.
Answer key: Review questions
1. 2 Fatigue will influence other coping strategies, such as distraction.
1 The progesterone level is decreased before labor. 3 The client does not
push during the first stage of labor; pushing is done during the second
stage. 4 Fatigue may decrease the quality of the contractions.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
2. 4 Interpretation of pain sensations is highly individual and is based on
past experiences, which include cultural values.
1 Age and sex affect pain perception only indirectly because they
generally account for past experience to some degree. 2 Overall physical
condition may affect the ability to cope with stress; however, unless the
nervous system is involved, it will not greatly affect perception. 3
Intelligence is a factor in understanding pain so it can be better
tolerated, but it does not affect the perception of intensity; economic
status has no effect on pain perception.
Clinical Area: Comprehensive Examination; Client Needs: Basic Care and
Comfort; Cognitive Level: Application; Nursing Process:
Assessment/Analysis
3. 3 The client is experiencing the expected discomforts of labor; the nurse
should initiate measures that will promote relaxation.
1 The client is in early first-stage labor; pushing commences during the
second stage. 2 Pattern-paced breathing technique should be used in
the transition phase, not the early phase of the first stage of labor. 4
There is no evidence that the client’s bleeding is excessive.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation
4. 2 The transition phase is the most difficult part of labor, and the client
needs encouragement and support to cope.
1 IV fluids may need to be increased because of the increase in
metabolism. 3 Medication at this time will depress the newborn and is
contraindicated. 4 Breathing patterns should be complex and require a
high level of concentration to distract the client.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation
5. 2 This statement, “I’ll rub your back, and you tell me if it helps,” offers
comfort measures while giving the client an opportunity to verbalize her
concerns further if she desires.
1 Stating “I’ll leave so you can talk to you partner” cuts off
communication with the client. 3 The client’s focus is on her prolonged
discomfort; there is no indication that she has other concerns at this
time. 4 The nurse should focus on the client, not on how other women
may feel; this may cut off communication.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring, Communication/Documentation; Nursing
Process: Planning/Implementation
6. 1 Slow, deep breathing expands the spaces between the ribs and raises the
abdominal muscles, allowing room for the uterus to expand and
preventing painful pressure of the uterus against the abdominal wall.
2 Pelvic rocking is used to relieve pressure from back labor. 3 Panting is
used to halt or delay the expulsion of the infant’s head before complete
dilation. 4 Pattern-paced breathing technique is used during the
transition phase of the first stage; the client has not yet reached this
phase.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
7. 2 Blowing forcefully through the mouth controls the strong urge to push
and allows for a controlled birth of the head.
1 Shallow breathing does not help control expulsion of the fetus. 3 Slow
chest breathing is used during the latent phase of the first stage of
labor; it is not helpful in overcoming the urge to push. 4 Modifiedpaced breathing pattern is used during active labor when the cervix is 3
to 7 cm dilated; it is not helpful in overcoming the urge to push.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
8. 3 The application of back pressure combined with frequent positional
changes will help alleviate the discomfort.
1 Although flexing her knees may be comfortable for some individuals,
rubbing the back and alternating positions usually are more effective. 2
The supine position places increased pressure on the back and often
aggravates the pain. 4 Neuromuscular control exercises are used to
teach selective relaxation in childbirth classes; they will not relieve back
pain during labor.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Teaching/Learning; Nursing
Process: Planning/Implementation
9. 3 Low back pain is aggravated when the mother is in the supine position
because of increased pressure from the fetus.
1 Sims position is one position that helps relieve back pain. 2 Sitting is
one position that helps relieve back pain. 4 Side-lying is one position
that helps relieve back pain.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
10. 4 Panting will slow the birthing process so the nurse can support the head
as it emerges.
1 Pushing will speed up the birth, which may injure the mother and fetus.
2 Usually, holding the breath causes involuntary pushing; it also
depletes the mother and fetus of oxygen. 3 Slow deep breathing is
helpful when active labor begins; it is impossible to maintain during a
second-stage labor contraction.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
11. Answers: 1, 2, 5, 3, 4
1 Cleansing breaths, breathing in through the nose and out through the
mouth, are used at the beginning and end of each contraction. 2 Slow,
deep breaths are used early in the first stage of labor to promote
relaxation of abdominal muscles. 5 Modified-paced breathing may be
used when the woman can no longer walk or talk through contractions;
it requires concentration and promotes relaxation and oxygenation. As
contractions increase in frequency and intensity, more complex
breathing techniques require enhanced concentration and therefore
block painful stimuli more effectively. 3 Patterned-paced breathing,
such as pant-blow, is used during the transition phase of the first stage
of labor. 4 Slow, exhalation pushing is used during the second stage to
facilitate a controlled birth, minimizing maternal trauma and/or the
need for an episiotomy.
Clinical Area: Comprehensive Examination; Client Needs: Health
Promotion and Maintenance; Cognitive Level: Analysis; Nursing
Process: Planning/Implementation; Integrated Process:
Teaching/Learning
12. 3 The voltage or current is adjusted on the basis of the degree of pain
relief experienced by the client.
1 The settings programmed by the health care provider may provide too
little or too much stimulation to achieve the desired response. 2 Turn a
pain suppressor transcutaneous electrical nerve stimulation (TENS)
unit on several times a day for 10 to 20 minutes, not a conventional unit.
4 The electrodes should be applied either on the painful area or
immediately near the area.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Nursing Process: Planning/Implementation
13. 1 Cold reduces the sensitivity of pain receptors in the skin. In addition,
local blood vessels constrict, limiting the amount of edema and its related
pressure and discomfort.
2 Local blood vessels constrict. 3 Local cold applications do not depress
vital signs. 4 Local cold applications do not directly affect blood
viscosity. This is not a clinical indicator that a nurse can observe.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
14. 3 Epidural regional anesthesia provides the safest method of pain relief
for clients with heart disease. If they expend more energy than their heart
can tolerate, especially during second-stage labor, cardiac decompensation
may occur.
1 Unless an emergency cesarean birth is needed, spinal anesthesia is
unnecessary for clients with class I heart disease who are not
experiencing problems. 2 Inhalation anesthesia is not indicated for a
vaginal birth for a client with class I heart disease; it may cause
respiratory difficulty. 4 Local perineal anesthesia is used when an
episiotomy is to be performed and the client has not had anesthesia
during labor.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Pharmacologic and Parenteral Therapies; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes; Integrated Process:
Teaching/Learning
15. Answers: 1, 2, 3
1 A baseline vaginal examination is needed to determine the extent of
cervical dilation and effacement. 2 Before any procedure is
implemented, the nurse should explain the procedure and answer any
questions. 3 Risk factors that contraindicate an epidural include
antepartum hemorrhage, a bleeding disorder, and an allergy to the
medication. None of these are indicated in the client’s history.
4 Although a signed informed consent is legally required for epidural
anesthesia, an invasive procedure, the adolescent, not the parents,
should sign the consent. A pregnant woman is considered an
emancipated minor and is legally empowered to sign the consent. 5 The
client should change position from side to side every hour to promote
distribution of the anesthetic and to maintain circulation to the uterus
and placenta.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Pharmacologic and Parenteral Therapies; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation
16. 1 Epidural anesthesia during the first stage of labor decreases metabolic
and respiratory demands and is preferred for obese clients.
2 Obese women are sensitive to systemic opioids, which predispose them
to respiratory depression; oral medications do not have a uniform rate
of absorption and are not recommended during labor. 3 A pudendal
block does not reach the uterus, so contractions are felt; it is used
during the second stage of labor. 4 Obese women are sensitive to
systemic opioids, which predispose them to respiratory depression; oral
medications do not have a uniform rate of absorption and are not
recommended during labor.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
17. 1 Maternal hypotension is a common complication of this anesthesia
during labor, and nausea is one of the first clues that this has occurred.
Turning the client onto her side will deflect the uterus from putting
pressure on the inferior vena cava, which causes a decrease in blood flow.
2 If signs and symptoms do not abate after turning on the side, the health
care provider should be notified. 3 Checking the vaginal area for
bleeding is not a specific observation after epidural anesthesia; it is part
of the general nursing care during labor. 4 If the FHR is being
monitored, it is a constant process and should be recorded every 15
minutes; if not, the FHR should be checked and recorded every 15
minutes.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Planning/Implementation
18. 1 Respiratory depression may occur in the newborn because the half-life
of meperidine hydrochloride is long, and circulating blood levels will be
high if birth occurs within 1 to 4 hours after administration.
2 Hydroxyzine is an antihistamine that has a sedative effect and is
administered early in labor to promote sleep and decrease anxiety. 3
Promethazine is an antihistamine that has a sedative effect and is
administered early in labor to promote sleep and decrease anxiety. 4
Diphenhydramine is an antihistamine that has a sedative effect and is
administered early in labor to promote sleep and decrease anxiety.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Analysis; Nursing Process: Evaluation/Outcomes
19. 4 Nalbuphine is classified as an opioid agonist-antagonist analgesic and
is effective for the relief of pain; there is little or no newborn respiratory
depression.
1 Nalbuphine does not induce amnesia. 2 Nalbuphine acts as an
analgesic, not an anesthetic. 3 Nalbuphine does not induce sleep.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Comprehension; Nursing Process: Planning/Implementation
20. 2 Paraphrasing encourages the client to express the rationale for this
request.
1 “You are worried about too much pain” is making an assumption
without enough information. 3 “I can understand that because labor is
uncomfortable” may increase the client’s anxiety. 4 Although the
client’s request for anesthesia should be forwarded to the health care
provider, the reason for the choice of general anesthesia should be
explored.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing Process:
Assessment/Analysis
C H AP T E R 1 0
Fetal assessment during labor
Basis for monitoring
Fetal response
• Blood supply to fetus prevents fetal hypoxia
• Factors that can interrupt the fetal oxygen supply
• Reduced blood flow in maternal vessels, including that caused by
hypertonic uterine activity
• Decreased oxygen in maternal blood
• Problems in fetal circulation, such as cord compression
• Disruption of placental blood flow
• How the fetal heart rate (FHR) responds to uterine contractions reveals
fetal well-being
Uterine activity
• Normal activity is described by frequency, duration, and strength of
contractions, plus resting tone and time, as well as contraction intensity.
Fetal compromise
• FHR monitoring establishes normal (aka “reassuring”) patterns versus
abnormal (aka “nonreassuring”) patterns
• Abnormal patterns are associated with fetal hypoxemia, which can result
in fetal hypoxia; if unchecked, hypoxia can lead to metabolic acidosis and
fetal asphyxia
Goals
• Detect fetal hypoxemia; prevent fetal acidosis
• Determining fetal well-being takes priority over all other measures. If the
FHR is absent or persistently decelerating, immediate intervention is
required.
Monitoring techniques
Intermittent auscultation
• Uses fetoscope, Doppler transducer, or ultrasound stethoscope to listen to
fetal heart sounds and assess FHR
• Easy to use, inexpensive, less invasive than electronic fetal monitoring
• Allows mother greater freedom of movement
• May be difficult in obese women
• FHR outside normal limits or slowed FHR after contraction ends is
reported promptly to the health care provider
Electronic fetal monitoring
• External
• Identify area of maximum intensity of fetal heart tones (Fig. 10.1; see
Chapter 11 for Leopold maneuvers to identify fetal position)
• Ensure monitor is working correctly; attach transducers
■ One transducer is placed over the area of maximum intensity of the
FHR to monitor it
■ Tocotransducer is placed over the fundus to measure uterine activity
• Encourage to limit movement to prevent interference with accurate
tracings
• Monitor during a contraction for rate, rhythm, increases, and decreases
and for 30 seconds after end of each contraction to identify increases or
decreases in fetal response to contractions
• Interpret electronic fetal/maternal monitoring results (see later)
■ Printout shows FHR and uterine activity simultaneous tracings
• Internal
• Uses spiral electrode (inserted clockwise and removed
counterclockwise) on the fetal presenting part and intrauterine
pressure catheter to assess uterine activity
• More accurate than electronic fetal monitoring because not interrupted
by movement
• Membranes must be ruptured to use internal monitoring
• Woman can assume position that is most comfortable because position
does not affect monitor, although side-lying is recommended to
promote maternal-fetal circulation
FIG. 10.1 Areas of maximum intensity of fetal heart tones [FHTs] for different fetal
positions. A, Presentation is usually breech if FHTs are heard above the umbilicus.
B, Presentation is usually vertex if FHTs are heard below the umbilicus. RSA, Right
sacrum anterior; ROP, right occipitoposterior; RMA, right mentum anterior; ROA,
right occipitoanterior; LSA, left sacrum anterior; LOP, left occipitoposterior; LMA, left
mentum anterior; LOA, left occipitoanterior. Source: (From Lowdermilk, D.L., Perry, S.E.,
Cashion, K., Alden, K.R. [2016]. Maternity and women’s health care [11th ed.]. St Louis: Elsevier.)
Application and review
1. A client is admitted to the birthing suite in early active labor. Which
nursing action takes priority during the admission process?
1. Auscultating the fetal heart
2. Obtaining an obstetric history
3. Determining when the last meal was eaten
4. Ascertaining whether the membranes have ruptured
2. A 36-year-old primigravida, accompanied by her husband, is admitted to
the birthing unit at 39 weeks’ gestation. External fetal monitoring is
instituted. What should the nurse consider when a fetus is being
monitored?
1. The machinery may be frightening to a laboring couple.
2. Internal monitoring will be used in the latter part of labor.
3. The mother will be given mild sedatives as labor progresses.
4. Older primigravidas are more concerned about labor than younger
women.
3. An internal fetal monitor is applied while a client is in labor. What should
the nurse explain about positioning while the monitor is in place?
1. The most comfortable position can be assumed.
2. Monitoring is more accurate in the side-lying position.
3. The monitor leads can be detached when sitting on the bedpan.
4. Maintaining a supine position holds the internal electrode in place.
4. After performing Leopold maneuvers on a laboring client, a nurse
determines that the fetus is in the right occiput posterior (ROP) position.
Where should the Doppler be placed to best auscultate fetal heart tones?
1. Above the umbilicus in the midline
2. Above the umbilicus on the left side
3. Below the umbilicus on the right side
4. Below the umbilicus near the left groin
5. What is a common problem that confronts the client in labor when an
external fetal monitor has been applied to her abdomen?
1. Intrusion on movement
2. Inability to take sedatives
3. Interference with breathing techniques
4. Increased frequency of vaginal examinations
See Answers on pages 173-175.
Fetal heart rate patterns
Baseline fetal heart rate
• Average rate during a 10-minute segment, excluding periodic or episodic
changes, periods of marked variability, and segments of baseline that
differ by more than 25 beats/min
• Expected range at term is 110 to 160 beats/min
• Variability
• Irregular fluctuations in baseline FHR of two or more cycles per minute
• Temporary decrease in variability when fetus is in a sleep state; sleep
states usually do not last longer than 30 minutes
• Ranges of variability based on visualization of amplitude of FHR in
peak-to-trough segment in beats/min
■ Absent or undetected variability (nonreassuring fetal sign)
■ Minimal variability (greater than undetected but not more than 5
beats/min)
■ Moderate variability (6–25 beats/min)
■ Marked variability (greater than 25 beats/min)
• Diminished variability: may result from fetal hypoxemia, acidosis, drugs
that depress the central nervous system (CNS; eg, opioids, barbiturates,
tranquilizers, general anesthetics)
• Interventions for diminished variability: monitor for other
nonreassuring FHR patterns; administer oxygen by face mask; provide
external or scalp stimulation; assist with placement of internal fetal
monitor; prepare for birth
• Interventions for increased variability (marked variability): monitor for
other nonreassuring FHR patterns
• Tachycardia
• Baseline FHR more than 160 beats/min for 10 minutes or longer; may be
early sign of fetal hypoxemia, especially when associated with late
decelerations and minimal or absent variability
• Can result from maternal or fetal infection, maternal hyperthyroidism,
fetal anemia, or in response to drugs (eg, atropine, hydroxyzine,
terbutaline), or illicit drugs (eg, methamphetamines, cocaine)
• Interventions: decrease maternal fever; administer oxygen by face mask
• Bradycardia
• Baseline FHR less than 110 beats/min for 10 minutes or longer; may be
later sign of fetal hypoxia
• Can result from placental transfer of drugs (eg, anesthetics), prolonged
compression of umbilical cord, maternal hypothermia or hypotension
• Interventions: observe for prolapsed cord, reposition on side,
administer oxygen by face mask, stimulate fetal scalp
Periodic and episodic changes in fetal heart rate
• Accelerations
• Abrupt increase in FHR above baseline to 15 beats/min or more lasting
15 or more seconds, with return to baseline less than 2 minutes from
beginning of the acceleration
• Occurrence during fetal movements indicates fetal well-being
• Decelerations
• Types classified by their relation to onset, duration, shape, and end of a
contraction; can be benign or nonreassuring
• Early decelerations (Fig. 10.2)
■ Decrease in FHR that begins before peak of a contraction with lowest
point occurring at peak of contraction; FHR returns to baseline when
uterine contraction ends
■ Common in first stage of labor when cervix is dilated 4 to 7 cm;
occasionally in second stage with pushing
■ Response to head compression: benign
■ Intervention: not necessary
• Late decelerations (Fig. 10.3)
■ Decrease in FHR that begins after contraction has started, with lowest
point of deceleration occurring after peak of contraction; FHR returns
to baseline after contraction ends
■ May occur at any time during labor
■ Indicates fetal hypoxemia due to uteroplacental insufficiency; may be
benign (eg, maternal supine hypotension syndrome) or caused by
preexisting maternal disorders, complications of pregnancy; ominous
if persistent, repetitive, and accompanied by decreased variability
and tachycardia
■ Interventions: identify cause (eg, palpate uterus to assess for
hyperstimulation, discontinue oxytocin if infusing), correct maternal
hypotension (eg, elevate legs, turn on side), increase IV flow rate,
administer oxygen via face mask, perform fetal scalp/acoustic
stimulation, assist with placement of internal fetal monitor, prepare
for and assist with birth
• Variable
■ Abrupt onset to lowest point in less than 30 seconds; decrease in FHR
below baseline
■ Decrease of 15 beats/min or more lasting at least 15 seconds; returns
to baseline less than 2 minutes from onset; rapid descent and ascent;
may have brief acceleration before and/or after deceleration
(“shoulders”)
■ Occur any time during uterine contraction phase
■ Related to umbilical cord compression, decreased amount of amniotic
fluid
■ Interventions during first stage: change maternal position (eg, side to
side, knee-chest); administer oxygen via face mask; discontinue
oxytocin if infusing; administer amnioinfusion with warmed saline if
oligohydramnios is present
■ Interventions during second stage: discourage pushing with
contractions to allow fetal recovery; assist with vaginal or cesarean
birth if decelerations are due to prolonged cord compression (eg,
tight nuchal cord, short cord, knot in cord, prolapsed cord)
• Prolonged
■ Visually evident decrease in FHR of at least 15 beats/minute below
the baseline, lasting longer than 2 minutes (but less than 10 minutes)
■ If the decrease lasts longer than 10 minutes, it is a change in the
baseline
■ Causes: prolonged cord compression or prolapsed, placental
insufficiency, uterine tachysystole or rupture, maternal hypotension,
regional anesthesia
FIG. 10.2 Early decelerations. Source: (From Tucker, S.M., Miller, L.A., Miller, D.A. (2009).
Mosby’s pocket guide to fetal monitoring, (6th ed.). St. Louis: Mosby.)
FIG. 10.3 Late decelerations. Source: (From Tucker, S.M., Miller, L.A., Miller, D.A. [2009].
Mosby’s pocket guide to fetal monitoring, [6th ed.]. St. Louis: Mosby.)
Categorization of patterns*
• Category I = normal
• Category I FHR tracings include all of the following:
■ Baseline rate 110 to 160 beats/min
■ Baseline FHR variability: moderate
■ Late or variable decelerations: absent
■ Early decelerations: either present or absent
■ Accelerations: either present or absent
• Category II = variable
• Category II FHR tracings include all FHR tracings not categorized as
category I or category III. Examples of category II tracings include any
of the following:
• Baseline rate
■ Bradycardia not accompanied by absent baseline variability
■ Tachycardia
• Baseline FHR variability
■ Minimal baseline variability
■ Absent baseline variability not accompanied by recurrent
decelerations
■ Marked baseline variability
• Accelerations
■ No acceleration produced in response to fetal stimulation
• Periodic or episodic decelerations
■ Recurrent variable decelerations accompanied by minimal or
moderate baseline variability
■ Prolonged decelerations (≥2 minutes but <10 minutes)
■ Recurrent late decelerations with moderate baseline variability
■ Variable decelerations with other characteristics, such as slow return
to baseline, “overshoots” or “shoulders”
• Category III = abnormal
• Category III FHR tracings include either
■ Absent baseline variability and any of the following:
■ Recurrent late decelerations
■ Recurrent variable decelerations
■ Bradycardia
■ Sinusoidal pattern
Other methods of assessment and interventions
Assessment techniques
• FHR acceleration of 15 beats/min for 15 or more seconds is reassuring for
both fetal scalp and vibroacoustic stimulation
• Lack of acceleration does not mean fetal compromise for certain; other
evaluation is indicated
• Do not perform either method if FHR decelerations or bradycardia is
present
• Both are performed when FHR is at baseline
• Fetal scalp and vibroacoustic stimulation
• Digital/tactile stimulation = application of pressure to fetal head,
moving fingers in a circular motion, during vaginal examination
■ Reactive if FHR accelerates; indicates fetal well-being; but an absent
response does not necessarily mean fetal compromise
■ Contraindications:
■ Preterm fetus
■ Prolonged rupture of membranes
■ Chorioamnionitis or maternal fever of unknown origin
■ Placenta previa
• Vibroacoustic (acoustic) stimulation
■ An artificial larynx (vibroacoustic stimulator) is placed on the
woman’s lower abdomen, turned on for up to 3 seconds
■ FHR acceleration of 15 beats/min for 15 or more seconds is
reassuring, but an absent response does not necessarily mean fetal
compromise
• Fetal scalp blood sampling
• Capillary blood taken from fetal scalp in utero tested for pH; done
during labor when fetal heart patterns are nonreassuring
■ Normal scalp pH is 7.25 to 7.35
■ If acidotic, immediate birth is indicated
• Nursing care: cleanse vaginal area to avoid contamination during test
• Seldom used in United States currently
• Umbilical cord blood acid–base determination
• Used to assess immediate condition of newborn
• Samples of cord blood from the umbilical artery and vein are tested for
pH, CO2 pressure, O2 pressure, and base deficit or excess.
• Umbilical artery values show fetal condition; umbilical vein values show
placental function
Interventions
• Amnioinfusion
• Infusion of room-temperature isotonic fluid into the uterus if amniotic
fluid is low
• Cushions fetus and cord; used to relieve cord compression
• Risk of overdistention
• Contractions should be monitored continually during infusion
• Tocolysis
• Relaxation of the uterus by inhibition of uterine contractions
• A medical therapy used when fetal stress is not resolved with other
methods
■ Terbutaline is most common tocolytic drug
• Also used when decision for cesarean birth is made
Client and family teaching
• Equipment can be source of anxiety to some parents
• Nurse responds to needs, whether emotional or informational
• Nurse assists with positioning and pushing; these can affect fetal status;
nurse asks woman to avoid supine position, encourages side-lying or
semi-Fowler position with lateral tilt to uterus
• Nurse instructs woman to keep mouth and throat open during pushing
Documentation
• Every FHR and uterine activity assessment must be completely
documented in the medical record
• Electronic monitoring allows tracing to be stored in the record
• Handwritten notes may be made on paper monitor strips
• Vital that the times and event notations on handwritten and electronic
record correspond
Application and review
6. A client in active labor has an external fetal monitor in place. Using the
monitor strip below, identify the correct assessment.
1. Tetanic contractions
2. Marked FHR variability
3. FHR baseline at 150 beats/min
4. Contractions lasting 130 seconds
7. A client’s membranes rupture while her labor is being augmented with an
oxytocin infusion. A nurse observes variable decelerations in the fetal
heart rate on the fetal monitor strip. What action should the nurse take
next?
1. Change the client’s position.
2. Take the client’s blood pressure.
3. Stop the client’s oxytocin infusion.
4. Prepare the client for an immediate birth.
8. When monitoring the FHR of a client in labor, the nurse identifies an
elevation of 15 beats more than the baseline rate of 135 beats/min lasting
for 15 seconds. How should the nurse document this event?
1. An acceleration
2. An early elevation
3. A sonographic motion
4. A tachycardic heart rate
9. A client in labor begins to experience contractions 2 to 3 minutes apart that
last about 45 seconds. Between contractions the nurse identifies a fetal
heart rate of 100 beats/min on the internal fetal monitor. What is the next
nursing action?
1. Notify the health care provider.
2. Resume continuous fetal heart monitoring.
3. Continue to monitor the maternal vital signs.
4. Document the fetal heart rate as an expected response to
contractions.
10. An external monitor is placed on the abdomen of a client admitted in
active labor. The nurse identifies that during each contraction, the fetal
heart rate decelerates as the contraction peaks. What should the nurse do
next?
1. Help the client to a knee-chest position to avoid cord compression.
2. Notify the health care provider because of possible head
compression.
3. Monitor the fetal heart rate until it returns to baseline when the
contraction ends.
4. Place the client in a semi-Fowler position to prevent compression of
the vena cava.
11. During labor, a nurse identifies that there is an early fetal heart rate
deceleration. How many fetal heartbeats per minute were there early in
the contraction that indicated to the nurse that the deceleration occurred?
1. 80 to 100
2. 100 to 120
3. 120 to 140
4. 140 to 160
12. During labor, a client has an internal fetal monitor applied. What fetal
heart rate should most concern the nurse?
1. Does not drop during contractions
2. Varies from 130 to 140 beats per minute
3. Drops to 110 beats per minute during a contraction
4. Returns to baseline heart rate after a contraction ends
13. At 38 weeks’ gestation, a client is admitted to the birthing unit in active
labor, and an external fetal monitor is applied. Late fetal heart rate
decelerations begin to appear when her cervix is dilated 6 cm, with
contractions occurring every 4 minutes and lasting 45 seconds. What does
the nurse conclude is the cause of these late decelerations?
1. Imminent vaginal birth
2. Uteroplacental insufficiency
3. Pattern of nonprogressive labor
4. Reassuring response to contractions
14. A nurse is observing a reading on the external fetal monitor of a client in
active labor. Which fetal heart pattern indicates cord compression?
1. Smooth, flat baseline tracings of 135 beats per minute
2. Abrupt decreases in fetal heart rate that are unrelated to the
contractions
3. Accelerations in the fetal heart rate of 10 beats per minute above
baseline
4. Decelerations when a contraction begins that return to baseline
when the contraction ends
See Answers on pages 173-175.
Answer key: Review questions
1. 1 Determining fetal well-being takes priority over all other measures. If
the FHR is absent or persistently decelerating, immediate intervention is
required.
2 Although obtaining an obstetric history is important, the determination
of fetal well-being is the priority. 3 Although determining when the last
meal was eaten is important, the determination of fetal well-being is
the priority. 4 Although ascertaining whether the membranes have
ruptured is important, the determination of fetal well-being is the
priority.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
2. 1 Nurses can become nonchalant about the equipment used during labor
and forget that it may be frightening for the layperson.
2 Internal monitoring is used if adequate readouts cannot be obtained on
an external monitor. 3 Sedation is never given on a routine basis to a
client in labor. 4 Feelings about labor are individual; many factors must
be considered, including childbirth education, the client’s personality,
health, support system, and so on.
Clinical Area: Comprehensive Examination; Client Needs: Reduction of
Risk Control; Cognitive Level: Application; Nursing Process:
Assessment/Analysis; Integrated Process: Caring
3. 1 Because electrodes are placed internally (on the fetal scalp, not on the
mother’s abdomen), position does not affect the monitor. The side-lying
position is recommended because it promotes maternal–fetal circulation,
but it is not essential for accurate internal fetal monitoring.
2 It is not the position but the internal placement of electrodes on the
fetal scalp that ensures accurate monitoring. 3 Constant monitoring
provides continuous ongoing assessment of fetal status; there is no
reason to detach the leads. 4 Although the supine position does not
affect the monitor, it should be discouraged because the gravid uterus
causes decreased venous return, leading to reduced cardiac output.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Analysis; Nursing Process:
Assessment/Analysis
4. 3 Fetal heart tones are best auscultated through the fetal back; because the
presenting part is in the right occiput posterior (ROP) position, the back is
below the umbilicus and on the right side.
1 Above the umbilicus in the midline should be used when the fetus is
lying in the midline in a breech position. 2 Above the umbilicus on the
left side is appropriate when the fetus is in the left sacrum anterior
(LSA) position. 4 Below the umbilicus near the left groin is appropriate
when the fetus is in the left occiput anterior (LOA) or left occiput
posterior (LOP) position.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
5. 1 Because the client is attached to a machine and movement may alter the
tracings, movement is discouraged.
2 Placement of the external monitor leads does not interfere with the
administration of sedatives. 3 An external monitor does not interfere
with breathing techniques. 4 An external monitor does not necessitate
more frequent vaginal examinations.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
6. 3 Electronic fetal monitoring provides a continuous graphic printout of
rate patterns and periodic changes; on this FHR strip the baseline heart
rate is 150 beats/min.
1 Contractions are not sustained; there is uterine relaxation between
contractions. 2 FHR variability is minimal, not marked. 4 Contractions
are lasting 100 seconds.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
7. 1 Variable decelerations usually are seen as a result of cord compression; a
change of position will relieve the pressure on the cord.
2 Variable decelerations are not related to the mother’s blood pressure. 3
Variable decelerations are not oxytocin related. 4 To prepare the client
for an immediate birth is premature; other nursing measures should be
tried first.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
8. 1 An acceleration is an abrupt elevation above the baseline of 15 beats/min
for 15 seconds; if the acceleration persists for more than 10 minutes, it is
considered a change in baseline rate.
2 Early decelerations, not elevations, occur. An early deceleration starts
before the peak of the uterine contraction and returns to the baseline
when the uterine contraction ends. 3 A sonographic motion is not a
fetal monitoring descriptive term. 4 A tachycardic FHR is above 160
beats/min.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Integrated Process: Communication/Documentation; Nursing Process:
Assessment/Analysis
9. 1 Bradycardia (baseline FHR below 110 beats/min) indicates the fetus may
be compromised, requiring medical intervention.
2 To resume continuous fetal heart monitoring may be dangerous; the
fetus may be compromised, and time should not be spent on
monitoring. 3 Continuing to monitor the maternal vital signs is not the
priority at this time. 4 The expected FHR is 110 to 160 beats/min
between contractions.
Client Need: Management of Care; Cognitive Level: Application; Nursing
Process: Planning/Implementation
10. 3 The fetal heart rate (FHR) is expected to decelerate when the head is
compressed during a contraction. If the FHR returns to baseline at the end
of the contraction, fetal well-being is indicated.
1 Cord compression during a contraction is a common occurrence; no
intervention is necessary if the FHR returns to baseline at the end of the
contraction. 2 No intervention is necessary if the FHR returns to
baseline at the end of the contraction. 4 A semi-Fowler position will
increase pressure on the vena cava.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Analysis; Nursing Process:
Assessment/Analysis
11. 2. Early fetal heart rate (FHR) decelerations, with onset before the peak
of the contraction and low point at the peak of the contraction, are due to
fetal head compression; the FHR rarely drops to below 100 beats/min.
1 FHR of 80 to 100 is marked bradycardia. 3 FHR of 120 to 140 is not a
deceleration; it is within expected limits. 4 FHR of 140 to 160 is not a
deceleration; it is within expected limits.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Analysis; Nursing Process:
Assessment/Analysis
12. 4 When the FHR returns to baseline heart rate after a contraction ends,
that is a late deceleration; it begins after the contraction has started, the
lowest point of the deceleration occurs after the peak of the contraction,
and the deceleration usually does not return to baseline until after the
contraction ends (late recovery). Late decelerations are caused by
uteroplacental insufficiency and are a sign of a compromised fetus.
1 The FHR does not always drop with a contraction in all labors. 2 Beat-tobeat variability indicates a fetus with a healthy nervous system; it does
not warrant concern. 3 When the FHR drops to 110 beats/min during a
contraction, that is an early deceleration that results from fetal head
compression during a contraction; the FHR returns to baseline at the
same time the contraction ends.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Analysis; Nursing Process:
Assessment/Analysis
13. 2 Late decelerations are indicative of uteroplacental insufficiency and, if
left uncorrected, lead to fetal hypoxia and/or fetal myocardial depression.
1 Imminent birth cannot be determined from fetal heart rate
decelerations, only from cervical dilation. Birth occurs after the cervix
has dilated to 10 cm and the fetus has passed through the birth canal. 3
Nonprogressive labor cannot be determined from fetal heart rate
decelerations, only from cervical dilation. 4 Late decelerations are not
expected, are not reassuring, and must not be ignored.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Assessment/Analysis
14. 2 This describes variable decelerations that indicate cord compression.
They are most common during the second stage of labor; this is
considered benign unless the heart rate does not recover adequately.
1 Flat baseline readings indicate decreased variability and may have many
causes, but are not related to cord compression. 3 Fetal heart rate
accelerations are not related to cord compression. 4 Decelerations when
a contraction begins that return to baseline when the contraction ends
describe decelerations that indicate head compression during
contractions; it is an expected, benign finding.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Analysis; Nursing Process:
Assessment/Analysis
*
From Macones, G., Hankins, G., Spong, C., Hauth, J., & Moore, T. (2008). The 2008 National Institute of
Child Health and Human Development workshop report on electronic fetal monitoring: Update on
definitions, interpretation, and research guidelines. Journal of Obstetric, Gynecologic and Neonatal Nursing,
37(5), 510-515.
C H AP T E R 11
Nursing care of the family during
labor and birth
First stage of labor
Assessment
• Prenatal data
• To be completed if not already available at the facility
• Ask questions between contractions; follow Health Insurance
Portability and Accountability Act (HIPAA) regulations
• Age, weight, weight gain, height, vital signs, allergies
• Prenatal care; medical history
• Diagnostic tests performed during pregnancy
• Expected date of birth; obstetric history; perception of previous births
• Interview
• Abbreviated if woman is in late labor
• Reason for arriving at facility (such as ruptured membranes)
• Time and type of last meal
• Time of onset of contractions (beginning of one contraction to
beginning of next contraction) and their frequency, duration, and
intensity; any change in contractions with change in position
• Presence and character of vaginal discharge/bloody show
• Status of amniotic membrane; characteristics of any fluid
• Respiratory status; bowel and bladder function
• Allergies (if not noted in prenatal data)
• Intent to breastfeed or formula feed
• Birth plan; if none written, nurse helps woman create it by reviewing
options and asking for preferences
• Orient to unit
• Psychosocial factors
• Note the general appearance and behavior of the woman and partner
• Notice body language and communication skills or barriers
• Understand that labor can provoke memories of sexual abuse
• Note emotional response to labor; presence of support persons
• Stress in labor
• Review woman’s previous experiences and expectations
• Clear fears as possible
• Ascertain partner’s stress level, concerns, and expectations
• Cultural factors
• Provide culturally sensitive care
• Consider cultural influences on behavior
• Use bilingual and/or bicultural nurse or interpreter for non-English–
speaking women
• Physical examination
• General systems assessment
■ Use standard precautions.
■ Time and assess contractions (eg, palpation, electronic monitor)
■ Document findings: first stage/latent phase—every 30 to 60 minutes;
first stage/active phase—every 15 to 30 minutes; second stage—every
5 to 15 minutes; more frequently if there are nonreassuring signs
■ Assist with or perform vaginal examination
■ Explain examination to woman
■ Confirms true labor
■ Determines whether membranes have ruptured
■ Performed on admission, before medication administration, with
significant change in maternal condition, on maternal request or if
perineal pressure is indicated by the woman, when membranes
rupture, or if there are variable decelerations in fetal heart rate
(FHR)
■ Heart, lungs, skin general assessment, including edema
■ Note woman’s weight, because obesity may affect other interventions
■ Assess vital signs for baseline measurements
■ Leopold maneuvers (Fig. 11.1) to determine fetal presentation,
position, and station
■ A—Identifies fetal lie (longitudinal or transverse) and presentation
(cephalic or breech)
■ B—Identifies fetal presentation
■ C—If head is presenting and not engaged, determines attitude of
head (flexed or extended)
■ D—If cephalic prominence is on same side as back, indicates that
presenting head is extended and face is presenting
■ FHR patterns
■ Point of maximal intensity is usually below the umbilicus if the
fetus is in vertex presentation (see Fig. 10.1)
■ Assess per stage of labor, immediately if membranes have
ruptured, with any change in contraction pattern, and before and
after any procedure or medication
■ Uterine activity: frequency, intensity (mild, moderate, strong),
duration, resting time
• Laboratory and diagnostic tests
• Urine specimen analysis
■ Specific gravity, color, amount indicate hydration
■ Test urine for protein and glucose (can show preeclampsia)
■ Leukocytes can indicate infection; ketones can indicate nutritional
problems
• Obtain blood for complete blood count (CBC), type, and crossmatch
(even if done prenatally, because hospital laboratory must confirm)
■ If HIV status is unknown, screening can occur with woman’s
permission
■ Additional screens if not performed prenatally
• If group B streptococcus status is unknown, rapid screen can be
performed
• Amniotic fluid
■ Spontaneous rupture of membranes (SROM or SRM): usually in midor late labor; can occur before contractions begin (premature rupture
of membranes [PROM]); when the membranes rupture, the potential
for infection is increased; thus rupture of membranes warrants
evaluation of the pregnant woman at the health care facility
■ Artificial rupture of membranes (amniotomy, AROM, or ARM):
expedites labor by increasing dilation and effacement; done when
presenting part is engaged
■ Confirmation of amniotic fluid
■ Nitrazine paper: positive when pH is greater than 7.0; paper
changes color; result compared with color code on nitrazine roll
■ Fern test: dried amniotic fluid on slide examined with microscope
reveals frondlike pattern
■ Assessment of amniotic fluid
■ Color: strawlike and clear; may contain small particles of vernix
caseosa; greenish color indicates meconium staining
(nonreassuring fetal sign)
■ Odor: musky smelling but not offensive; foul smelling indicates
infection (chorioamnionitis)
■ Amount: approximately 1000 mL at term; 1500 to 2000 mL
(hydramnios, polyhydramnios); scant amount (oligohydramnios);
congenital anomalies associated with scant or excessive (eg,
esophageal atresia) fluid
FIG. 11.1 Leopold maneuvers. Source: (From Lowdermilk, D.L., Perry, S.E., Cashion, K.,
Alden, K.R. [2016]. Maternity and women’s health care [11th ed.]. St. Louis: Elsevier.)
Nursing interventions
• General hygiene
• Encourage handwashing; change linens if they are wet or stained with
blood
• Use of showers or warm baths can minimize discomfort
• Nutrient and fluid intake
• Adequate intake of fluids and calories meets energy needs; labor slows
if needs are not met; however, expert opinion is concerned regarding
aspiration of gastric contents, so food is usually restricted during labor
■ Common practice is to allow clear liquids during early labor,
changing to only water/ice as labor progresses
■ Consider cultural influences
■ Follow health care provider orders
• Intravenous intake
■ Monitor IV fluid intake
■ Electrolyte solutions without glucose are common, because they do
not affect the newborn’s insulin and glucose levels
• Elimination
• Have the woman empty her bladder to prevent discomfort when
performing Leopold maneuvers and every 2 hours
■ A full bladder increases pain and can delay descent of the fetus
• If woman is unable to void and the bladder is distended, follow protocol
to allow catheterization
• If the woman expresses a need to defecate, check the perineum in case
the head is crowning
• Decreased intestinal motility during labor means most women do not
have bowel movements
■ Already formed stool may be passed when bearing down; to prevent
infection, nurse removes stool and cleanses the perineum
• Ambulation and positioning
• If membranes are intact and the fetal presenting part is well engaged,
encourage ambulation; allow activity as desired to encourage fetal
descent and decrease discomfort; recognize maternal movements are
restricted with an external fetal monitor
• Assist woman to change position every 30 to 60 minutes if she has not
already done so; many positions are appropriate for a laboring woman:
upright, seated, leaning forward, squatting, hands-and-knees, sidelying, use of a birth ball, etc.
• Support the woman as she changes to upright for safety
• Prevent supine hypotension by positioning on side to keep gravid
uterus from compressing vena cava
• Positions are only contraindicated if they affect fetal status
• Supportive care during labor and birth
• Provide emotional support to client and labor coach; use measures to
promote comfort and rest
■ Explain procedures and equipment; keep environment comfortable
for woman (lights, noises, temperature)
■ Provide comfort measures; encourage relaxation techniques,
positions, pressure points, and other techniques learned in childbirth
classes
■ Assist with breathing techniques (first stage: latent phase—slowedpaced; active phase—modified-paced; transition phase—patternpaced; second stage: any rhythmic breathing that enhances
relaxation) and rebreathing techniques to correct and prevent
hyperventilation
■ Encourage pant-blow breathing until cervix is completely dilated,
especially if the woman has the urge to push
■ Administer prescribed analgesics or anesthesia; avoid opioids less
than 2 hours before birth to prevent fetal depression; have naloxone
available
■ Labor support by others
■ Supportive partner: nurse supports partner as well, teaches what to
expect, how to help
■ Supportive grandparent(s): treat with respect, support similarly to
partner
■ Labor support by doula is associated with decreased analgesia and
incidence of operative birth, increased maternal satisfaction; doula
and nurse work together to support woman
• Identify signs of impending second stage of labor
■ Decrease maternal oral intake because vomiting may occur during
transition phase
■ Observe perineum for bloody show
■ Shakiness and restlessness
■ Monitor for spontaneous rupture of membranes
■ Assess for prolapsed cord
■ Obtain FHR
■ Assess characteristics of amniotic fluid (see earlier)
• Monitor for clinical manifestations of potential complications
■ Prolonged strong contractions (tetanic uterus)
■ Taut, boardlike abdomen (abruptio placentae)
■ Increased pulse and temperature (infection)
■ Hypertension (preeclampsia)
■ Hypotension (effect of epidural or spinal anesthesia)
■ Bright-red vaginal bleeding (placenta previa)
■ Meconium-stained amniotic fluid (breech position or late
nonreassuring fetal sign)
■ Abnormal variations in FHR patterns (nonreassuring fetal sign)
Application and review
1. The husband of a client who is in the transition phase of the first stage of
labor becomes very tense and anxious during this period and asks a nurse,
“Do you think it is best for me to leave, because I don’t seem to be doing
my wife much good?” What is the nurse’s best response?
1. “This is the time your wife needs you. Don’t run out on her now.”
2. “This is hard for you. Let me try to help you coach her during this
difficult phase.”
3. “I know this is hard for you. You should go have a cup of coffee to
help you relax and then come back in a little while.”
4. “If you feel that way, you’d best go out and sit in the fathers’ waiting
room for a while. You may transmit your anxiety to your wife.”
2. A nurse observes a laboring client’s amniotic fluid and decides that it is
the expected color. What description of amniotic fluid supports this
conclusion?
1. Clear, dark amber, and contains shreds of mucus
2. Straw colored, clear, and contains little white specks
3. Milky, greenish yellow, and contains shreds of mucus
4. Greenish yellow, cloudy, and contains little white specks
3. The membranes of a client who is at 39 weeks’ gestation have ruptured
spontaneously. Examination in the emergency department revealed that
her cervix is 4 cm dilated and 75% effaced, and the FHR is 136 beats/min.
She and her partner are admitted to the birthing unit. What should the
nurse do upon their arrival?
1. Place the client in bed and attach an external fetal monitor.
2. Have the client undress while taking her history from her partner.
3. Introduce the staff nurses to the couple and try to make them feel
welcome.
4. Ask the couple to wait in the examining room while notifying the
health care provider.
4. A pregnant woman at 39 weeks’ gestation arrives in the triage area of the
birthing unit, stating she thinks her “water broke.” What should the nurse
do first?
1. Auscultate the fetal heart to determine fetal well-being.
2. Perform Leopold maneuvers to rule out a breech presentation.
3. Check the vaginal introitus for the presence of the umbilical cord.
4. Do a nitrazine test on the vaginal fluid for verification of ruptured
membranes.
5. Why should a nurse withhold food and oral fluids as a laboring client
approaches the second stage of labor?
1. The mechanical and chemical digestive processes require energy
that is needed for labor.
2. Undigested food and fluid may cause nausea and vomiting and limit
the choice of anesthesia.
3. The gastric phase of digestion stimulates the release of hydrochloric
acid and may cause dyspepsia.
4. Food and fluid will further aggravate gastric peristalsis, which is
already increased because of the stress of labor.
6. A nurse performs Leopold maneuvers on a pregnant client and documents
the following data: soft, firm mass in the fundus; several small parts on
the right side; hard, round, movable object in pubic area; and cephalic
prominence on right side. Applying these findings, which fetal position
does the nurse identify?
1. Left sacroposterior (LSP)
2. Right sacroposterior (RSP)
3. Left occipitoanterior (LOA)
4. Right occipitoanterior (ROA)
7. A primigravida is admitted to the birthing suite at term with contractions
occurring every 5 to 8 minutes and a bloody show. She and her partner
attended childbirth preparation classes. Vaginal examination reveals the
cervix at 3 cm dilation and 75% effacement, +1 station with occiput
anterior, and intact membranes. The client is cheerful and relaxed and
asks the nurse whether it is all right for her to walk around. Based on
observations of the contractions and the client’s knowledge of the
physiology and mechanism of labor, how should the nurse respond?
1. “I can’t make a decision on that; I will have to ask your health care
provider.”
2. “Please stay in bed; walking may interfere with effective uterine
contractions.”
3. “It’s all right for you to walk as long as you feel comfortable and
your membranes are intact.”
4. “You may sit in a chair because your contractions cannot be timed
when you walk, and I won’t be able to listen to the fetal heart.”
8. At 40 weeks’ gestation a client is admitted to the birthing unit in early
labor. She asks the nurse, “Why do you want me to lie on my side?” What
response explains the primary purpose of the side-lying position during
labor?
1. “Lying on the side prevents fetal hyperactivity.”
2. “It decreases the incidence of nausea and vomiting.”
3. “It enhances blood flow to the uterus and contractions.”
4. “Lying on the side encourages descent of the presenting part.”
9. When the cervix of a woman in labor is dilated 9 cm, she states that she has
the urge to push. How should the nurse respond?
1. Have her pant-blow during contractions.
2. Place her legs in stirrups to facilitate pushing.
3. Encourage bearing down with each contraction.
4. Review the pushing techniques taught in childbirth classes.
See Answers on pages 185-188.
Second stage of labor
Description
• Begins with full cervical dilation and complete effacement; ends with birth
• Normal length is 30 minutes to 3 hours depending on parity and use of
regional anesthesia; considered prolonged if longer
• Consists of latent phase (relative calm) and active pushing phase (urge to
bear down is strong)
Assessments
• Maternal blood pressure, pulse, respirations every 5 to 30 minutes
• FHR and pattern every 5 minutes
• Maternal appearance, affect
• Vaginal show, signs of fetal descent
• Every contraction and bearing-down effort
Positioning
• Allow client to choose pushing and positioning techniques, especially if
unmedicated; assist if pushing is ineffective; upright positions shorten
labor
• Position legs simultaneously if placed in stirrups to avoid trauma to
uterine ligaments
Bearing-down efforts
• Open glottis pushing is encouraged, not closed glottis (Valsalva
maneuver); holding breath is discouraged because it can decrease
placental/fetal oxygenation
• Remind woman to breathe deeply before and after each contraction
• Pushing should not last longer than 7 seconds
• Encourage panting as baby’s head crowns; to slow a precipitous birth, also
discourage bearing down
Fetal heart rate and pattern
• Check often (every 5 minutes or more often)
• If baseline rate slows or if late, variable or prolonged decelerations (signs
of uteroplacental insufficiency) occur (see Chapter 10), help turn woman
on her side, administer oxygen; if normalization does not occur, notify
health care provider immediately
• Document concurrently with birth process
Support of the father or partner
• Instruct support persons to wear gown and other personal protective
equipment if in delivery or operating room
• Encourage partners to be present at birth; support cultural considerations
Birth room and equipment
• Equipment, including crib or warmer, usually set up during transition
• Check facility procedure for precise item list
Additional interventions
• Transfer to birthing room or prepare birthing bed when perineum bulges
during contractions
• Assist with anesthesia, which may include pudendal block, saddle block,
or local infiltration
• Cleanse perineum per protocol
• Continue to support woman and monitor fetal status
• Be ready to assist with birth if health care provider not present
• Three phases of vertex birth: head, shoulders, body and extremities (see
Chapter 8)
• Record time of birth
Immediate care of the newborn (see chapter 17)
• Clear airway of mucus
• Determine Apgar score at 1 and 5 minutes after birth to determine
respiratory effort and physical status (see Chapter 17)
• Maintain body heat; mother–newborn skin-to-skin positioning most
effective; dry
• Assess for visible anomalies
• Allow parents to see newborn; place on maternal abdomen to enhance
breastfeeding and begin attachment/bonding process
• Administer antibiotic ophthalmic medication into each eye to prevent
ophthalmia neonatorum and vitamin K injection to prevent hemorrhagic
disorders
• Apply identification bracelets to newborn and parents (some facilities
include significant others) before leaving birthing area according to
institutional protocol
Perineal trauma
• Includes lacerations of perineum, urethra, and vagina, as well as cervical
injuries and episiotomy (see Chapter 16)
• Perineal lacerations are graded as first (skin and vagina), second (through
perineal muscle but not anal sphincter), third (involves external anal
sphincter), or fourth degree (through rectal mucosa, internal and external
anal sphincters)
Third stage of labor
Placental separation and expulsion
• Delivery of the placenta usually occurs 10 to 15 minutes after baby is born;
considered retained if not delivered after 30 minutes
• May be heralded by sudden gush of blood, firmly contracting fundus
• Placenta examined for completeness; then any repairs can occur
• Some families choose to take placenta home; be aware of cultural
considerations
Nursing care
• Assist with birth of placenta: monitor uterine contractions, encourage
woman to bear down
• Cleanse vulva after any repairs are performed
• Continue to assess maternal blood pressure, pulse, and respirations
• Continue to promote attachment behaviors and to provide comfort
measures
• Provide support for parents whether or not infant is healthy
• Document birth and accompanying events
Fourth stage of labor
Assessment (see also chapter 14)
• Palpate fundus for firmness every 15 minutes; if relaxed and bladder is not
distended, massage until firm
• Locate fundus: 2 cm below umbilicus immediately after birth; rises to
level of umbilicus 1 hour after birth
• Palpate for bladder distention (uterus above umbilicus and dextroverted);
encourage voiding (uterus unable to contract if bladder is full, resulting
in hemorrhage)
• Observe perineum for vaginal bleeding (lochia rubra); count vaginal pads;
assess for concurrent uterine relaxation, massage as needed
• Observe episiotomy or laceration sites for hematoma, bleeding, or edema;
apply ice bag to perineum immediately after birth to reduce edema;
perineal ecchymosis and perineal/rectal pressure indicate vaginal
hematoma
• Monitor vital signs; report fluctuations
Nursing interventions
• Continue to assess maternal blood pressure, pulse, and respirations
• Administer prescribed oxytocic medication if needed; may be
administered immediately after birth to enhance uterine contraction
• Keep warm to diminish sensation of chilling; shivering common after
birth (exact cause unknown)
• Provide fluid and food as tolerated
• Encourage skin-to-skin contact
• Encourage and teach breastfeeding techniques within first hour of birth
(see Chapter 18)
• Support family and family–newborn relationships
Evaluation/outcomes
• Mother
• Progresses through labor culminating in safe birth
• Remains free of infection
• Maintains homeostasis
• Newborn
• Establishes airway and respiratory effort, sustaining life without
assistance
• Achieves Apgar score of 7 or above at 5 minutes after birth
• Attempts first breastfeeding
Application and review
10. Epidural anesthesia was initiated 30 minutes ago for a client in labor. The
nurse identifies that the fetus is experiencing late decelerations. List the
following nursing actions in order of priority.
1. _____ Increase IV fluids.
2. _____ Reposition client on her side.
3. _____ Reassess fetal heart rate pattern.
4. _____ If late decelerations persist, notify the health care provider.
5. _____ Document interventions with related maternal/fetal
responses.
11. When a client’s legs are placed in stirrups for birth, the nurse confirms
that both legs are positioned simultaneously to prevent what?
1. Venous stasis in the legs
2. Pressure on the perineum
3. Excessive pull on the fascia
4. Trauma to the uterine ligaments
12. The cervix of a client in labor is fully dilated and effaced. The head of the
fetus is at +2 station. What should the nurse encourage the client to do
during contractions?
1. Relax by closing her eyes.
2. Push with her glottis open.
3. Blow to slow the birth process.
4. Pant to prevent cervical edema.
13. After a client gives birth, what physiologic occurrence indicates to the
nurse that the placenta is beginning to separate from the uterus and is
ready to be expelled?
1. Relaxation of the uterus
2. Descent of the uterus in the abdomen
3. Appearance of a sudden gush of blood
4. Retraction of the umbilical cord into the vagina
14. A client arrives at the hospital in the second stage of labor. The head of
the fetus is crowning, the client is bearing down, and birth appears
imminent. What should the nurse tell the client to do?
1. Pant while pushing gently.
2. Breathe with her mouth closed.
3. Hold her breath while bearing down.
4. Pant while resisting the urge to bear down.
15. A primipara gave birth to an infant weighing 9 pounds 15 ounces (4508 g).
She had a midline episiotomy and a third-degree laceration. She tells the
nurse that her perineal area is very painful. What should the nurse
consider before explaining the reason for the pain?
1. Perineal muscles have been cut.
2. The anal sphincter muscle has been injured.
3. The anterior wall of the rectum is traumatized.
4. Structures superficial to muscles have been damaged.
16. During a client’s labor, the fetal monitor reveals a fetal heart pattern that
signifies uteroplacental insufficiency. What is the nurse’s first
intervention?
1. Insert a urinary retention catheter.
2. Administer oxygen via nasal cannula.
3. Assist the client to turn to the side-lying position.
4. Encourage the client to pant with her next contraction.
17. In the second stage of labor, the nurse should plan to discourage a client
from holding her breath longer than 7 seconds while pushing with each
contraction. What complication does this prevent?
1. Fetal hypoxia
2. Perineal lacerations
3. Carpopedal spasms
4. Maternal hypertension
See Answers on pages 185-188.
Answer key: Review questions
1. 2 Both the father and the mother need additional support during the
transition phase of the first stage of labor.
1 The statement, “This is the time your wife needs you. Don’t run out on
her now” is judgmental; it suggests that the father will be failing his
wife. 3 The husband should be present throughout labor to support his
wife; he should be assisted in this support role. 4 The statement, “If you
feel that way, you’d best go out and sit in the fathers’ waiting room for
a while. You may transmit your anxiety to your wife” does not
encourage the husband to fulfill his role of supporting his wife during
labor.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/Implementation
2. 2 By 36 weeks’ gestation, amniotic fluid should be pale yellow with small
particles of vernix caseosa present.
1 Dark, amber-colored fluid suggests the presence of bilirubin, an
ominous sign. 3 Greenish-yellow fluid may indicate the presence of
meconium and suggests fetal compromise. 4 Cloudy fluid suggests the
presence of purulent material, and greenish yellow may indicate the
presence of meconium.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
3. 3 The client is in the first stage of labor; she and the fetus were assessed
earlier, and both are stable. At this time the priority of care is to establish
a trusting relationship with her and her partner. This will help to allay
their anxiety.
1 Placing the client in bed and attaching an external fetal monitor may be
necessary later; however, it is not the priority. 2 The history should be
taken from the client as long as she is capable of providing it. 4
Notifying the health care provider is not a priority; the health care
provider may have been notified already.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/Implementation
4. 3 The priority is to assess for a prolapsed umbilical cord. This is a life-
threatening emergency for the fetus and must be ruled out first.
1 Auscultating the fetal heart to determine fetal well-being is done after
verifying that the umbilical cord is not visible in the vaginal introitus. 2
Performing Leopold maneuvers is not the priority; it can be done after
confirming fetal well-being. 4 Doing a nitrazine test on the vaginal fluid
for verification of ruptured membranes is not the priority; it can be
done after confirming fetal well-being.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
5. 2 Gastric peristalsis often ceases during periods of stress. Abdominal
contractions put pressure on the stomach and can cause nausea and
vomiting, increasing the risk for aspiration.
1 Although it is true that the mechanical and chemical digestive processes
require energy that is needed for labor, it is not the reason for
withholding food or oral fluids during labor. 3 Although food may
cause dyspepsia, the primary reason for withholding it is to prevent
aspiration. 4 Gastric peristalsis is decreased, not increased, during the
stress of labor and birth.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
6. 3 In the left occipitoanterior (LOA) position, the small parts are on the
right, the smooth back is on the left, and the head is in the pelvis.
1 The left sacroposterior (LSP) position is a breech position, and therefore
the fetal head will not be in the pelvic area; the data reveal a hard,
round, movable object in the pubic area, which indicates that the fetus
is in the vertex position. 2 The right sacroposterior (RSP) position is a
breech position, and therefore the fetal head will not be in the pelvic
area; the data reveal a hard, round, movable object in the pubic area,
which indicates that the fetus is in the vertex position. 4 In the right
occipitoanterior (ROA) position, the small parts will be on the left and
the smooth back on the right.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Analysis; Nursing Process:
Assessment/Analysis
7. 3 Contractions become stronger and more regular when the woman is
standing; also, during walking, the diameter of the pelvic inlet increases,
and it allows easier entrance of the head into the pelvis.
1 Based on the admitting assessment, the nurse is qualified to make the
decision that the woman can walk. 2 Contractions of true labor are
enhanced when the mother walks around. 4 Timing and Doppler
auscultation of the fetal heart rate can continue even if the client walks
around.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Communication/Documentation
8. 3 In the side-lying position, the gravid uterus does not impede venous
return; cardiac output increases, leading to improved uterine perfusion,
uterine contractions, and fetal oxygenation.
1 Lying on the side does not affect fetal activity. 2 Side-lying will not
decrease nausea and vomiting; nausea and vomiting may occur as labor
progresses toward the second stage. 4 Walking or squatting will best
accomplish descent of the presenting part.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
9. 1 Although there are exceptions, with the information given, the best
response is to inhibit pushing by using pant-blow breathing. Pushing may
cause cervical trauma when the cervix is not completely dilated.
2 It is too early to prepare for the second stage of labor; the cervix is not
fully dilated. 3 It is too early to bear down with each contraction; the
cervix is not fully dilated. 4 At 9 cm dilation with the urge to push, the
client is completely introverted and will be unreceptive to a review of
pushing techniques.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation
10. Answer: 2, 1, 3, 4, 5
2 Repositioning to the side increases uterine blood flow, improves cardiac
output, and moves pressure of the uterus off of the vena cava. 1
Increasing IV fluids augments uterine blood flow and improves cardiac
output. 3 Reassessing the FHR pattern enables the nurse to determine
whether the FHR has returned to a safe level without reflex late
decelerations. 4 Persistent late decelerations is a nonreassuring fetal
sign; the health care provider should be informed. 5 Documentation of
interventions and client responses includes the information in the
client’s legal clinical record and provides communication to other care
providers.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation
11. 4 As the uterus rises into the abdominal cavity, the uterine ligaments
become elongated and hypertrophied; raising both legs at the same time
limits the tension placed on these ligaments.
1 Lifting the legs simultaneously does not affect circulation in the legs. 2
There is already pressure on the perineum from the head of the fetus;
raising both legs simultaneously eases tension on the uterine
ligaments. 3 There is no effect on the fascia with positioning both legs
simultaneously on the stirrups.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
12. 2 The contractions in the second stage of labor are expulsive in nature;
having the client push or bear down with the glottis open will hasten
expulsion.
1 Contractions are now intense, and the client will be unable to relax;
relaxation occurs between contractions. 3 The breathing pattern of
blowing to slow the birth process prevents pushing and should not be
encouraged until the fetal head crowns (+4 station) and a controlled
birth is desired. 4 The breathing pattern of panting to prevent cervical
edema prevents pushing and should not be encouraged until the fetal
head crowns (+4 station) and a controlled birth is desired.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
13. 3 When the placenta separates from the uterine wall, it tears blood
vessels and results in a gush of blood from the vagina.
1 The uterus should become firm when the placenta begins to separate. 2
The fundus rises in the abdomen when the placenta separates. 4 The
reverse occurs; as the placenta separates, it descends into the vaginal
introitus, and the umbilical cord appears longer and protrudes from the
vagina.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
14. 4 Panting prevents the mother from putting pressure on the fetal head.
The nurse applies gentle pressure against the fetus’s head as it emerges to
prevent a precipitous birth, which could result in central nervous system
injury to the fetus and vaginal lacerations to the mother.
1 It is impossible to pant and push at the same time. 2 Breathing with the
mouth closed promotes the bearing-down reflex. 3 Bearing down
during the birth is unsafe because both fetus and mother can be
injured.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation
15. 2 A third-degree laceration extends through the perineal muscles and
continues through the external anal sphincter muscle.
1 When the perineal muscles have been cut, it is a second-degree
laceration. 3 When the rectum has been traumatized, it is a fourthdegree laceration. 4 When superficial muscles have been damaged, it is
a first-degree laceration.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Physiologic Adaptation; Cognitive Level: Comprehension; Nursing
Process: Assessment/Analysis
16. 3 The side-lying position improves uterine blood flow, and fetal
oxygenation will increase.
1 It is unnecessary to insert a urinary retention catheter; in addition, it
requires a health care provider’s order. 2 Oxygen may be administered
eventually if necessary, but it is not the first intervention. 4
Encouraging the client to pant with her next contraction will not
increase uterine blood flow or oxygen to the fetus.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Planning/Implementation
17. 1 Prolonged holding of the breath at this stage decreases placental/fetal
oxygenation.
2 Perineal lacerations occur with rapid, uncontrolled expulsion of the
fetus. 3 Carpopedal spasms are not caused by prolonged holding of the
breath. 4 Maternal hypertension is not caused by prolonged holding of
the breath.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
C H AP T E R 1 2
Labor and birth complications
Preterm labor and birth
Definition
• Contractions begin after 20th week but before end of 37th week of
gestation, causing effacement and dilation of the cervix
• Hazards to fetus are greatest before 34 weeks of gestation
• About two-thirds of neonatal deaths in the United States are the result of
preterm birth
Nursing care of women during preterm labor
• Assessment/analysis
• Number of weeks gestation
• Fetal status
• Signs of labor: two contractions lasting 30 seconds within 15 minutes;
cervical dilation less than 4 cm; effacement 50% or less
• Signs of hemorrhage or infection
• Signs of severe preeclampsia
• Rupture of membranes; length of time since rupture
• Emotional status of mother
Preterm birth versus low birth weight
• Although previously preterm birth and low birth weight were interchanged
terms, now that gestational age can more accurately be determined, it is
vital to recognize the difference
Spontaneous versus indicated preterm birth
• Spontaneous preterm births are ∼3⁄4 of U.S. preterm births
• A preterm birth can be deliberate (indicated) to fix maternal or fetal risk
from continuing a pregnancy
Causes of spontaneous preterm labor and birth
• Previous preterm labors; nonwhite race; substance use; multiple gestation;
reproductive and urinary system infections, including bacterial vaginitis;
multiple abortions; pyelonephritis; asymptomatic bacteriuria
Testing
• Transvaginal cervical sonography
• Immunoassay for fetal fibronectin
• Vaginal examinations to determine cervical changes
Interventions
• Prevention
• Smoking cessation
• Prenatal counseling for all women, and especially for women with
history of preterm birth, of the symptoms of preterm birth
• Prophylactic progesterone administration in women with history of
preterm birth
• Early recognition
• Activity restrictions (no evidence to support effectiveness of
continuous bed rest)
• Treatment of etiology (eg, antibiotics for pyelonephritis)
• Suppression
• Tocolytic therapy to decrease frequency and duration of contractions,
postponing birth
■ Magnesium sulfate
■ Betasympathomimetics: terbutaline
■ Calcium channel blockers: nifedipine
■ Prostaglandin inhibitors: indomethacin
• Corticosteroid therapy (antenatal glucocorticoids)
■ Betamethasone (Celestone)
■ Administered 24 to 48 hours before birth
■ Reduces incidence and severity of respiratory distress syndrome
(RDS) in preterm infants; enhances formation of surfactant
■ May be contraindicated if woman has an infection
• Planning/implementation
• Prevention by decreasing risk factors
■ Discuss impact of drug use and lifestyle risks
■ Teach importance of early reporting of temperature elevations
■ Check results of prenatal vaginal cultures
■ Monitor for urinary tract infections; asymptomatic bacteriuria shows
a positive culture of more than 100,000/mm3
• Arrange for home health nurse to supervise maternal and fetal status
(eg, vital signs, fetal heart rate [FHR], breath sounds, fetal activity,
hematologic and cervical status, blood and urine glucose levels, fundal
height, maternal weight, urine evaluation, presence of edema)
• Provide home instruction for halting preterm labor
■ Rest periods in lateral position; avoidance of vigorous activity
■ Increase fluid intake
■ Avoid nipple stimulation
■ Avoid stressful events
■ Empty bladder regularly and if contractions occur
• Monitor vital signs, FHR, contractions, and progression of labor
• Maintain bed rest if ordered
• Provide emotional support; reduce anxiety and prepare for perinatal
death
• Provide care related to tocolytic medications
■ Teach about medication; explain that use of pain medications will be
limited to avoid their depressive effects on fetus
■ Use an infusion pump for administration of IV medications
■ Obtain baseline hematologic data and electrocardiographic (ECG)
readings if appropriate
■ Monitor vital signs (hypotension can occur with all tocolytics;
tachycardia can occur with terbutaline)
■ Maintain hydration; monitor for pulmonary edema
■ Monitor for signs of hypokalemia and hyperglycemia
■ Monitor input and output (I&O)
■ Provide care related to magnesium sulfate therapy (eg, assess reflexes
and respirations)
• Prepare to administer corticosteroid therapy
• Prepare for preterm birth
• Evaluation/outcomes
• Exhibits cessation of labor
• Fetus remains in utero with acceptable FHR and fetal movements
• Mother and partner list signs and symptoms of preterm labor
Premature rupture of membranes
Definition and implications
• Spontaneous rupture of membranes before onset of labor at any
gestational age
• Maternal implication: ascending infection (chorioamnionitis) is a risk (see
“Chorioamnionitis” and its risks, later)
• Fetal implications
• Prolapsed cord can result from decreased amniotic fluid cushion
• FHR decelerations caused by cord compression from lack of amniotic
fluid
• Sepsis from ascending infection
Therapeutic interventions
• Although each case is handled individually, because infection is the
greatest risk, immediate labor and birth are attempted from 34 weeks to
term gestations
• If pulmonary maturity is confirmed, can attempt birth at 32 to 33 weeks
• Gestations of less than 32 weeks are usually managed conservatively with
hospitalization
• Fetal assessment by nonstress test (NST), daily fetal movement counts,
and biophysical profile
• Antenatal glucocorticoids administered to decrease fetal complications
• Prophylactic antibiotics
Nursing care of women with premature rupture of
membranes
• Assessment/analysis
• Time of rupture
• FHR and maternal vital signs
• Perineum for prolapsed cord
• Characteristics of leaking amniotic fluid (eg, odor and color)
• Confirmation that fluid is amniotic fluid
■ Fern test: microscopic examination reveals fernlike crystals of sodium
chloride
■ Nitrazine test: confirms presence of amniotic fluid; paper changes
color when touched by alkaline amniotic fluid (7.0–7.5) rather than
acidic vaginal secretions
• Planning/implementation
• Monitor FHR and maternal vital signs; temperature and pulse every 2
hours
• Monitor uterine activity
• Avoid vaginal/cervical stimulation (eg, unnecessary vaginal
examinations)
• Ensure adequate hydration
• Educate parents (eg, amniotic fluid is still being produced)
• Provide perineal hygiene
• Administer antibiotics as prescribed
• Evaluation/outcomes
• Remains free from infection
• Progresses through labor to safe birth of healthy newborn
Chorioamnionitis
Definition and etiologies
• Infection of fetal membranes, usually ascended from vagina or urethral
tract
• Most common complication of premature rupture of membranes (PROM)
• Associated with extended duration of labor, PROM, multiple vaginal
examinations
Diagnosis
• Maternal fever; maternal and fetal tachycardia
• May also have uterine tenderness; purulent, foul-smelling amniotic fluid
• If membranes have not ruptured, transabdominal amniocentesis can be
used to examine amniotic fluid
Risks
• Causes risk of dysfunctional labor
• Can develop into maternal bacteremia
• Fetal risks: pneumonia, bacteremia, sepsis, central nervous system
damage
Therapeutic interventions
• Intravenous antibiotics
• Birth of fetus
Postterm pregnancy, labor, and birth
Postterm pregnancy
• Extends beyond 42nd week of gestation or 2 weeks beyond estimated date
of birth (EDB); 37 to 42 weeks’ gestation is considered full-term
Risk factors
• Decreased amniotic fluid (oligohydramnios) may lead to cord
compression during labor
• Decreased placental function because placental aging lowers oxygen and
nutritional transport; fetus jeopardized during labor (eg, asphyxia,
hypoglycemia)
• Increasing fetal size (mainly length) and hardening of skull may
contribute to cephalopelvic disproportion
• Maternal risks if infant is excessively large, because of dysfunctional labor:
perineal trauma, hemorrhage, infection
Assessment
• Biophysical profile and/or NST to determine ability to tolerate labor
• Assessment of amniotic fluid volume; decreased amniotic fluid is result of
decreased kidney perfusion related to decreased fetal oxygen levels
• Daily fetal movement counts
• Assess for signs of labor
Therapeutic intervention
Therapeutic intervention
• Induction of labor
• Continuous fetal monitoring for FHR and pattern to quickly identify fetal
hypoxia
• May include amnioinfusion of fluid if oligohydramnios is present
Nursing care of women during postterm labor
• Assessment/analysis
• Number of weeks gestation; date of last menstrual period; estimated
date of birth
• Presence of meconium in amniotic fluid
• Level of anxiety related to delayed date of birth
• Newborn may have postmaturity syndrome (eg, little vernix; long nails
and hair; peeling, wrinkled skin; reduced subcutaneous fat; meconium
staining)
• Planning/implementation
• See Planning/implementation under “Induction of Labor”
• Evaluation/outcomes
• Progresses through labor to safe birth of healthy newborn
• Remains free from complications
Dysfunctional labor (dystocia)
Definition
• Dystocia = difficult labor; can be from abnormal uterine activity or labor
patterns, maternal position, alterations in pelvic structure or maternal
psychologic responses to labor, or fetal causes (see “Obstetric
Emergencies” later for shoulder dystocia)
Maternal complications
• Cervical trauma, postpartum hemorrhage, infection, and exhaustion
Abnormal uterine activity/faulty uterine
contractions
• Contributing factors: maternal fatigue; fluid and electrolyte imbalance;
hypoglycemia; excessive analgesia or anesthesia; maternal physiologic
responses to stress and pain; cephalopelvic disproportion; multiple
gestation
• Hypertonic
• Regular contractions that do not result in cervical dilation and
effacement
• Increased uterine resting tone; mother becomes exhausted
• Primigravidas or very anxious women at risk
• Trial of warm shower/bath, analgesia or sleep medication may resolve
exhaustion and hypertonicity
• Amniotomy or oxytocin may be used to speed labor
• Hypotonic: inefficient generation of contractions; slowing of rate and
intensity of contractions usually in latter part of the first stage of labor;
associated with uterine overdistention
• May respond to IV fluids, nonpharmacologic strategies
• Rule out cephalopelvic disproportion (CPD), assess FHR and pattern,
check amniotic fluid if membranes have ruptured
• Amniotomy or oxytocin may be used to speed labor if other factors are
normal
• Therapeutic interventions
• Intervention based on length of labor; status of mother and fetus; extent
of cervical effacement and dilation; and fetal presentation, position, and
station
• Secondary powers
• Bearing down can be compromised with anesthesia, maternal position,
and exhaustion
Abnormal labor patterns
• Abnormal patterns include prolonged latent phase, protracted active
phase, arrested active phase, and three problems of descent: protracted
descent, arrested descent, and failure of descent; precipitous labor is also
considered an abnormal pattern (see later)
• First or second stage of labor can be protracted (take a very long time) or
arrested (completely stopped)
• Diagnosis of progress problem can be made by plotting cervical dilation
and fetal descent on a graph over time and comparing the graph to that of
normal labor for a nullipara or multipara; health care provider should be
notified of an abnormal pattern
Alterations in pelvic structure
• Mechanical factors
• Pelvic “contracture” = small pelvis
■ Can be abnormally shaped or just small; inlet, midpelvis, or outlet
can be the problem area, or a combination
• Soft tissue obstruction
■ Can be placenta previa, leiomyoma, other tumor, full bladder or
rectum that is preventing progress of the fetus; cervical edema can
contribute
Fetal causes
• Anomalies that increase the size of the fetus can cause dystocia:
hydrocephalus, ascites, tumors, and others
• CPD
• Mismatch of size of fetus with size of maternal pelvis; can be from
macrosomia or malposition of the fetal presenting part
• Ultrasonography can determine fetal and pelvic size
• Malposition
• Occiput posterior position of fetus occurs in up to 15% of labors; this
prolongs the second stage and adds back pain
■ Can use maternal position to help turn fetus, such as Sims position
and hands-and-knees position
• Malpresentation
• Face and brow presentations uncommon
• Breech birth is the most common type of malpresentation
■ Associated with multifetal pregnancies, preterm birth, anomalies,
and problems with the quantity of amniotic fluid
• Maternal implication: cesarean birth may be required, especially for
primigravida
• Fetal implications
■ Increased mortality
■ Prolapsed cord, leading to asphyxia
■ Birth trauma (eg, brachial palsy, fracture of upper extremities)
• Types of breech birth
■ Frank: only buttocks; thighs flexed on hips; knees extended
■ Complete: buttocks and feet; thighs and knees flexed
■ Incomplete: one or both feet (footling) extend below buttocks
• Trial of labor may be attempted if pelvis is normal size and shape, fetus
is not macrosomic, fetal head is well flexed, breech is complete or frank
• Vaginal birth of breech presentation requires experience and skill of
health care provider
• Cesarean section is usually performed if external version is not possible
and for transverse presentations
• Nursing care of women during vaginal breech birth
■ Assessment/analysis
■ Leopold maneuvers and vaginal examination to identify fetal
presentation
■ Auscultation of fetal heart tones above umbilicus
■ Presence of meconium despite fetal well-being; results from
contraction of uterus on lower colon of fetus
■ Ultrasound may be used to confirm position
■ Planning/implementation
■ Promote comfort
■ Monitor FHR in an upper quadrant
■ Monitor for prolapsed cord; if it occurs
○ With a sterile gloved hand, push presenting part off cord
○ Place in Trendelenburg position to keep presenting part away
from cord
○ Keep prolapsed cord moist with sterile saline
■ Observe for frank meconium from pressure on fetal abdomen
■ Prepare for a forceps-assisted birth if vaginal birth is anticipated
■ Teach mother and partner about process of breech birth
■ Prepare for cesarean birth if necessary
■ Evaluation/outcomes
■ Mother remains free from injury
■ Newborn remains free from injury
• Multifetal pregnancy
• Frequency increasing; related to higher incidence of fertility drug use
• Increasing rate of elective fetal reduction to decrease risk of fetal death;
greater incidence of twin births; lower incidence of triplet and higherorder births
• Perinatal morbidity and mortality rates are higher with a multiplegestation pregnancy because the greater metabolic demands and the
possibility of malpositioning of one or more fetuses increase the risk
for complications: high probability for developing preterm labor,
gestational hypertension, hyperemesis gravidarum, iron or folate
anemia, dystocia (distended uterus contributes to hypotonic
dysfunction), twin-to-twin transfusion, postpartum uterine atony
• High risk for fetuses being born with congenital anomalies and
intrauterine growth restriction (IUGR)
• Twin vaginal birth can be attempted, but triplet or more infants is by
cesarean
• Monozygotic (identical) twins: develop from one fertilized ovum and are
of same gender, race, heredity, parity; maternal age has no influence on
incidence
• Dizygotic (fraternal) twins: develop from two ova, each of which is
fertilized by a different sperm; may be same or different genders;
familial predisposition; increased incidence in women who are African
American, multiparous, and younger than 35 years of age
• Nursing care of women with a multifetal pregnancy: see “Nursing Care
of Women with Premature Rupture of Membranes” and “Nursing Care
of Women During Preterm Labor”
Position of the woman
• Can be used for mechanical advantage by use of gravity
• Recumbent or lithotomy position can decrease progress
Psychologic responses
• Pain and absence of support can cause dysfunctional labor
• Immobility compounds psychologic response
• Anxiety inhibits dilation, increases pain perception, prolongs labor
Nursing care of women with dystocia
• Assessment/analysis
• Progress of labor
• Status of mother
• Status of fetus
• Planning/implementation
• Relieve back pain caused by prolonged posterior pressure if fetus in
occiput posterior position (eg, apply sacral pressure during
contractions; encourage side-lying position)
• Observe for signs of maternal exhaustion (eg, dehydration,
acidosis/alkalosis)
• Monitor for nonreassuring fetal signs
• Have oxygen, suction, and resuscitation equipment available
• Provide care related to oxytocin infusion (see “Nursing Care of Women
During Induction or Stimulation of Labor”)
• Provide emotional support; keep client and family informed about
progress
• Administer fluids as ordered
• Administer sedatives as prescribed
• Evaluation/outcomes
• Rests/sleeps between contractions and after birth
• Progresses through labor to safe birth of newborn
• Remains free from complications
Precipitous labor
Overview
• Rapid labor and birth of less than 3 hours’ duration
• Maternal complications: perineal laceration, postpartum hemorrhage
• Newborn complications: anoxia, intracranial hemorrhage
Nursing care of women during precipitate birth
• Assessment/analysis
• Rapid cervical dilation
• Accelerated fetal descent
• History of rapid labor
• Rapid uterine contractions with decreased periods of relaxation between
contractions
• Planning/implementation
• Remain with mother continuously
• Keep emergency birth pack at bedside
• Keep mother and partner informed throughout process of labor and
birth
• Support and guide fetal head through birth canal when birth occurs;
distribution of the fingers around the head will prevent a rapid change
in intracranial pressure while the head is being born and keeps the
head from “popping out,” causing maternal perineal trauma
• Newborn: establish airway (eg, position head slightly lower than chest
to drain mucus by gravity; rub back to initiate crying)
• Evaluation/outcomes
• Mother remains free from injury
• Newborn remains free from injury
Obesity
Overview
• Defined as body mass index of 25 or greater
• Increased risks before pregnancy of hypertension, diabetes
• More likely to require cesarean birth
• Alterations in dosing of analgesics make regional anesthesia desirable
• Prior bariatric surgeries can affect nutrient absorption, putting the fetus at
risk
Care management
• Furniture alterations needed
• Contraction and FHR monitoring can be difficult
• Mobility issues complicate care
• Postpartum risk of thromboembolism and wound disruption after
cesarean
Application and review
1. A primigravida is concerned about the health of her baby and asks the
nurse, “What is the most common cause of death of babies?” The nurse
explains that the cause of more than half of the neonatal deaths in the
United States is due to what?
1. Atelectasis
2. Preterm births
3. Congenital heart disease
4. Respiratory distress syndrome
2. A client arrives at the clinic in preterm labor, and terbutaline is prescribed.
For what therapeutic effect should the nurse monitor the client?
1. Increased blood pressure and pulse
2. Reduction of pain in the perineal area
3. Gradual cervical dilation as labor progresses
4. Decreased frequency and duration of contractions
3. Despite medication, a client’s preterm labor continues, her cervix dilates,
and birth appears to be inevitable. Which medication does the nurse
anticipate will be prescribed to increase the chance of the newborn’s
survival?
1. Fenoterol
2. Misoprostol
3. Terbutaline
4. Betamethasone
4. A client who is at 26 weeks’ gestation tells a nurse at the prenatal clinic
that she has pain when urinating, back tenderness, and pink-tinged urine.
A diagnosis of pyelonephritis is made. What is the most important
nursing intervention at this time?
1. Limiting fluid intake
2. Examining her urine for protein
3. Observing for signs of preterm labor
4. Maintaining her on a moderate-sodium diet
5. A client asks the nurse at the prenatal clinic whether she can continue to
have sexual relations while pregnant. What is an indication that the client
should refrain from intercourse during pregnancy?
1. Fetal tachycardia
2. Presence of leukorrhea
3. Premature rupture of membranes
4. Being close to expected date of birth
6. An expectant couple asks the nurse about the cause of low back pain in
labor. The nurse replies that this pain occurs most often when the position
of the fetus is what?
1. Breech
2. Transverse
3. Occiput anterior
4. Occiput posterior
7. During an emergency birth the fetal head is crowning on the perineum.
How should a nurse support the head as it is being born?
1. Apply suprapubic pressure
2. Place a hand firmly against the perineum
3. Distribute the fingers evenly around the head
4. Maintain pressure against the anterior fontanel
See Answers on pages 206-208.
Obstetric procedures
Version
• Turning of fetus; can be external or internal
• Ultrasound rules out placenta previa and insufficient size of maternal
pelvis; checks amniotic fluid levels, gestational age and anomalies; locates
umbilical cord; determines fetal position
• External: gentle constant pressure (60%–75% are successful)
• Contraindications include CPD, oligohydramnios, multifetal pregnancy,
nuchal cord, and others
• Nurse monitors FHR and pattern during external version procedure, as
well as maternal vital signs
• Moxibustion of acupuncture point next to fifth toenail shows improved
rate of spontaneous version
• Rh-negative unsensitized women should receive Rh immune globulin
because version can cause fetomaternal bleeding
• Internal
• Health care provider uses hand inside uterus to change presentation
• Used rarely; sometimes to deliver second twin
• Nurse monitors status of fetus during procedure
Induction of labor
• Chemical or mechanical induction of labor before spontaneous onset
• Elective induction (initiation of labor)
• Performed when continued pregnancy is a danger to woman or fetus
■ When intrauterine environment could harm fetus or evidence of fetal
jeopardy
■ PROM
■ Postterm pregnancy
■ Chorioamnionitis
■ Hypertension in pregnancy
■ Additional maternal conditions that worsen with continued
pregnancy: diabetes, pyelonephritis, Rh incompatibility, hydramnios,
placental insufficiency, history of precipitate birth
■ Fetal death
• Gestational age should be determined first, as well as any risks to
woman or fetus; not to be initiated until 39 weeks or more
• Contraindications are those that are contraindications to labor and
vaginal birth: CPD, malpresentation of fetus, nonreassuring signs of
fetal status or inability to adequately monitor fetal status, placenta
previa, vasa previa, previous cesarean with incision that prohibits trial
of labor
• Risks: increased cesarean delivery, increased neonatal morbidity, cost
• Pharmacologic (chemical)
■ Prostaglandin: vaginal insertion of E1 (eg, misoprostol) or E2 (eg,
dinoprostone) to promote cervical softening (ripening; see later) and
effacement
■ Oxytocin: intravenous infusion approximately 8 to 12 hours after
prostaglandin administration to stimulate contractions (less effective
at cervical ripening)
■ Can be used to induce labor or augment labor that is progressing
slowly if cervix is ripe; more effective at augmentation than
induction
■ Risks are dose related; include uterine tachysystole; if contractions
occur more frequently than every 2 minutes, the infusion should be
stopped and the FHR and pattern checked to assess fetal status,
then check if contractions have diminished and notify health care
provider; oxygen administration may be indicated
■ Oxytocin is structurally related to vasopressin, so it may decrease
diuresis, resulting in water intoxication
• Mechanical
■ Artificial rupture of membranes (AROM) (amniotomy) can be used if
cervix is favorable to induce labor or to augment labor if progress is
slow; used if presenting part is engaged
■ Risk is that if labor does not begin, chorioamnionitis may occur
■ Active herpes infection is contraindication
■ Progressive cervical dilation and effacement are anticipated
■ Nipple massage to stimulate secretion of oxytocin from posterior
pituitary gland
• Nursing care of women during induction or stimulation of labor
• Assessment/analysis
■ Obstetric history, estimated date of birth
■ Maternal status (eg, contractions, status of membranes, status of
cervix, ultrasound findings, level of anxiety)
■ Fetal status (eg, gestational age, absence of CPD or other problems,
position, results of fetal monitoring and NST)
• Planning/implementation
■ Prepare mother and labor coach for induction (eg, explain all
procedures, obtain informed consent)
■ Obtain and record baseline information: maternal vital signs, FHR
and pattern, contractions for later comparison
■ Continue to monitor vital indices
■ Monitor oxytocin administration
■ Administer piggybacked through infusion device; titrated
according to contraction pattern and fetal response
■ Discontinue: sustained uterine contraction; persistent fetal
decelerations; signs of placenta previa or abruptio placentae
■ Assist with AROM (amniotomy)
■ Maintain asepsis
■ Assess FHR immediately after rupture
■ Observe color, odor, consistency, and amount of amniotic fluid
■ Record time of rupture (prolonged time after rupture may
predispose to sepsis)
■ Monitor woman’s temperature
○ Maintain hydration
○ Provide for blood typing, Rh compatibility, crossmatching
○ Have oxygen, suction, and resuscitation equipment available
○ Prepare for emergency cesarean birth if necessary
• Evaluation/outcomes
■ Progresses through labor to safe birth of newborn
■ Remains free from complications
• Cervical ripening
• Chemical or mechanical
■ Chemical: application of prostaglandin E2 or misoprostol to soften
cervix; possible stimulation of uterine tachysystole with abnormal
heart rate
■ Mechanical: intracervical balloon insertion, filled with sterile water to
put pressure on and stretch the cervical os; balloon falls out when
dilation reaches ∼3 cm; dilation stimulates release of endogenous
prostaglandins; safer than prostaglandin E2 and misoprostol; also
used are hygroscopic dilators that absorb water and expand
• Advantages: decreased oxytocin induction time
• Scoring systems exist (such as Bishop Scoring System) to determine
whether success is likely
• Amniotic membrane stripping or sweeping is used to release
prostaglandins and oxytocin; appropriate after 39 weeks to speed onset
of spontaneous labor
• Nursing care: document procedures; assess for urinary retention,
membrane rupture, uterine tenderness/pain, contractions, bleeding,
infection, fetal distress
Augmentation of labor
• Augmentation of labor: promotes labor when it is not progressing
(prolonged labor); employs pharmacologic or mechanical means; see
earlier for descriptions of oxytocin administration and amniotomy
Operative vaginal birth
• Device is used to shorten second stage of labor and facilitate birth
• Forceps assisted
• Forceps: instrument applied to fetus’ head or presenting part, allowing
health care provider to control the birth
• Indications: prolonged second stage (ineffective pushing), some fetal
malpositions, fetal distress, large infants, and women with heart
disease
• Requirements: cervix must be dilated fully, bladder should be empty,
presenting part engaged, membranes ruptured, maternal pelvis
adequate (no CPD)
• Nursing care
■ Obtain the forceps chosen by the physician
■ Keep the woman informed; after birth, assess mother for lacerations,
urinary retention, hematoma; assess infant for bruising, facial palsy,
subdural hematoma
• Vacuum assisted
• Also called vacuum extraction: cup is placed on fetus’ head or presenting
part; applied suction promotes descent; newborn may develop caput
succedaneum, but is otherwise unharmed
• Same indications as forceps assisted; same requirements and vertex
presentation
• Takes less anesthesia than forceps and easier to place
• Risks to fetus: cephalhematoma, lacerations, subdural hematoma
• Maternal risks: lacerations and soft tissue hematomas
■ Nursing care
■ Keep woman informed and supported; continue encouragement in
active birth process
■ Continue to assess FHR during procedure
■ Document the procedure
■ Inform woman, partner, and caregivers that caput succadeneum
usually disappears within 5 days, but give signs for which they
should alert health care provider
Cesarean birth
• Birth of infant via abdominal incision, usually transverse incision of lower
uterine segment, to preserve maternal and fetal well-being
• Indications: CPD, dystocia, placenta previa, abruptio placentae, congenital
anomalies, growths within birth canal, hypertensive disorders,
nonreassuring fetal heart pattern, active herpes, maternal HIV,
malpresentations (eg, breech, shoulder), previous cesarean birth,
maternal conditions of increased intracranial pressure, maternal
respiratory disease, certain maternal cardiac diseases, some congenital
anomalies
• Potential complications and risks
• Maternal infection, hemorrhage, urinary tract trauma, thrombophlebitis
or thromboembolism, paralytic ileus, atelectasis, anesthesia
complications
• Fetal risks include unintended preterm birth (with associated lung
immaturity), transient tachypnea, pulmonary hypertension, injury
including lacerations
• Few contraindications: maternal coagulation conditions, fetal death or
fetus that is too immature to survive
• Elective is cesarean on request; risks include longer hospital stay and cost,
increased respiratory problems for infant, greater complications in
subsequent pregnancies; not performed until at least 39 weeks; not
available if woman desires several additional children because risks
increase with each child born via cesarean
• Scheduled if labor and vaginal birth are contraindicated, birth is needed
but cannot be induced, chosen based on previous cesarean
• Unplanned cesarean has greater psychologic consequences; little time to
plan or explain because must be done quickly
• Woman may refuse a cesarean, but health care providers are obligated
to protect the mother and fetus; providers make every effort to give
information about the necessity, but may need to get a court order to
allow cesarean; this situation is termed forced cesarean birth
• Anesthesia
• Epidural is commonly used, but may also include spinal and general
anesthesia
• Type of anesthesia depends on woman’s medical conditions
• Preoperative care
• Provider discusses with woman and family the need for cesarean birth
and expected prognosis
• Anesthesia provider assesses cardiovascular status
• If elective, blood tests are usually done days ahead or on arrival
• Assessment/analysis
■ Vital signs, FHR and pattern
• Planning/implementation
■ Ensure consent is signed; keep client and partner informed
■ Obtain specimens for laboratory tests (if not already performed)
■ Prepare for surgery (eg, arrange for operating room, insert urinary
catheter)
■ Equipment prepared for infant
• Intraoperative care
• Woman is positioned (usually with wedge) so uterus is displaced
laterally
• Catheter is placed; legs are strapped to ensure positioning
• Team confers on preoperative checklist items
• Nurse communicates with partner if partner not present; nurse updates
woman if she is awake
• Additional nurse present to provide infant care
• Infant may be placed on mother for skin-to-skin contact or given to
partner to hold
• If infant condition is compromised, infant is taken to neonatal intensive
care unit; once stabilized, to neonatal unit
• Physician reports to family
• Immediate postoperative care
• Mother in postanesthesia recovery unit
• Nurses follow postsurgical protocols:
■ Airway maintenance, vital signs
■ Dressing status: intact, presence of bleeding
■ Status of incision: REEDA (no Redness, Edema, Ecchymosis, or
Discharge and well Approximated)
■ Fundus and lochia: one or two pads may be saturated during first
hour after birth; usually less than after a vaginal birth
■ IV intake, possibly with oxytocin
■ Urinary output: amount, specific gravity, presence of blood
■ Promote lung aeration (eg, deep breathing and coughing, incentive
spirometer)
■ Presence of pain; medications administered before it becomes severe
■ Initial breastfeeding; note response to neonate
■ Woman is discharged from postanesthesia recovery when alert,
oriented, and able to feel and move extremities
• Postoperative care
• Standard care
■ Monitor vital signs, fundal height and tone, abdominal incision
■ Maintain IV infusion of oxytocin if prescribed
■ Administer analgesics as prescribed
■ Maintain fluid and electrolyte balance; monitor I&O
■ Encourage early ambulation once catheter is removed to prevent
circulatory stasis and promote peristalsis
■ Gradual return to oral intake: clear liquids, full liquids, then solid
food to promote peristalsis (prevents distention) when bowel sounds
have returned
• Assist with parent and newborn bonding and attachment; encourage
touching; include father in process; offer emotional support
• Support early breastfeeding if desired
• Nursing interventions
• Daily: perineal care, breast care, routine hygiene
• Additional: vital signs, incision, lochia, breath and bowel sounds,
circulatory status of lower extremities, urinary/bowel elimination
• Emotional status and attachment with infant
• Teach postpartum care regarding surgery recovery, including alternative
positions for breastfeeding that do not disturb the incision
• Discharge teaching; usually third postpartum day; sometimes home
care is an option
• Evaluation/outcomes
• States relief from pain
• Maintains urinary and fecal elimination
• Remains free from complications
• Parents demonstrate attachment behaviors with newborn
Trial of labor
• Observance of a woman and fetus for 4 to 6 hours of spontaneous active
labor to determine the safety of vaginal birth
• May be appropriate for abnormal presentation or position, or if mother’s
pelvic size or shape is questionable, or if a vaginal birth after cesarean
section (VBAC) is being considered
• Evaluation during labor includes adequate contractions, engagement and
descent of fetus, cervical effacement and dilation, FHR and pattern
• If signs of a potential problem occur, nurse notifies health care provider,
takes action, monitors maternal and fetal responses and documentation
• Nurse supports woman and her partner, provides information
Vaginal birth after cesarean
• An alternative for women who had a transverse uterine incision for a
previous cesarean birth
• Each pregnancy may have different variables that make this attempt
possible or impossible
• Requirements before consideration:
• One or two cesarean births IF they were low-transverse incisions
• Maternal pelvis adequate
• No other uterine scars or history of rupture
• Physicians who can perform an emergency cesarean section are
immediately available throughout labor
• Success rate is 60% to 80%; prior indication for cesarean influences the
success rate
• Major risk is uterine rupture
• Advantage: if VBAC is successful, woman has less hemorrhage and
infection and shorter recovery
• Contraindications
• Previous classic or “T” incision
• Previous uterine rupture
• Other complications that preclude vaginal delivery
• Inform and support woman during pregnancy about her options.
Obstetric emergencies
Shoulder dystocia
• Head is born, but anterior shoulder cannot pass under pubic arch; caused
by fetopelvic disproportion related to excessive fetal size (>4000 g) or
maternal pelvic abnormalities; also associated with prolonged second
stage of labor and shoulder dystocia with a previous birth
• Nurse may observe head retracting into perineum after being born
(turtle sign)
• Newborn: may experience asphyxia, birth injuries (eg, brachial plexus
damage, fracture of humerus or clavicle)
• Mother: may experience trauma (eg, lacerations, rectal injuries, extension
of episiotomy); postpartum hemorrhage is a risk
• Care management:
• Be prepared at every birth with a planned sequence of interventions
• Stay calm and call for assistance
• Position mother to facilitate birth (eg, legs flexed apart with knees on
abdomen [McRoberts maneuver; this position preferred with epidural
anesthesia], hands-and-knee position [Gaskin maneuver], squatting,
lateral recumbent)
• Document maneuvers and time; provide encouragement
Prolapsed umbilical cord
• Cord lies below the presenting part; may be occult (hidden)
• Interruption of blood flow through the cord slows fetal oxygenation; may
cause death
• Monitor for prolapsed cord; signs include variable or prolonged
deceleration during contractions, woman reports feeling the cord after
rupture of the membranes, cord is seen or felt in the vagina
• If it occurs:
• Push call button; have others call health care provider
• With a sterile gloved hand, push presenting part off cord; keep hand
there holding the part off the cord
• Place in Trendelenburg position (or modified Sims or knee-chest
position) to keep presenting part away from cord
• Administer oxygen to woman; start IV fluids or increase drip rate
• Keep prolapsed cord moist with sterile saline
• Continue to monitor FHR; continue to communicate with woman and
support persons
• Prepare for immediate vaginal birth if cervix is fully dilated or cesarean
if it is not
Rupture of the uterus
• Life-threatening injury of a nonsurgical opening in all uterine layers
• Major risk factor is scarred uterus (myomectomy or previous cesarean
birth); additional risk factors are induced birth (can cause tachysystole of
uterus)
• May occur before or during labor, at home or at the hospital
• Types
• Complete
• Incomplete or uterine dehiscence = separation of a prior scar; may go
unnoticed
• Signs and symptoms vary with severity
• Fetal bradycardia that may or may not have variable or late
decelerations is the most common sign
• Loss of fetal station
• Woman can have constant pain, change in uterine shape, stopping of
contractions; may have shock because of hemorrhage
• Management
• Incomplete or small rupture may require laparotomy, birth of infant,
repair of rupture, blood transfusions
• If rupture is too large to repair or if woman is unstable
hemodynamically, may require hysterectomy
• Nursing care
• Start IV fluids, transfuse blood products, administer oxygen, assist with
preparations for surgery
• Support family and provide information; suggest contact of spiritual
support
• Prepare for risk of fetal or maternal death
Amniotic fluid embolus
• Also called anaphylaxis of pregnancy or anaphylactoid syndrome of pregnancy
• Amniotic fluid is drawn into woman’s circulation and carried to the lungs.
Theory is that fetal particles obstruct pulmonary vessels.
• Signs: sudden acute hypoxia/respiratory distress, hypotension,
cardiovascular collapse; disseminated intravascular coagulopathy can
follow; signs are similar to anaphylactic or septic shock; diagnosis is
clinical
• Interventions
• Administer oxygen, prepare for intubation
• Cardiopulmonary resuscitation (CPR), assist or initiate
• Position woman on her side if CPR is successful; administer IV fluids
and blood products; correct coagulation defects
• Insert indwelling catheter; monitor output
• Once woman is stabilized, prepare for emergency birth
• If cardiac arrest, immediate cesarean is indicated
• Provide support to partner and family
Application and review
8. A client has been receiving oxytocin to augment labor. For what adverse
reaction caused by a prolonged oxytocin infusion should the nurse
monitor the client?
1. Change in affect
2. Hyperventilation
3. Water intoxication
4. Elevated temperature
9. A client is admitted to the birthing unit in active labor. An amniotomy is
performed. What physiologic change does the nurse expect to occur after
the procedure?
1. Diminished vaginal bleeding
2. Less discomfort with contractions
3. Progressive dilation and effacement
4. Increased maternal and fetal heart rates
10. A client is receiving an IV piggyback infusion of oxytocin to augment
labor. The nurse identifies that there have been three contractions lasting
80 to 90 seconds that are less than 2 minutes apart. There is a specific
protocol that is followed in response to this observation. List in order of
priority the nursing actions that should be taken.
1. _____ Check the fetal heart rate.
2. _____ Stop the piggyback infusion.
3. _____ Notify the health care provider.
4. _____ Administer oxygen via face mask.
5. _____ Document maternal/fetal responses.
6. _____ Determine whether the contractions have diminished.
11. A client is admitted to the birthing unit in active labor. Cervical dilation
has progressed from 2 to 3 cm during an 8-hour period. The health care
provider determines that she has hypotonic dystocia, and an infusion of
oxytocin is prescribed to augment her contractions. What is the most
important nursing action at this time?
1. Checking the perineum for bulging
2. Documenting the fetal heart rate and its variations
3. Preparing the client for an emergency cesarean birth
4. Monitoring the duration and intensity of the contractions
12. A client at 38 weeks’ gestation is admitted for induction of labor. Her
membranes ruptured 12 hours ago. There are no other signs of labor.
Which medication does the nurse anticipate will be prescribed?
1. Oxytocin
2. Estrogen
3. Ergonovine
4. Progesterone
13. A pregnant client with severe abdominal pain and heavy bleeding is
prepared for a cesarean birth. What is the priority nursing intervention?
1. Teaching coughing and deep-breathing techniques
2. Sterilizing the surgical site and administering an enema
3. Providing a sterile gown and inserting an indwelling catheter
4. Obtaining an informed consent and assessing for drug allergies
14. A client in labor at 39 weeks’ gestation is told by the health care provider
that she will need a cesarean birth. The nurse reviews the client’s prenatal
history. What preexisting condition is the most likely reason for the
cesarean birth?
1. Gonorrhea
2. Chlamydia
3. Chronic hepatitis
4. Active genital herpes
15. What is the safest position for a woman in labor when a nurse observes a
prolapsed cord?
1. Prone
2. Fowler
3. Lithotomy
4. Trendelenburg
See Answers on pages 206-208.
Answer key: Review questions
1. 2 About two thirds of neonatal deaths are associated with preterm births;
there appears to be a correlation with teenage and older-age pregnancies,
lack of prenatal care, women who are nonwhite, and those who have
chronic health problems.
1 Atelectasis may occur from respiratory distress, which in turn is
associated with preterm births, the leading cause of death. 3 Most
infants who die of congenital heart disease die after the neonatal
period. 4 Respiratory distress syndrome is one complication of a
preterm birth.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Nursing Process: Planning/Implementation
2. 4 Terbutaline sufate is a beta-mimetic that acts on the smooth muscles of
the uterus to reduce contractility, which in turn inhibits dilation and the
frequency and duration of contractions.
1 Although terbutaline may increase blood pressure and pulse, this is a
side, not a therapeutic, effect requiring frequent assessments. 2
Terbutaline is not an analgesic. 3 Terbutaline should stop cervical
dilation, rather than increase it.
Client Need: Pharmacological and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes
3. 4 Betamethasone enhances fetal lung maturity when administered before
a preterm birth.
1 Fenoterol is a tocolytic agent used to prevent preterm birth; this birth is
inevitable. 2 Misoprostol is used for labor induction. 3 Terbutaline is a
tocolytic agent used to prevent preterm birth; this birth is inevitable.
Client Need: Pharmacological and Parenteral Therapies; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation
4. 3 Pyelonephritis often causes preterm labor, leading to increased neonatal
morbidity and mortality.
1 Fluids should be increased; the inflammatory process may lead to fever,
dehydration, and an accumulation of toxins. 2 Proteinuria occurs with
preeclampsia; the client’s signs and symptoms are indicative of a
kidney infection. 4 A moderate-sodium diet is not relevant to the
client’s problem.
Client Need: Physiological Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
5. 3 Ruptured membranes leave the products of conception exposed to
bacterial invasion. Intact membranes act as a barrier against organisms
that may cause an intrauterine infection.
1 Fetal tachycardia may occur during sex, but there is no evidence
indicating that it is harmful for the fetus. 2 Leukorrhea is common
because of increased production of mucus containing exfoliated vaginal
epithelial cells; intercourse is not contraindicated. 4 Intercourse is not
contraindicated if membranes are intact; modification of sexual
positions may be needed because of the enlarged abdomen.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
6. 4 A persistent occiput posterior position causes intense back pain because
of fetal compression of the maternal sacral nerves.
1 Breech positions are not associated with back pain. 2 The transverse
position usually does not cause back pain. 3 Occiput anterior is the
most common fetal position and does not cause back pain.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
7. 3 Distribution of the fingers around the head will prevent a rapid change
in intracranial pressure while the head is being born and keeps the head
from “popping out,” causing maternal perineal trauma.
1 Applying suprapubic pressure will not assist with the birth of the head.
2 Placing a hand firmly against the perineum may interfere with the
birth and harm the neonate. 4 Maintaining pressure against the
anterior fontanel could injure the neonate.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Nursing Process: Planning/Implementation
8. 3 Oxytocin, a posterior pituitary hormone, has an antidiuretic effect, acting
to reabsorb water from the glomerular filtrate.
1 Affect is not altered by oxytocin. 2 Hyperventilation is caused by
inappropriate breathing patterns, not by prolonged use of oxytocin. 4
Fever occurs with infection or dehydration, not with prolonged use of
oxytocin.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Pharmacological and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes
9. 3 An amniotomy allows for more effective pressure of the fetal head on
the cervix, enhancing dilation and effacement.
1 Vaginal bleeding may increase because of the progression of labor. 2
Discomfort may increase because contractions usually become more
intense after an amniotomy. 4 An amniotomy should not affect
maternal or fetal heart rates.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
10. Answer: 2, 1, 6, 3, 4, 5
2 The nurse should first stop the oxytocin infusion when tetanic
contractions occur; this should relax the uterus and prevent uterine
tetany and rupture. 1 The FHR should be checked to determine the
effect of the tetanic contractions on the fetus. 6 After the FHR is
assessed then the maternal response to the interruption of the infusion
should be assessed. 3 After these measures, the primary caregiver
should be notified. 4 Fetal well-being will be improved when oxygen is
administered. 5 After emergency measures have been taken, the
maternal/fetal responses should be documented.
Client Need: Pharmacological and Parenteral Therapies; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation
11. 4 Oxytocin increases the intensity and duration of contractions;
prolonged (tetanic) contractions will jeopardize the safety of the fetus and
necessitate discontinuing the drug.
1 A bulging perineum indicates that there is complete cervical dilation
and birth is imminent; because cervical dilation is only 2 to 3 cm, a
bulging perineum is not expected. 2 Documenting the fetal heart rate
and its variations is important throughout labor. 3 There is no
indication at this time that a cesarean birth is necessary.
Client Need: Pharmacological and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Planning/Implementation
12. 1 Oxytocin is a small polypeptide hormone synthesized in the
hypothalamus and secreted from the neurohypophysis (posterior
pituitary gland) during parturition or suckling; it promotes powerful
uterine contractions and thus is used to induce labor.
2 Estrogen suppresses the follicle-stimulating and luteinizing hormones,
thus helping to maintain the pregnancy. 3 Ergonovine can lead to
sustained contractions, which is contraindicated during labor; it may be
prescribed in the postpartum period to promote or maintain a
contracted uterus. 4 Progesterone causes hyperplasia of the
endometrium in preparation for implantation of the fertilized ovum;
later it helps to maintain the pregnancy.
Client Need: Pharmacological and Parenteral Therapies; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation
13. 4 In an emergency surgical situation when invasive techniques are
necessary, it is important to have a consent signed, as well as a history of
the client’s known allergies.
1 Teaching coughing and deep-breathing techniques is not a priority in an
emergency such as this. 2 In an emergency sterilizing the surgical site is
done in the operating room; an enema usually is not given before a
cesarean, especially to a bleeding client, because it may stimulate
contractions and further bleeding. 3 In an emergency, providing a
sterile gown and inserting an indwelling catheter are done in the
operating room.
Client Need: Management of Care; Cognitive Level: Analysis; Nursing
Process: Planning/Implementation
14. 4 Once the membranes have ruptured, the active herpes infection
ascends and can infect the fetus; because herpes does not cross the
placenta, a cesarean birth prevents transfer of the virus to the fetus.
1 Gonorrhea is not an indication for a cesarean birth; treatment is
pharmacologic. 2 Chlamydia is not an indication for a cesarean birth;
treatment is pharmacologic. 3 Chronic hepatitis is not an indication for
a cesarean birth; treatment is pharmacologic.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
15. 4 A position in which the mother ’s head is below the level of the hips
helps decrease compression of the cord and therefore maintains the blood
supply to the fetus.
1 Prone position is impossible to maintain and will not relieve the
pressure of the oncoming head on the cord. 2 Fowler position will
increase the pressure of the presenting part on the cord. 3 The pressure
of the presenting part on the cord is not relieved in the lithotomy
position. Also, pressure on the vena cava will ultimately decrease
placental perfusion.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Nursing Process: Planning/Implementation
C H AP T E R 1 3
Postpartum physiologic changes
Puerperium
• The 6-week period after birth during which reproductive organs undergo
physical and physiologic changes
• Emotional changes as responsibilities of parenthood take hold
• Additional body systems also undergo changes
• Trend is to increase this period to 3 months and rename it fourth
trimester of pregnancy
Reproductive system and associated structures
Uterus
• Weight of the uterus at term is ∼1000 g, or 10 to 20 times the nonpregnant
uterus
• Decreases to 500 g in 1 week to ∼350 g the second week
• Involution process
• Involution is the uterus’s gradual return to its nonpregnant state over
∼6 weeks
• Caused by sudden decrease in estrogen and progesterone
• Oxytocin released during breastfeeding enhances involution
• Involution follows a one-fingerbreadth descent daily
• Fundus cannot be felt by day 9 to 10
• Subinvolution is the term meaning that the uterus did not return to its
nonpregnant state
• Uterine cavity easily accessible to microorganisms from exterior
• Unique process that allows healing of placental site without scarring
• Necrotic tissue is sloughed off; reparative process ensures future
fertilized ova will implant in an unscarred uterus
• Contractions
• Contraction causes involution and promotes hemostasis
• Afterpains, especially in multiparas, may cause discomfort necessitating
analgesics
• Placental site
• Placental attachment site is like an open wound
• It is the last area of the uterus to heal (around 6 weeks)
• Lochia: vaginal discharge after birth changes from rubra (red; 1 to 3 days)
to serosa (reddish brown; 3 to 27 days), then becomes alba (yellow-white;
usually 10 to 14 days postpartum); lochia occurs after vaginal and
cesarean deliveries, so perineal care is needed for all postpartum women
• Breastfeeding does not affect the duration of lochia, but increases the
flow
• However, a continuous trickle of blood indicates continuous bleeding
• Often there is a temporary increase between days 7 and 14 indicating
the slough of the area that had covered the placental attachment; if it
does not subside in 1 to 2 hours, the patient should be evaluated for
possible retained placental fragments. Ultrasound examination may be
helpful in establishing retained tissue.
• Malodorous lochia may indicate infection
Cervix
• Immediately after birth, the cervix is soft, looks bruised, and has
lacerations, potentiating infection
• The cervical os closes gradually (down to 2 to 3 cm at day 2 to 3
postpartum, down to 1 cm by 1 week); does not regain its prepregnancy
circular shape; instead it appears like a jagged slit
• The cervix shortens and becomes more firm within 2 to 3 days postpartum
• Regression of the histologic cervical growth that occurred during
pregnancy is evident within 4 days after delivery
• By 6 weeks postpartum, most of the changes have resolved
• Lactation delays the production of cervical mucus
Vagina and perineum
• Vagina
• At first appears bruised and edematous
• Returns almost to its prepregnant appearance (rugae return but are not
as prominent) in ∼3 weeks through healing of soft tissue
• Returns to prepregnant form in ∼6 weeks
• Thickening of vaginal mucosa returns with ovarian function
• Perineum
• Often edematous and bruised after delivery
• May be difficult to visualize episiotomy unless positioning is favorable
(lithotomy)
■ Healing of episiotomy is the same as any surgical incision; most
complete in 3 weeks, but may take a total of 4 to 6 months
Menstruation
• Occurs on average at 7 to 9 weeks after birth in nonlactating mothers and
in most nonlactating women by 12 weeks; up to 24 weeks in breastfeeding
mothers, although it can sometimes take longer
• First menses is usually anovulatory, but birth control should still be used
Endocrine system
Estrogen and progesterone
• Rapid decrease of estrogen and progesterone (produced by placenta) after
placental expulsion
• Estrogen levels fall immediately after delivery and remain low in lactating
women
• In nonlactating women, estrogen levels begin to rise 2 weeks after delivery
• Human chorionic gonadotropin levels drop quickly, but may be detected
up to 4 weeks after birth
Metabolic changes
• Decreases in multiple hormones after birth result in lower blood glucose
levels, making gauging of glucose tolerance difficult in the first days
• Basal metabolic rate stays elevated for 1 to 2 days after birth
Pituitary hormones and ovarian function
• Prolactin rises throughout pregnancy and further after birth; prolactin
promotes milk production and ejection
• Influenced by breastfeeding frequency and duration and whether
supplementary feedings are used
• In nonbreastfeeding women, prolactin levels decline to prepregnant
levels within 3 weeks
• Oxytocin triggers let-down reflex with milk ejection as infant suckles
• Luteinizing hormone of anterior pituitary activated after placenta is
expelled
• Follicle-stimulating hormone (FSH) levels are identical in lactating and
nonlactating women; ovary does not respond to FSH with the raised
prolactin levels
• Ovulation may return within a month
• Average nonlactating woman ovulates 70 to 75 days after delivery,
usually within 3 months
• Average lactating woman ovulates 6 months after delivery; prolactin
secretion inhibits ovulation
Thyroid
• Thyroid volume increases ∼30% during pregnancy and returns to normal
gradually over 12 weeks postpartum
• Thyroid hormone levels return to normal within 4 weeks
• For those taking thyroid medication, levels can be checked at 6 weeks to
adjust dosage
• Postpartum thyroiditis occurs in ∼10% of women; risk is increased with all
types of diabetes
• Thyroid function studies are appropriate in women who develop
postpartum depression 2 to 3 months after delivery
• Hyper- and hypothyroidism can both be treated during breastfeeding
Breasts
• Temporary breast engorgement in both breastfeeding and
nonbreastfeeding mothers occurs on second or third day; caused by
vasodilation before lactation
• Resolves spontaneously in 24 to 48 hours
• Supportive bra is indicated
Breastfeeding mothers (see also chapter 18)
• Little change in first 24 hours; colostrum can be expressed
• Transition to mature milk at 72 to 96 hours after delivery
• Prolactin secretion stimulates milk production, inhibits ovulation
• Posterior pituitary releases oxytocin that initiates let-down reflex with
milk ejection as infant suckles
• Breasts can feel lumpy when glands and ducts fill with milk, but these
lumps can shift position unless those of fibrocystic breast disease or
cancer
Nonbreastfeeding mothers
• Breasts may be tender on postpartum day 2 or 3
• Nonnursing mothers: absence of suckling inhibits oxytocin and prolactin
release; let-down reflex diminishes, inhibiting milk production
• Ice packs and mild analgesics can be used for engorgement
• Lactation ceases within a week or less if suckling and milk expression is
not begun
Weight loss
• Despite the estimate of 10 to 13 lb (4.5 to 6 kg) being lost during delivery,
that loss may not be evident for 1 to 2 weeks after delivery because of
fluid retention
• Physiologic stress of labor and delivery activates antidiuretic hormone,
which leads to short-term sodium and water retention
• Most postpartum weight is lost in first 3 months, with additional loss in
the second 3 months
• Only approximately one-fourth of women have returned to
prepregnancy weight at 6 weeks postpartum
• Women who returned to prepregnancy weight in 6 months are more
likely to have gained less weight at 5 to 10 years’ follow-up
• Breastfeeding and aerobic exercise are both associated with significantly
less weight gain over time
Urinary system
Components
• Dilation of the collecting system in pregnancy returns to normal at 6
weeks postpartum
• Return to prepregnancy functional level (glomerular filtration rate and
creatinine clearance) occurs by 8 weeks
• However, renal plasma flow remains decreased from the third trimester
through at least 24 weeks; normal values in the study returned by 50 to 60
weeks after delivery. Hence, because of changes in renal clearance,
medication levels may need to be rechecked at 4 to 6 weeks postpartum.
• Lactose in urine from lactogenic hormone may occur in breastfeeding
women, but glycosuria usually resolves within 1 week
• Nitrogen excretion increases from breakdown of the extra uterine tissue
• Composition returns to normal in ∼6 weeks
Fluid loss (see also weight loss earlier)
• Diuresis and diaphoresis (see Integumentary System later) account for ∼5
lb (2.3 kg) of weight loss
• Urinary output: increases from second to fifth postpartum day (diuresis);
may lose up to 3 L/day
• Urethra and bladder
• Prolonged labor and epidural anesthesia diminish postpartum bladder
function temporarily
• May have been traumatized by delivery
• Anesthetic agents can impede urination (see also Fluid Loss earlier)
• Decreased urge to void + physiologic diuresis can result in bladder
distension, which displaces the uterine fundus superiorly and to the right
• Retention: diminished bladder tone during pregnancy may result in small,
frequent voidings indicating retention with overflow
• Bladder tone usually returns in 5 to 7 days
• Stress incontinence can occur because of tissue trauma.
Application and review
1. A nurse examines a client who had a cesarean birth. It is 3 days since the
birth, and the client is about to be discharged. Where does the nurse
expect the fundus to be located?
1. 1 fingerbreadth below the umbilicus
2. 2 fingerbreadths below the umbilicus
3. 3 fingerbreadths below the umbilicus
4. 4 fingerbreadths below the umbilicus
2. When palpating a client’s fundus on the second postpartum day, a nurse
identifies that it is above the umbilicus and displaced to the right. What
does the nurse conclude?
1. There is a slow rate of involution.
2. There are retained placental fragments.
3. The bladder has become overdistended.
4. The uterine ligaments are overstretched.
3. A client gives birth to a baby weighing 7 pounds 2 ounces and has made
the decision to breastfeed. The nurse is instructing the client regarding
breastfeeding. What should the nurse tell the client to expect?
1. Weight loss will occur rapidly.
2. Lochial flow will be increased.
3. Uterine involution will be delayed.
4. Cold compresses will promote lactation.
4. Before discharge, what suggestion should the nurse give to a nonnursing
mother to help limit breast engorgement?
1. Wear a supportive brassiere.
2. Stop drinking milk for 1 week.
3. Take an analgesic every 4 hours.
4. Apply warm compresses to the breasts.
5. A client who had a cesarean birth is being discharged. What statement
indicates to the nurse that teaching is required?
1. “I may take a Percocet tablet if my incision hurts.”
2. “I should take a mild laxative if I don’t have a bowel movement.”
3. “I can begin mild exercises once my incisional pain has stopped.”
4. “I don’t need perineal care because I didn’t give birth through the
vagina.”
6. A nurse is assessing a postpartum client. What sign should alert the nurse
that the client is hemorrhaging?
1. Decrease in pulse rate
2. Increase in blood pressure
3. Continuous trickling of blood
4. Persistent muscular twitching
See Answers on pages 217-218.
Cardiovascular system
Cardiovascular system
Blood volume
• Rapid changes: plasma volume drops almost 1 liter after delivery,
replenished by the third day
• Lose ∼300 to 500 mL vaginal delivery; twice as much with cesarean
delivery
• Elimination of placenta and its circulation
• Rapid reduction of size of uterus
• Increase of blood flow to vena cava
• Mobilization of body fluids accumulated during pregnancy
• Plasma volume decreases over next few days because of diuresis (see later)
• Loss of placental endocrine function decreases vasodilation
• Blood volume: returns to prepregnant state in 3 weeks
Cardiac output (CO)
• CO increases through 24 weeks’ gestation, increases right after birth by
60% to 80%; can be a factor in women with previous heart disease.
Returns toward prepregnancy rates after delivery by weeks 6 to 8 in most
women; increases can still be evident 1 year after delivery.
• Point of maximal impulse and electrocardiogram (ECG) normalize after
birth
Vital signs
• Temperature: increases (not above 100.4° F) up to 24 hours after birth as
result of exertion and dehydration; thereafter fever may indicate infection
• Blood pressure
• Slight rise after delivery for 4 days postpartum, then returns to baseline
in weeks to months; a decrease suggests hemorrhage; increase suggests
gestational hypertension or preeclampsia
• Orthostatic hypotension can occur: pelvic blood flow resistance
decreases after delivery, decreasing blood pressure; woman may
complain of lightheadedness or dizziness or even faint. Instruct woman
to rise slowly to prevent.
• Pulse rate: rises immediately after delivery or rises for 30 to 60 minutes,
then decreases as a result of decreased cardiac effort and decreased blood
volume. Can drop to 40 to 60 beats/min = “puerperal bradycardia.”
Blood components
• Hematocrit level drops for 3 to 4 days, then returns to normal by 8 weeks
in most women
• Hematocrit can be lower with extensive blood loss
• Leukocytosis: White blood cells (WBCs) may increase to 30,000/mm3 if
labor was lengthy; average is 12,000/ mm3; normal levels return within 10
days postpartum
• Can make diagnosis of infection difficult in first postpartum days
• Blood fibrinogen levels and clotting factors increase in pregnancy and
remain high after birth; may lead to thrombus formation; if deep vein
thrombosis develops, heparin followed by warfarin may be prescribed
• Coagulability is increased during pregnancy and remains high for the
first 48 hours after delivery
• Changes in coagulation system plus vessel trauma and lack of exercise
in the puerperium lead to increased risk of thromboembolism,
especially after cesarean section. Frequent ambulation can decrease the
likelihood of thrombus formation.
• Dyspnea and tachypnea hallmark signs of pulmonary embolus
• Tests for thrombophilia and hemostasis should be delayed for 10 to 12
weeks
Varicosities
• Varicosities in the legs, vulva, and anus (hemorrhoids) are common
during pregnancy, but diminish rapidly after delivery to be completely or
nearly completely regressed in the postpartum period
Respiratory system
• Breathing is easier without gravid uterus (decrease in intraabdominal
pressure), which restores diaphragmatic excursion, but elasticity of the
rib cage may take months to return
Gastrointestinal system
• Hunger and thirst requiring oral nourishment to replace calories, protein,
and fluid lost during all stages of labor
• Constipation and abdominal distention: bowel movements delayed for
several days because of decreased peristalsis, stretched abdominal
muscles, decreased food intake during labor; soreness and swelling of
perineum from hemorrhoids and/or episiotomy; fear of pain
• Fiber, fluid, exercise helpful; stool softeners, suppositories, or enema
may be prescribed
• Woman usually has bowel movement within 3 days postpartum
• Women who had third and fourth-degree perineal lacerations that involve
the anal sphincter have a risk for postpartum anal incontinence, which
usually resolves within 6 months
Neurologic system
• Diminished carpal tunnel syndrome symptoms from decreased fluid
retention
• Headaches may continue postpartum for a variety of reasons; should be
investigated
• Emotional changes common due to rapid drop of estrogen and
progesterone (see also Chapter 7)
• Emotional lability, irritability, restlessness, and anxiety (postpartum
blues) during third to tenth day
• Postpartum blues common: starts a few days after delivery and lasts 1 to
2 weeks; include tearfulness, insomnia, lack of appetite,
disappointment
• Depression without psychotic features (postpartum depression); begins
by fourth week or within the first year (see also Chapter 7)
• Depression with psychotic features (postpartum psychosis); by second
week after birth; may have history of psychiatric disorder (eg, bipolar
disorder) (see also Chapter 7)
Musculoskeletal system
• Pelvic muscular support can be injured during delivery; Kegel exercises
are recommended
• Abdominal wall: soft, relaxed for first 2 weeks after birth; regains tone in
∼6 weeks, depending on previous tone, exercise, and amount of adipose
• Separation of abdominal muscles may occur, especially because of
multiple fetuses or a large fetus: “diastasis recti”; becomes less
apparent with time
• Ambulation helps abdominal muscle strength
• Relaxin hormone decreases after delivery, so ligaments and cartilage of
pelvis and entire skeleton (except for the feet) begin to return to
prepregnant state; back pain usually resolves in weeks to months
• Temporary, reversible decrease in bone mineralization resolves by 12 to 18
months postpartum; it is unaffected by calcium supplementation or
exercise
Integumentary system
• Postpartum diaphoresis
• Elimination of excess fluid (and wastes) through the skin
• Body’s way of getting rid of excess fluid accumulated during pregnancy
• Profuse diaphoresis occurs most often at night
• Melanocyte-stimulating hormone decreases rapidly, so pigmented skin
(eg, striae, linea nigra, darkened areolae) begins to fade; does not return
to nulliparous state
• Melasma (“mask of pregnancy”) remains in ∼30% of women, but usually
disappears during postpartum
• Spider nevi and erythema from estrogen lessen and usually disappear
• Striae gravidarum (stretch marks) fade but do not disappear
• Hair growth: more rapid hair turnover occurs for up to 3 months after
delivery, so more hair falls out with brushing, called telogen effluvium:
patients may need to be reassured that growth will return to normal in
few months
• Fingernails return to prepregnancy state
Immune system
• Mildly suppressed during pregnancy
• Gradual return to prepregnancy state
• Autoimmune disorders (such as systemic lupus erythematosus, multiple
sclerosis, and autoimmune thyroiditis [see earlier]) can have
exacerbations during the postpartum period
Application and review
7. A client on the postpartum unit asks why the nurses are always
encouraging her to walk. What should the nurse consider when forming a
response in language the client will understand?
1. Respirations are enhanced.
2. Bladder tonicity is increased.
3. Abdominal muscles are strengthened.
4. Peripheral vasomotor activity is promoted.
8. A nurse is assessing the apical and radial pulses of a postpartum client 3
hours after the birth of her second child. Which clinical finding does the
nurse expect?
1. Thready pulse
2. Slow heartbeat
3. Bounding pulse
4. Irregular heartbeat
9. During the postpartum period it is expected for women to have an
increased cardiac output. This knowledge should motivate a nurse who is
caring for a client with cardiac problems to monitor for what?
1. An irregular pulse
2. Respiratory distress
3. Hypovolemic shock
4. An increase in vaginal bleeding
10. A client’s temperature is 100.4° F 12 hours after a spontaneous vaginal
birth. What does the nurse suspect is the cause of the elevated
temperature?
1. Mastitis
2. Dehydration
3. Puerperal infection
4. Urinary tract infection
11. When palpating the fundus of a postpartum client, a nurse identifies
separation of the abdominal muscles. How should the nurse document
this finding?
1. Split fundus
2. Diastasis recti
3. Abdominus separatus
4. Ruptured abdominal muscle
12. What does a nurse expect when checking the vital signs of a client 1 day
after delivery?
1. Bradycardia with no change in respirations
2. Tachycardia with a decrease in respirations
3. Increased basal temperature with a decrease in respirations
4. Decreased basal temperature with an increase in respirations
13. After giving birth, a mother’s vital signs are T: 99.4° F; P: 80, regular; R: 16,
even; and BP: 148/92 mm Hg. Which vital sign should the nurse continue
to monitor?
1. Pulse rate
2. Respirations
3. Temperature
4. Blood pressure
14. A client has a cesarean birth. What is the most important nursing
intervention to prevent thromboembolism on the client’s first postpartum
day?
1. Provide oxygen therapy.
2. Administer pain medication.
3. Encourage frequent ambulation.
4. Recommend an increase in oral fluids.
See Answers on pages 217-218.
Answer key: Review questions
1. 3 The fundus descends one fingerbreadth per day from the first
postpartum day.
1 If the fundus were at 1 fingerbreadth below the umbilicus, the nurse
should suspect that involution has been delayed and further
investigation is required. 2 If the fundus were at 2 fingerbreadths below
the umbilicus, the nurse should suspect that involution has been
delayed and further investigation is required. 4 Although 4
fingerbreadths below the umbilicus is not expected, it is a benign
occurrence.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
2. 3 A distended bladder will displace the fundus upward and laterally to the
right.
1 A slow rate of involution is manifested by slow contraction and uterine
descent into the pelvis. 2 If there were retained placental fragments, in
addition to being displaced, the uterus would be boggy and vaginal
bleeding would be heavy. 4 From palpating a client’s fundus on the
second postpartum day, the nurse cannot make a judgment about
overstretched uterine ligaments.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
3. 2 Breastfeeding stimulates oxytocin release and uterine contractions,
resulting in increased lochia flow.
1 Weight loss may occur more slowly in the breastfeeding mother because
of increased nutritional and caloric intake. 3 The increased levels of
oxytocin and subsequent uterine contractions will enhance involution. 4
Although cold compresses applied to the breasts may ease the
discomfort of engorgement, they depress milk production. Warm
compresses are preferred for the breastfeeding mother.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
4. 1 Wearing a supportive brassiere provides greater comfort when
engorgement occurs 36 hours after birth; it lasts for about 1 to 2 days.
2 Milk and fluids should not be restricted during the postpartum period.
3 Medication will reduce pain but will not limit further engorgement. 4
Cold, not warm, compresses will limit further engorgement in the
nonnursing mother.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
5. 4 After a cesarean birth, the client has the same vaginal discharge (lochia)
as a client who gave birth vaginally. Perineal care is necessary to prevent
an ascending infection.
1 Oxycodone/acetaminophen or a similar analgesic usually is prescribed. 2
Mild laxatives are permitted if needed. 3 Mild exercise once the
incisional pain has stopped is not contraindicated.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes; Integrated Process:
Teaching/Learning
6. 3 Trickling of blood indicates continuous bleeding.
1 The pulse will increase, not decrease, with hemorrhage. 2 Blood
pressure will decrease, not increase, with hemorrhage. 4 Persistent
muscular twitching is not a sign of hemorrhage.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
7. 4 There is extensive activation of the blood clotting factors after a birth;
this, together with immobility, trauma, or sepsis, encourages
thromboembolization, which can be limited through activity.
1 Enhanced respiration can be accomplished by encouraging the client to
turn from side to side and to deep-breathe and cough. 2 Bladder tone is
improved by the regular emptying and filling of the bladder. 3 Exercise
during the next 6 weeks can strengthen the abdominal muscles.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
8. 2 The heartbeat can drop as low as 40 beats/min for up to 10 days after the
birth. It occurs because of the decreased blood volume and increased
stroke volume after the pregnancy has terminated.
1 A thready pulse may be a sign of postpartum hemorrhage with
impending shock. 3 A bounding pulse may be a sign of hypertension.
Although there may be a slight rise in blood pressure for several days,
hypertension is not expected. 4 An irregular heartbeat may be a sign of
cardiac decompensation that requires further investigation.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
9. 2 With the mobilization of extravascular fluid and the rapid decrease in
uterine blood flow, the heart of a client with a cardiac problem may begin
to fail. As the heart fails, the respiratory rate and effort increase in an
attempt to maintain oxygen to all body cells.
1 Although pulse rate is important, the primary assessment should be for
respiratory distress. 3 Signs of heart failure, not hypovolemic shock,
might develop if the respiratory distress is not treated. 4 Increased
vaginal bleeding is not caused by alterations in cardiac status.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
10. 2 A client’s temperature may be elevated to 100.4° F during the first 24
hours postpartum as a result of dehydration from the exertion and stress
of labor.
1 Mastitis usually develops after breastfeeding is established and milk is
present. 3 Puerperal infection usually begins with a fever of 100.4° F or
higher on 2 successive days, excluding the first 24 hours postpartum. 4
Urinary tract infections usually become evident later in the postpartum
period.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
11. 2 Diastasis recti refers to separation of the rectus muscle from the
abdominal wall; this can occur during pregnancy as the result of pressure
from the enlarging uterus.
1 The fundus is not split; the fundus is the body of the uterus. 3
Abdominus separatus is an incorrect term. 4 The abdominal muscle is
separated, not ruptured.
Clinical Area: Comprehensive Examination; Client Needs: Management
of Care; Cognitive Level: Comprehension; Nursing Process:
Assessment/Analysis; Integrated Process:
Communication/Documentation
12. 1 In the postpartum period, a slow pulse rate can be anticipated as a
result of a combination of factors, such as decreased cardiovascular
workload, emotional relief and satisfaction, and rest after labor and birth.
2 Bradycardia is more likely; respirations generally are unchanged. 3, 4
The temperature may rise slightly, but usually respirations are
unchanged.
Clinical Area: Comprehensive Examination; Client Needs: Reduction of
Risk Control; Cognitive Level: Application; Nursing Process:
Assessment/Analysis
13. 4 148/92 mm Hg blood pressure is elevated; gestational hypertension may
occur during the early postpartum period, and the blood pressure should
be monitored. If it returns to healthy levels within 12 weeks, it is called
transient hypertension.
1 The pulse rate is within expected limits. 2 The respirations are within
expected limits. 3 The slight temperature elevation is consistent with
the physiology of labor.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Planning/Implementation
14. 3 Ambulation involves muscle contractions that promote an increase in
circulation in the lower extremities. During pregnancy, hypercoagulation
is associated with an increase in clotting factors and fibrinogen, which
increase the risk for thromboembolism.
1 Oxygen therapy will not prevent thromboembolism. 2 Relieving pain
does not prevent thromboembolism, but pain medication may be
needed to help the client tolerate ambulation. 4 Increasing fluid intake
will not prevent thromboembolism.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Planning/Implementation
C H AP T E R 1 4
Nursing care of the family during the
postpartum period
Transfer from the recovery area
• Transfer occurs to a postpartum room if the woman is not in a labor,
delivery, recovery, postpartum (LDRP) room
• Because the recovery nurse is responsible for the client’s care until
another nurse assumes that responsibility, the nurse should report
directly to the client’s primary nurse. Otherwise, the recovery nurse could
be charged with abandonment.
• When initial assessments confirm that the patient is stable, the transfer
report is done, which uses information from admission (such as gravida
and para and medical/surgical history), birth (such as episiotomy and
method of anesthesia), and recovery (such as health of infant).
• Information is also collected for the neonatal nursery staff.
• Bedside reporting may also be used because the format of the hand-off
report is changing.
Planning for discharge
Continual process
• Begins with admission and continues until the patient and family leave
the facility
Length of stay is variable
• Discharge from birthing centers may occur within hours
• If risk of complications is low, may occur 24 to 36 hours after birth
• Health plans cover a minimum of 48 hours after uncomplicated vaginal
delivery, and 96 hours after cesarean section
Criteria for discharge
• Any early problems should have been identified
• Verification that mother is able and confident to care for infant
• Evaluation of individual situation is key
Care management: Physical needs
• Most models of care view the mother/baby as a unit and have one nurse
caring for both; some still retain the nursery nurse as primary caregiver
for the infant.
Ongoing physical assessment
• Vital signs (bradycardia is expected), skin color, breast assessment
• Fundal location and firmness; status of abdominal incision, if present
• Amount and color of lochia (rubra: 1 to 3 days; serosa: 4 to 10 days; alba:
10 to 21 days)
• Perineal assessment (episiotomy/incision: redness, edema, ecchymosis,
discharge, and approximation [REEDA]; see also Chapter 16; anus for
hemorrhoids)
• Pain assessment and ability to move if regional anesthesia was used
• Legs: lower extremity assessment to check for thrombus formation
• If positive or if there are other indications of thrombophlebitis, woman
should be kept in bed to prevent complications until a definitive
diagnosis can be made
• IV infusion
• Urinary output and bowel function
• Energy and emotional status: interaction with infant; adjustment from
self-care to caring for infant
Routine laboratory tests
• Hemoglobin and hematocrit to assess blood loss
• Urinalysis
• Rubella immunity status may require immunization
• Rh status may require administration of Rh immune globulin (RhoGAM)
Nursing interventions
• Interventions based on assessment, comfort, safety, and education are
prioritized
• Confirm identity of mother and infant, orient mother to surroundings,
establish agreeable routine
• Discuss security measures for infants
• Continual evaluation allows changes to the plan as needed
• Use standard precautions and aseptic technique during perineal care
• Preventing excessive bleeding
• All new mothers are at risk for excessive bleeding; women who had a
multifetal pregnancy are at higher risk because the uterus is more likely
to have atony from excessive stretching; lack of uterine tone (atony) can
cause excessive bleeding
• Monitor lochia for color, amount, clots, odor (foul odor indicates
beginning infection); report deviations from what is expected; visible
trickle of blood is sign of possible hemorrhage
• Visual estimation of lochial flow: scant, small/light, moderate, or
large/heavy by the amount of perineal pad saturation or the amount of
time to saturate one pad
• Amount on pad in less than 2 hours
■ Scant: less than 1 inch
■ Light: less than 4 inches
■ Moderate: less than 6 inches
■ Heavy: more than 6 inches
• Weigh items saturated with blood or blood clots to establish losses of
volume
• Monitor serial hemoglobin or hematocrit measurements
• Maintenance of uterine tone and prevention of bladder distention are
the two most important ways to prevent excessive bleeding
• Monitor vital and other signs when excessive bleeding occurs, especially
pulse, respirations, urinary output, skin condition and level of
consciousness; however, blood pressure measurements do not indicate
blood loss early enough to be useful in diagnosis of hemorrhage
• Maintaining uterine tone
• Firm, midline, level in relationship to umbilicus
• Gentle massage of the fundus can help restore uterine tone, although it
can cause a temporary increase in vaginal bleeding
■ Explain the purpose before beginning because it can be
uncomfortable; have the woman empty her bladder first
■ Palpate for firmness and location (Fig. 14.1); should remain firm and
descend (involute) from midline at level of umbilicus 1 fingerbreadth
(1 to 2 cm) per day
■ Massage boggy fundus until firm; boggy uterus indicates inadequate
contractile power of uterus, resulting in bleeding
■ Teach woman to massage her own fundus if she is willing
■ IV fluids and oxytocic medications are used if excessive bleeding and
uterine atony occur
■ Administer prescribed oxytocic to promote involution (eg, oxytocin,
methylergonovine, ergonovine, carboprost); methylergonovine and
ergonovine may cause hypertension; withhold if blood pressure is
higher than 140/90 mm Hg
■ Maintains uterus in contracted state; controls bleeding from
intrauterine sites; maintains tone, rate, amplitude of rhythmic
contractions required for involution
• Preventing bladder distention
• Bladder distention can cause uterine atony and excessive bleeding
• Small, frequent voiding may indicate bladder distention with overflow
• Palpate for full bladder, which displaces the fundus upward toward
right
• Assist to void, as needed, as early as possible; secure catheterization
order if necessary
• Preventing infection
• Maintain a clean environment; change drawsheets and pads; adhere to
hand hygiene and standard precautions; teach woman to wash hands
before changing perineal pad
• Maintain proper perineal care; assess episiotomy site: REEDA scale (see
earlier)
• Interpret vital signs: temperature above 100.4° F (38° C) for 2
consecutive days (excluding first 24 hours after birth) is sign of
beginning puerperal infection; can occur after hemorrhage or trauma; if
suspected infection, culture of lochia and laboratory studies (white
blood cell [WBC] count) may be ordered (perform before giving
antibiotics); administer prescribed antibiotics, antipyretics; perform
other ordered diagnostic studies; monitor temperature
• Promoting comfort
• Common sources of pain: uterine contractions (“afterpains”), perineal
lacerations or episiotomy, hemorrhoids, breast engorgement, and sore
nipples
• Lack of objective signs does not negate woman’s perception of pain
• Pharmacologic interventions include prescribed analgesic for pain;
women with cesarean section will likely have more pain and flatus, and
so will need more pain medication
• Nonpharmacologic interventions vary based on pain site
• Comfort for episiotomy: apply cold applications for first 24 hours, then
sitz baths for promoting vasodilation and increased circulation; lying
on side; healing overall takes ∼6 weeks; see also Chapters 12 and 16
• Warmth for afterpains
• Cold packs for hemorrhoids
• Interventions for breast engorgement in nonbreastfeeding women:
apply ice compresses or cool cabbage leaves to breasts, if ordered, to
minimize engorgement; heat is not advised because it increases milk
flow; well-fitted brassiere to support breasts; avoid nipple stimulation
or expressing any milk
• Interventions for breast engorgement for breastfeeding women include
feeding every 2 hours, softening one breast through feeding and
pumping the other; warmth before feeding and cold after (see also
Chapter 18)
• Purified lanolin can be used for sore nipples, but most important is
correction of any latch-on technique problem (see also Chapter 18)
• Promoting rest is essential; fatigue and symptoms of depression are
interrelated; rest can distinguish fatigue from depression
• Observe for postpartum blues; may be caused by drop in hormonal
levels and psychologic factors; screen for postpartum depression (PPD)
if indicated
• Encourage ambulation to prevent blood stasis; maintain bed rest and
notify health care provider if signs of thrombophlebitis occur (eg,
discomfort, edema, erythema)
• Promoting ambulation prevents venous thromboembolism; caution is
advised to ensure the woman does not have orthostatic hypotension; if
so, instruct woman to rise slowly to prevent this from occurring and be
prepared to sit back down if dizziness occurs; exercise to promote leg
circulation while the woman is in bed can also be advised
• Exercises to be promoted include abdominal exercises, Kegel exercises
to strengthen the pelvic floor, pelvic tilts to aid in abdominal
strengthening
• Promoting nutrition (see also Chapters 4 and 18)
• Most women have a good appetite postpartum
• Respect dietary preferences, cultural and other
• Energy requirements are higher for breastfeeding women, but vary
depending on activity
• Breastfeeding women especially need omega-3 polyunsaturated fatty
acids (PUFAs; docosahexaenoic acid [DHA]) for infant’s health; good
source is low-mercury fish; vegans and undernourished women may
need a DHA and multivitamin supplement
• Prenatal vitamins can be continued; iron supplements may be indicated
by hematocrit or hemoglobin level
• Promoting normal bladder and bowel patterns
• Bladder function: mother should void within 6 to 8 hours, although
trauma or fear may delay (see also “Preventing bladder distention”
earlier)
• Bowel function: constipation common (from dehydration, pain
medication, immobility, episiotomy, hemorrhoids)
■ High fluid and high fiber intake recommended
■ May need stool softeners or laxatives per health care provider
■ Ambulation can help stimulate passing flatus
• Promoting breastfeeding
• Benefits to mother: aids in uterine involution; decreased bleeding; an
earlier return to prepregnancy weight; and decreased risks of breast
cancer, ovarian cancer, and osteoporosis
• Ideally initiated within first 1 to 2 hours after delivery; nurse can
encourage mother to watch infant for signs of readiness
• Women breastfeed longer if they feel supported in their efforts
• Lactation suppression for mothers not breastfeeding or in cases of
neonatal death: supportive bra, avoid stimulation and milk expression;
ice packs and mild analgesic or antiinflammatory
• Health promotion for planning future pregnancies and children:
vaccinations
• Informed consent needed for each vaccine; for rubella and varicella, this
includes information about teratogenic effects on fetus
• Rubella: recommended for women who are not serologically immune;
woman must understand she must not get pregnant for 28 days after
vaccination
• Varicella: recommended for women who have no immunity before
postpartum discharge; woman must understand she must not get
pregnant for a total 3 months after first vaccination (28 days after each
vaccination; second dose of varicella given at postpartum follow-up visit
at 4 to 8 weeks after first dose)
• Tetanus-diphtheria-acellular pertussis (Tdap): recommended for
postpartum women who have not received the vaccine; others who will
be around the infant should be vaccinated with Tdap if they have not
received it previously
• Rh immune globulin for Rh-negative woman who has had an Rhpositive infant; dosage depends on amount of fetomaternal transfusion;
may suppress response to any live virus immunization, such as rubella,
so retesting for rubella immunity is needed in 3 months
FIG. 14.1 Involution of the uterus after childbirth. Note that the uterine fundus height
drops by approximately one fingerbreadth per day. Source: (From Leifer, G. [2012].
Maternity nursing: An introductory text [11th ed.]. Philadelphia: Saunders.)
Application and review
1. A nurse is evaluating the effectiveness of fundal massage on a postpartum
client 3 hours after giving birth. An IV infusion of 10 units of oxytocin is
infusing at 100 mL/hr. Her blood pressure is 135/90, the uterus is boggy at
3 cm above the umbilicus and displaced to the right, and her perineal pad
is saturated with lochia rubra. What should the nurse do next?
1. Massage the fundus again.
2. Notify the health care provider.
3. Assist the client to the bathroom.
4. Increase the IV infusion rate as prescribed.
2. A nurse teaches a postpartum client how to care for her episiotomy to
prevent infection. Which behavior indicates that the teaching was
effective?
1. The perineal pad is changed twice daily.
2. She washes her hands whenever a perineal pad is changed.
3. She rinses her perineum with water after using an analgesic spray.
4. The perineum is cleansed from the anus toward the symphysis
pubis.
3. A nurse observes that a client is voiding frequently in small amounts 8
hours after giving birth. What should the nurse conclude about this small
output of urine during the early postpartum period?
1. It may indicate retention of urine with overflow.
2. It may be indicative of beginning glomerulonephritis.
3. This is common because less fluid is excreted after birth.
4. This is common because fluid intake diminishes after birth.
4. A nurse is caring for a postpartum client who is formula feeding. What
should the nurse teach her about minimizing breast discomfort?
1. Apply covered ice packs to her breasts.
2. Gently apply cocoa butter to her nipples.
3. Place warm, wet washcloths on her nipples.
4. Manually express colostrum from her breasts.
5. Two days after having had a cesarean birth, a client tells a nurse that she
has pain in her right leg, and after an assessment the nurse suspects that
the client may have a thrombus. What is the nurse’s initial response?
1. Maintain bed rest.
2. Apply warm soaks.
3. Encourage leg exercises.
4. Massage the affected area.
6. Two days after giving birth a client’s temperature is 101° F. A nurse
notifies the health care provider and receives a variety of orders and two
prescriptions. In what order should they be implemented?
1. _____ Obtain a chest x-ray study.
2. _____ Send a lochia specimen for culture.
3. _____ Administer the prescribed IV antibiotic.
4. _____ Offer the as-needed acetaminophen for a fever more than 100°
F.
5. _____ Document the client’s temperature 30 minutes after
administering the medications.
7. A client who recently gave birth is transferred to the postpartum unit by
the nurse. What must the nurse do first to avoid a charge of
abandonment?
1. Assess the client’s condition.
2. Document the client’s condition and the transfer.
3. Orient the client to the room and explain unit routines.
4. Report the client’s condition to the responsible staff member.
8. A nurse teaches a multipara who has just given birth to a large baby how
she can maintain a contracted uterus. Which statement indicates to the
nurse that the teaching was effective?
1. “If I start to bleed, I will call for help.”
2. “I will massage my uterus regularly to keep it firm.”
3. “If I urinate frequently, my uterus will stay contracted.”
4. “I will call you every 15 minutes to massage my uterus.”
9. A nurse determines that a postpartum client’s fundus is firm and is shifted
to the right and two fingerwidths above the umbilicus 2 hours after giving
birth. What should the nurse conclude about this finding?
1. Bladder fullness
2. Early involution
3. Retained secundines (placenta)
4. Concealed hemorrhage
10. A nurse discusses breast engorgement with a new mother who is formula
feeding her infant. She has remained on the unit because she had a
cesarean birth. Which statement alerts the nurse that the client needs
further teaching?
1. “I know the discomfort will go away in a few days.”
2. “I will wear my new brassiere to keep me from hurting.”
3. “I will take a pain medicine if my breasts begin to hurt.”
4. “I should apply heat to my breasts to ease my discomfort.”
11. A nurse plans to assess a postpartum client’s uterine fundus. What
should the nurse ask the client to do before this assessment?
1. Drink fluid.
2. Empty her bladder.
3. Perform the Valsalva maneuver.
4. Assume the semi-Fowler position.
12. A client undergoes a cesarean birth because of cephalopelvic
disproportion. What care is needed for this client in addition to the
routine nursing care given to all postpartum clients during the first 24
hours?
1. Encourage early ambulation.
2. Assess the fundus gently but firmly.
3. Check vital signs for evidence of shock.
4. Administer the prescribed pain medication.
13. A nurse on the postpartum unit is assessing several clients. Which
clinical finding requires immediate investigation?
1. An inflamed episiotomy
2. A slow trickle of blood from the vagina
3. An estimated blood loss of half a liter during a vaginal birth
4. A boggy uterine fundus that becomes firm after prolonged massage
14. A nurse is assessing a postpartum client for signs of hemorrhage by
evaluating the degree of perineal pad saturation. How else can the nurse
estimate blood loss in a postpartum client?
1. Odor of the lochia
2. Color of the lochia
3. Presence of small clots on the pad
4. Length of time between pad changes
15. As the nurse assists a postpartum client to change the perineal pad, the
client comments, “I wish you didn’t have to look at the pad; it’s
embarrassing for me.” What is the best nursing response?
1. “This is uncomfortable for you, but I have to estimate the amount of
blood loss to prevent any problems.”
2. “There can be more blood lost than you realize. We can calculate the
loss, based on the formula we use.”
3. “This is a common practice that helps us keep you safe. It is a
necessary part of the job, and I don’t mind.”
4. “It’s a policy we follow to determine the extent of your bleeding, and
then we can give you the necessary care.”
16. A nurse who is caring for a postpartum client is concerned because the
woman is at risk for hemorrhage. Which factor in the client’s history
alerted the nurse to this concern?
1. Multifetal pregnancy
2. Short duration of labor
3. Previous cesarean birth
4. Age more than 40 years
17. In the second hour after giving birth, a client’s uterus is found to be firm,
above the level of the umbilicus, and to the right of midline. What is the
appropriate nursing intervention at this time?
1. Observe for signs of retained secundines.
2. Massage the uterus to prevent hemorrhage.
3. Assist the client to the bathroom to empty her bladder.
4. Tell the client that this is a sign of uterine stabilization.
See Answers on pages 228-232.
Care management: Psychosocial needs
Effect of the birth experience
• Assess the meaning of the birth experience for the family, and encourage
family and sibling bonding
• Parents may need to review the birth experience; be willing to listen
• Use every contact to assess patient understanding as assessment for
patient teaching, using the steps in the nursing process
• Encourage mother to ask questions
• Support rooming-in and assist with infant care as needed
• Meet mother’s needs to enable her to meet infant’s needs; explore
feelings and concerns
Maternal self-image
• Self-concept includes body image and sexuality, and all three are
interrelated
• Include the topic of sexuality during routine assessment and teaching
Adaptations to parenthood and parent–infant
interactions
• Psychosocial adaptations can be evaluated within evaluation of the
parents’ interactions with the infant
• Bonding of newborn and mother occurs in stages
• Realistic acceptance of the infant’s needs shows adaptation; if missing,
nurse needs to investigate, screen for “baby blues” (PPD) or other serious
condition
• Physical conditions such as fatigue can affect adaptation
• Family situation affects adaptation: partner, other children, and other
relatives
Effect of cultural diversity
• Assessment of beliefs and practices that may affect nursing care is
essential, as well as any expectations the family has of the health care
team
• Rituals and traditions need to be respected
• For instance, birth control practices vary and must be considered when
discussing family planning
• Cultures that place importance on hot and cold states may not permit the
mother to have cold beverages or use ice
• The nurse should not assume a mother wants to follow any particular
cultural practice
Discharge teaching
Content
• Include self-care topics such as prescribed medications, follow-up care,
resumption of sexual intercourse and contraception, family planning,
exercise (continue Kegel and abdominal exercises as well as walking), and
nutrition
• Teach self-care and assist as needed; encourage mother to contact
personnel when questions arise
• Initiate discussion of breastfeeding, infant care, other concerns in order to
determine woman’s and family’s educational needs
• Communicate danger signs for herself (such as fever and foul-smelling
lochia indicating infection) and for her infant
• Involve family in care and teaching; educate about infant care and observe
to see if additional teaching is needed
• Stress the importance of handwashing when caring for self and infant;
emphasize infection prevention
• Mother and support persons should be alerted to signs and symptoms of
PPD (mothers with history of depression are more likely to have PPD)
• Teach breast care appropriate to breastfeeding or bottlefeeding mother
• Food plan with adequate proteins and calories to restore body tissues;
increased caloric intake if breastfeeding (see Chapter 4); build on cultural
and personal food preferences
• Discuss resumption of intercourse and family planning; include
information about when to expect menses
• Education can be provided through video, pamphlets, return
demonstrations
• Include additional community resources such as La Leche League for
breastfeeding
Safety
• Mother and infant identification bracelets must be confirmed by nurse
before discharge
Evaluation/outcomes
• Progresses through process of involution
• Remains free from hemorrhage, infection, and pain
• Maintains bowel function
• Initiates voiding and empties bladder
• Performs perineal care after each voiding/defecation
• Successfully feeds and cares for infant
• Maintains emotional health
Application and review
18. A client who just gave birth has three young children at home. She
comments to the nursery nurse that she must prop the baby during
feedings when she returns home because she has too much to do, and
anyway holding babies during feedings spoils them. What is the nurse’s
best response?
1. “You seem concerned about time. Let’s talk about it.”
2. “That’s up to you because you have to do what works for you.”
3. “Holding the baby when feeding is important for development.”
4. “It is not safe to prop a bottle. The baby could aspirate the fluid.”
19. A primipara has just given birth at 37 weeks’ gestation. What should the
nurse do to help promote the attachment process between the mother and
her newborn?
1. Teach how to breastfeed the baby.
2. Encourage continuous rooming-in.
3. Assign one nurse to care for both of them.
4. Allow extra visiting privileges in the nursery.
20. A multigravida of Asian descent weighs 104 pounds, having gained 14
pounds during the pregnancy. On her second postpartum day, the client’s
temperature is 100.2° F. She is anorectic and rarely gets out of bed. What
should the nurse do?
1. Ask the nursing supervisor to discuss this with the health care
provider.
2. Encourage the family to bring in special foods preferred in their
culture.
3. Order a high-protein milkshake as a between-meal snack to
stimulate her appetite.
4. Explain to the family that the dietician plans nutritious meals that
the client should eat.
21. At 9 p.m. visiting hours are officially over, but the sister of a newly
admitted postpartum client remains at the bedside. What is the most
appropriate nursing intervention?
1. Remind the client’s sister that visiting hours are over.
2. Get written permission from the client for her sister to remain.
3. Call the evening nursing supervisor to tactfully handle the situation.
4. Encourage the sister to participate in care as much as the client
wishes.
22. What should a nurse include in the discharge teaching of a postpartum
client?
1. The perineal tightening exercises should be continued.
2. The episiotomy sutures will be removed at the first postpartum visit.
3. She may not have a bowel movement for up to a week after the birth.
4. She should schedule a postpartum checkup as soon as her menses
return.
23. A nurse in the postpartum unit must complete several interventions
before a client’s discharge from the hospital. The nurse plans to delegate
some of the tasks to the nursing assistant. Which activity must be
performed by the nurse?
1. Taking the neonate’s picture
2. Placing the infant car seat in the car
3. Comparing the identification bands of mother and infant
4. Preparing the discharge gift packages and distributing them to
parents
24. A nurse is teaching a postpartum client the characteristics of lochia and
any deviations that should be reported immediately. What client
statement indicates that the teaching was effective?
1. “If I pass any clots, I’ll notify the clinic.”
2. “I’ll call the clinic if my lochia changes from red to pink.”
3. “I’ll notify the clinic if my lochia becomes foul smelling.”
4. “If my vaginal discharge continues for 3 weeks, I’ll call the clinic.”
See Answers on pages 228-232.
Answer key: Review questions
1. 3 Before any other action is taken, the client must empty her bladder. If
she is unsuccessful despite measures to promote urination, such as
running water, she will need to be catheterized.
1 Massaging the fundus is useless and may be dangerous unless the
bladder is empty. 2 The health care provider should be notified if the
uterus remains boggy and above the umbilicus after the bladder has
been emptied and the fundus massaged, if necessary. 4 Increasing the
IV infusion rate as prescribed is useless and may be dangerous unless
the bladder is empty.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
2. 2 Washing hands whenever a perineal pad is changed prevents the
transfer of microorganisms from the hands to the genital tract or from the
genital tract to the hands.
1 Two changes per day is an inadequate number of changes; soiled pads
promote the growth of microorganisms because they are warm and
moist and provide a medium for growth. 3 Rinsing her perineum with
water after using an analgesic spray action interferes with the analgesic
action of the spray and does not prevent infection. 4 Cleansing the
perineum from the anus toward the symphysis pubis promotes
contamination of the vagina and urethra by organisms from the
perianal area.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
3. 1 Retention of urine with overflow will be manifested in small, frequent
voidings. The bladder should be palpated for distention.
2 An elevated temperature with urinary alterations would indicate
impending infection. 3 More circulating fluid is present, causing an
increased output. 4 The client usually is thirsty and fluid intake
increases.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
4. 1 Covered ice packs promote comfort by decreasing vasocongestion.
2, 3 Nipple stimulation precipitates the release of prolactin, which leads
to more milk production and further engorgement and discomfort. 4
Emptying the breasts stimulates lactation, leading to further
engorgement and discomfort.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
5. 1 Although thrombophlebitis is suspected, before a definitive diagnosis
the client should be confined to bed so that further complications may be
avoided.
2 Application of warm soaks may cause vasodilation, which could allow a
thrombus to dislodge and circulate freely. 3 If a thrombus is present,
leg exercises may dislodge it and lead to a pulmonary embolism. 4 If a
thrombus is present, massaging the affected area may dislodge it and
lead to a pulmonary embolism.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing Process:
Planning/Implementation
6. Answers: 2, 3, 4, 1, 5
2 The culture should be obtained before antibiotics are given to ensure
that the antibiotic does not interfere with accurate culture results. 3 The
antibiotic is the most important of these orders and should be given as
soon as possible to counteract any infective processes, but it should not
be administered before obtaining the specimen for the culture. 4 The
acetaminophen is a comfort measure that can be administered at any
time, but does not take precedence over the antibiotic. 1 Arranging for
a chest radiograph will not interfere with implementing any of the
other orders; it may take time to schedule a radiograph. 5 The client’s
response to the acetaminophen should have lowered the client’s
temperature within 30 minutes.
Client Need: Management of Care; Cognitive Level: Analysis; Nursing
Process: Planning/Implementation
7. 4 Because the nurse is responsible for the client’s care until another nurse
assumes that responsibility, the nurse should report directly to the client’s
primary nurse.
1 Making an assessment of the client’s condition is not enough. 2
Although documentation is important, it is insufficient. 3 Explanation
of unit orientation and routines is insufficient. Although the nurse
should carry out these activities, they can be done after reporting the
client’s condition to the staff.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Management of Care; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process:
Communication/Documentation
8. 2 The uterus responds rapidly to touch, and this involves the mother in
her care.
1 The uterus must be massaged before there are signs of bleeding. 3
Although frequent urination may be beneficial, the client should be
taught to massage the uterus to cause it to contract. 4 Calling the nurse
does not actively involve the mother in her own care and could be
unsafe if the uterus becomes boggy between the 15-minute time
periods.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
9. 1 A distended bladder usually displaces the fundus upward and toward
the right because of the anatomic proximity of the bladder and uterus.
2 In early involution, the position of the fundus is at the level of the
umbilicus or below, in the midline, rather than shifted to the right. 3 If
parts of the placenta and/or membranes are retained, the client will be
bleeding and the fundus will be boggy. 4 The fundus is firm; therefore,
bleeding at this time is not a problem.
Clinical Area: Comprehensive Examination; Client Needs: Health
Promotion and Maintenance; Cognitive Level: Application; Nursing
Process: Evaluation/Outcomes
10. 4 Although heat application may help ease the discomfort, it increases
milk flow, which is an undesired outcome in nonbreastfeeding women;
application of cold is recommended to limit engorgement and ease the
discomfort.
1 Engorgement lasts about 48 hours; no further teaching is needed. 2 A
supportive bra will help suppress milk production; no further teaching
is needed. 3 Analgesics will help lessen the discomfort of engorgement;
no further teaching is needed.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes; Integrated Process:
Teaching/Learning
11. 2 An empty bladder ensures accurate assessment of fundal height. A full
bladder may promote a boggy uterus and may elevate the uterus upward
and toward the client’s right side.
1 There is no need to drink fluid before this assessment; however, the
client should drink at least 2 L of fluid a day during the postpartum
period. 3 The Valsalva maneuver has no effect on the assessment of
fundal height. 4 Assessing the fundus while the client is in the semiFowler position will result in an inaccurate assessment. The bed should
be flat, and the client should assume the supine position.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
12. 4 Because of increased pain and increased flatus, these clients require
more pain medication than do women who have vaginal births.
1 Early ambulation is encouraged for all postpartum clients. 2 Although it
may be difficult because of the incision, palpating the fundus is a
necessary part of postpartum care. 3 Checking vital signs is done
routinely for all postpartum clients.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Physiologic Adaptation; Cognitive Level: Application; Nursing Process:
Evaluation/Outcomes
13. 2 Vaginal bleeding may be an early sign of hemorrhage; hypovolemic
shock can develop.
1 An inflamed episiotomy is an expected finding; ice packs help resolve
the inflammation. 3 An expected blood loss for a vaginal birth is 300
mL to 500 mL. 4 A fundus that has been overstretched or is
multiparous may require prolonged massage until it becomes firm.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
14. 4 Hemorrhage can occur after the third stage of labor or within the first
24 postpartum hours; hemorrhage is defined as a blood loss in excess of
500 mL. A saturated perineal pad is estimated to contain 100 mL of blood;
the best estimation of blood loss considers a combination of factors,
including degree of saturation of perineal pads and frequency of pad
changes.
1 An odor will reflect the possible complication of infection, not
hemorrhage. 2 The color of vaginal discharge at this time will not
indicate hemorrhage. The color of the lochia during the first
postpartum day is expected to be red (rubra). 3 The presence of clots is
common and is not an indicator of the amount of blood loss.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
15. 1 “This is uncomfortable for you, but I have to estimate the amount of
blood loss to prevent any problems” identifies feelings and provides an
explanation for the intervention. Blood loss can be estimated from the pad
count, the degree of saturation, and the time taken for the saturation to
occur; an estimate of loss can give the nurse an opportunity to prevent
complications due to hemorrhage.
2 “There can be more blood lost than you realize. We can calculate the
loss, based on the formula we use” does not identify the client’s
feelings; also, this statement may be alarming. 3 “This is a common
practice that helps us keep you safe. It is a necessary part of the job,
and I don’t mind” does not identify the client’s feelings; it is a general
response that does not educate the client as to why this assessment is
necessary. 4 “It’s a policy we follow to determine the extent of your
bleeding, and then we can give you the necessary care” does not
identify the client’s feelings; also, this statement may be alarming.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process: Caring
16. 1 Overdistention of the uterus because of a large fetus, multiple
gestation, or hydramnios predisposes a woman to uterine atony, which
may cause postpartum hemorrhage.
2 Short duration of labor may lead to a precipitous birth, which is
potentially harmful to the fetus but does not affect uterine contractions
after the birth. 3 Previous cesarean birth is not related; unless uterine
atony is present, hemorrhage should not occur. 4 Age more than 40
years is not a factor in involution of the uterus.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Assessment/Analysis
17. 3 A full bladder commonly elevates the uterus and displaces it to the
right; even though the uterus feels firm, it may relax enough to foster
bleeding; therefore, the bladder must be emptied to maintain uterine
tone.
1 If parts of the placenta, umbilical cord, or fetal membranes are not fully
expelled during the third stage of labor, their retention limits uterine
contraction and involution; a boggy uterus and bleeding will be
evident. 2 The uterus is firm and does not need massaging; however, if
the bladder is not emptied, the uterus will not stay contracted, and
massage will not make it firm. 4 A firm uterus, above the level of the
umbilicus and to the right of midline, is not a sign of uterine
stabilization; the uterus cannot remain contracted when there is a full
bladder.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation
18. 1 The nurse should suggest talking about the client’s concern regarding
the time. This opens up an area of communication to determine what
really is troubling the mother about feeding her baby.
2 The nurse is aware that propping the baby during feedings is not the
best method when using a bottle to feed an infant; the problem of time
should be explored with the mother. 3 Holding can be accomplished at
times other than feeding periods; talking about the importance to
development does not explore the client’s feelings. 4 “It is not safe to
prop a bottle. The baby could aspirate the fluid” is true, but the mother
should not be challenged so directly; a more gentle explanation should
be offered.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring;
Communication/Documentation; Nursing Process:
Planning/Implementation
19. 2 Rooming-in provides time for the mother and newborn to be together;
the mother can become acquainted with the infant more quickly.
1 It is possible that the client does not want to breastfeed; attachment can
be furthered by a variety of methods. 3 One nurse for the baby and
mother’s care will not promote bonding and attachment. 4 Although
visiting in the nursery is unlimited for the parents, rooming-in is
preferable.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation
20. 2 Family centered childbearing should adapt care to the client’s cultural
system whenever possible.
1 It is the nurse’s responsibility, not the nurse’s supervisor. 3 A highprotein milkshake as a between-meal snack to stimulate appetite may
be useful, but the primary intervention is to address the client’s
cultural needs. 4 Explaining to the family that the dietician plans
nutritious meals that the client should eat does not address the
underlying problem.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
21. 4 Family-centered care focuses on the whole family, including the
relatives; visiting hours in the birthing unit are flexible.
1 It is an inappropriate intervention to ask the sister to leave; familycentered care focuses on the whole family, and the sister should be
permitted to remain. 2 Written permission is not required. 3 There is no
need for the nursing supervisor to be summoned.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation
22. 1 Kegel exercises can be resumed immediately and should be done for
the rest of the client’s life because they help strengthen muscles needed
for urinary continence and may enhance sexual intercourse.
2 Episiotomy sutures do not have to be removed. 3 Bowel movements
should spontaneously return in 2 to 3 days after giving birth; a delay of
bowel movements promotes constipation, perineal discomfort, and
trauma. 4 The usual postpartum examination is 6 weeks after birth;
menses can return earlier or later than this and should not be a factor
when scheduling a postpartum examination.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
23. 3 It is the nurse’s professional responsibility to compare the mother’s
and infant’s identification bands one last time before discharge. This
ensures that the correct infant is discharged with the infant’s birth
mother.
1, 2, 4 Taking the neonate’s picture, placing the infant car seat in the car,
and preparing the discharge gift packages and distributing them to
parents are activities within the role of the nursing assistant and can be
delegated safely.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Management of Care; Cognitive Level: Analysis; Nursing Process:
Planning/Implementation
24. 3 Lochia has a characteristic menstruallike musky or fleshy smell. A foulsmelling discharge, along with fever and uterine tenderness, suggests an
infection.
1 Clots are a common occurrence. 2 It is expected that the lochia changes
from red to pink as lochia rubra progresses to lochia serosa. 4 Although
many women have a minimal discharge after 2 weeks, it is not
uncommon for lochia alba to last 6 weeks.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Reduction of Risk Control; Cognitive Level: Application; Nursing
Process: Evaluation/Outcomes; Integrated Process: Teaching/Learning
C H AP T E R 1 5
Transition to parenthood
Parental attachment, bonding, and acquaintance
Attachment and bonding
• Concepts basic to parent–infant relationships
• Early, frequent parent–infant contact essential for attachment
(bonding), the process whereby parent and child love and accept each
other
• Having parents assist with infant care promotes the new relationship
• Developmental stages
■ Biologic changes at puberty and during pregnancy influence
development of nurturance
■ Interaction between mother and infant begins from moment of
conception; can be shared with father
■ Childbearing: parenting abilities can be fostered and developed
■ Childrearing: parental behavior is learned; frequent parent–infant
contact enhances parenting abilities; ambivalence is natural
phenomenon, as are feelings of resentment
• Development of parent–infant love
■ Love for infant grows as parents interact and give care
■ As parent gives to infant and infant accepts, parent in turn receives
satisfaction from parenting tasks
■ Disturbance in give-and-take cycle initiates frustrations in parents
and infant
• Infant’s basic needs
• Physiologic: food, clothing, hygiene, and protection from environment
• Emotional: security, comfort, fondling, caressing, rocking, verbalizing,
consistent contact with caregiver
• Basis for parenting
• Biologic inborn desire to reproduce
• Role concepts that begin with own childhood experiences
• Primitive emotional relationships
• Level of maturity
• Parent–infant relationship influences
• Readiness for pregnancy
■ Planned or unplanned
■ Health status before pregnancy
■ Determinants: age, cultural backgrounds, number in family unit,
financial status
• Nature of pregnancy
■ Health status during pregnancy
■ Preparation for parenthood
■ Support from family members and health care team
• Characteristics of labor and birth
■ Length and pattern of labor; type of birth
■ Type and amount of analgesia/anesthesia received
■ Support from family and health team
• Factors that impede attachment
■ Impaired physical status of newborn and/or mother
■ Treatments that interfere with attachment
■ Disturbance related to idealized image of infant versus actual
• Supportive care to promote attachment
• Allow time to explore and identify with infant; encourage parents to
touch, fondle, and hold infant, as well as help with the infant’s care
• Encourage interaction between parents and infant
• At the initial discussion, teach about characteristics and typical
behaviors of newborns
• Demonstrate infant care to help parents learn how to meet infant’s and
their own needs
• Evaluate parents’ and infant’s responses; revise plan as necessary;
identify disturbed relationships
• Provide therapeutic environment for various family lifestyle types:
nuclear, single parent, gay, blended
• Promoting attachment with multiple births
• It may be difficult for family to bond to more than one infant at a time
• Assist parents to recognize individuality of infants; use individual
names
• Infants should sleep alone at home for optimal safety
Assessment of attachment behaviors
• Observation is a key component for assessment of attachment
• Notice verbal and nonverbal behaviors of the parents: talking to the
infant, reaching for the infant, holding the infant closely, signs of
affection, use of comforting behaviors
• Interviewing can give additional information
• Assess parents’ original expectations of the infant versus the parents’
understanding now that the infant has been born
• Consider how the labor experience affected the mother.
Parent–infant contact
Early contact
• Many researchers have shown that early, close contact between the mother
and infant right after birth helps attachment
• Skin-to-skin contact with infant on mother’s bare chest promotes early
breastfeeding and is associated with less infant crying and other
benefits
• Parents need to explore their child visually and tactilely to assure
themselves the child is healthy and help them accept the reality of the
infant
• If it is not possible to have early, close contact because the infant is ill and
needs separate care, reassure parents that it is not essential for
attachment
Extended contact
• Rooming-in, where the infant stays in the room with the mother, promotes
family-centered care
• It allows extended contact of the infant with the parents, which promotes
development of the relationship, as well as contact with other family
members
Communication between parent and infant
The senses
• Communication occurs with touch, eye contact, vocalizations (voice), and
odor
• Touch allows parents to explore the infant and share body warmth
• The face-to-face position (en face) allows sustained eye contact between
infant and parent
• Bright lights are disturbing to newborns and may impede mother–
infant interaction, whereas dim light encourages the infant to open eyes
• Touch and eye contact behaviors vary by culture
• Infants turn toward parents’ voices, now hearing them from the
“outside” of the mother instead of through her abdomen
• Infants can distinguish the odor of their own mother’s breast milk;
parents respond to the infant’s smell as well
• Use of all of these senses helps the parents accept the reality of the infant
and move from the imagined version of the infant to getting acquainted
with the infant
• An infant’s quiet alert state is the ideal time to foster the parent–infant
relationship
Entrainment
• Infants move in rhythm to adult speech, which is called entrainment
Biorhythmicity
• Infants are already accustomed to the sounds of mother’s heartbeat
Reciprocity and synchrony
• Body movement that provides the observer with cues is called reciprocity
• Synchrony describes how the infant’s cues fit the parent’s response
Parental role after birth
Transition to parenthood
• Transition to parenthood is a developmental transition that includes
positive and negative aspects: disorder and joy, for instance
• It can be considered an opportunity for growth and learning
Parental tasks and responsibilities
• One of the first tasks parents face is accepting the infant just as she or he
is; resolution about unmet expectations is key
• Demands of meeting the infant’s physical needs can be overwhelming
• The nurse teaches the parents to manage fatigue and adapt to a relaxed
schedule
• Especially in the first 6 weeks, emphasis should be on caring for the
mother and baby; asking extended family and friends to help can be
suggested
• The mother especially needs to rest if she is breastfeeding
• Stress reduction techniques can be taught to the parents, including
supporting open communication and the need for recreation
Becoming a mother
• Reva Rubin’s significant phases of maternal adjustment
• Taking-in phase: mother’s needs must be met before she can meet
infant’s needs; talks about self rather than infant; may not touch infant;
cries easily; integrates birth experience into reality
• Taking-hold phase: mother starts to assume responsibility for her
infant; lasts from day 2 to day 10; concerned about infant; interested in
learning; teachable, reachable, and referable at this time
• Letting-go phase: mother discards idealized notion of childbirth; may
have periods of guilt or grief over childbirth experience
• Give-and-take inherent in the mother–infant relationship helps the
mother develop understanding of the infant’s patterns
• Because parenting is a learned behavior based on past experiences and
current motivation to learn, a mother’s ideas of childhood roles and
concepts will affect the new relationship
• Educating the mother about what to expect from herself helps her set
realistic expectations
• She needs to be aware of the possibility of postpartum “blues” and to
know the signs of more serious depression
• Techniques for coping with the blues can be offered as part of teaching
for self-management
Becoming a father
• Bonding has already begun when father/partner feels the fetus move or
hears the heartbeat
• They may feel, like the mother, overwhelmed for the first several weeks
• Fathers/partners redefine their role as they adjust to parenthood
• Expectation is replaced by reality, as they create their role of an involved
parent
• Increased interaction with newborn shows adjustment and transition
• Engrossment is shown by holding, studying, and touching the infant
• Fathers spend less time with the infant and have less support compared
with mothers in their new role
• They should be included in all teaching sessions about newborn care, and
a teamwork approach encouraged
Adjustment for the couple
• Variable emotions, sleep deprivation, and new responsibilities strain even
the best relationships
• Changes in the couple’s relationship are to be expected; scheduling time
for conversations and time apart from the infant can help support
communication
• Concerns about sexual intimacy can be addressed by the nurse; plans for
other pregnancies and contraception should be reviewed with new
parents
• Each parent also adjusts to the new relationship with the infant
Diversity in transitions to parenthood
Age
• Adolescent mother or father
• Adolescent parenthood may mean the parents are unprepared
emotionally to handle the tasks of parenting
• Education and support are especially important for adolescent parents
to adjust to their new roles
• Maternal or paternal age older than 35 years
• Different circumstances confront older parents: grandparents may not
be there or may not be able to help; work and career may be sources of
conflict; symptoms for mothers of perimenopause may be confusing in
addition to parenting; reassessment of goals and realistic expectations
also occurs
Parenting in same-sex couples
• Lesbian and gay couples face similar challenges to heterosexual parents in
terms of time and responsibility demands and adjustment to the new
roles, in addition to facing social sanctions or public ignorance
• In lesbian couples, the nonchildbearing partner can stimulate milk
production and breastfeed the infant if desired
• Gay couples may become parents through adoption or assisted
reproduction
• Support networks are especially important, although they can be a source
of conflict
Socioeconomic conditions
• Parenthood can be complicated by concern for one’s own health or
financial problems
• Nurses can help new parents connect with available resources
Personal aspirations
• Nurses can listen as parents express feelings about how parenthood will
affect their personal aspirations
Parental sensory impairment
Visually impaired parent
• Visual impairment does not have a negative effect on early parenting
• Assess the parents’ capabilities and plan teaching strategies accordingly
• Visually impaired parents may need to be reminded to use facial
expressions when talking with the infant
Hearing-impaired parent
• Hearing-impaired parents face challenges; some technologies can be
helpful, such as devices that change sound to light to monitor the infant’s
cry
• Vocalizing can help the infant learn to vocalize, even if the parent is not
trained in speech
• Use of recordings can aid the infant in learning about the human voice
• Young children can easily learn to sign
• If the hospital receives funds from the U.S. Department of Health and
Human Services, it must have communication resources available,
including certified interpreters or staff members who are proficient in
sign language
• Written material with demonstrations can be used for education; video
recordings with concurrent signing are ideal
Sibling adaptation
• Promote sibling acceptance of infant
• Encourage siblings to visit mother; hold infant
• May focus more on looking at infant head and face, less on touching
infant
• Siblings are less likely to talk to infant
• Adaptation depends on age and development
• Younger siblings may consider newborn as competition (sibling rivalry)
and exhibit behaviors such as regression, jealousy, and frustration
• Older siblings can help prepare for the infant and help care for the
infant
• Special time should be set aside for both parents to give to older siblings
Grandparent adaptation
Emotional and role changes
• A range of reactions is possible depending on how the grandparent views
the birth
Practical considerations
• Level of involvement depends on proximity and willingness
• Parenting practices change from one generation to next
• May bring conflict in child rearing between parents and grandparents
• Attending grandparenting classes is encouraged
Care management
• Priority: helping parents become accustomed to infant care and new roles
through encouragement, support, and education
• Provide practical information about infant care
• Give guidance about expected infant development
• Be sure parents have contact information for follow-up care for mother
and infant
Application and review
1. After an 8-hour, uneventful labor, a client gives birth. After an airway is
ensured and the neonate is dried and wrapped in a blanket, the nurse
places the newborn in the mother’s arms. The mother asks, “Is my baby
normal?” What is the nurse’s best response?
1. “Most babies are normal; of course your baby is.”
2. “Your baby must be all right; listen to that strong cry.”
3. “Yes, because your entire pregnancy has been so normal.”
4. “We will unwrap your baby; now you can see for yourself.”
2. What should supportive nursing care in the beginning mother–infant
relationship include?
1. Suggesting the mother choose breastfeeding instead of formula
feeding
2. Encouraging the mother to assist with simple aspects of her
newborn’s care
3. Advising the mother to participate in rooming-in with the newborn
at the bedside
4. Observing the mother–infant interaction unobtrusively to evaluate
the relationship
3. What is the most important factor for a nurse to consider when selecting
nursing measures to help parent–child relationships during the
immediate postpartum period?
1. Physical status of the infant
2. Duration and difficulty of the labor
3. Anesthesia during the labor process
4. Health and emotional status during the pregnancy
4. A client is rooming-in with her newborn. A nurse observes the infant lying
quietly in the bassinet with eyes opened wide. What action should the
nurse take in response to the infant’s behavior?
1. Brighten the lights in the room.
2. Wrap and then turn the infant to the side.
3. Encourage the mother to talk to her baby.
4. Begin the physical and behavioral assessments.
5. The practice of separating parents and their newborn immediately after
birth and limiting their time with their newborn in the first few days
contradicts studies based on what?
1. Early rooming-in
2. Taking-in behaviors
3. Taking-hold behaviors
4. Parent–child attachment
6. What is most important for a nurse to do when helping a new mother on
the postpartum unit develop her parenting role?
1. Teach her how to care for the infant.
2. Provide time for her and her infant to be together.
3. Respond to any questions she has about her infant’s behavior.
4. Demonstrate infant care and evaluate her return demonstration.
7. What should the nurse’s initial discussion include to best assist new
parents to understand the unique characteristics of a newborn?
1. Auditory acuity
2. Typical behaviors
3. Need for parent–infant attachment
4. Need to establish a feeding schedule
8. After an emergency cesarean birth, the client tells the nurse that she was
hoping for a “natural” childbirth, but she’s glad she and her baby are all
right. Which postpartum phase of adjustment does this statement most
closely typify?
1. Taking in
2. Letting go
3. Taking hold
4. Working through
9. A nurse is caring for several new mothers in the birthing unit. They are in
the taking-in phase of the postpartum period. What information is most
appropriate for these clients at this time?
1. Perineal care
2. Infant feeding
3. Infant hygiene
4. Family planning
10. What is the nursing action that best promotes parent–infant attachment
behaviors?
1. Supporting rooming-in with parental infant care
2. Encouraging the parents to choose breastfeeding
3. Restricting nonparent visitation on the postpartum unit
4. Keeping the new family together immediately after birth
11. Which behavior indicates to a nurse that a new mother is in the takinghold phase?
1. Calling the baby by name
2. Talking about the labor and birth
3. Touching the baby with her fingertips
4. Being involved with her own need to eat and sleep
12. When caring for a family on a postpartum unit, a nurse must consider
that parenting includes all the tasks, responsibilities, and attitudes that
make up child care and that either parent can exhibit these qualities.
Which factor is the most important influence on parenting ability?
1. Inborn instincts
2. Marriage with flexible roles
3. Childhood roles and concepts
4. Education about growth and development
13. A pilot program is being developed to assist new mothers who are at risk
for mother–infant relationship problems. Which mother’s situation would
make her a candidate for the program?
1. The pregnancy was not planned.
2. There are negative feelings about the birth experience.
3. The pregnancy elicited ambivalent feelings during the first
trimester.
4. There was a preference for one sex, but she gave birth to a baby of
the other sex.
See Answers on pages 240-241.
Answer key: Review questions
1. 4 Mothers need to explore their infants visually and tactilely to assure
themselves that their infants are healthy.
1 Saying that “most babies are normal” closes off communication with
the mother at an opportune moment. 2 A strong cry is not indicative of
a healthy newborn. 3 The “normalcy” of the mother’s pregnancy does
not necessarily have a relationship to the health of the newborn.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation
2. 2 Holding, touching, and interacting with the newborn while providing
basic care promotes attachment.
1 The nurse’s infant feeding preference should not be forced upon the
mother. 3 Although rooming-in helps promote attachment, not all
women have the physical or emotional ability to provide 24-hour care to
the newborn so early in the postpartum period. 4 Early observation is
not adequate; this can be done only by allowing the mother ample time
to interact with her baby.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation
3. 1 Attachment between parent and infant is most successful when
interaction is possible immediately after birth; if the infant is ill, contact is
limited.
2 Although the duration and difficulty of labor is a factor, the most
important factor is the physical condition of the infant. 3 Although the
effect of anesthesia is a factor, the most important one is the physical
condition of the infant. 4 Health and emotional status during
pregnancy may be factors, but the most important factor after the birth
is the physical condition of the infant.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
4. 3 A quiet, alert state is an optimum time for infant stimulation.
1 Bright lights are disturbing to newborns and may impede mother–
infant interaction. 2 This position is used for the sleeping infant. 4
Physical and behavioral assessments are not the priorities; they can be
delayed.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
5. 4 There is a sensitive period in the first minutes or hours after birth
during which it is important for later interpersonal development that the
parents have close contact with their newborn.
1 Rooming-in may not be instituted immediately after birth. 2 Taking-in is
a maternal psychologic behavior described by Reva Rubin that occurs
during the first 2 postpartum days. 3 Taking-hold is a maternal
psychologic behavior described by Reva Rubin that occurs after the
third postpartum day.
Client Need: Psychosocial Integrity; Cognitive Level: Comprehension;
Nursing Process: Assessment/Analysis
6. 2 Parenting can begin only when the infant and the mother get to know
each other. To promote development, the nurse should provide time for
mother–infant interaction.
1 Although the mother should be taught how to care for the infant, it is
not the priority action. 3 Although the nurse should respond to
questions she has about her infant’s behavior, it is not the priority
action. 4 Although infant care should be demonstrated to the mother
and her return demonstration evaluated, it is not the priority action.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Planning/Implementation
7. 2 Information about typical behaviors assists parents to understand the
unique features of their newborn and promotes interaction and
appropriate care.
1 Auditory acuity is too limited; the parents need a broader discussion of
infant behaviors. 3 Although important, the need for parent–infant
attachment can best be fostered if parents know what behaviors to
expect from their infant. 4 The need to establish a feeding schedule is
too limited; in addition, most infants are on a demand feeding
schedule, which fosters individuality.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
8. 1 By discussing the experience, the client is bringing it into reality; this is
characteristic of the taking-in phase.
2 The client is not ready to assume the tasks of the letting-go phase until
the tasks of the taking-in and taking-hold phases have been completed.
3 The taking-hold phase is marked by an increased desire to resume
independence. 4 The working-through phase is not a separate phase of
adjustment to parenthood; this is not relevant.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Assessment/Analysis
9. 1 During the taking-in phase, a woman is primarily concerned with being
cared for and being cared about.
2 Infant feeding is best taught during the taking-hold phase of
postpartum adjustment. 3 Infant hygiene is best taught during the
taking-hold phase of postpartum adjustment. 4 Family planning is not a
primary concern during the immediate postpartum period.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Health Promotion and Maintenance; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Integrated Process:
Teaching/Learning
10. 4 A sensitive period occurs during the first few hours of life that is
important in the promotion of parent–infant attachment, although for
some parents, it may take longer to develop attachment behaviors.
1 Encouraging rooming-in is helpful because it increases the amount of
contact between the parents and the newborn; however, this contact
occurs after the first few critical hours. 2 Contact with the newborn can
be achieved with breastfeeding or formula feeding; it is the contact, not
the method of feeding, that promotes attachment. 3 Contact with the
entire family is important during the taking-in phase of postpartum
adjustment.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Planning/Implementation
11. 1 The mother has moved into the taking-hold phase when she takes
control and becomes actively involved with her infant and calls the infant
by name. She has completed the taking-in phase when her own needs no
longer predominate.
2 Talking about the labor and birth occurs in the taking-in phase when
she has the need to integrate the experience. 3 Touching the baby with
her fingertips is the initial early action of the taking-in phase. 4 Being
involved with her need to eat and sleep is part of the taking-in phase.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
12. 3 Parenting is a learned behavior based on past experiences and current
motivation to learn.
1 Parenting is learned, not inborn. 2 Specific marital roles do not
influence parenting behaviors. 4 Knowledge alone does not ensure the
ability to parent.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
13. 4 This mother is at risk for having difficulty with attachment because her
baby did not meet her expectations.
1 Unplanned pregnancies usually do not pose a risk for attachment
problems because the decision was made to continue the pregnancy,
allowing time to accept it. 2 Reliving the birthing experience, whether it
involves positive or negative feelings, occurs during the first few
postpartum days during the taking-in phase. Unless there are other
emotional problems, these feelings are resolved during this phase, and
then the mother moves into the taking-hold phase, which initiates the
attachment process. 3 Ambivalent feelings during the first trimester are
common and usually resolve during the second trimester.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
C H AP T E R 1 6
Postpartum complications
Postpartum hemorrhage
• Bleeding in excess of 500 mL within first 24 hours after birth
Risk factors
• Uterine atony; vaginal, cervical, and perineal lacerations; hematomas;
retained placental fragments; multifetal pregnancy; numerous previous
pregnancies (bleeding increases risk of infection)
• Uterine atony: caused by overdistention of uterus; prolonged labor,
birth trauma, grand multiparity
• Classification of lacerations
■ First degree: superficial, extends through perineal skin and vaginal
epithelium
■ Second degree: extends through perineal muscles; episiotomies are
second degree
■ Third degree: extends partially or totally through fibers of the
external and/or internal anal sphincters
■ Fourth degree: extends through anterior rectal wall
• Hematomas: in perineum, vagina, uterus; caused by increased fundal
pressure by fetus, forceps, or manipulation
• Placental abnormalities: can cause life-threatening hemorrhage
■ Placenta accreta: chorionic villi adhere to uterine myometrium
■ Placenta increta: chorionic villi invade myometrium
■ Placenta percreta: chorionic villi invade and pass through the
myometrium to peritoneal covering
Clinical findings
• Excessive frank, red bleeding
• Boggy uterus; uterus above umbilicus
• Hypotension
• Disseminated intravascular coagulopathy (DIC)
• Profuse, uncontrollable bleeding from uterus
• Oozing of blood from episiotomy, laceration, or IV site
• Fragmented or distorted red blood cells (RBCs)
• Decreased coagulation factors (pathologic form of clotting)
Therapeutic interventions
• Maintenance of empty bladder
• Massage of fundal portion of uterus
• Administration of oxytocics
• Replacement of blood if severe blood loss
• Surgical repair of lacerations
• Removal of retained placental fragments
• Cryoprecipitate, fresh frozen plasma for DIC
Nursing care of women with postpartum
hemorrhage
• Assessment/analysis
• History of multiparity; prolonged labor; analgesia; multiple gestations;
abruptio placentae or placenta previa; hypertensive disorders,
especially HELLP (hemolysis, elevated liver enzymes, low platelet
count) syndrome
• Vaginal bleeding with clots
• Uterus for tone (firm, boggy)
• Urinary output for decrease
• Vital signs
• Results of blood studies
• Clinical manifestation of shock; anemia
• Level of anxiety
• Planning/implementation
• Monitor vital signs
• Assess fundus for height and firmness every 15 minutes; if boggy,
massage until firm
• Monitor bleeding (eg, number of perineal pads, presence of clots)
• Administer oxytocic as prescribed
• Encourage emptying bladder to prevent distension, which interferes
with uterine contraction; insert indwelling catheter as ordered if
voiding is insufficient; monitor input and output (I&O)
• Prepare for ultrasonography if retained placental fragments are
suspected
• Maintain nothing by mouth (NPO) in case surgical intervention
becomes necessary
• Prepare for blood transfusions or emergency surgery if condition
worsens
• Evaluation/outcomes
• Demonstrates hemodynamic stability
• Remains free from complications
Application and review
1. A patient who had a postpartum hemorrhage is to receive 1 unit of packed
red blood cells (RBCs). The nurse manager observes a staff nurse
administering the packed RBCs without wearing gloves. What does the
nurse manager conclude?
1. Patient does not have an infection.
2. Donor blood is free of bloodborne pathogens.
3. Nurse should have worn gloves for self-protection.
4. Nurse was skilled enough to prevent exposure to the blood.
2. During the second postpartum hour after a long labor and birth, a nurse
identifies that the patient has heavy vaginal bleeding that does not
diminish after fundal massage. The patient states, “I am so thirsty. Can I
have some ginger ale?” How should the nurse reply?
1. “It is good to regain your fluids. I will bring some for you right
now.”
2. “I can imagine how thirsty you are. However, I must get an order
before giving you any fluid.”
3. “Your fluid level should return to normal as quickly as possible. The
blood loss can begin to balance if you drink enough fluids.”
4. “As difficult as it is, it is best for you to wait for the bleeding to
subside. I can give you a moisturizer for your lips to relieve the
dryness.”
3. A patient who has six living children has just given birth. After the
expulsion of the placenta, an infusion of lactated Ringer solution with 10
units of oxytocin is prescribed. What should the nurse explain to the
patient when asked why this infusion is needed?
1. “You had a precipitous birth.”
2. “This is required for an extramural birth.”
3. “It will help expel the retained placental fragments.”
4. “Your uterus may have a relaxed tone after multiple pregnancies.”
4. A nurse is assessing several postpartum patients. Which patients are at
risk for developing postpartum hemorrhage? Select all that apply.
1. Twin birth
2. Overdistended bladder
3. Hypertonic uterine dystocia
4. Retained placental fragments
5. Mild gestational hypertension
5. A nurse is reviewing a patient’s history. What two predisposing causes of
puerperal (postpartum) infection should alert the nurse to monitor this
patient?
1. Malnutrition and anemia
2. Hemorrhage and trauma during labor
3. Preeclampsia and retention of placental fragments
4. Organisms in the birth canal and trauma during labor
6. Two hours after an uneventful labor and birth, a patient’s uterus is four
fingerbreadths above the umbilicus. After urinary catheterization, the
fundus remains firm and four fingerbreadths above the umbilicus. What
is the priority nursing action?
1. Recheck the vital signs.
2. Catheterize again in 1 hour.
3. Notify the health care provider.
4. Palpate the fundus every 2 hours.
See Answers on pages 251-252.
Hemorrhagic (hypovolemic) shock
• Occurs when there is loss of fluid resulting in inadequate tissue perfusion;
caused by excessive bleeding, diarrhea, or vomiting; fluid loss from
fistulas or burns
• Life-threatening cycle; without prompt, effective treatment can lead to
death
Clinical findings
• Subjective: apprehension; restlessness; paresis of extremities
• Objective: weak, rapid, thready pulse; rapid, shallow respirations;
diaphoresis; cold, clammy skin; pallor; decreased urine output;
progressive loss of consciousness; decreased mean arterial pressure
(normal is 80 to 120 mm Hg)
Therapeutic interventions
• Correction of underlying cause
• Fluid and blood replacement; rapid IV infusion of crystalloid solution;
packed RBCs if no improvement is seen after crystalloid infusion
• Oxygen therapy, ventilator
• Elevation of lower extremities to ensure circulation to vital organs
• Cardiac and hemodynamic monitoring
Nursing care of women in shock
• Assessment/analysis
• Postpartum, may not show classic signs until more than 30% of blood
volume is gone; important to anticipate potential problems
• Signs of covert bleeding: rapid, thready pulse; hypotension; increased
respirations; cold, clammy skin
• Mental status changes: restlessness and confusion progressing to
lethargy and decreased level of consciousness
• Cardiovascular status: pulse, blood pressure, electrocardiogram (ECG),
hemodynamic monitoring, peripheral vascular assessment
• Respiratory status: breath sounds (before and after fluid replacement),
arterial blood gases, Sao2
• Planning/implementation
• Establish venous access early; ideally via two large-bore IV catheters
• Keep warm; place in supine position
• Monitor hemodynamic status and vital signs
• Monitor urine output and specific gravity via indwelling catheter
• Allay anxiety
• Administer intravenous fluids and titrate parenteral vasoactive
medications as prescribed
• Monitor oxygen saturation and provide oxygen therapy as indicated
• Evaluation/outcomes
• Maintains stable hemodynamic status
• Maintains urine output >30 mL/hour
• Remains oriented to time, place, and person
• Maintains adequate cardiac output
Application and review
7. A nurse in the postanesthesia care unit is caring for a postpartum patient
who received a general anesthetic. Which finding should the nurse report
to the health care provider?
1. Patient pushes the airway out.
2. Patient has snoring respirations.
3. Respirations of 16 breaths/min are shallow.
4. Systolic blood pressure drops from 130 to 90 mm Hg.
8. An emergency department nurse is admitting a pregnant patient after an
automobile collision. The health care provider estimates that the patient
has lost about 30% to 35% of blood volume. Which assessment finding
should the nurse expect this patient to exhibit?
1. Urine output of 50 mL/hr
2. Blood pressure of 150/90 mm Hg
3. Apical heart rate of 142 beats/min
4. Respiratory rate of 16 breaths/min
See Answers on pages 251-252.
Coagulopathies
• Should be suspected when no source can be found for continuous
bleeding
• Promptly assess coagulation status, and repeat assessments appropriately
• Causes include decreased platelets, increased prothrombin time,
increased partial thromboplastin time, decreased fibrinogen level, and
increased fibrin degradation products
Idiopathic thrombocytopenic purpura (ITP)
• Autoimmune disorder that appears to result from production of an
antiplatelet antibody that coats surface of platelets and facilitates their
destruction by phagocytic leukocytes
• Can cause severe bleeding with cesarean birth, cervical lacerations,
vaginal lacerations, increased incidence of postpartum uterine bleeding
• May cause neonatal thrombocytopenia
• Clinical findings
• Subjective: fatigue, headache, paresthesias, dyspnea; sore mouth with
pernicious anemia; bleeding gums and epistaxis
• Objective: low platelet count, ecchymotic areas, hemorrhagic petechiae
• Therapeutic interventions
• Corticosteroids, IV immunoglobulin
• Significant bleeding: platelet transfusions
• Splenectomy if unresponsive to medical management
von Willebrand disease (vWD)
• Congenital defect in clotting protein (von Willebrand factor) of blood
• Rare, but one of the most common clotting diseases in women of
childbearing age in the United States
• Factor VIII increases during pregnancy, but vWD decreases, creating risk
for postpartum hemorrhage; risk is increased for 1 month postpartum
• Clinical findings
• Objective: recurrent bleeding episodes, bruising, prolonged bleeding
time, factor VIII deficiency, bleeding from mucous membranes
• Therapeutic interventions
• Desmopressin
• Transfusion of plasma products containing factor VIII and vWD
Episiotomy
• Incision into perineum to facilitate birth, prevent lacerations and
overstretching of pelvic floor usually on perineum between vaginal
introitus and rectum; may be midline or mediolateral
• Closed surgically; usually performed under regional anesthesia
• More painful, more difficult to repair, and causes more perineal trauma
and infection than repair of lacerations
Nursing care of women after an episiotomy
• Assessment/analysis
• Clinical manifestations of (redness, edema, ecchymosis, discharge,
approximation) REEDA
• Extent of pain
• Signs of hematoma
• Planning/implementation
• Apply cold to perineum if ordered (limits edema during first 12 to 24
hours)
• Provide and teach perineal care, including when to change pads
• Administer prescribed analgesics; may be systemic and/or local
• Provide sitz baths if ordered; promotes dilation of blood vessels,
increases blood to area, facilitates healing
• Teach perineal exercises (Kegel)
• Evaluation/outcomes
• States relief from pain
• Remains free from infection
Application and review
9. A patient tells a nurse that she does not want an episiotomy and would
rather tear naturally. What information should be offered regarding each
birthing method?
1. Lacerations are more painful than an episiotomy.
2. Lacerations are easier to repair than an episiotomy.
3. An episiotomy causes less posterior trauma than lacerations.
4. An episiotomy is preferred over lacerations according to evidencebased practice.
10. Sitz baths are ordered for a patient with an episiotomy during the
postpartum period. A nurse encourages her to take the sitz baths because
they aid the healing process by doing what?
1. Promoting vasodilation
2. Cleansing perineal tissue
3. Softening the incision site
4. Tightening the rectal sphincter
See Answers on pages 251-252.
Venous thromboembolic disorders
• Superficial venous thrombosis: thrombosis or inflammation of the
superficial saphenous venous system
• Deep venous thrombosis (DVT): thrombophlebitis associated with clot
formation
• Pulmonary embolism: emboli develop from thrombi in peripheral
circulation or right side of heart; peripheral emboli travel and obstruct
the pulmonary artery or its branches
• Postpartum early ambulation has helped to decrease incidence
• Causes related to pregnancy: venous stasis, hypercoagulation
Risk factors
• Genetic risk factors, smoking, operative vaginal birth, cesarean birth,
positive history for thromboembolic disease, obesity, maternal age >35
years, multiparity, and infection
Clinical findings
• Definitively diagnosed via venography; however, this is invasive with
potential for serious complications; Doppler ultrasound, auscultation;
ECG preferred
• Superficial venous thrombosis
• Subjective: pain, tenderness in legs, feet
• Objective: warm skin, redness, hardened veins in thrombotic area
• Deep venous thrombosis
• May be asymptomatic
• Subjective: unilateral leg pain, calf tenderness
• Objective: leg/calf swelling, warm skin redness, pain in calf with
dorsiflexion of foot
• Pulmonary embolism
• Subjective: anxiety
• Objective: dyspnea, tachypnea, tachycardia, cough, hemoptysis, elevated
temperature, syncope, and pleuritic chest pain
Therapeutic interventions
• Superficial venous thrombosis
• Nonsteroidal antiinflammatory drugs, rest, elevation of affected leg(s),
compression stockings, moist heat application
• Deep venous thrombosis
• Anticoagulants (usually IV heparin, oral warfarin), analgesics, bed rest,
elevation of affected leg(s); compression stockings for when patient is
released from bed rest
• Pulmonary embolism
• Continuous IV heparin until symptoms have resolved, then
subcutaneous heparin and/or oral anticoagulants
Nursing care of women with venous
thromboembolic disorders
• Assessment/analysis
• Inspect, palpate affected areas
• Peripheral pulses
• Homans sign
• Measure, compare leg circumference
• Assess for hemorrhage
• Signs of pulmonary embolism
• Respiratory status; crackles
• Prothrombin, partial thromboplastin times
• Planning/implementation
• Teach patient and family regarding thromboembolic disorders
• Teach patient and family bed rest care and considerations
■ Changing positions to prevent tissue breakdown
■ Avoid bending knees sharply
• Provide comfort measures for patient
■ Application of warm, moist heat
■ Analgesic, antiinflammatory therapy
• Provide assistance while patient is on bed rest
• Teach patient not to rub/massage affected area
• Administer medications as ordered
• Notify health care provider if nontherapeutic clotting times
• Teach patient that breastfeeding is safe while on anticoagulant therapy
• Teach patient regarding ongoing medications
• Provide information on bleeding and injury prevention while patient is
on anticoagulant therapy
• Teach patient not to take oral contraceptives because of risk of
thrombus formation
• Evaluation/outcomes
• Patient understands her diagnosis
• Patient is able to cope with recovery time
• Patient understands importance of continuing anticoagulant therapies;
understands schedule, self-administration (for injections), and side
effects of medications after discharge
• Patient takes appropriate contraceptive measures if on warfarin
Postpartum infections
• Major cause of maternal morbidity and mortality
• Most common in women who have operative vaginal or cesarean births or
who have immunosuppressive conditions (Box 16.1)
• Any infection of the urogenital tract up to 1 month after delivery,
miscarriage, or abortion
• Often caused by streptococcal or anaerobic organisms
BOX 16.1
P re disposing F a ct ors for P ost pa rt um I nfe ct ion
Preconception or antepartal factors
• History of previous venous thrombosis, urinary tract infection, mastitis,
pneumonia
• Diabetes mellitus
• Alcoholism
• Drug abuse
• Immunosuppression
• Anemia
• Malnutrition
Intrapartal factors
• Cesarean birth
• Operative vaginal birth
• Prolonged rupture of membranes
• Chorioamnionitis
• Prolonged labor
• Bladder catheterization
• Internal fetal/uterine pressure monitoring
• Multiple vaginal examinations after rupture of membranes
• Epidural analgesia/anesthesia
• Retained placental fragments
• Postpartum hemorrhage
• Episiotomy or lacerations
• Hematomas
From Lowdermilk, D.L., Perry, S.E., Cashion, K., & Alden, K.R. (2016). Maternity and women’s health
care (11th ed.). St Louis: Elsevier.
Endometritis
• Most common infection
• Starts as localized infection at placental site and can spread to entire
endometrium
• Clinical findings
• Subjective: nausea, pelvic pain, fatigue
• Objective: fever, tachycardia, chills, anorexia, increased white blood cell
count, increased RBC sedimentation rate, anemia, foul-smelling vaginal
discharge
• Therapeutic interventions
• Complete blood count, blood cultures, tissue cultures
• Broad-spectrum IV antibiotic therapy
• Pain management
• Supportive care (rest, hydration)
• Nursing care of women with endometritis
• Assessment/analysis
■ Assess vaginal discharge
■ Vital signs
■ Changes in condition
• Planning/implementation
■ Provide supportive measures (cool compresses, blankets, perineal
care)
■ Teach patient side effects of medications
■ Teach patient signs of worsening infection
■ Teach patient importance of compliance with medication regimen
• Evaluation/outcomes
■ Patient complies with drug treatment regimen
■ Infection resolves
Wound infections
• Usually develop after discharge
• Sites include cesarean incision, episiotomy
• Clinical findings
• Subjective: pain, tenderness
• Objective: redness, swelling, warmth, drainage, wound separation
• Therapeutic interventions
• Complete blood count, blood cultures, tissue cultures
• Antibiotic therapy
• Wound debridement, drainage
• Nursing care of women with wound infections
• Assessment/analysis
■ Assess wound
■ Vital signs
• Planning/implementation
■ Provide wound/dressing care
■ Provide supportive measures (warm compresses, sitz bath, perineal
care)
■ Teach patient good hygiene techniques, self-wound-care measures
■ Teach patient signs of worsening infection
• Evaluation/outcomes
■ Patient complies with drug treatment regimen
■ Wound heals completely
■ Patient is free of infection
Urinary tract infections
• Clinical findings
• Subjective: tenderness, flank pain
• Objective: painful urination, frequency and urgency, fever, urinary
retention, red/white blood cells in urine
• Therapeutic interventions
• Urine culture
• Antibiotic therapy
• Adequate hydration
• Analgesia
• Nursing care of women with urinary tract infections
• Assessment/analysis
■ Urine for color, clarity, odor, presence of red/white blood cells
• Planning/implementation
■ Teach patient to take temperature
■ Teach patient signs of improving (or worsening) infection
■ Teach patient importance of adherence to medication regimen
■ Teach patient possible complications
■ Teach patient good hygiene techniques
■ Teach patient regarding increasing fluid intake
• Evaluation/outcomes
■ Expresses relief of pain on urination
■ Resumes expected urinary patterns
■ Describes methods to prevent recurrence of infection
Maternal death
• Very rare in the United States
• Maternal risk factors
• Embolism
• Preeclampsia
• Maternal age >35 years
• Lack of prenatal care
• African American
• Surviving family
• Should be provided access to grief counseling, referral to social services
• At risk for complicated grieving
• At risk for altered parenting of baby (if infant survives) or other
children
• Important to provide emotional support
• Nurses caring for patient
• May experience guilt, sadness, anger, depression
• Critical incident debriefing and/or morbidity/mortality review should be
considered
• May benefit from participation in grief rituals (memorial, funeral
services)
Answer key: Review questions
1. 3 The Centers for Disease Control and Prevention (CDC) recommends
that gloves be worn when there is potential contact with blood or other
body fluids.
1 Even if the patient does not have an infection, gloves are always worn
when exposure to blood or other body fluids is a possibility. 2 All blood
is considered to be potentially infectious. 4 Nurses are required to take
precautions that limit exposure; gloves must be worn.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
2. 4 The patient should receive nothing by mouth while heavy bleeding
continues because surgical intervention may become necessary.
1 Providing oral fluids at this time is inappropriate and could result in
aspiration if surgery becomes necessary. 2 The nurse does not need an
order to give fluids to a postpartum patient; the nurse must make an
independent judgment regarding the withholding of fluids. 3 Although
oral fluids can increase the blood volume, it would be inappropriate to
provide fluids while the patient is bleeding.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Planning/Implementation
3. 4 Multiple full-term pregnancies and births result in overstretched uterine
muscles that do not contract efficiently, and bleeding may ensue.
Oxytocin promotes uterine contractions.
1 A precipitous birth does not predispose to uterine atony unless there is
a complication. 2 Giving birth outside the birthing area does not
predispose the patient to uterine atony. 3 Multiparity does not
predispose to retained placental fragments.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Planning/Implementation
4. Answers: 1, 2, 4
1 Overdistention of the uterus may lead to delayed or inadequate uterine
contractions. 2 An overdistended bladder may inhibit uterine
contractions. 4 Retained placental fragments inhibit uterine
contractions. 3 Patients with ineffective uterine contractions are treated
with rest and sedatives; although labor is prolonged, postpartum
hemorrhage is not expected. 5 Mild gestational hypertension does not
interfere with uterine involution.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes
5. 2 Blood loss depletes the cellular response to infection; trauma provides an
excellent avenue for bacteria to enter.
1 Malnutrition and anemia may create problems if hemorrhage occurs
because the hemoglobin and hematocrit are already low. 3
Preeclampsia is not a predisposing cause of postpartum infection;
retained placental fragments cause hemorrhage and if not removed
immediately will result in hypovolemic shock, not infection. 4
Endogenous infections are rare; infections usually are caused by
outside contamination. Trauma and the denuded placental site may
contribute to the development of infection.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
6. 3 The increased height of the uterus may result from accumulation of
blood in the uterus from internal hemorrhaging; vital signs may be
indicative of impending shock.
1, 2, 4 Rechecking the vital signs, catheterizing in 1 hour, and palpating
the fundus every 2 hours are unsafe; the patient needs immediate
therapeutic intervention.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
7. 4 A drop in blood pressure; rapid pulse rate; cold, clammy skin; and
oliguria are signs of decreased blood volume and shock, which if not
treated promptly can lead to death.
1 The patient will push out the airway as the effects of anesthesia subside;
this is an expected response. 2, 3 Snoring and shallow respirations are
common responses to depressant effects of anesthesia.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing Process:
Planning/Implementation
8. 3 In hypovolemic shock, tachycardia is a compensatory mechanism in an
attempt to increase blood flow to body organs.
1 Urine output would fall to less than 30 mL/hr because a decreased blood
volume causes a decreased glomerular filtration rate. 2 The blood
pressure is decreased because of the decreased blood volume. 4 16
breaths/min is within the accepted range of 12 to 20 breaths/min; the
respiratory rate is rapid with hypovolemic shock.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
9. 2 Lacerations require less suture time and cause less perineal trauma,
which can have lifelong implications such as rectal-vaginal fistulas.
1 Lacerations are less painful than an episiotomy and tend to heal more
quickly. 3 An episiotomy causes more posterior trauma than
lacerations. 4 Evidence indicates that a routine episiotomy policy
results in more perineal trauma, more suturing time, and more
complications than lacerations.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation
10. 1 Heat causes vasodilation and an increased blood supply to the area.
2 Cleansing is done with a perineal bottle and cleansing solution
immediately after voiding and defecating. 3 Sitz baths do not soften the
incision site. 4 Neither relaxation nor tightening of the rectal sphincter
will increase healing of an episiotomy.
Client Need: Basic Care and Comfort; Cognitive Level: Comprehension;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
C H AP T E R 1 7
Nursing care of the newborn and
family
Physiologic and behavioral adaptations of the
newborn
Transition to extrauterine life
• First stage (period of reactivity)
• Lasts 0 to 30 minutes
• Alert and moving
• Gustatory movements
• Heart rate: 160 to 180 beats/min for 15 minutes; declines to baseline of
100 to 120 beats/min
• Respirations: 40 to 60 breaths/min; abdominal; irregular; grunting,
flaring of nostrils; intermittent chest retractions
• Second stage (period of decreased responsiveness)
• Lasts 30 minutes to 2 hours
• Relaxation and rest
• Heart rate between 100 and 120 beats/min
• Respirations: rapid, shallow, synchronous; chest shape gradually
changes to increase anterior-posterior diameter
• Audible bowel sounds
• Third stage (second period of reactivity)
• Lasts 2 to 8 hours
• Increased responsiveness to stimuli
• Cardiac and respiratory rates may increase
• Changes in color and muscle tone
• Bowel sounds more frequent; may pass meconium
Physiologic adjustments
Physiologic adjustments
• Respiratory system
• Forty to 60 breaths/min during first 2 hours after birth, then 30 to 50
breaths/min; irregular rate; abdominal excursions
• Cardiovascular system
• Changes in fetal circulation after umbilical cord is clamped
■ Foramen ovale closes
■ Ductus arteriosus closes; becomes ligamentum arteriosum
■ Umbilical arteries obliterate
■ Circulation becomes similar to adult within 1 hour after birth
• Heart rate regular; 110 to 160 beats/min; variable depending on infant’s
activity; soft heart murmur common for first month of life
• Clotting mechanism inadequate because intestinal bacteria necessary
for synthesis of prothrombin are lacking; exogenous vitamin K needed
• Liver large but immature; cannot destroy large number of red blood
cells (RBCs) that consist of fetal hemoglobin, resulting in physiologic
jaundice by third day
• Hemoglobin 14 to 20 g/100 mL; fetal hemoglobin replaced by adult form
in 6 weeks
• White blood cell (WBC) count high: 6000 to 22,000/mm3
• Temperature
• Maintained at 97.8° F to 98° F (36.6° C to 36.7° C); environment may
cause fluctuations
• Excretory
• Stools
■ Meconium: first 2 days; black-green; tenacious
■ Transitional: by third day; mixes with milk stool; green-yellow
• Urine
■ Kidneys immature
■ Voids in first 24 hours; voids 20 times daily at 2 weeks of age
■ Contains albumin and urates during first week causing brick-red
staining on diaper
• Digestive system
• Fetus stores nutrients toward end of third trimester; needs little
nourishment during first few days
• Rooting and sucking reflexes active at birth
• Simple carbohydrates, fats, and proteins readily digested
• Inadequately developed cardiac sphincter; regurgitation after feeding
• Swallowing of air when suckling requires being burped during and after
feedings
• Gastric acidity is low for 2 to 3 months
• Hepatic system
• Liver and gallbladder formed by fourth week of gestation
• At birth, liver enlarged (40% of abdominal cavity)
• Full-term infant has iron stores for 4 to 6 months (preterm or small-forgestational-age (SGA) infants have less); iron in breast milk has best
bioavailability to replenish stores
• Liver palpated 1 cm below right costal margin
• Immune system
• Passive immunity in utero: immunoglobulin G (IgG) passes from
mother to fetus through placenta
• Active immunity in utero: fetus produces immunoglobulin M (IgM) by
end of first trimester
• Passive immunity after birth: immunoglobulin A (IgA) passes from
mother to infant through colostrum, the precursor to breast milk
• Integumentary system
• Lanugo: fine, downy hair growth over entire body; preterm infants have
more lanugo
• Vernix caseosa: whitish, cheesy substance covers body; more abundant
in creases; more in preterm infant and less in postterm infant
• Milia: small, whitish, pinpoint spots over nose caused by retained
sebaceous secretions that resolve within a month
• Mongolian spots: blue-black discolorations on back, buttocks, and sacral
region that disappear by first year; common on dark-skinned infants
• Telangiectatic nevi (stork bites): pink or red areas caused by capillary
dilation
• Neuromuscular reflexes
• Rooting: when cheek is touched with finger, head turns to search for
finger; may persist for up to 1 year
• Sucking: object close to mouth elicits sucking movements; persists
throughout infancy
• Gag: stimulation of posterior pharynx causes choking; helps prevent
aspiration; persists through life
• Grasp: pressure on palm (palmar) or on sole of foot below toes (plantar)
elicits flexion; palmar lessens by 3 months, plantar by 8 months
• Babinski: when outer undersurface of foot is stroked in an arc toward
inner undersurface, toes separate and flare out; disappears after 1 year
• Moro (startle): sudden jar, noise, or change in equilibrium causes
extension and abduction of extremities, followed by flexion and
adduction into embrace position; may cry out; disappears by 3 to 4
months
• Crawl: when in prone position on firm surface, crawling movements are
elicited; disappears at about 6 weeks
• Step or dance: when supported under both arms with feet on firm
surface, stepping movements are elicited; disappears after 3 to 4 weeks
• Tonic neck (fencing): when in supine position, arm and/or leg on side to
which head is turned extends with flexion of contralateral limbs;
usually disappears by 3 to 4 months
• Metabolic
• Attempts to maintain body temperature by flexion of extremities,
breaking down of brown fat, and vasoconstriction
• Loses 5% to 10% of body weight by first week of life
• Needs screening for inborn errors of metabolism
■ Phenylketonuria (PKU) testing done 24 to 48 hours after first feeding;
test may be done earlier with repeat test at first follow-up visit;
infants with excess phenylalanine require special low-phenylalanine
diet to prevent cognitive impairment
■ Thyroxine (T4) screening; inadequate thyroxine without replacement
therapy leads to cretinism
■ Lactose intolerance; requires nonmilk formula
• Hypoglycemia
■ Caused by inadequate glycogen reserve
■ Clinical findings: jitteriness, temperature and respiratory instability
■ Risk factors: preterm infants, small for gestational age (SGA), large
for gestational age (LGA), infants of diabetic mothers (IDMs), birth
trauma, congenital anomalies, endocrine disorders (eg,
hyperinsulism, hypopituitarism, hypothyroidism)
• Endocrine system
• Related to hormones transmitted by mother
• Males: breast enlargement (gynecomastia); edematous scrotum
• Females: breast enlargement; secretion from nipples (witch’s milk);
edematous labia; blood-tinged vaginal discharge (pseudomenstruation)
• Neurologic system
• Immature central nervous system (CNS) and brain; most responses are
reflexive
• Early neural activities: breathing, sucking, crying; necessary for survival
• Sleep (see also Sleep–wake states, later)
• Lowers body metabolism
• Helps restore energy and assimilate nutrients for growth
Behavioral characteristics
• Sleep–wake states
• During reactivity, sleep and activity are systematic
• Six sleep–wake states (Box 17.1)
• First 2 to 3 days of life, newborns sleep almost continually
• More time is spent awake as infants age
• Newborns spend 16 to 18 hours asleep
• Approximately 50% of sleep time is in light sleep state
• May not follow diurnal cycle
• Influence of gestational age
• Gestational age affects CNS development
• Preterm infants have an immature CNS, which affects what behaviors
they are able to exhibit in response to stimuli
■ Delayed reflex development
■ Difficulty transitioning between sleep–wake states
■ Difficulty maintaining active–alert stage without becoming
overstimulated
■ More likely to exhibit fatigue or physiologic stress than full-term
counterparts
• Sensory behaviors
• Vision
■ At birth eye structures incomplete; musculature immature;
accommodation not present; cannot detect color
■ Corneal reflex intact; able to blink; pupils reactive to light; clear visual
distance is 17 to 20 cm (8 to 12 in); responsive to light and darkness
■ Visual acuity matches adult by 6 months
■ Will track movement with eyes within minutes of birth
■ Engagement in eye-to-eye contact important for infant–parent
bonding
■ Like patterns and visual stimulation
• Hearing
■ Hearing is similar to adult level at birth
■ Loud sounds elicit Moro reflex
■ Quiet or slow, rhythmic sounds have a calming effect
■ May recognize mother’s voice at birth from intrauterine exposure
• Smell
■ Infants have well-developed sense of smell
■ React positively to sweet smells
■ React negatively to sour or strong smells
■ Can recognize the smell of their mother within the first week
• Taste
■ Have basic sense of taste
■ Respond positively to sweet tastes
■ Respond negatively to sour or bitter tastes
• Touch
■ Depending on gestational age and complications (eg, birth injury,
maternal substance abuse); newborns very responsive to touch
■ Mouth, face, hands, and feet are most sensitive to touch at birth
• Response to environmental stimuli
• Habituation: psychologic or physiologic phenomenon whereby
neonate’s response to a repetitive stimulus decreases; promotes
environmental selectivity and learning
• Consolability: ability of infant to console self or to allow self to be
consoled; infants often initiate methods to reduce their own distress
(eg, sucking, visual distraction)
• Cuddliness: ability of infant to relax into person holding him or her;
helps to promote parent–infant bonding
• Irritability: a measure of how intensely infants respond to negative
stimuli (eg, loud noises, wetness, hunger); some infants respond
quickly and intensely to stimulation, whereas others need significant
stimulation to respond
• Crying: behavior exhibited in response to hunger, pain, desire for
attention, irritability; each type of cry is different, and crying behavior
can extend for differing amounts of time
BOX 17.1
S t a t e s of S le e p a nd A ct ivit y
Deep sleep: Closed eyes; regular breathing; no movement except for
occasional sudden bodily twitch; no eye movement
Light sleep: Closed eyes; irregular breathing; slight muscular twitching of
body; rapid eye movements under closed eyelids; may smile
Drowsy: Eyes may be open; irregular breathing; active body movement
variable, with occasional mild startles
Quiet alert: Eyes wide open and bright; responds to environment by active
body movement and staring at close-range objects; minimum body
activity; regular breathing; focuses attention on stimuli
Active alert: May begin with whimpering and slight body movement; eyes
open; irregular breathing
Crying: Progresses to strong, angry crying and uncoordinated thrashing of
extremities; eyes open or tightly closed; grimaces; irregular breathing
From Hockenberry, M. & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed.). St.
Louis: Elsevier.
Application and review
1. A nurse who is assessing a newborn 3 minutes after birth takes into
consideration that the heart rate of a healthy, alert neonate may range
between what?
1. 120 and 180 beats/min
2. 130 and 170 beats/min
3. 110 and 160 beats/min
4. 100 and 130 beats/min
2. In a noisy room a sleeping newborn initially startles and has rapid
movements but soon goes back to sleep. What is the most appropriate
nursing action in response to this behavior?
1. Accept the infant’s behavior.
2. Assess the infant’s vital signs.
3. Test the infant’s ability to hear.
4. Stimulate the infant’s respirations.
3. A nurse is assessing a newborn’s respirations. What clinical findings
indicate that the respirations are within the expected range?
1. Regular, thoracic, 40 to 60/min
2. Irregular, thoracic, 30 to 60/min
3. Regular, abdominal, 40 to 50/min
4. Irregular, abdominal, 30 to 60/min
4. Which behavior should a nurse identify as the Moro reflex response?
1. Extension and adduction of the arms
2. Abduction and then adduction of the arms
3. Adduction of the arms and fanning of the toes
4. Extension of the arms and curling of the fingers
5. A newborn has small, whitish, pinpoint spots over the nose that are caused
by retained sebaceous secretions. When documenting this observation,
what does a nurse identify them as?
1. Milia
2. Lanugo
3. Whiteheads
4. Mongolian spots
6. A nurse observes a healthy newborn lying in the supine position with the
head turned to the side and legs and arms extended on the same side and
flexed on the opposite side. Which reflex does the nurse identify?
1. Moro
2. Babinski
3. Tonic neck
4. Palmar grasp
7. Which should the nurse explain to a new mother will be delayed until her
newborn is 36 to 48 hours old?
1. Vitamin K injection
2. Test for blood glucose level
3. Test for necrotizing enterocolitis
4. Screening for phenylketonuria
8. A nurse teaches a group of postpartum patients that all their newborns
will be screened for phenylketonuria (PKU) to do what?
1. Assess protein metabolism
2. Reveal potential retardation
3. Detect chromosomal damage
4. Identify thyroid insufficiency
9. When assessing a 9-lb (4 kg) neonate 2 hours after birth, a nurse identifies
jitteriness, apneic episodes, tachycardia, and temperature instability. What
complication do these findings indicate to the nurse?
1. Hyponatremia
2. Hypoglycemia
3. Cardiac defect
4. Immature CNS
See Answers on pages 267-270.
Care management: Birth through the first 2 hours
Immediate care after birth
• Aspirate mucus to provide an open airway
• Dry infant and place in skin-to-skin contact with mother or under radiant
warmer to maintain body temperature
• Perform newborn assessment
• Promote interaction between parents and newborn
• Identify by applying matching identification bands to infant and mother;
may include father and significant others
• Obtain heel-stick blood specimen for laboratory tests to assess adaptation
to extrauterine life and presence of congenital conditions; use outer
aspect of heel to prevent lancet penetration of bone (Fig. 17.1)
FIG. 17.1 Heel-stick sites. Source: (From Lowdermilk, D.L., Perry, S.E., Cashion, K., & Alden,
K.R. [2016]. Maternity and women’s health care [11th ed.]. St Louis: Elsevier.)
Initial assessment of the newborn
• Apgar score
• Evaluate 1 and 5 minutes after birth
• Score determined by points for heart rate (most critical), respiration,
muscle tone, reflex irritability, and color (Table 17.1)
• Scores: 7 to 10, good condition; 3 to 6, moderately depressed; 0 to 2,
severely depressed; lower scores related to high neonatal morbidity and
mortality with need for resuscitative interventions
• Gestational age
• Preterm: birth at less than 37 completed weeks’ gestation
• Term: birth between the 37th and 42nd week of gestation
• Postterm (postmature): birth after 42 weeks’ gestation; subjected to
effects of progressive placental insufficiency and diminished amniotic
fluid
• Gestational age assessment: new Ballard scale determines gestational
age of very-low-birthweight infants as well as at term (Fig. 17.2)
• General measurements
• Overview
■ Measurements are recorded regularly
■ Compared over time and in relation to each other
• Chest and head circumference
■ Chest circumference is usually 30.5 to 33 cm (12 to 13 inches)
■ Head circumference is usually 2 to 3 cm (approximately 1 inch)
greater than chest circumference
■ Molding may cause head circumference to equal chest circumference
■ If head circumference <than chest: may be microcephaly or
premature closure of the sutures
■ If head is >4 cm (approximately 1½ inches) larger than chest: may be
hydrocephalus
• Head circumference and sitting height
■ Sitting height is usually 31 to 35 cm (12.5 to 14 inches)
■ Should be close to equal to head circumference
• Total body length
■ Average length is 48 to 53 cm (19 to 21 inches)
• Birthweight
■ Appropriate for gestational age (AGA): between 10th and 90th
percentile (between 6 and 8.5 lb (2.7 and 5 kg))
■ LGA: above 90th percentile
■ SGA: below 10th percentile
■ Low birthweight (LBW): less than 2500 g (5.5 lb)
■ Very low birthweight (VLBW): less than 1500 g (3.5 lb)
■ Extremely low birthweight: less than 1000 g (2.2 lb)
■ Intrauterine growth restriction (IUGR): fetal growth rate below
expected range for gestational age
• Vital signs: moves from least to most invasive
• Respirations, heart rate, temperature, pain
• Respirations: abdominal and irregular; 40 to 60 breaths/min during first
2 hours; then 30 to 50 breaths/min retractions with sternal depression
indicate pathology
• Heart rate: 100 beats/min at rest, 180 beats/min when crying; more than
160 beats/min at rest indicates cardiac disorder
• Temperature: 97.7° F to 98.9° F
• Pain: see “Pain” in Chapter 19, Neonatal Complications
• Physical assessment
• Skin
■ Body: pink with cyanosis of hands and feet (acrocyanosis); jaundice
during first 24 hours is sign of pathology
■ Markings: abrasions, rashes, crackling, birthmarks, forceps marks,
ecchymosis, papules
■ Turgor: elasticity indicates adequate tissue hydration
• Head and sensory organs
■ Head and chest circumference: nearly equal with chest slightly
smaller than head; if reversed, indicates microcephaly; if head is
more than 1½ inch (4 cm) larger than chest, it indicates hydrocephaly
■ Fontanels: flat; bulging when crying; bulging at rest indicates
increased intracranial pressure; sunken indicates dehydration
■ Symmetry of face: sides of face should move equally when crying
■ Characteristics of head: molding, abrasions, or skin breakdown; caput
succedaneum (edema of soft tissue of scalp); cephalohematoma
(edema of scalp caused by effusion of blood between skull bone and
periosteum)
■ Neck: adequacy of range of motion indicated by full head movement
in all directions when extended; head lags as infant is raised
■ Eyes: discharge or irritation; pupils for reaction to light; equality of
eye movements (usually some ocular incoordination); sclerae for
clarity, jaundice, or hemorrhage
■ Nose: patency of both nostrils; frequent sneezing in an attempt to
clear mucus from nose
■ Mouth: color and continuity of gums and hard and soft palates; white
patches that bleed on rubbing indicate thrush, a monilial infection
■ Ears: auricles open; vernix covers tympanic membrane, response
when bell is rung close to ear; both eyes at same level as ears (ears
lower than eyes indicate possible congenital anomaly); upper
earlobes curved (flatness indicates kidney anomaly)
• Chest and abdomen
■ Chest auscultation: respiratory sounds audible (noisy crackling
sounds are unexpected); regular heart rate
■ Breasts and nipples: edematous; witch’s milk is response to maternal
hormone stimulation
■ Abdomen
■ Bowel sounds over abdomen
■ Spleen: tip should be palpable by fingertips under left costal
margin
■ Liver: palpation on right side; 1 cm below costal margin
■ Umbilical cord: redness, odor, or discharge; contains one vein and
two arteries (two vessels or two veins and one artery indicate
possible congenital anomalies)
■ Umbilical hernia when crying
■ Femoral pulses: gentle palpation at inner aspect of groin; pulses
indicate intact circulation to extremities
• Genitalia
■ Males
■ Testes in scrotum: palpable; one or both may be undescended in
preterm infants and some full-term newborns; usually descend
during childhood; must descend by puberty or sperm are
destroyed by high temperature in abdominal cavity
■ Scrotum: edematous; enlargement indicates hydrocele and
diagnosis confirmed by transparent appearance of scrotum when
flashlight is held close to scrotal sac (transillumination)
■ Penis: urinary meatus at tip; meatus on upper surface of penis
(epispadias); meatus on lower surface (hypospadias)
■ Voiding pattern, frequency
■ Females
■ External: labia, urinary meatus, and vaginal opening
■ Labia: edema
■ Vagina: bloody, mucoid discharge response to maternal hormones
■ Voiding frequency
■ Ambiguous genitalia: unclear identification of gender; studies
needed to determine gender (eg, genetic, surgical procedure)
• Extremities
■ Hands and arms: thumbs clenched in fist; wrist angle is 0° at term
■ Fingers: number and variation
■ Movement of clavicles and scapulae while putting arms through
range of motion: clicking or resistance indicates dislocation or
fracture
■ Fractures; indicated by crepitation
■ Feet and legs
■ Toes: appearance and number
■ Adduction and abduction of feet during range of motion: resistance
or tightness indicates need for further assessment
■ Flexion of both legs onto lower abdomen with abduction of knees:
click (Ortolani sign) indicates developmental dysplasia of hip
(DDH)
■ Feet placed on flat surface with bent knees: knees of unequal height
(Allis sign) indicates DDH
■ Symmetry of gluteal folds; asymmetry indicates DDH
• Back: dimples, separations, or swellings along spinal column indicates
spina bifida
• Anus: patency confirmed with passage of meconium; imperforate anus
ruled out by digital examination
• Neuromuscular development: reflexes
FIG. 17.2 Neuromuscular maturity and physical maturity. Source: (From Ballard, J.L.,
Khoury, J.C., Wedig, K., Wang, L., Eilers-Walsman, B.L., & Lipp, R. [1991]. New Ballard score,
expanded to include extremely premature infants. Journal of Pediatrics 119:417–423.)
TABLE 17.1
Apgar Score
Data from Apgar, V. (1953). A proposal for a new method of evaluation of the newborn infant. Current
Researches in Anesthesia and Analgesia. 32(4): 260–267.
Special care of the newborn
• Provide prophylactic eye care; instill prescribed antibiotic (eg,
erythromycin) in each eye to prevent ophthalmia neonatorum caused by
gonorrhea or chlamydia infection
• Vitamin K
• Administer vitamin K to prevent hemorrhage
• Intestinal flora will naturally begin synthesizing prothrombin
• However, the infant’s intestine is sterile at birth, and breast milk is low
in vitamin K
• Without administration of vitamin K, supply will be inadequate for 3 to
4 days
• Vaccination
• Centers for Disease Control and Prevention mandate that newborns
receive hepatitis B (Hep B) vaccine, regardless of mother’s status
• Administer prophylactic ophthalmic antibiotic to prevent ophthalmia
neonatorum within 1 hour of birth
• Screening tests
• Determined by state law/institutional practice
• Blood sampling may be used to detect congenital disorders
• Tandem mass spectrometry may be used to detect disorders of fatty
acid oxidation, amino acids, and organic acids
• If screening is called for, nurse should educate parents regarding
importance of screens
• High-risk infants (see Chapter 19, Newborn Complications)
Application and review
10. An infant is born with a bilateral cleft palate. Plans are made to begin
reconstruction immediately. What nursing intervention should be
included to promote parent–infant attachment?
1. Demonstrating a positive acceptance of the infant
2. Placing the infant in a nursery away from view of the general public
3. Explaining to the parents that the infant will look normal after the
surgery
4. Encouraging the parents to limit contact with the infant until after
the surgery
11. A nurse who is assessing a newborn 1 minute after birth determines that
the cry is lusty, the heart rate is 150 beats/min, and the extremities are
flexed, but the bottoms of the feet have a marked bluish tinge. What
Apgar score does the nurse assign to the neonate? Record your answer
using a whole number.
Answer: ____________
12. What is a nurse’s primary critical observation when performing an
assessment for determining an Apgar score?
1. Heart rate
2. Respiratory rate
3. Presence of meconium
4. Evaluation of Moro reflex
13. Which newborn assessment identified immediately after birth will
probably necessitate prolonged follow-up care?
1. Apgar score of 5
2. Weight of 3500 grams
3. Blood glucose level of 50 mg/dL
4. Umbilical cord with two blood vessels
14. A neonate at 1 minute after birth has a weak cry, a heart rate of 90
beats/min, some flexion of the extremities, grimacing, and acrocyanosis.
What is the Apgar score for this neonate? Record your answer using a
whole number.
Answer: ____________
15. A newborn’s Apgar score at 5 minutes is 5. With what condition does a
low Apgar score at 5 minutes after birth correlate that requires intensive
monitoring of this neonate?
1. Cerebral palsy
2. Genetic defects
3. Cognitive impairment
4. Neonatal morbidity
16. While a mother is inspecting her newborn she expresses concern that her
baby’s eyes are crossed. How should the nurse respond?
1. “Take another look. They seem fine to me.”
2. “It’s all right. Most babies have crossed eyes.”
3. “This is expected. Your baby is trying to focus.”
4. “You’re right. I’ll contact your health care provider.”
See Answers on pages 267-270.
Care management: From 2 hours after birth to
discharge
Bathing
• Provide daily sponge bath; change diaper frequently
• Provide care of umbilical cord stump
• Observe for edema, redness, drainage
• Adhere to hospital protocol; clamp usually removed before discharge
• Keep dry, secure diaper below level of cord
• Teach parents to sponge bathe until cord falls off
• Circumcision
• Observe penis for bleeding; monitor urination
• Apply diaper loosely
• Change dressing with each diaper change or at least every 4 hours and
apply petrolatum to glans
• Teach care to parents if appropriate
• No circumcision
• Bathe daily
• Do not retract foreskin
Common newborn problems
• Birth injuries (see Chapter 19, Newborn Complications)
• Jaundice
• Caused by elevated levels of serum bilirubin
• Assessment
■ Assessed in every newborn
■ Visual: apply pressure to bony prominence, assess skin color before
capillaries refill; assess conjunctival sacs, buccal mucosa
■ Transcutaneous: transcutaneous bilirubinometry provides accurate
assessment of significant jaundice and is noninvasive; cannot be used
after phototherapy initiated
■ Serum: bilirubin levels
■ Hour-specific bilirubin assessments used with nomogram to
determine risk of developing hyperbilirubinemia
• Evaluation based on serum, transcutaneous bilirubin; gestational age;
time since birth; family history; physiologic status; progression of
serum bilirubin levels
• Risk factors
■ Gestational age <38 weeks
■ Breastfeeding
■ Family history (sibling)
■ Appearance of jaundice before discharge
• Follow-up screening for healthy newborns
■ If discharged <24 hours after birth: within 3 days
■ If discharged 24 to 48 hours after birth: within 4 days
■ If discharged >48 hours after birth: within 5 days
• Hypoglycemia (see Chapter 19, Newborn Complications)
Laboratory and diagnostic tests
• Hematologic
• Bleeding time (Ivy)
■ Neonatal: 2 to 7 minutes
• Fibrinogen
■ Neonatal: 125 to 300 mg/dL
• Hemoglobin
■ Term: 14.5 to 22.5 g/dL
■ Preterm: 15 to 24 g/dL
• Hematocrit
■ Term: 48% to 69%
■ Preterm: 45% to 55%
• Reticulocytes
■ Term: 0.4% to 6%
■ Preterm: up to 10%
• Fetal hemoglobin
■ Term: 40% to 70%
■ Preterm: 80% to 90%
• RBCs
■ Term: 4.8 to 7.1 × 106
• Platelet count
■ Term: 150,000 to 300,000/mm3
■ Preterm: 120,000 to 180,000/mm3
• WBCs
■ Term: 9000 to 30,000/µL
■ Preterm: 10,000 to 20,000/µL
• Neutrophils (“segs”)
■ Term: 54% to 62%
■ Preterm: 47%
• Eosinophils
■ Term: 1% to 3%
• Basophils
■ Term: 0% to 75%
• Lymphocytes
■ Term: 25% to 33%
■ Preterm: 33%
• Monocytes
■ Term: 3% to 7%
■ Preterm: 4%
• Immature WBCs
■ Term: 10%
■ Preterm: 16%
• Biochemical
• Bilirubin, direct
■ Neonatal: 0 to 1 mg/dL
• Bilirubin, total
■ Neonatal, cord: <2 mg/dL
■ 0 to 1 day, peripheral blood: 6 mg/dL
■ 1 to 2 days, peripheral blood: 8 mg/dL
■ 2 to 5 days, peripheral blood: 12 mg/dL
• Serum glucose
■ Neonatal: 40 to 60 mg/dL
• Blood gases, neonatal
■ Arterial
■ pH: 7.31 to 7.49
■ Pco2: 26 to 42 mm Hg
■ Po2: 60 to 70 mm Hg
■ Venous
■ pH: 7.31 to 7.41
■ Pco2: 40 to 50 mm Hg
■ Po2: 40 to 50 mm Hg
• Urinalysis, neonatal
• Color: clear, straw
• Specific gravity: 1.001 to 1.020
• pH: 5 to 7
• Protein: negative
• Glucose: negative
• Ketones: negative
• RBCs: 0 to 2
• WBCs: 0 to 4
• Casts: none
Neonatal pain (see chapter 19, newborn
complications)
Discharge planning
• Postpartum stay usually 12 to 24 hours (may be as little as 8 to 12 hours
after vaginal birth)
• Clear discharge criteria (Box 17.2) help ensure safety of the infant and
mother
• Mother may be exhausted, unable to process large amounts of information
• Discharge teaching should begin before infant’s birth
BOX 17.2
E a rly N e wborn D ischa rge C rit e ria
• It was a singleton birth between 38 and 42 weeks of gestation.
• Baby was delivered by uncomplicated vaginal delivery.
• Birthweight is appropriate for gestational age.
• Physical examination was normal.
• Vital signs are normal and stable as measured in an open crib with
adequate clothing.
• Infant has urinated and passed at least one stool.
• Infant has completed at least two successful feedings.
• Clinical significance of jaundice, if present, has been determined and
appropriate management or follow-up plans put in place.
• Appropriate maternal and infant blood tests have been performed.
• Appropriate neonatal immunizations have been administered.
• Newborn hearing screening has been completed per hospital protocol
and state regulations.
• Family, environmental, and social risk factors have been assessed.
• Documentation is in place that mother has received usual infant care
training and has demonstrated competency.
• Support persons are available to assist mother and her infant after
discharge.
• Continuing medical care is planned, including that infants discharged
sooner than 48 hours be examined within 48 hours of discharge from
hospital.
From Hockenberry, M., & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed.). St.
Louis: Elsevier. Data from American Academy of Pediatrics. (2004). Policy statement: hospital stay for
healthy term newborns. Pediatrics 113(5):1434–1436.
Application and review
17. A nurse decides on a teaching plan for a new mother and her infant. What
should the plan include?
1. Schedule for teaching infant care
2. Demonstration and explanation of infant care
3. Discussion of mothering skills in a nonthreatening manner
4. Emotional support and dependence on the nurse’s expertise
18. What should be included in a plan of care to limit the development of
hyperbilirubinemia in the breastfed neonate?
1. Encouraging more frequent breastfeeding during the first 2 days
2. Instituting phototherapy for 30 minutes every 6 hours for 3 days
3. Substituting breastfeeding with formula feeding on the second day
4. Supplementing breastfeeding with glucose-water during the first
day
19. At 10 hours of age a neonate’s oral cavity is filled with mucus and
cyanosis develops. What should the nurse do first?
1. Suction.
2. Administer oxygen.
3. Record the incident.
4. Insert a nasogastric tube.
20. A nurse is testing a newborn’s heel blood for the level of glucose. Which
newborns does the nurse anticipate will experience hypoglycemia? Select
all that apply.
1. Preterm infants
2. Infants with Down syndrome
3. SGA infants
4. LGA infants
5. AGA infants
See Answers on pages 267-270.
Answer key: Review questions
1. 3 The newborn’s heart rate varies with activity; crying can increase it to
180 beats/min, whereas deep sleep may lower it to 80 to 100 beats/min; a
rate between 110 and 160 beats/min is the average.
1 The heart rate of an alert, noncrying newborn that is above 160
beats/min indicates tachycardia. 2 The heart rate of an alert, noncrying
newborn that is above 160 beats/min indicates tachycardia. 4 The heart
rate of an alert, noncrying newborn that is below 110 beats/min
indicates bradycardia.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
2. 1 The initial response is a reflection of the startle reflex; when the
stimulus is repetitive, the response to the stimulus decreases; this
decrease in response is called habituation and is expected.
2 Assessing the vital signs is not necessary because the neonate’s
response is expected. 3 The infant is responding to noise and therefore
hears. 4 Stimulating respirations is not necessary because the neonate’s
response is expected.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Planning/Implementation
3. 4 The expected breathing patterns are abdominal and irregular in rhythm
and depth (alternates between shallow and deep); the expected rate
ranges from 30 to 60 breaths/min.
1 Newborns’ respirations are irregular and abdominal. 2 Newborns’
respirations are abdominal. 3 Newborns’ respirations are irregular.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Knowledge; Nursing Process: Assessment/Analysis
4. 2 The Moro reflex is a sudden extension and abduction of the arms at the
shoulders and spreading of the fingers. This is followed by flexion and
adduction of the arms, with the index finger and thumb forming the letter
“C”; the infant may cry.
1 Extension and abduction, not adduction, is the first part of the Moro
reflex. 3 Although the reflex response includes adduction of the arms,
the toes are not involved. 4 Although the reflex starts with extension of
the arms, the fingers fan out before forming the “C” position.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
5. 1 Milia are common, are not indicative of illness, and eventually
disappear.
2 Lanugo is fine, downy hair. 3 Whitehead is a lay term for milia; it is not
used when documenting. 4 Mongolian spots are bluish-black areas on
the buttocks that may be present on dark-skinned infants.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
6. 3 The tonic neck reflex (fencing position) is a spontaneous postural reflex
of the newborn; it persists until the third month.
1 The Moro reflex is exhibited when a sudden change in equilibrium
causes extension and abduction of the extremities followed by flexion
and adduction. 2 The Babinski reflex is exhibited when the examiner
runs a finger up the lateral (small toe side) undersurface of the foot
from the heel to the toes and then across the ball of the foot; the toes
separate and flare out. 4 The palmar grasp reflex is exhibited when the
fingers flex around a person’s finger as it is placed in the infant’s palm.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
7. 4 In 36 to 48 hours, the newborn will have ingested an ample amount of
the amino acid phenylalanine, which if not metabolized because of a lack
of a specific liver enzyme, can result in excess levels of phenylalanine in
the bloodstream and brain, resulting in cognitive impairment; early
detection is essential to prevent this.
1 The infant will have a vitamin K injection soon after birth to prevent
bleeding problems. 2 Blood is withdrawn from the heel soon after birth
to test for hypoglycemia. 3 Necrotizing enterocolitis is a disorder that
can affect preterm infants. It is not identified by a test.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
8. 1 Phenylalanine is an essential amino acid necessary for growth that may
be absent in infants with phenylketonuria (PKU); testing is done on all
neonates born in the United States.
2 Untreated PKU can lead to retardation; the test will not identify
retardation. 3 PKU is a genetic, not a chromosomal, disorder. 4
Identifying thyroid insufficiency is done at the same time as PKU
testing, but thyroid deficiency is a problem related to a hormone
deficiency, not to PKU.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
9. 2 Hypoglycemia causes CNS and sympathetic nervous symptom
responses.
1, 3, 4 Hyponatremia, cardiac defect, and an immature CNS are not signs
of this problem.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
10. 1 By demonstrating acceptance of the infant, without regard for the
defect, the nurse acts as a role model for the parents, thus enhancing their
acceptance.
2 Infants with cleft palates can remain in the newborn nursery; they
should not be hidden. 3 Telling the parents the infant will look normal
after surgery is false reassurance; it does not promote parent–infant
attachment behaviors. 4 Encouraging parents to limit contact will delay
attachment; the parents should be encouraged to have frequent contact
with their infant.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/Implementation
11. Answer: 9
A value of 1 is assigned to the color category (acrocyanosis); a value of 2
is assigned to the heart rate that is within the expected range of 100 to
160 beats/min; the flexed extremities reflect healthy muscle tone; and a
lusty cry represents the other two categories—reflex irritability and
respiratory rate—each of which is assigned a value of 2. The Apgar
score is 9, demonstrating a healthy newborn.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
12. 1 The heart rate is vital for life and is the most critical observation in
Apgar scoring.
2 Respiratory effort rather than rate is included in the Apgar score; the
rate is very erratic. 3 Meconium may or may not be present at this time
and is not a part of Apgar scoring. 4 The Moro reflex is not a part of
Apgar scoring but should be assessed later.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
13. 4 The congenital absence of a blood vessel in the umbilical cord is often
associated with life-threatening congenital anomalies. There should be
two arteries and one vein.
1 It is too soon to determine whether the newborn needs prolonged
follow-up care; the second Apgar score 5 minutes later determines this.
2 3500 g is the average weight for a full-term newborn. 3 The expected
glucose level in a healthy newborn is 40 to 69 mg/dL.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
14. Answer: 5
Weak cry = 1; heart rate of 90 bpm = 1; some flexion of extremities = 1;
grimacing = 1; and acrocyanosis = 1.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis
15. 4 A score of 5 at 5 minutes is related to neonatal morbidity and mortality;
by 5 minutes the healthy neonate is relatively stable with an Apgar score
of 8 to 10 and requires routine care.
1 The presence of cerebral palsy is not related to the Apgar score. It is
rarely diagnosed in the newborn. 2 Genetic defects may or may not be
apparent at this time. They are not related to the Apgar score. 3
Cognitive impairment has not been proven to be related to the Apgar
score, although research continues in this area.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
16. 3 Newborns’ eye movements are uncoordinated, and the eyes appear
crossed as they try to focus. As the eye muscles mature, the apparent
strabismus disappears.
1 Telling the mother to take another look discounts the mother’s concern
and is demeaning. 2 Although it is true that most babies have crossed
eyes, the mother should be given an explanation for the apparent
strabismus. 4 Intimating there is a reason to call the health care
provider is misinformation that will increase the mother’s anxiety.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Caring;
Communication/Documentation; Nursing Process:
Planning/Implementation
17. 2 Teaching the mother by example is a nonthreatening approach that
allows her to proceed at her own pace.
1 Learning does not occur by schedule; questions must be answered as
they arise. 3 Mothers need demonstration of appropriate mothering
skills, not just a discussion. 4 Although emotional support is required,
the plan should encourage independent caregiving.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
18. 1 More frequent breastfeeding stimulates more frequent evacuation of
meconium, thus preventing resorption of bilirubin into the circulatory
system.
2 Phototherapy is the treatment for hyperbilirubinemia, and it is
maintained continuously; it does not prevent the development of
hyperbilirubinemia. 3 It is not necessary to formula feed. Early
breastfeeding tends to keep the bilirubin level low by stimulating
gastrointestinal activity. 4 Increasing water intake does not limit the
development of hyperbilirubinemia because only small amounts of
bilirubin are excreted by the kidneys.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Nursing Process: Planning/Implementation
19. 1 The mucus must be removed to maintain a patent airway and promote
respirations and gaseous exchange.
2 Oxygenation is ineffective if the airway is obstructed. 3 Documentation
is important, but it is not the priority. 4 Inserting a nasogastric tube is
done to aspirate stomach contents, not to clear the airway.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
20. Answers: 1, 3, 4
1 Preterm infants have low glycogen stores. 3 SGA infants have low
glycogen stores. 4 LGA infants are prone to hyperinsulinemia; often
they have mothers who have diabetes, which exposes them to high
circulating glucose levels while in utero. After prolonged exposure to
high glucose levels, hyperplasia of the pancreas occurs, resulting in
hyperinsulinemia.
2 Infants with Down syndrome are not at risk for developing
hypoglycemia. They are at risk for congenital cardiac defects. 5 AGA
infants are not at risk for developing hypoglycemia.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
C H AP T E R 1 8
Newborn nutrition and feeding
Recommended infant nutrition
Options
• The American Academy of Pediatrics (AAP) recommends exclusive
breastfeeding for the first 6 months of life and continued breastfeeding
for 1 year
• Breast milk or iron-fortified commercial formulas are options for the first
year of life; AAP states iron-fortified commercial formula is acceptable
but not preferred alternative to breastfeeding
• Note: Whole cow’s milk should not be introduced until after 1 year of age;
it is difficult to digest; inadequate in carbohydrates, iron, vitamin C, and
other essential nutrients; and contains too much protein, calcium,
potassium, chloride, and sodium
Psychologic considerations
• Feeding behavior and degree of satisfaction influence psychologic
development
• Close mother/father–infant relationship during feeding process meets
basic need of trust (Erikson’s stage of trust versus mistrust)
Choosing an infant feeding method
Factors influencing decision
• Support from others, including staff knowledge (Box 18.1)
• Cultural expectations
• Employment and employment facilities
BOX 18.1
T e n S t e ps t o S ucce ssful B re a st fe e ding
1. Have a written policy to support breastfeeding.
2. Train all health care providers.
3. Inform all pregnant women about the benefits of management of
breastfeeding.
4. Initiate breastfeeding within 1 hour after birth.
5. Show mothers how to breastfeed and maintain lactation even if they
are separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless
medically indicated.
7. Allow mothers and infants to remain together 24 hours a day (ie,
rooming-in).
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers.
10. Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital or clinic.
Modified from WHO/UNICEF (1989). Protesting, promoting, and supporting breastfeeding: the
special role of maternity services, a joint WHO/UNICEF statement. Geneva, World Health
Organization.
Breastfeeding
• Advantages
• Optimum nutritional value; macronutrients in best possible form and
combination
• Reduces risk for infection because of maternal antibodies in colostrum
and milk
• Psychologic value of closeness and satisfaction in beginning mother–
infant relationship
• Economical and readily accessible
• Fewer allergies
• Aids in development of facial muscles because stronger sucking is
necessary
• Promotes involution of uterus as it stimulates oxytocin secretion that
initiates let-down reflex
• Stimulates evacuation of meconium because of frequent feeding; helps
prevent reabsorption of bilirubin into circulation
• Appears to provide some level of protection against childhood
overweight and obesity
• Prerequisites
• Psychologic readiness of mother is major factor for successful
breastfeeding
• Adequate diet to ensure high-quality milk; increased intake of milk,
protein, calories, and noncaffeinated fluids
• Motivation to allow time for rest
• Adequacy of infant’s sucking force; stimulates maternal production and
release of oxytocin into circulation; oxytocin causes constriction of
lactiferous sinuses to move milk down through nipple ducts (let-down
reflex)
• Family support; minimum emotional stress (anxiety inhibits let-down
reflex)
• Contraindications
• Mother
■ Illnesses: active tuberculosis; acute contagious disease; HIV positive;
chronic disease (e.g., cancer, advanced nephritis, cardiac disease,
hepatitis); extensive surgery
■ Opioid addiction
■ Prescription, over-the-counter drugs and supplements: excreted in
breast milk; may have harmful effects; must be avoided or taken
judiciously, if necessary; requires careful monitoring of infant
• Infant
■ Any condition that interferes with or prevents grasping the nipple
(e.g., cleft lip or palate, other congenital anomalies)
■ Inadequate sucking force (e.g., prematurity, cardiac problems)
■ Inborn errors of metabolism that result in negative response to breast
milk (e.g., phenylketonuria, lactose intolerance)
• Implementation
• Teach feeding techniques (see also “Supporting Breastfeeding Mothers
and Infants,” later)
■ Mother should wash her hands before beginning
■ Mother and infant in comfortable position, semireclining or in
comfortable chair; mother should not lean forward because this
promotes tiresome posture and inadequate latch-on
■ Entire body of infant turned toward mother’s breast; alternate
starting breast; use both breasts at each feeding
■ Initiate feeding by stimulating rooting reflex by touching infant’s
cheek; ensure areola is in infant’s mouth to promote latching on
■ Burp infant during and after feeding to allow for escape of air: sit
infant on lap, flexed forward; rub or pat back, while avoiding jarring
• Teach care of breasts
■ Cleanse with plain water once daily (soap or alcohol can cause
irritation and dryness)
■ Allow nipples to air dry at intervals; avoid plastic bra liners because
they increase heat and perspiration and decrease air circulation
necessary for keeping nipples dry
■ Wear brassiere that supports breasts day and night
■ Place nursing pads inside bra cup to absorb milk leaking between
feedings
■ If breasts are engorged, take warm showers, hand express some milk
before putting infant to breast to allow latch-on, and put infant to
breast more frequently, at least every 3 hours for at least 10 minutes
per breast
• Teach feeding schedule
■ Self-demand schedule is desirable; infant usually self-regulates to a
schedule of every 2 to 3 hours
■ Length of feeding time is variable; about 15 to 20 minutes per breast,
with greatest quantity of milk consumed in first 5 to 10 minutes
■ Feed more often if lactation diminishes to stimulate increased milk
production; lactation sometimes diminishes upon first arriving
home; if so, increase the frequency of feedings
• Frequently asked questions
■ After lactation is established, occasional formula feeding can be
substituted, but is not recommended; breast milk can be expelled
manually or pumped and saved for future feeding
■ Age of infant for weaning varies
■ Infant is getting enough milk if she or he has 6 to 8 wet diapers each
day
Formula feeding
• Advantages
• Alternative to breastfeeding
• Less restrictive than breastfeeding; may meet needs of working mothers
• Accurate assessment of intake
• Required for infant with congenital anomaly (e.g., cleft lip, cleft palate)
• Required for infant needing special formula (e.g., allergies, inborn
errors of metabolism)
• Types of formulas
• Commercial liquid or powdered formulas are mostly based on cow’s
milk, but modified, including being fortified with iron; no additional
supplementation is needed for 6 months
• Special formulas are available
• Unmodified cow’s milk, liquid or reconstituted, is not appropriate for
infants before 12 months of age; contains more protein and calcium
than breast milk; contains less vitamin C, iron, and carbohydrate than
breast milk
• Contraindications
• Deficient knowledge of formula preparation and maintaining asepsis
• Poor storage and refrigeration
• Contaminated or unreliable water supply
• Cost of formula and equipment
• Lack of equipment to adequately prepare bottles
• Implementation
• Parent education important for formula preparation, feeding techniques
• First feeding is ideally given as soon as the infant is stable
• Teach preparation of formula
■ The low gastric acidity in newborns predisposes them to
gastrointestinal (GI) infections; this is why cleanliness is key; tap
water used to dilute concentrated or powdered formulas should be
boiled for 1 to 2 minutes and allowed to cool; otherwise, formula
should be sterilized
■ Ready-to-use is most expensive, but easiest to use
■ Concentrated formula is diluted with water; can be refrigerated for 48
hours
■ Powdered formula is least expensive, but must be mixed with water
■ Caution parents regarding dangers of overdilution (inadequate
weight gain) and underdilution (excess weight gain)
■ Water used to dilute formula should not include fluoride in the first 6
months
• Teach feeding schedule
■ Inform parents why feedings should be offered on demand to meet
infant’s needs; formula-fed infants fed on demand or about every 3 to
4 hours; need 6 to 8 feedings in 24 hours
■ First 2 days, infant consumes 15 to 30 mL/feeding; up to 150
mL/feeding at end of second week
• Teach feeding techniques
■ Hold infant during feeding to provide warm body contact; bottle
propping can contribute to aspiration of formula and dental caries
■ Hold bottle so that nipple is filled with milk to prevent excessive air
ingestion
■ Adjust size of nipple hole according to infant’s suckling ability;
preterm infants and those with cardiac defects need a larger hole that
requires less intense sucking
• Burp during and after feeding
• If infant spits up, amount may need to be decreased, burping more
frequent, or smaller amounts fed more frequently; infant can be held
upright and not placed on belly for 30 minutes after feeding
• Bottles and nipples need to be washed in warm soapy water with a
bottle and nipple brush, then placed in boiling water for 5 minutes and
allowed to air dry; or they can be cleaned in a dishwasher
Application and review
1. On a 6-week postpartum visit, a new mother tells a nurse she wants to feed
her baby whole milk after 2 months because she will be returning to work
and can no longer breastfeed. The nurse plans to teach her that she should
switch to formula feeding because whole milk does not meet the infant’s
nutritional requirements for which constituents?
1. Fat and calcium
2. Vitamin C and iron
3. Thiamine and sodium
4. Protein and carbohydrates
2. A woman learning about infant feedings asks a nurse how anyone who is
breastfeeding gets anything done with a baby on demand feedings. Which
is the best response by the nurse?
1. “Most mothers find that feeding the baby whenever the baby cries
works out fine.”
2. “Perhaps a schedule might be better because the baby is already
accustomed to the hospital routine.”
3. “Babies on demand feedings eventually set a schedule, so there
should be time for you to do other things.”
4. “Most breastfeeding mothers find that their babies do better on
demand because the amount of milk ingested may vary at each
feeding.”
3. A client who is breastfeeding is being discharged. The client tells the nurse
that she is worried because her neighbor’s breasts “dried up” when she
got home and she had to discontinue breastfeeding. What should the
nurse reply?
1. “Once lactation is established, this rarely happens.”
2. “You have little to worry about because you already have a good
milk supply.”
3. “This can happen with the excitement of going home, but putting
the baby to breast more often should reestablish lactation.”
4. “This commonly happens, so we will give you a bottle of formula to
take home; then the baby won’t go hungry until your milk supply
returns.”
4. What client behavior indicates to the nurse that a woman needs further
teaching about breastfeeding her newborn?
1. When she leans forward to place her breast into the infant’s mouth
2. If she holds the infant level with her breast while in a side-lying
position
3. If she touches her nipple to the infant’s cheek at the beginning of
the feeding
4. When she puts her finger in the infant’s mouth to break the suction
after the feeding
5. A nurse is caring for four clients who each have one of the following
conditions. Which client should the nurse anticipate will be instructed not
to breastfeed by the health care provider?
1. Mastitis
2. Inverted nipples
3. Herpes genitalis
4. Human immunodeficiency virus
6. A nurse is teaching breast care to a client who is breastfeeding. Which
client statement indicates that the teaching was effective?
1. “I should air dry my nipples after each feeding.”
2. “Mild soap is appropriate for washing my breasts.”
3. “My breast pads should be lined with plastic shields.”
4. “I will remove my brassiere before I go to bed at night.”
7. A nurse is teaching breastfeeding to a client. Which client statement
indicates the need for further instructions?
1. “I will try to empty my breasts at each feeding.”
2. “I will start with an alternate breast at each feeding.”
3. “My breasts should be washed with soapy water before I
breastfeed.”
4. “My baby’s cheek should be stroked gently when I am ready to
breastfeed.”
8. Two days after being discharged a new mother calls the clinic stating that
she is not sure if her baby is receiving enough breast milk. What
information does the nurse need to determine whether the infant is being
fed adequately?
1. Number of wet diapers each day
2. Sleeps 3½ to 4 hours between feedings
3. Has at least two or more bowel movements a day
4. Nurses 5 minutes on the first breast and 10 on the other
9. A client who is breastfeeding tells a nurse that her breasts are swollen and
painful. What can the nurse teach her to do to limit engorgement?
1. “Breastfeed four times a day, then offer water if the baby cries.”
2. “Offer one bottle a day when you are experiencing discomfort.”
3. “Nurse at least every 3 hours for at least 10 minutes on each breast.”
4. “Limit nursing to 4 to 6 minutes on each breast at least six times a
day.”
10. A nurse is teaching participants in a prenatal class about breastfeeding
versus formula feeding. A client asks, “What is the primary advantage of
breastfeeding?” What is the nurse’s best reply?
1. “Breastfed infants have fewer infections.”
2. “Breastfeeding inhibits ovulation in the mother.”
3. “Breastfed infants adhere more easily to a feeding schedule.”
4. “Breastfeeding provides more protein than does cow’s milk
formula.”
11. A parent of a newborn asks, “Why must I scrub and sterilize my baby’s
formula bottles?” What information about a newborn should the nurse
consider before replying in language the parent will understand?
1. Gastric acidity is low and it does not provide bacteriostatic
protection.
2. Absence of hydrochloric acid renders the stomach vulnerable to
infection.
3. Infants are almost completely lacking in immunity and require
sterile fluids.
4. Escherichia coli, a bacterium that is found in the stomach, does not
act on milk.
12. A client asks about the difference between cow’s milk and breast milk.
The nurse should respond that cow’s milk differs from human milk in that
it contains what?
1. Less protein, less calcium, and more carbohydrates
2. Less protein, more calcium, and more carbohydrates
3. More protein, less calcium, and fewer carbohydrates
4. More protein, more calcium, and fewer carbohydrates
See Answers on pages 280-283.
Cultural influences on infant feeding
Beliefs vary
• Not all culturally held beliefs apply to each member of a particular culture
• Still, nurses must be aware that cultural expectations can influence
decisions about infant feeding so they can provide culturally congruent
care that is safe for infant and mother
• Influences of family members should be explored as well so that any
misinformation can be corrected
Nutrient needs
Overview
• Simple proteins, carbohydrates, fats, vitamins, and minerals needed for
continued cell growth
• Breast milk: most complete diet for first 6 months; may require vitamin D
supplementation (see later)
Fluids
• During first 2 days, 60 to 80 mL of fluid per kilogram of body weight per
day; this rises to 100 to 150 mL/kg/day on days 3 to 7; to 120 to 180
mL/kg/day for the rest of the first month
• Breast milk is mostly water, so it meets the fluid needs of newborns
• Feeding water to newborns can replace fluids with calories when they
need calories for rapid growth; additional water is unnecessary
Energy
• Newborns need, on average, 110 kcal/kg/day; this need per kilogram
decreases at 3 months to 100 kcal/kg/day and again around 6 months to 95
kcal/kg/day
• Fat in breast milk provides up to half of the kilocalories; it is easily
digested and vital to brain growth
Carbohydrate
• The Institute of Medicine recommends 60 g/day for the first 6 months and
95 g/day for the second 6 months
• Lactose is the primary source of carbohydrate in breast milk
Protein
• Newborns need 9.1 g/day for growth and development
• The ratio of whey to casein in human milk makes it easily digestible
Vitamins
• The AAP states that all breastfed infants are to receive 400 International
Units of vitamin D daily, beginning in the first few days of life
• Nonbreastfeeding infants should also receive that dose if they do not
consume at least 1 quart of vitamin D–fortified milk daily
• A vitamin K injection is given to newborns to prevent bleeding problems
before their gut bacteria are making enough vitamin K
• Breastfed infants depend on mother’s store and intake of vitamin B12, so
mothers who are vegans will need a B12 supplement for their infants, as
may those who have had bariatric surgery
Minerals
• For breastfed infants, iron supplement needed by 6 months; preterm
infants need iron supplementation earlier
• For breastfed infants, the need for fluoride supplementation is
determined by fluoride content of water supply; started between 6
months and 3 years; AAP and American Dental Association do not
recommend fluoride supplementation for first 6 months of life; fluoride
supplementation is controversial, but continues to be recommended
Anatomy and physiology of lactation
Overview
• Internal breast anatomy is designed for lactation; however, the external
size and shape of the breast is not an indication of its ability to produce
milk
• Hormones during pregnancy prepare the breasts for lactation
Lactogenesis
• Fall in progesterone at birth signals prolactin release from the pituitary
gland; prolactin production is stimulated by infant suckling and emptying
the breasts
• The more milk removed from the breast, the more it will produce; the less
milk removed, the less it will produce; supply increases or decreases with
demand
• Oxytocin, stimulated by infant suckling via the hypothalamus and
pituitary gland, produces the milk ejection reflex (“let-down” reflex)
• Materials from the mother’s bloodstream are made into breast milk
Uniqueness of human milk
• Three stages of lactogenesis with changes in breast milk composition
• Lactogenesis I: breasts prepare colostrum, rich in immunoglobulins,
protein, and some vitamins and minerals
• Lactogenesis II: birth through about day 10; milk changes from
colostrums to mature milk; milk is called transitional; lactose, fat, and
calories increase
■ At about day 3 to 4, engorgement of the breasts (from the lymphatic
system) is common
• Lactogenesis III: mature milk is established; still contains
immunoglobulins and is sufficiently rich even though it appears
thinner than colostrum
• Milk production increases in response to infant growth spurts and as
infant grows
Supporting breastfeeding mothers and infants
Keys
• Anticipatory guidance prenatally if possible, but education can occur
postpartum
• Support is critical during the first 2 weeks, as mother gains confidence
• Health care professionals need knowledge, skills, and attitudes to support
breastfeeding
• Supportive physical environment in hospitals and health care offices
Positioning
• Initial semireclining position can help mother relax
• Four traditional positions: cradle/cross-cradle (across the lap), football
hold, side-lying
Latch
• Tickling the infant’s lips with the nipple stimulates the mouth to open
• When the mouth is open wide, the mother brings the baby quickly to the
breast
• The infant’s mouth should be placed past the nipple at least 1 to 1½
inches, over areola and breast, making a seal; infant’s lips should be
flared open
• The amount of areola in the infant’s mouth depends on the mouth and the
areola, but more is better because it is more efficient at removing milk
and because it is less likely to cause sore nipples
• Teach mother to insert a finger between breast and infant mouth to break
suction so that nipple is not injured
Milk ejection or let-down
• May be perceived as tingling; can trigger uterine cramping in days after
birth
• Opposite breast may leak
• Infant’s suck becomes slower
Frequency of feedings
• Newborns breastfeed every 2 to 3 hours (from the beginning of one
feeding to the beginning of the next feeding), or 8 to 12 times in 24 hours
• Teach parents to feed baby at least every 3 hours during the day, every 4
hours at night
• After breastfeeding is established, demand feeding allows infant to
determine frequency of feedings, although the infant should still feed at
least 8 times in 24 hours
• Teach mother to recognize feeding-readiness cues: sucking motions, handto-mouth or hand-to-hand movements, rooting reflex, increased activity;
crying is a late sign
• Average length of a feeding varies; usually 15 to 20 minutes per breast
• Complete emptying of at least one breast per feeding ensures baby gets
milk with higher fat content needed for growth
Indicators of effective breastfeeding
• Milk production strong (comes “in” by day 3–4)
• Mother feels tugging sensation (let-down reflex) but not pain or pinching
• Mother has increased thirst
• Breasts softer or lighter after feeding
• Swallowing is audible
• Infant latches without problems
• Infant has at least 3 bowel movements and 6 to 8 wet diapers every 24
hours
Special considerations
Sleepy baby/fussy baby
• Infant more likely to nurse if awakened from light sleep instead of deep
sleep
• Infant may need to be calmed before feeding
• Fussiness can be from GI distress, or may indicate illness
• Teach mother that if infant refuses to breastfeed or cries persistently to
contact health care provider
Slow weight gain
• Infants may lose up to 10% of their birth weight in their first days; if
weight loss exceeds 7%, continues beyond 3 days, or is not regained by
day 10, they should be evaluated for feeding problems
• After mature milk is in, infants gain ∼4 to 7 oz/week or about 1 oz/day for
the first 3 months
• Usual solution to slow weight gain is increased frequency of feeding and
improved feeding technique
Preterm infants
• Human milk is best for preterm infants
• If a preterm infant cannot breastfeed immediately, teach and encourage
the mother to pump her milk
• Late preterm infants have low energy stores and high energy needs, which
put these infants at risk for feeding problems
• They may be less coordinated and sleepier than full-term infants
• Best positioning may be football hold where mother can hold infant’s
head
Multiple infants
• Mothers can produce adequate milk; support is important in managing
feedings
Expressing and storing breast milk
• Hand expression can increase milk production in the first few days after
birth
• Mechanical expression/pumping is especially useful for women returning
to work
• Hand pumps portable, least expensive
• Electric pumps most closely duplicate infant suckling; can pump both
breasts simultaneously
• Milk should not be stored with a nipple on the bottle, as it allows
microorganisms to enter
• Fresh unrefrigerated milk should be used within 3 to 4 hours; refrigerated
milk can be stored for 72 hours
• Milk can be frozen and used within 6 months ideally; hard containers are
recommended to decrease the chance of puncture
Maternal employment
• Employed mothers can continue to breastfeed, either by having the infant
brought to them at work or by pumping their milk and using it for the
next workday
Weaning
• Weaning starts with the first food introduced that is not breastfeeding
and ends with the last breastfeeding
• Omitting one feeding at a time decreases the chance of uncomfortable
engorgement; abrupt weaning is discouraged
• Infants can be weaned directly from breast to a cup
Resource
• La Lache League International is recommended as a resource for
information and continuing support of breastfeeding
Application and review
13. A nurse is teaching a group of new mothers about breastfeeding. Which
factor that influences the availability of milk in the lactating woman
should the nurse include in the teaching?
1. Age of the woman at the time of the birth
2. Distribution of erectile tissue in the nipples
3. Amount of milk products consumed during pregnancy
4. Viewpoint of the woman’s family toward breastfeeding
14. While teaching a prenatal class about infant feeding, the nurse is asked a
question about the relationship between the size of breasts and
breastfeeding. How should the nurse respond?
1. “Breast size is not related to milk production.”
2. “Motivated women tend to breastfeed successfully.”
3. “You seem to have some concern about breastfeeding.”
4. “Glandular tissue in the breasts determines the amount of milk
produced.”
15. On the third postpartum day, a woman who is breastfeeding calls the
nurse at the clinic and asks why her breasts are tight and swollen. What
should the nurse consider before explaining why her breasts are
engorged?
1. There is an overabundance of milk.
2. Breastfeeding probably is ineffective.
3. The breasts have been inadequately supported.
4. The lymphatic system in the breasts is congested.
See Answers on pages 280-283.
Answer key: Review questions
1. 2 Whole milk does not meet the infant’s need for vitamin C and iron.
1 Whole milk contains adequate fats, but the calcium content is 3½ times
that of human milk. 3 Whole milk contains adequate thiamine, but the
sodium content is 3 times that of human milk. 4 Whole milk contains
adequate carbohydrates, but the protein content is 3 times that of
human milk.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning Nursing Process:
Assessment/Analysis
2. 3 Most average-sized infants regulate themselves to an approximate 3- to
4-hour schedule. However, wide variations do exist.
1 Some of the episodes of crying do not indicate that the infant is hungry;
the mother will learn the difference. 2 It is best to allow the infant to set
the schedule. 4 Although it is true that most babies do better on
demand because the amount of milk ingested may vary at each feeding,
this does not answer the mother’s question concerning when she will
have free time.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
3. 3 Frequently the emotional excitement of going home will diminish
lactation and/or the let-down reflex for a brief period. When the mother is
aware that this may happen and knows how to cope with it, the problem
is apt to be a minor one and easily overcome.
1 It is false reassurance to say “Once lactation is established, this rarely
happens.” Many factors (stresses) inhibit lactation, and the client
should be aware of this. 2 It is false reassurance to say “You have little
to worry about because you already have a good milk supply.” The milk
supply may diminish or stop under stress. 4 Using formula until milk
supply returns is contraindicated. Lack of breast stimulation during
formula feeding could diminish lactation.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
4. 1 When the breast is pushed into the infant’s mouth, a typical response is
for the mouth to close too soon, resulting in inadequate latching-on.
2 Holding the infant level with her breast in a side-lying position
facilitates latching-on and maintains the infant’s head in correct
alignment, which promotes sucking and swallowing. 3 Touching her
nipple to the infant’s cheek at the beginning of feeding will stimulate
the rooting reflex and promote latching-on. 4 Putting her finger in the
infant’s mouth to break the suction after the feeding prevents trauma
to the nipple when removing the infant from the breast.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
5. 4 Breastfeeding by a mother with human immunodeficiency virus (HIV)
is contraindicated because breast milk can transmit the virus to the infant.
1 Breastfeeding by a mother with mastitis is not always contraindicated;
during antibiotic treatment lactation can be maintained by pumping
the breasts and discarding the milk. When the infection has resolved,
breastfeeding can resume. 2 Breastfeeding is not contraindicated with
inverted nipples because a breast shield can provide mild suction to
help evert a nipple. 3 Breastfeeding is not contraindicated for a client
with genital herpes. The newborn may contract the infection during a
vaginal birth, not via breast milk.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
6. 1 Air-drying nipples after feedings limits irritation and disruption of skin
integrity.
2 Application of soap to breast tissue may result in drying and cracking. 3
Plastic liners trap moisture against tissue and may cause skin
breakdown. 4 Wearing a brassiere continuously, except for bathing, is
recommended for 2 to 3 weeks to provide support to breast tissue
structures.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
7. 3 Soap irritates, cracks, and dries breasts and nipples, making it painful
for the mother when the baby sucks; also, it increases the risk for
mastitis.
1 The client should empty the breasts at each feeding to keep milk
flowing. 2 Starting with an alternate breast at each feeding is a
permissible and often-used technique of breastfeeding. 4 Stroking the
baby’s cheek gently elicits the rooting reflex, causing the infant’s head
to turn toward and touch the mother’s breast.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes
8. 1 Typically 6 to 8 wet diapers a day indicate adequate fluid intake.
2 Sleeping 3½ to 4 hours between feedings may be a sign of inadequate
nutritional intake. A breastfeeding infant usually sleeps 1½ to 2½ hours
between feedings because breast milk digests rapidly. 3 The number of
bowel movements per day is not related to the amount of milk
ingested, although breastfeeding infants do defecate more frequently
than formula-fed infants. 4 The length of nursing time at each breast
does not indicate the amount of milk being ingested.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Assessment/Analysis
9. 3 Frequent nursing reduces engorgement. A 10-minute period provides for
complete emptying of the breast.
1 Breastfeeding just four times/day and giving water if the baby cries will
not decrease engorgement; in addition, the infant will be deprived of
nourishment. 2 A relief bottle will prevent emptying of the breasts; this
will increase pain and swelling. 4 Limiting nursing to 4 to 6 minutes on
each breast at least 6 times a day does not provide for complete
emptying of the breasts.
Clinical Area: Basic Care and Comfort; Client Needs: Health Promotion
and Maintenance; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Teaching/Learning
10. 1 Maternal antibodies are transferred from the mother in breast milk,
which provides protection for a longer time than those transferred to the
fetus via the placenta. The neonate is protected by these antibodies; the
fetus’s own antibody system is immature at birth.
2 Lactating mothers rarely ovulate for the first 9 postpartum weeks;
however, they may ovulate at any time after that period; although this
may be considered an advantage, it is not a primary advantage. 3
Because of the higher carbohydrate content of breast milk, which is
digested rapidly, breastfed infants wake more frequently than formulafed infants. Their feeding demands take more time to regulate than the
formula-fed infant’s. 4 Breast milk has 1.1 g protein/100 mL; cow’s milk
has 3.5 g/100 mL; whole cow’s milk is unsuitable for infants.
Clinical Area: Safety and Infection Control; Client Needs: Safe and
Infection Control; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Teaching/Learning
11. 1 The low gastric acidity in newborns predisposes them to GI infections.
2 Hydrochloric acid is present in the gastric juices, but not enough to
protect the infant. 3 The infant is born with passive immunity from
maternal antibodies. 4 Escherichia coli is an intestinal bacterium; it is not
found in the stomach.
Clinical Area: Safety and Infection Control; Client Needs: Safe and
Infection Control; Cognitive Level: Comprehension; Nursing Process:
Assessment/Analysis; Integrated Process: Teaching/Learning
12. 4 Cow’s milk is more difficult to digest because it is meant to meet a
calf’s, not an infant’s, nutritional needs. It is not recommended until after
the infant is 1 year old. Formula is preferred if the mother is not
breastfeeding.
1 Cow’s milk contains more protein and more calcium. 2 Cow’s milk
contains more protein and fewer carbohydrates. 3 Cow’s milk contains
more calcium.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
13. 4 If the woman perceives a negative viewpoint about breastfeeding from
significant others, she may be tense and the let-down reflex may not
occur; a positive attitude from significant others toward breastfeeding
promotes relaxation and the let-down reflex.
1 Age of the woman at time of birth has no influence on lactation. 2
Distribution of erectile tissue in the nipples has no influence on
lactation. 3 Milk or milk product intake during pregnancy has little
influence on lactation.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis
14. 1 The question should be answered directly in the class. However, the
mother’s statement indicates some concerns about breastfeeding that
should be explored privately later.
2 Saying that motivated women tend to breastfeed successfully is false
reassurance; successful breastfeeding requires mastery, and some
women have difficulty. 3 Although the nurse perceives the client’s
concerns, this response is inappropriate in a class with others present.
The nurse should elicit more information privately later. 4 The infant’s
suckling and emptying of the breasts will determine the amount of
milk produced.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
15. 4 Congestion of the lymphatic system in the breasts occurs before
lactation; it is an exaggeration of venous and lymphatic circulation caused
by prolactin.
1 Engorgement occurs before lactation or milk production. 2 Effective
breastfeeding does not prevent engorgement; a lag between the
production of milk and the efficiency of the ejection reflex often causes
engorgement. 3 Inadequate support does not cause engorgement, but
support may relieve some of the discomfort.
Clinical Area: Basic Care and Comfort; Client Needs: Health Promotion
and Maintenance; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Teaching/Learning
C H AP T E R 1 9
Newborn complications
Nursing care of high-risk newborns
Preterm infants
• Classification: based on gestational age with consideration of birth weight;
full-term infant may be of low birth weight (intrauterine growth
restriction [IUGR]), preterm infant may not be low birth weight (infant of
diabetic mother [IDM])
• Near-term: 35 to 37 weeks
• Preterm: 36 weeks or less
• Low birth weight: less than 2500 g
• Very low birth weight: less than 1500 g
• Extremely low birth weight: less than 1000 g; may be both preterm and
small for gestational age (SGA)
• Stillborn: fetus of 20 or more weeks’ gestation who dies before or during
birth
• Incidence: preterm births account for 75% to 85% of neonatal morbidity
and mortality
• Risk factors
• Preconception disorders: diabetes; incompetent cervical os
• Postconception disorders: preeclampsia; pyelonephritis; placenta
previa; abruptio placentae
• Maternal malnutrition: associated with higher preterm birth rates and
IUGR
• Age: adolescent
• Destructive lifestyle: drug use, smoking, unprotected sex
• Prevention
• Correction or control of preconception disorders, if possible
• Preconception and continued education about nutrition
• Education about hazards of destructive lifestyle; support to change
behavior
• Early and regular prenatal health supervision
• Referrals to community agencies to facilitate services for those in need
• Therapeutic interventions immediately after birth
• Suctioning of mucus to maintain open airway
• Direct laryngoscopy, tracheal suctioning, intubation, and mouth-to-tube
resuscitation to initiate respirations
• Suctioning of stomach contents to facilitate respirations
• Maintenance of body temperature using radiant warmer; difficult
because of heat loss through skin evaporation and limited
subcutaneous fat
• Oxygenation and resuscitation as needed
• Characteristics
• Skin
■ Wrinkled because of minimum subcutaneous fat
■ Transparent with visible blood vessels and bony structures
■ Lanugo on face and body; absent eyebrows
■ Color changes with movement; upper half or one side of body pale,
lower half or one side of body red (harlequin sign)
• Head
■ Circumference large compared with chest
■ Small fontanels
■ Skull bones soft; prone to intracranial hemorrhage
■ Ear cartilage soft; cannot support ear pinna
• Chest: small breast buds; underdeveloped nipples
• Posture: complete relaxation with marked extension of legs and
abduction of hips
• Extremities: random movements with slightest stimulus; square window
sign
• Central nervous system: underdeveloped
■ Heat regulation center: heat loss caused by large body surface area,
lack of subcutaneous and brown fat, lack of shivering
■ Insufficient heat production: inadequate metabolism
■ Respiratory center: diminished oxygen consumption causing asphyxia
• Respirations
■ Inefficient respirations caused by muscle weakness of rib cage and
limited surfactant production; prone to atelectasis
■ Retraction at xiphoid (evidence of air hunger)
• Circulation
■ Weak heart action slows circulation with inadequate oxygenation
■ Capillary fragility; low red blood cell (RBC) and white blood cell
(WBC) counts; anemia during first few months of life
• Nutrition
■ Weak sucking and swallowing reflexes
■ Small capacity of stomach
■ Low gastric acidity
■ Calories: full-term intake 110 to 130 calories/kg (50–60 calories/lb) of
body weight is increased to 200 to 220 calories/kg (100 calories/lb) for
adequate growth and to compensate for inadequate metabolism
• Excretion: reduced glomerular filtration rate results in decreased ability
to concentrate urine and conserve fluid
Nursing care of preterm infants
• Assessment/analysis
• Respiratory rate and effort; heart rate; temperature; blood pressure
• Oxygen concentrations via oximeter
• Skin color and integrity
• Central nervous system (CNS) integrity
• Daily weight; fluid and electrolyte status (radiant warmer causes
dehydration)
• Sucking ability; nutritional status
• Parents’ ability to cope with preterm birth
• Planning/implementation
• Monitor vital signs; skin color; intake and output; laboratory reports of
blood gases for acidosis
• Maintain airway
■ Suction secretions when necessary
■ Position with head and chest elevated to promote ventilation
• Maintain respirations
■ Observe for changes in respiratory status (e.g., increasing cyanosis;
rapid, irregular respirations; flaring of nostrils; intercostal or
suprasternal retractions; grunting on expiration)
■ Stimulate if apnea occurs
■ Administer oxygen as needed; monitor responses, regulate flow rate
to prevent retinopathy of the newborn
■ Check ventilator function, if used
• Maintain body temperature
■ Monitor for temperature lability
■ Adjust environmental temperature of radiant heater accordingly
• Monitor for CNS changes (e.g., muscle twitching; seizures; cyanosis;
abnormal respirations; short, shrill cry)
• Maintain nutrition
■ Observe weight gain pattern
■ Monitor amount of intake
■ Adhere to techniques of gavage feeding
• Maintain aseptic technique to prevent infection
• Institute phototherapy for hyperbilirubinemia as ordered
• Support parents
■ Encourage verbalization to relieve anxiety
■ Provide liberal visiting hours
■ Encourage participation in care; encourage talking to and touching
infant
■ Refer to support group
• Arrange for follow-up care before and after discharge
• Evaluation/outcomes
• Maintains respiratory functioning
• Maintains body temperature within acceptable limits
• Remains free from infection
• Gains weight
Application and review
1. A nurse must continuously monitor a preterm infant’s temperature and
provide appropriate nursing care because of what characteristic of the
preterm infant compared with the full-term infant?
1. Cannot use shivering to produce heat
2. Cannot break down glycogen to glucose
3. Has a limited supply of brown fat available to provide heat
4. Has a limited amount of pituitary hormones to control internal heat
2. A nurse must meet the hydration needs of a preterm infant. What should
the nurse consider about the preterm infant’s kidney function?
1. Large amounts of urine are excreted.
2. It is the same as in a full-term newborn.
3. Urine is concentrated with an elevated specific gravity.
4. Acid–base and electrolyte balance are adequately maintained.
3. What is the most common complication for which a nurse must monitor
preterm infants?
1. Hemorrhage
2. Brain damage
3. Respiratory distress
4. Aspiration of mucus
4. A nurse is caring for preterm infants with respiratory distress in the
neonatal intensive care unit (NICU). What is the priority nursing action?
1. Limit caloric intake to decrease metabolic rate.
2. Maintain the prone position to prevent aspiration.
3. Limit oxygen concentration to prevent eye damage.
4. Maintain a high-humidity environment to promote gas exchange.
See Answers on pages 316-322.
Acquired problems of newborns
Respiratory distress syndrome
• Deficiency in surface-active (detergentlike) lipoproteins (surfactant),
resulting in inadequate lung inflation and ventilation
• Most common in preterm and low-birth-weight newborns, also in infants
after cesarean birth
• Therapeutic intervention: surfactant replacement through endotracheal
tube
• Nursing care of infants with respiratory distress syndrome
• Assessment/analysis
■ Cyanosis
■ Tachypnea, dyspnea, sternal retractions, nasal flaring, grunting
■ Respiratory and metabolic acidosis
• Planning/implementation
■ Admit to NICU
■ Maintain patent airway
■ Maintain oxygenation and high humidity; prevent chilling
■ Administer surfactant by aerosol as prescribed
■ Administer antibiotics as prescribed
■ Maintain mechanical ventilation, if used
■ Monitor for respiratory and metabolic acidosis
■ Administer feedings as ordered; attempt to prevent exhaustion
• Evaluation/outcomes
■ Remains free from respiratory distress
■ Maintains fluid and electrolyte balance
■ Gains weight
Birth injuries
• Cranial birth injuries
• Caput succedaneum: edema with extravasation of serum into scalp
tissues caused by molding during birth process; crosses suture lines of
bony skull plates; no treatment; subsides in several days (Fig. 19.1)
• Cephalohematoma: scalp edema with effusion of blood between skull
bone and periosteum; contained within suture line of bony skull plate;
no treatment; disappears in several weeks to several months; resolution
of hematoma can lead to hyperbilirubinemia
• Intracranial hemorrhage
■ Bleeding into cerebellum, pons, and medulla oblongata caused by
tearing of tentorium cerebelli
■ Risk factors: preterm infants, prolonged labor, difficult forceps birth,
precipitate birth, version, breech extraction
• Nursing care of infants with intracranial hemorrhage
■ Assessment/analysis
■ Abnormal respirations, cyanosis
■ Shrill or weak cry
■ Flaccidity or spasticity, seizures
■ Restlessness, wakefulness
■ Impaired sucking reflex
■ Planning/implementation
■ Maintain oxygenation in high-Fowler position
■ Maintain body temperature
■ Administer prescribed vitamins C and K to control and prevent
further hemorrhage
■ Institute ordered gavage feedings if sucking reflex is impaired
■ Support parents because of guarded prognosis
■ Evaluation/outcomes
■ Remains free from neurologic damage
■ Gains weight
• Neuromusculoskeletal birth injuries
• Facial paralysis: temporary paralysis of one side of face caused by
pressure on cranial nerve VII (facial nerve) during difficult vaginal or
forceps birth; no treatment; disappears in several days
• Erb-Duchenne paralysis (brachial palsy): paralysis of upper arm
muscles caused by injury to brachial plexus during prolonged, difficult
labor or traumatic birth; treatment depends on severity of paralysis
• Dislocations and fractures: caused by difficult birth/extraction birth;
treatment depends on site of fracture
• Nursing care of infants with neuromusculoskeletal birth injuries
■ Assessment/analysis
■ Facial paralysis: inability to close eye; drawing mouth to one side;
absence of forehead wrinkles when crying
■ Erb-Duchenne paralysis: flaccid arm with elbow extended; unequal
Moro reflex
■ Fractures: variation in range of movement, immobility, crepitation
■ Planning/implementation
■ Facial paralysis: continue monitoring
■ Erb-Duchenne paralysis (brachial paralysis or palsy)
○ Massage and exercise arm as ordered to prevent contractures
○ Place in traffic cop or maître d’ position
○ Apply ordered splints and braces (used when paralysis is severe)
○ Dislocations and fractures: position as ordered; provide care if
swaddling, splints, slings, or casts are applied
○ Reassure parents; teach necessary care and positioning
■ Evaluation/outcomes
■ Maintains correct alignment of limb
■ Achieves movement in affected part
FIG. 19.1 Differences between caput succedaneum and cephalohematoma. (A)
Caput succedaneum. Edema of scalp noted at birth crosses suture lines. (B)
Cephalohematoma. Bleeding between periosteum and skull bone appearing within
first 2 hours; does not cross suture lines. Source: (From Seidel, H., Ball, J., Dains, J., &
Benedict, G. [2006]. Mosby’s guide to physical examination [6th ed.]. St. Louis: Mosby.)
Infections
• Thrush
• Oral infection caused by Candida albicans, a fungus
• Transmitted as neonate passes through vaginal canal
• Postnatal risk factors: unclean feeding utensils, inadequately cleansed
breasts before breastfeeding, ineffective hand-washing techniques
• Nursing care of infants with thrush
■ Assessment/analysis
■ White patches on tongue, palate, inner cheeks that bleed when
touched
■ Sucking difficulties
■ Planning/implementation
■ Teach mother how to cleanse breasts or feeding equipment before
feeding
■ Teach how to apply oral antifungal topical agents (e.g., nystatin)
■ Evaluation/outcomes
■ Infant achieves infection-free status
■ Infant gains weight
• Ophthalmia neonatorum
• Eye infection caused by Neisseria gonorrhoeae or Chlamydia trachomatis
• Transmitted from genital tract of infected mother during birth or by
infected hands
• Prevention: ophthalmic antibiotic (e.g., 0.5% erythromycin ophthalmic
ointment) instilled at birth
• Nursing care of infants with ophthalmia neonatorum
■ Assessment/analysis
■ Perinatal history of maternal infection
■ Purulent conjunctivitis without treatment manifested 3 to 4 days
after birth
■ Respiratory status with chlamydial infection (may cause
pneumonia)
■ Planning/implementation
■ Cleanse eyes with normal saline solution by wiping from inner to
outer canthus
■ Administer prescribed antibiotic
■ Refer for ophthalmic evaluation
■ Monitor vital signs
■ Administer oxygen with chlamydial infection
■ Evaluation/outcomes
■ Maintains or achieves infection-free status
■ Remains free from sequelae of infection
• Syphilis
• Congenital systemic infection caused by Treponema pallidum
• Transmitted to fetus by mother
• Incidence: varies with stage of mother’s disease at time of pregnancy
• Fetus infected after fourth month of pregnancy; earlier in pregnancy
Langerhans cells in chorion provide protective barrier
• Length of time infection is untreated correlates with amount of damage
to fetus
• Adequate treatment of pregnant woman with antibiotic treats fetus
• Nursing care of infants with syphilis
■ Assessment/analysis
■ Perinatal history of maternal infection and treatment with
antibiotic
■ Signs of congenital syphilis (e.g., maculopapular lesions of palms of
hands and soles of feet)
■ Restlessness
■ Rhinitis, hoarse cry
■ Enlargement of spleen, palpable lymph nodes
■ Enlarged ends of long bones on x-ray examination
■ Planning/implementation
■ Administer prescribed antibiotics (usually penicillin); not
contagious after 12 hours of treatment
■ Teach parents importance of continued health supervision
■ Evaluation/outcomes
■ Maintains or achieves infection-free status
■ Remains free from sequelae of infection
• Human immunodeficiency virus
• Generalized invasion of T cells by human immunodeficiency virus
(HIV)
• Maternal clinical findings
■ Recurrent vulvovaginal candidiasis
■ Bacterial vaginosis
■ Recurrent genital herpes simplex virus
■ Human papillomavirus
■ Pelvic inflammatory disease
■ Cervical dysplasia and neoplasms
• Transmitted by mother to fetus
• Clinical manifestations not present at birth
• Treatment with zidovudine (AZT) during pregnancy reduces risk of
transmission
• Nursing care of infants who are HIV positive or have acquired
immunodeficiency syndrome (AIDS)
■ Assessment/analysis
■ Signs of prematurity or SGA
■ Failure to thrive
■ Enlarged spleen and liver
■ Diarrhea, weight loss
■ Neurologic deficits
■ Subsequent frequent and debilitating infections
■ Planning/implementation
■ Obtain blood specimen for HIV screening; done if either parent is
at high risk for HIV or has been diagnosed as HIV positive
■ Institute and teach parents standard precautions
■ Inform parents that virus may be transmitted via breast milk and
that infant should be formula fed (in developing countries
breastfeeding may be acceptable where there are no safe
alternatives)
■ Emphasize importance of continued health supervision
■ Encourage and provide human contact to meet infant’s emotional
needs
■ Evaluation/outcomes
■ Infant remains free from opportunistic infections
■ Caregiver maintains standard precautions
• Sepsis
• Generalized bacterial infection
• Risk factors: infected amniotic fluid; infected birth canal; break in
aseptic technique after birth
• Nursing care of infants with sepsis
■ Assessment/analysis
■ Poor feeding, vomiting
■ High temperature, inability to maintain temperature
■ Lethargy, increasing irritability
■ Signs of anemia (e.g., pallor, weakness)
■ Frequent stools
■ Planning/implementation
■ Monitor IV fluid administration
■ Administer oxygen as ordered
■ Administer prescribed IV antibiotic therapy
■ Aid in decontaminating areas on the unit that house newborns
■ Evaluation/outcomes
■ Maintains fluid and electrolyte status
■ Achieves infection-free status
• TORCH
• Acronym for:
■ T—Toxoplasmosis (Toxoplasma gondii)
■ Acquired by eating raw or undercooked meat, contact with cat feces
■ Crosses placenta, severity related to gestational age at time of
exposure
■ Newborn sequelae: hydrocephalus, intracranial calcifications,
chorioretinitis
■ O—Others: HIV, gonorrhea, syphilis, human papillomavirus,
varicella, group B streptococcus, hepatitis B virus, measles, mumps,
Zika virus
■ R—Rubella (rubella virus)
■ Greatest risk if maternal infection occurs in first 12 weeks of
gestation
■ May have active viral infection requiring isolation until pharyngeal
mucus and urine are free of virus
■ Newborn sequelae: encephalitis, ocular abnormalities, cardiac
maldevelopment, other defects
■ Vaccine should be administered in immediate postbirth period to
mothers who have not had rubella or who are serologically
negative; it should not be administered during pregnancy
■ C—Cytomegalic inclusion disease (cytomegalovirus)
■ Sexually transmitted infection; pregnant women usually
asymptomatic
■ Newborn sequelae: hemolytic anemia, hydrocephalus,
microcephalus, IUGR, neonatal death
■ H—Herpes genitalis (herpesvirus)
■ Contracted during sexual activity
■ Characterized by exacerbations and remissions; first attack most
severe
■ Intercourse should be avoided during last 4 to 6 weeks of
pregnancy
■ Cesarean birth required during exacerbation because vaginal birth
may cause neonatal infection resulting in death
■ Newborn sequelae: CNS involvement, visual impairment
• Therapeutic interventions: prevention and early treatment of pregnant
woman to eliminate or reduce risk to fetus
Substance dependence (neonatal abstinence
syndrome)
• Physiologic dependence on addictive substance (e.g., alcohol, methadone,
heroin, cocaine) resulting from maternal drug use and/or abuse
• Incidence: perinatal mortality 6 to 8 times higher than in control group
• Maternal alcohol abuse can result in fetal alcohol syndrome producing
congenital defects (e.g., short, thin upper lip; hypoplastic maxilla;
microcephaly; motor and cognitive impairment; persistent growth lag)
• Clinical findings
• Respiratory distress, jaundice, congenital anomalies, behavioral
aberrations
• Withdrawal signs appear soon after birth; severity depends on length of
maternal addiction, type of drug used, amount of drug taken,
concurrent use of other drugs, and when drug was taken before birth;
may persist for up to 4 months
• Nursing care of infants who are dependent on alcohol or opioids
• Assessment/analysis
■ Maternal intake of drug: type, time, amount
■ Signs of withdrawal
■ Facial scratches, hyperactivity, tremors, seizures
■ Yawning, disturbed sleep
■ Tachypnea, sneezing, stuffy nose
■ Shrill cry
■ Ineffective sucking, drooling, vomiting
■ Diarrhea, excoriated buttocks
• Planning/implementation
■ Monitor neuromuscular status
■ Monitor vital signs, support respiratory functioning
■ Provide small, frequent feedings
■ Administer prescribed sedatives or opioids
■ Minimize environmental stimuli, maintain seizure precautions
■ Promote parent-infant attachment when possible, provide constant
caregiver
■ Hold and cuddle frequently, provide periods of uninterrupted rest
■ Swaddle when in crib
■ Use soft nipple to reduce sucking effort, administer supplemental
methods of nutritional support as prescribed
■ Encourage continued health supervision
■ Refer to appropriate community-service agencies for family support
and supervision
• Evaluation/outcomes
■ Maintains respiratory functioning
■ Survives withdrawal from drug
■ Establishes a sleeping pattern
■ Gains weight
Application and review
5. While performing bag-and-mask ventilation on a newborn, a nurse does
not see the newborn’s chest rise. Place the following interventions in order
of their priority.
1. _____ Reposition the head.
2. _____ Open the mouth slightly.
3. _____ Apply the mask for a better seal.
4. _____ Suction the mouth if there are secretions.
5. _____ Assess the neonate’s response to these measures.
6. The nurse is differentiating between cephalohematoma and caput
succedaneum. What finding is unique to caput succedaneum?
1. Scalp over the area is tender.
2. Edema crosses the suture line.
3. Edema increases during the first day.
4. Scalp over the area becomes ecchymosed.
7. For what complication should a nurse assess a newborn after a precipitate
birth?
1. Brachial palsy
2. Dislocated hip
3. Fractured clavicle
4. Intracranial hemorrhage
8. A preterm neonate admitted to the NICU has muscle twitching, seizures,
cyanosis, abnormal respirations, and a short, shrill cry. What complication
does the nurse suspect?
1. Tetany
2. Spina bifida
3. Hyperkalemia
4. Intracranial hemorrhage
9. An infant is born in the breech position, and assessment of the newborn
indicates the presence of Erb palsy (Erb-Duchenne paralysis). What
clinical manifestation supports this conclusion?
1. Absent grasp reflex on the affected side
2. Negative Moro reflex on the unaffected side
3. Inability to turn the head to the unaffected side
4. Flaccid arm with the elbow extended on the affected side
10. What should nursing care for the affected arm of an infant born with ErbDuchenne paralysis (brachial palsy) include?
1. Keeping it immobilized
2. Measuring the length of the arm daily
3. Teaching the parents to manipulate the arm muscles
4. Starting passive range-of-motion exercises immediately
11. A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What
does a nurse identify as the cause of this complication?
1. A disease acquired in utero
2. An X-linked inheritance pattern
3. A tumor arising from muscle tissue
4. An injury to the brachial plexus during birth
12. A newborn has an asymmetric Moro reflex. What does a nurse identify as
a cause of this problem?
1. Down syndrome
2. Cranial nerve damage
3. Cerebral or cerebellar birth injuries
4. Brachial plexus, clavicular, or humeral birth injuries
13. A nurse suspects that a newborn is experiencing opioid withdrawal.
Which assessment supports this suspicion?
1. Lethargy and constipation
2. Grunting and low-pitched cry
3. Irritability and nasal congestion
4. Watery eyes and rapid respirations
14. For what should a nurse assess in a newborn of a mother who is known to
abuse opioids?
1. Dehydration
2. Hyperactivity
3. Hypotonicity of muscles
4. Prolonged periods of sleep
15. A nurse in the clinic assesses that a 4-day-old neonate who was born at
home has a purulent discharge from the eyes. What condition does the
nurse suspect?
1. A Chlamydia trachomatis infection
2. Human immunodeficiency virus (HIV)
3. Retinopathy of prematurity (retrolental fibroplasia)
4. A reaction to the ophthalmic antibiotic instilled after birth
16. An infant develops purulent conjunctivitis on the fourth day of life and is
brought to the emergency department. What is the priority nursing
action?
1. Assess for signs of pneumonia.
2. Secure an order for allergy testing of the infant.
3. Bathe the infant’s eyes with tepid boric acid solution.
4. Teach the mother to wash her hands before touching the infant.
17. What should the care of a newborn infant whose mother has had
untreated syphilis since the second trimester of pregnancy include?
1. Examining for a cleft palate
2. Testing for congenital syphilis
3. Assessing for muscle hypotonicity
4. Observing for maculopapular lesions of the soles
See Answers on pages 316-322.
Hemolytic disorders
Rh incompatibility
• Rh-negative woman is sensitized to blood from her Rh-positive fetus or
other sources (e.g., Rh-positive blood transfusion), causing production of
antibodies to Rh-positive blood
• These antibodies transfer through placenta to fetus in subsequent
pregnancies; if fetus is Rh positive, agglutination and destruction of fetal
red cells occur (pathologic jaundice, erythroblastosis fetalis); rarely a
problem in first pregnancy unless previously sensitized
• Prevention: RhoGAM (Rho [D] immune globulin) administered
intramuscularly to Rh-negative mother at about 28 weeks’ gestation and
within 72 hours after birth or abortion; prevents production of antibodies
in this pregnancy; mother must be negative for Rh antibodies to receive
RhoGAM
ABO incompatibility
• No anti A or Anti B are produced during an initial exposure as anti A or
Anti B antibodies are naturally occurring in the maternal blood stream
• Most common when fetal blood type is A, B, or AB and mother is type O;
mother’s anti-A or anti-B antibodies transfer through placenta to fetus,
causing hemolysis resulting in fetal anemia, jaundice, and kernicterus
(excessively high bilirubin levels) within first 24 hours after birth
(pathologic jaundice)
• More common but less severe than Rh incompatibility; previous exposures
to A, B, or AB blood do not increase formation of anti-A or anti-B
antibodies, so first pregnancy can be affected
Therapeutic interventions
• During pregnancy: amniotic fluid determinations using chemical and
spectrophotometric analysis; elevated readings warrant either
intrauterine exchange transfusion or induction of labor, depending on
number of weeks’ gestation
• Phototherapy: reduces mild to moderate kernicterus
• Transfusions or exchange transfusions of Rh-negative blood for severely
affected infants to decrease antibody level and increase RBC count and
hemoglobin level
Nursing care of infants with hemolytic disorders
• Assessment/analysis
• Verification of blood incompatibility (e.g., ABO, Rh) between mother
and fetus
• Jaundice; increasing bilirubin levels during first 24 hours after birth
• Laboratory results of bilirubin, hematocrit, and hemoglobin levels
• Lethargy or irritability
• Ineffective feeding pattern, vomiting
• Enlargement of liver and spleen
• Signs of kernicterus (e.g., absence of Moro reflex, apnea, high-pitched
cry, opisthotonos, tremors, seizures)
• Planning/implementation
• Monitor maternal antibody titers
• Administer RhoGAM to Rh-negative mother within 72 hours after birth
if neonate is Rh positive and mother has not been sensitized
• Teach parents
■ Why RhoGAM is necessary if not previously sensitized
■ Reason for intrauterine or extrauterine exchange transfusions
• Provide care during phototherapy
■ Bank of phototherapy lights: place unclothed under lights at distance
as per protocol; turn according to protocol; cover eyes completely
with opaque mask; remove mask during feedings to check eyes and
promote visual contact; monitor temperature; maintain adequate
hydration
■ Fiberoptic blanket: place blanket around torso or place flat in bed;
place thin pad between device and newborn; cover eyes with mask as
per protocol; may be held
• Evaluation/outcomes
• Mother remains free from Rh isoimmunization
• Neonate remains free from injury
Application and review
18. At 12 weeks’ gestation, a patient who is Rh negative expels the total
products of conception. What is the nursing action after it has been
determined that she has not been previously sensitized?
1. Administer RhoGAM within 72 hours.
2. Make certain that RhoGAM is administered at the first clinic visit.
3. Withhold the RhoGAM because the gestation lasted only 12 weeks.
4. Withhold the RhoGAM because it is not used after the birth of a
stillborn.
19. A patient who has type O Rh-positive blood gives birth. The neonate has
type B Rh-negative blood. When the nurse assesses the neonate 11 hours
after birth, the infant’s skin appears yellow. What is the most likely cause?
1. Neonatal sepsis
2. Rh incompatibility
3. Physiologic jaundice
4. ABO incompatibility
20. A nurse in the newborn nursery observes a yellowish skin color of an
infant whose mother had a cesarean birth. What is the immediate nursing
action?
1. Notify the health care provider.
2. Ascertain how many hours ago the neonate was born.
3. Take a heel blood sample and send it to the laboratory.
4. Cover the eyes and place the neonate under high-intensity light.
21. A primigravida has just given birth. The nurse is aware that she has type
AB Rh-negative blood. Her newborn’s blood type is B positive. What
should the plan of care include?
1. Determining the father’s blood type
2. Preparing for a maternal blood transfusion
3. Observing the newborn for signs of ABO incompatibility
4. Obtaining an order to administer RhoGAM to the mother
22. A nurse is assessing a newborn for signs of hyperbilirubinemia
(pathologic jaundice). What clinical finding confirms this complication?
1. Neurologic signs during the first 24 hours
2. Muscular irritability within 1 hour after birth
3. Jaundice developing between the first 12 and 24 hours
4. Jaundice developing between 48 and 72 hours after birth
See Answers on pages 316-322.
Infants of diabetic mothers
• Risk for complications in infant is the same for mothers with diabetes or
gestational diabetes
• Most important factor in decreasing risk for infant is maintaining normal
glucose levels in mother
• Increased hemoglobin A1c, especially at the beginning of the pregnancy,
is associated with increased risk for congenital anomalies
Clinical findings
• Large for gestational age (LGA); however, if diabetes in mother is
advanced enough, may be SGA
• Lethargic
• Hypotonic
• Larger-than-normal shoulders, abdomen
• Round, full face
• Hypoglycemia
• Hypocalcemia
• Hypomagnesemia
• Polycythemia
• Hyperbilirubinemia
• Cardiomyopathy
• Respiratory distress syndrome
• Deep vein thrombosis
• Cardiac and CNS congenital anomalies
• Hypoglycemia after birth
• Caused by increased insulin activity in blood of IDMs
• Treatment is recommended for infants with serum glucose <40 mg/dL
Nursing care of infants of diabetic mothers
• Assessment/analysis
• History of mother’s course of disease
• Serum glucose of infant assessed often in the first 48 to 96 hours
• Assess for respiratory distress syndrome
• Examination for presence of congenital anomalies
• Planning/implementation
• Maintain adequate thermoregulation
• Maintain adequate serum glucose
■ Asymptomatic IDMs who can feed
■ 10% dextrose and water via IV
■ Symptomatic IDMs who cannot feed
■ Blood glucose >20 mg/dL: 10% dextrose at 4 to 6 mg/min/kg via
continuous IV infusion
■ Blood glucose <20 mg/dL: 10% dextrose at 200 mg/kg given bolus
over 2 to 4 minutes, then 10% dextrose and water via IV
• Monitor infant for birth injury
• Teach mother how to monitor blood glucose in infant; signs and
symptoms of low glucose
• Teach mother regarding adequate nutrition for self and infant
• Evaluation/outcomes
• Maintain serum glucose of infant between 40 and 50 mg/dL
• Prevention of later health problems associated with poor glucose
control
Congenital anomalies
Cardiac malformations
• Disrupted circulatory changes at or shortly after birth: failure of foramen
ovale, ductus arteriosus, and/or ductus venosus to close; rapid increase in
pulmonary circulation resulting from decreased oxygen concentration
• Incidence: 5 to 8 per 1000 births
• Defects with increased pulmonary blood flow
• Ventricular septal defect
■ Abnormal opening between ventricles
■ Severity depends on size of opening
■ Higher pressure in right ventricle causes hypertrophy, with
development of pulmonary hypertension
■ Low, harsh murmur heard throughout systole
■ Specific therapeutic intervention: transcatheter closure (TCC) with
occlusive device; open heart surgical repair
■ Prognosis: single membranous defect has less than a 5% death rate;
multiple muscular defects can have mortality risk of 20%
• Atrial septal defect (ASD)
■ Types
■ Ostium primum defect (ASD1): opening at lower end of septum;
may be associated with mitral valve abnormalities
■ Ostium secundum defect (ASD2): opening is near center of septum
■ Sinus venosus defect: superior portion of atrial septum fails to form
near junction of atrial wall with superior vena cava
■ Murmur heard high in chest, with fixed splitting of second heart
sound
■ Specific therapeutic intervention: TCC with occlusive device; open
heart surgical repair
■ Prognosis: less than 1% operative mortality
• Patent ductus arteriosus
■ Failure of fetal connection between aorta and pulmonary artery to
close
■ Blood shunted from aorta back to pulmonary artery; may progress to
pulmonary hypertension and cardiomegaly
■ Machinery-type murmur; heartbeat heard in left second or third
intercostal space
■ Specific therapeutic interventions
■ Closure of opening between aorta and pulmonary artery: insertion
of coils, which expand to fill the ductus; surgery
■ Critically ill newborns: pharmacologic closure may be attempted
with prostaglandin inhibitor (e.g., indomethacin)
○ Prognosis: less than 1% mortality
• Atrioventricular canal defect
■ Abnormal openings between atria and ventricles together
■ Caused by a low ASD in combination with a high ventricular septal
defect
■ Allows blood to flow among all chambers
■ Flow is determined by pressure gradients, resistances, and chamber
compliance, but is generally left to right
■ Predisposes child to moderate to severe heart failure
■ Common findings include characteristic murmur, cyanosis
■ Most commonly associated with Down syndrome
■ Specific therapeutic interventions
■ Severe symptoms in small infants: pulmonary artery banding
■ Complete surgical repair in infancy: closure of septal defects;
reconstruction of atrioventricular valve tissues
○ Prognosis: less than 5% operative mortality
• Defects with decreased pulmonary blood flow
• Tetralogy of Fallot
■ Four associated defects
■ Pulmonary valve stenosis
■ Ventricular septal defect, usually high on septum
■ Overriding aorta, receiving blood from both ventricles, or aorta
arising from right ventricle
■ Right ventricular hypertrophy
○ Specific therapeutic interventions
○ Open heart surgery: complete repair usually performed soon
after birth; closure of ventricular septal defect and resection of
infundibular stenosis, possibly with pericardial patch to
enlarge right ventricular outflow tract
○ Palliative treatment (Blalock-Taussig procedure): surgery to
increase pulmonary blood flow; may be done prenatally
○ Prognosis: less than 5% surgical repair mortality
• Transposition of the great vessels (arteries)
■ Aorta exits from right ventricle and pulmonary artery leaves left
ventricle
■ Incompatible with life unless communication exists between both
sides of heart (e.g., ASD, ventricular septal defect, patent ductus
arteriosus)
■ Specific therapeutic interventions
■ Open heart surgery: complete repair usually performed soon after
birth; transposing great vessels to their correct anatomic placement
with reimplantation of coronary arteries
■ Palliative procedures: alternative surgical procedure to prevent
pulmonary vascular resistance if unable to tolerate complete repair
■ Pharmacologic: pediatric prostaglandins to dilate patent ductus
arteriosus (e.g., alprostadil)
■ Prognosis: 5% to 10% surgical mortality
• Tricuspid atresia
■ Absence of tricuspid valve
■ Incompatible with life unless communication exists between right
and left sides of heart (e.g., ASD, ventricular septal defect, patent
ductus arteriosus)
■ Specific therapeutic interventions
■ Open heart surgery: complete repair; conversion of right atrium
into outlet for pulmonary artery; placement of tubular conduit with
valve closing ASD
■ Palliative procedures: performed if unable to tolerate complete
repair
■ Prognosis: surgical mortality greater than 10%
• Truncus arteriosus
■ Single great vessel arising from base of heart; serves as pulmonary
artery and aorta
■ Systolic murmur; single semilunar valve produces loud second heart
sound that is not split
■ Specific therapeutic intervention: fetal surgery to reimplant
pulmonary arteries to right ventricle
■ Prognosis: mortality of 10%
• Total anomalous pulmonary venous connection
■ Pulmonary vein does not join to the left atrium; pulmonary vein may
connect to the right atrium or veins draining toward right atrium
■ Mixed blood is returned to the right atrium; may be shunted to the
left through an atrial septal defect
■ Causes right-sided hypertrophy of heart
■ If not corrected, heart failure leads to death
■ Clinical findings: cyanosis, heart failure
■ Classification
■ Supracardiac: pulmonary vein attaches above the diaphragm (e.g.,
superior vena cava)
■ Cardiac: pulmonary vein attaches to the heart (e.g., right atrium)
■ Infradiaphragmatic: pulmonary vein attaches below the diaphragm
(e.g., inferior vena cava)
■ Specific therapeutic intervention: corrective surgical repair;
pulmonary vein is reconnected to left atrium; any ASD is closed;
anomalous connections are ligated
■ Prognosis: less than 10% mortality
• Obstructive defects
• Pulmonary (pulmonic) stenosis
■ Narrowing of pulmonary valve; decreased blood flow to lungs;
increased pressure in right ventricle
■ Specific therapeutic intervention: valvotomy or balloon angioplasty
■ Prognosis: less than 2% mortality
• Aortic stenosis
■ Narrowing of aortic valve; increased workload of left ventricle;
lowered pressure in aorta reduces coronary artery blood flow
■ Specific therapeutic intervention: division of stenotic valves of aorta
■ Prognosis: mortality greater than 20% in critically ill newborns; older
children have lower mortality risk
• Coarctation of the aorta
■ Localized narrowing of aorta near insertion of ductus arteriosus
■ Increased systemic circulation above stricture: bounding radial and
carotid pulses; headache; dizziness; epistaxis
■ Decreased systemic circulation below stricture: absent femoral
pulses; cool lower extremities
■ Increased pressure in aorta above defect causes left ventricular
hypertrophy
■ Murmur may or may not be heard
■ Specific therapeutic intervention: angioplasty; resection of defect with
anastomosis of ends of the aorta
■ Prognosis: less than 5% mortality with isolated coarctation
• Valvular aortic stenosis
■ Malformed cusps on the aortic valve create a bicuspid (instead of
tricuspid) valve
■ Causes increased workload of left ventricle; lowered pressure in aorta
reduces coronary artery blood flow
■ Can be progressive; sudden episodes of ischemia can result in death
■ Clinical findings: decreased cardiac output, hypotension, tachycardia,
lack of appetite, chest pain, dizziness, characteristic murmur
■ Strenuous activity may be contraindicated
■ Increased risk of endocarditis, insufficiency, ventricular dysfunction
■ Specific therapeutic intervention
■ Nonsurgical: balloon dilation via cardiac catheterization; usually
first-line treatment
■ Surgical: aortic valve replacement; valvotomy—surgical repair of
valve rarely results in normal valve
■ Prognosis: 25% of nonsurgical patients require further intervention
(valve replacement) within 10 years
• Clinical findings
• Infancy
■ Heart rate more than 200 beats/min
■ Respiratory rate about 60 breaths/min
■ Circumoral or generalized cyanosis
■ Feeding difficulty, failure to thrive (first signs usually recognized by
parents)
• Dyspnea, especially on exertion
• Stridor or choking spells
• Heart murmurs
• Signs of heart failure
■ Tachycardia and hypotension progressing to extreme pallor or
duskiness
■ Tachypnea, dyspnea, costal retractions progressing to grunting
respirations
■ Fluid retention: weight gain; ascites; pleural effusions progressing to
peripheral edema
• Therapeutic interventions
• Surgical
■ Repair of cardiac anomaly by surgery and/or interventional radiology
■ Prophylactic antibiotic therapy before surgery, before invasive
procedures, may be throughout life
■ Postoperative prevention of constipation to avoid straining and
Valsalva maneuver, which increase intrathoracic pressure, causing
tension on sutures
• Pharmacologic
■ Cardiac glycosides to increase efficiency of heart action
■ Positive inotropic effect: increases myocardial contractility
■ Negative chronotropic effect: decreases heart rate
■ Negative dromotropic effect: slows conduction velocity
■ Variety of medications: same qualitative effect on heart action but
differ in potency, rate of absorption, amount absorbed, onset of
action, speed of elimination
• Nursing care of children with cardiac malformations
• Assessment/analysis
■ Color (e.g., cyanosis, pallor)
■ Apical pulse rate, peripheral pulse quality, murmurs
■ Respiratory rate and effort, dyspnea, frequency of colds
■ Blood pressure
■ Chest abnormalities
• Planning/implementation
■ Teach parents home administration of medications
■ Administer medication at scheduled intervals; use calendar to
mark off each dose; post reminder (sign on refrigerator); if
vomiting occurs after administration, do not readminister dose; if
dose is missed, call health care provider
■ Refill prescription before medication is completely used
■ Administer by slowly squirting it in side and back of mouth
■ Do not mix with other foods or fluids (refusal to consume results in
inaccurate dosage)
■ If child has teeth, give water after administration; when possible,
brush teeth to prevent tooth decay from elixir
■ Accidental overdose: contact health care provider or nearest poison
control center immediately
■ Help parents cope with manifestations of illness
■ During dyspneic/cyanotic spell: place in side-lying knee-chest
position, with head and chest elevated
■ Keep warm; encourage rest and sleep
■ Decrease child’s anxiety by remaining calm
■ Feeding strategies
○ Feed slowly, burp frequently
○ Teach gavage feedings, if required
○ Offer small, frequent feedings
○ Introduce solids and spoon-feeding early
○ Encourage to eat if anorectic
■ Foster growth-promoting family relationships
■ Encourage parents to
○ Discuss feelings
○ Include others in child’s care to prevent caregiver exhaustion
○ Maintain expectations of all siblings as equally as possible
○ Provide consistent discipline to prevent behavioral problems
○ Avoid hazards of fostering overdependency
■ Help parents to
○ Feel adequate in their parental roles by emphasizing growth and
developmental progress
○ Foster development by formulating age-appropriate goals
consistent with activity tolerance; provide social experiences for
child
■ Discuss school entry with parents, teacher, and school nurse
■ Preoperative planning for postoperative care
■ Keep sleep record to organize care around usual rest pattern
■ Assess elimination pattern to avoid postoperative constipation and
straining; know words used for elimination; teach use of bedpan
■ Record level of activity; list favorite toys or games that require
gradually increased exertion
■ Determine fluid preferences
■ Observe verbal and nonverbal responses to pain
■ Prepare physically and emotionally for surgery
■ Based on developmental and chronologic age
■ Based on principle that fear of the unknown increases anxiety
■ Prepare for cardiac catheterization
○ Frequent assessments (e.g., vital signs, pulse oximetry,
observation of catheter insertion site)
○ Immobility of extremity used for catheter insertion site for
several hours
■ Provide for consistency in preoperative and postoperative
preparation as source of support for both child and parents (e.g.,
same nurse should provide care if possible)
■ Know what equipment is used after open- or closed-heart surgery
■ Encourage therapeutic play with equipment (e.g., stethoscope,
blood pressure machine, oxygen mask, pulse oximeter, suction
equipment, syringes without needles); for preschooler, use dolls
and puppets to describe procedures
■ Teach about size of bandage, size of incision
■ Familiarize with postoperative environment (e.g., postanesthesia
and intensive care units, strange noises)
■ Teach coughing and breathing with incentive spirometer
■ Explain why coughing and moving are necessary despite discomfort
■ Explain what tubes may be used and what they will look like
■ Explain to parents that chest tubes may be used to drain air and
fluid from pleural cavity
■ Discuss specifics of postoperative care (similar to those for any major
surgery)
■ Identify problems associated with adjusting to improved physical
status
■ Has become accustomed to sick role and its secondary gains
■ May have difficulty learning to relate to peers and siblings
competitively
■ Disability can no longer be used as crutch for educational and
social shortcomings
■ Help family adjust to correction of cardiac defect
■ Improved physical status may be difficult for parents because it
reduces child’s dependency on them
■ Parental expectations must be modified to accommodate child’s
new physical vigor and search for independence
• Evaluation/outcomes
■ Participates in appropriate activities for age, energy, and
developmental level
■ Consumes sufficient nutrients for growth and development
■ Family and child discuss fears and feelings about disorder and
limitations
■ Family demonstrates home care for child
Nasopharyngeal and tracheoesophageal anomalies
• Failure of esophagus to develop continuous passage to stomach; failure of
trachea and esophagus to develop into separate structures
• Risk factors: low birth weight; about 50% associated with other anomalies
(e.g., vertebral anomalies, imperforate anus, radial and renal dysplasia,
limb anomalies, cardiac malformations)
• Tracheopharyngeal anomalies
• Absence of esophagus
• Atresia of esophagus without tracheal fistula
• Tracheoesophageal fistula
• Most common: proximal esophageal atresia combined with distal
tracheoesophageal fistula
• Other associated anomalies
• Chalasia: incompetent cardiac sphincter
• Choanal atresia: no opening between one or both nasal passages and
nasopharynx
• Clinical findings
• Excessive salivation, drooling
• Choking, sneezing, coughing during feeding, regurgitation of formula
through mouth and nose
• Catheter cannot be passed into stomach (depending on type)
• Abdominal distention (depending on type)
• Therapeutic intervention: surgical repair; one procedure or several,
depending on health status and severity of defect
• Nursing care of children with nasopharyngeal and tracheoesophageal
anomalies
• Assessment/analysis
■ Three Cs indicating tracheoesophageal fistula: coughing, choking,
cyanosis
■ Signs of respiratory distress
■ Nutritional status/weight
■ Fluid and electrolyte balance
■ Parent/infant interaction
• Planning/implementation
■ Preoperative nursing care
■ Observe for signs of respiratory distress; suction oropharynx to
remove accumulated secretions
■ Keep NPO; monitor intake and output; offer pacifier to meet
sucking needs
■ Change position to prevent pneumonia
■ Maintain with head elevated on inclined plane of at least 30 degrees
■ Maintain patency of nasogastric tube if used to decompress
stomach
■ Postoperative nursing care
■ Maintain body temperature
■ Maintain nasogastric/gastrostomy tube to drainage
■ Change position to prevent pneumonia
■ Maintain function of chest tubes, if used
■ Maintain nutrition by oral, parenteral, or gastrostomy route
■ Use pain rating scale and medicate appropriately
■ Provide comfort and physical contact; provide a pacifier for
nonnutritive sucking until oral feedings are resumed
• Evaluation/outcomes
■ Maintains patent airway
■ Tolerates oral feedings
■ Consumes adequate calories for growth and development
Intestinal obstruction
• Congenital life-threatening obstruction of intestinal tract
• Mechanical: constricted or occluded lumen (e.g., incarcerated inguinal
hernia progressing to strangulated with interruption of blood supply;
intussusception; volvulus)
• Muscular: interference with regular muscular contractions
• Clinical findings
• Abdominal distention, paroxysmal pain
• Absence of stools, meconium in newborn (meconium ileus)
• Vomiting of feeding progressing to bile-stained material, may be
projectile
• Weak, thready pulse; cyanosis; weak, grunting respirations from
abdominal distention, causing diaphragm to compress lungs
• Therapeutic interventions
• Surgical repair: single-staged; multistaged for severe defect
• Prevention of aspiration pneumonia
• Supportive nutritional therapy
• Nursing care of children with an intestinal obstruction
• Assessment/analysis
■ Abdomen for distention, visible peristaltic waves
■ Characteristics and amount of vomitus
■ Absence or presence of bowel sounds, bowel movements;
characteristics of stool
• Planning/implementation
■ Preoperative nursing care
■ Maintain NPO; provide pacifier
■ Observe for signs of dehydration and shock
■ Maintain nasogastric suction; monitor I&O
■ Postoperative nursing care based on type of surgery performed
■ Keep operative site clean and dry, especially after passage of stool
■ Position on side to prevent pulling legs up to chest
■ Use pain rating scale and medicate appropriately
■ Provide colostomy care
○ Prevent skin excoriation by frequent cleansing; apply skin
protective agent, diaper, or ostomy appliance
○ Teach parents colostomy care (e.g., avoidance of tight diapers
and clothes around abdomen)
• Evaluation/outcomes
■ Establishes regular pattern of bowel elimination
■ Maintains fluid and electrolyte balance
■ Consumes adequate nutrition to support growth
■ Rests comfortably
Musculoskeletal anomalies
• Clubfoot
• Bone deformity and malposition of foot with soft tissue contracture;
foot twisted out of alignment; may be misshapen
• Talipes equinovarus most common type; foot is fixed in plantar flexion
(downward) and deviated medially (inward)
• Clinical findings
■ Deformity apparent at birth
■ Classification
■ Rigid or flexible
■ Mild (positional): may correct spontaneously; may require passive
exercise or serial casting
■ Syndromic: associated with other congenital anomalies
■ Congenital: wide range of rigidity and prognosis; usually requires
surgical intervention
• Therapeutic interventions
■ Treatment started during newborn period most successful; delay
causes abnormal development of leg muscles and bones with
shortening of tendons
■ Nonsurgical treatment: gentle, repeated manipulation of foot with
casting; done every few days for 1 to 2 weeks, then at 1- to 2-week
intervals
■ Surgical treatment: done if nonsurgical treatment ineffective
■ Tight ligaments released
■ Tendons lengthened or transplanted
■ Follow-up care
■ Emphasizes muscle reeducation (by manipulation) and correct
walking
■ Corrective shoes: may have sole and heel lifts on lateral border to
maintain position; shoes must be maintained in good repair
■ Extended orthopedic supervision: tendency to recur; considered
cured when able to wear regular shoes and walk correctly
• Nursing care of children with clubfoot
■ Assessment/analysis
■ Parental understanding of treatment regimen
■ Skin and neurovascular assessment of affected limb
■ Planning/implementation
■ Provide care associated with casting
○ Monitor neurovascular status of affected extremity (e.g., color,
skin temperature, capillary refill, toe movement)
○ Check cast for weakness and wear, especially if child is allowed
weight bearing
○ See “Developmental Dysplasia of the Hip,
Planning/implementation”
■ Teach parents neurovascular assessments, care of cast and special
shoes
■ Emphasize need for follow-up, which may be prolonged
■ Evaluation/outcomes
■ Remains free from complications
■ Parents demonstrate ability to care for child
■ Continues follow-up orthopedic supervision
• Developmental dysplasia of the hip (DDH)
• Imperfect development of hip; involvement includes femoral head,
acetabulum, or both
• Incidence: 60% are females
• Classification
■ Acetabular: mildest form; femoral head remains in acetabulum
■ Subluxation: most common form; femoral head partially displaced
■ Dislocation: femoral head not in contact with acetabulum; displaced
posteriorly and superiorly
• Clinical findings
■ Limited abduction of leg on affected side
■ Asymmetry of gluteal, popliteal, and thigh folds
■ Audible click when abducting and externally rotating hip on affected
side (Ortolani test)
■ Apparent shortening of femur on affected side
■ Waddling gait and lordosis
• Therapeutic interventions
■ Directed toward enlarging and deepening acetabulum by placing
head of femur within acetabulum and applying constant pressure
■ Positioned with legs slightly flexed and abducted (e.g., Pavlik harness,
spica cast, brace)
■ Surgical intervention (e.g., open reduction with casting)
• Nursing care of children with DDH
■ Assessment/analysis
■ Limb shorter on affected side
■ Positive Ortolani test (hip click)
■ Restricted abduction of hip on affected side
■ Planning/implementation
■ Limit risk for hypostatic pneumonia caused by enforced immobility
○ Change position frequently; raise head of mattress/crib rather
than head only to prevent neck flexion
○ Teach parents postural drainage; exercises to increase lung
expansion (e.g., blowing bubbles)
○ Encourage parents to notify health care provider immediately if
congestion or cough develops
■ Maintain skin integrity
○ Assess circulation to toes (e.g., pedal pulses, signs of blanching)
○ Prevent small toys or food from slipping under cast
○ Teach parents to recognize signs of infection (e.g., odor)
○ Protect cast edges with adhesive tape or waterproof material,
especially around perineum
○ Use disposable diapers with plastic lining to minimize soiling by
feces and urine
■ Prevent constipation
○ Teach parents to observe child for straining on defecation
○ Increase fluids and high-fiber foods
■ Encourage intake of nutritious foods appropriate for activity level
○ Provide small, frequent meals because of inflexibility of cast
around waist (window may be made over abdominal area to
allow for expansion with meals)
○ Teach parents to adjust calorie intake because less energy
expenditure can lead to obesity
■ Move and position safely when in spica cast
○ Use wagon or stroller with back flat or mechanic’s creeper for
transportation
○ Protect from falling when being positioned
○ Avoid using bar between legs of cast for lifting; two people may
be needed to provide adequate body support when moving
○ Use specially designed car restraint system for transportation in
motor vehicle
■ Meet emotional needs
○ Use touch as much as possible; small children can be picked up
and cuddled
○ Stimulate and provide play activities appropriate for age
■ Provide parents with help and support
○ Reinforce teaching with written instructions
○ Schedule home visits with telephone or e-mail counseling
available
○ Stress need for follow-up care because treatment may be
prolonged
○ Prepare parents for application of abduction brace after cast is
removed
○ Additional cast care
■ Evaluation/outcomes
○ Moves about and controls environment
○ Remains free of injury
○ Regains earlier movement (crawling/walking) when device is
removed
○ Parents demonstrate ability to care for child
Genitourinary anomalies
• Exstrophy of the bladder
• Absence of portion of abdominal wall and bladder wall; bladder is
outside abdominal cavity
• Associated defects
■ Pubic bone malformations, inguinal hernia
■ Males: epispadias, undescended testes, short penis
■ Females: cleft clitoris, absent vagina
• Incidence: twice as frequent in males
• Clinical findings
■ Bladder: exposed; appears inside-out
■ Constant seepage of urine leading to skin breakdown and infection
■ Progressive renal failure from infection and obstruction
• Therapeutic interventions
■ First surgery: repair of bladder and urethra within 48 hours if
possible; temporary insertion of suprapubic catheter
■ Second surgery: attachment of pelvic bones
■ Surgery to repair other malformations may be combined with other
surgeries
■ Urinary bypass surgery if necessary
■ Ileal conduit (ureteroileal cutaneous ureterostomy); ileostomy
appliance worn over stoma; collects continuously flowing urine
■ Cutaneous ureterostomy; ureters attached directly to abdominal
wall, usually at site proximal to level of kidneys; two collecting
appliances worn over bilateral openings
• Nursing care of children with exstrophy of the bladder
• Assessment/analysis
■ Renal function, urine output
■ Condition of skin
■ Parental response; interaction with newborn/child
• Planning/implementation
■ Scrupulously clean area around bladder; apply sterile, nonadherent,
moist dressing over exposed bladder tissue to prevent infection
■ Monitor and maintain fluid balance because of large insensible water
losses from exposed viscera
■ Dress infant with loose clothing to avoid pressure over area; change
clothing frequently because of odor
■ Care for urine-collecting appliance; change frequently
■ Help parents to accept disorder and long-term sequelae
• Evaluation/outcomes
■ Maintains skin integrity
■ Remains free from infection
■ Maintains renal function within acceptable limits
■ Family demonstrates ability to care for infant
• Displaced urethral openings
• Abnormally located urethral opening; can be sign of ambiguous
genitalia
• Severity varies in males: depends on distance of opening from tip of
penis, presence of other penile anomalies (e.g., chordee [head of penis
curves downward])
• Classification
■ Hypospadias
■ Males: urethra opens on lower surface of penis from behind glans
to perineum (placement varies)
■ Females: urethra opens into vagina
■ Epispadias
■ Occurs only in males
■ Urethra opens on dorsal surface of penis; often associated with
bladder exstrophy
• Clinical findings
■ Interference with reproduction if severely affected
■ Increased risk for urinary tract infection
• Therapeutic interventions
■ Surgical repair of defect; circumcision, if desired, is delayed until
after surgical repair
■ Surgery may be performed in several stages
• Nursing care of children with a displaced urethral opening
• Assessment/analysis
■ Parental knowledge of defect
■ Origin of urinary stream
• Planning/implementation
■ Provide parents with explanation of potential future functioning
■ Help male child to cope with anatomic difference from peers;
adjustment to voiding in sitting position
■ Prepare child and parents for surgery
• Evaluation/outcomes
■ Remains free from pain
■ Maintains peer interactions
■ Child and parents verbalize feelings/concerns about effects of defect
■ Surgical repair corrects voiding pattern
Application and review
23. A newborn is admitted to the neonatal intensive care unit (NICU) with
choanal atresia. Which part of the infant’s body should the nurse assess?
1. Rectum
2. Nasopharynx
3. Intestinal tract
4. Laryngopharynx
24. What behavior does the nurse anticipate while feeding a newborn with
choanal atresia?
1. Chokes on the feeding
2. Has difficulty swallowing
3. Does not appear to be hungry
4. Takes about half of the feeding
25. An infant is admitted to the pediatric intensive care unit (PICU) after
open heart surgery for the repair of a ventricular septal defect. Place these
nurse assessments in order of priority.
1. _____ Heart rate
2. _____ Operative site
3. _____ Urinary output
4. _____ Respiratory status
5. _____ Intravenous catheter
26. An infant is admitted to the neonatal intensive care unit (NICU) with
exstrophy of the bladder. What covering should the nurse use to protect
the exposed area?
1. Loose diaper
2. Dry gauze dressing
3. Moist sterile dressing
4. Petroleum jelly gauze pad
27. An additional defect is associated with exstrophy of the bladder. For what
anomaly should the nurse assess the infant?
1. Imperforate anus
2. Absence of one kidney
3. Congenital heart disease
4. Pubic bone malformation
28. A nurse is caring for an infant born with exstrophy of the bladder. What
does the nurse determine is the greatest risk for this infant?
1. Infection
2. Dehydration
3. Urinary retention
4. Intestinal obstruction
29. A home care nurse is visiting a family for the first time. The 4-week-old
infant had surgery for exstrophy of the bladder and creation of an ileal
conduit soon after birth. When the nurse arrives, the mother appears tired
and the baby is crying. After an introduction, which is the most
appropriate statement by the nurse?
1. “Tell me about your daily routine.”
2. “You look tired. Is everything all right?”
3. “When was the last time the baby had a bottle?”
4. “Oh, it looks like you two are having a bad day.”
30. The nurse observes that an infant has asymmetric gluteal folds. For which
disorder should the nurse perform a focused assessment?
1. Congenital inguinal hernia
2. Central nervous system damage
3. Peripheral nervous system damage
4. Developmental dysplasia of the hip
31. A 3-month-old infant with severe developmental dysplasia of the hip has
a hip spica cast applied. What should the nurse teach the parents to
prevent a serious complication?
1. Change diapers frequently.
2. Decrease the number of feedings per day.
3. Avoid turning from prone to supine positions.
4. Call the health care provider if there is a foul smell.
32. A 4-month-old infant had a spica cast applied. What should the nurse
include in the discharge instructions to the parents?
1. Obtain a specially designed car seat.
2. Keep diapers on to prevent soiling of the cast.
3. Change the infant’s position every 8 hours.
4. Use the bar between the infant’s legs to change positions.
33. What procedure should a nurse use when elevating the head of an infant
in a spica cast?
1. Change this position after an hour.
2. Place pillows under the shoulders.
3. Pad the edge of the cast with folded diapers.
4. Raise the entire mattress at the head of the crib.
34. A parent brings a 2-week-old infant to the clinic because the infant
continually regurgitates. Chalasia, an incompetent cardiac sphincter, is
suspected. What instructions should the nurse give the parent?
1. Keep the infant in an upright position after feedings.
2. Prevent the infant from crying for prolonged periods.
3. Keep the infant in the prone position after feedings.
4. Ensure that the infant drinks a full bottle of formula at each feeding.
35. A nurse is caring for a 3-month-old infant whose abdomen is distended
and whose vomitus is bile stained. The nurse suspects an intestinal
obstruction. What clinical manifestations support this suspicion? Select all
that apply.
1. Weak pulse
2. Hypotonicity
3. Paroxysmal pain
4. High-pitched cry
5. Grunting respirations
36. A 5-month-old infant is brought to the pediatric clinic for a routine
monthly examination. What assessment alerts the nurse to notify the
health care provider?
1. Temperature of 99.5° F
2. Blood pressure of 75/48 mm Hg
3. Heart rate of 100 beats per minute
4. Respiratory rate of 50 breaths per minute
37. A nurse is reviewing the clinical records of infants and children with
cardiac disorders who developed heart failure. What did the nurse
determine is the last sign of heart failure?
1. Tachypnea
2. Tachycardia
3. Peripheral edema
4. Periorbital edema
38. What is a common finding that the nurse can identify in most children
with symptomatic cardiac malformations?
1. Cognitive impairment
2. Inherited genetic factors
3. Delayed physical growth
4. Clubbing of the fingertips
39. A 1-year-old child has a congenital cardiac malformation that causes
right-to-left shunting of blood through the heart. What clinical finding
should the nurse expect?
1. Proteinuria
2. Peripheral edema
3. Elevated hematocrit
4. Absence of pedal pulses
40. The parents of a child who is scheduled for open heart surgery ask why
their child must be subjected to chest tubes after surgery. What should
the nurse consider before responding in language the parents will
understand?
1. They will increase tidal volumes.
2. Drainage of air and fluid will be facilitated.
3. They will maintain positive intrapleural pressure.
4. Pressure on the pericardium and chest wall will be regulated.
See Answers on pages 316-322.
Preterm infants
Pain
• Assessment
• Based on infant behavior, physiologic changes
■ Total body response; arms and legs may tremor
■ Facial expressions: grimaces, surprise, frowns, facial flinching
■ Tense, harsh cry
■ Increased blood pressure and heart rate, decreased oxygen saturation
■ No recognition of cause and effect of pain
• Multidimensional scales designed specifically for neonates helpful
• Pain behaviors in preterm infants may be less obvious
• Pain in infants is often untreated/undertreated
• Assume preterm infant would experience pain with the same stimuli
that would cause pain in an older child or adult; treat pain before infant
exhibits pain behaviors
• Memory of pain
• Infants remember pain
■ Show guarded behaviors once exposed to repeated painful
procedures
■ Repeated exposure to painful stimuli may affect infant’s nervous
system permanently
■ Because of guarding behaviors, repeated exposure to pain can delay
infant’s development
• Management
• Nonpharmacologic: positioning, swaddling, music (humming, singing),
use of sucrose, rocking, use of pacifier, reduction of environmental
noise/light
• Pharmacologic: morphine, fentanyl
Retinopathy of prematurity
• Constriction of immature retinal vasculature that causes hypoxemia in the
retina; stimulates retinal capillaries in hypoxic area and can cause retinal
detachment
• Prevention of preterm birth is most effective prevention method
• Diagnosed by examination
• Clinical findings
• Vascular growth of retina
• Blindness
• Therapeutic interventions
• Cryotherapy
• Laser photocoagulation
• Surgery to repair detached retina
• Administration of bevacizumab to stop growth of retinal capillaries and
prevent retinal detachment
• Nursing care of children with retinopathy of prematurity
• Assessment/analysis
■ Early screening and detection in infants born <28 weeks of gestation
■ Monitor oxygen levels closely
• Planning/implementation
■ Decrease exposure to bright light
■ Use of supplemental oxygen to prevent hypoxia (avoid
overoxygenation)
■ Postoperative pain management
■ Teach parents about condition and provide emotional support
• Evaluation/outcomes
■ Infant will retain sight
Bronchopulmonary dysplasia
• Chronic lung condition resulting from prolonged mechanical ventilation,
certain respiratory viruses
• Condition may cause poor growth, developmental delays
• Diagnosed via pulmonary function tests, radiography, arterial blood
gasses
• Clinical findings
• Tachypnea, dyspnea
• Barrel chest
• Cyanosis
• Wheezing, coughing
• Inability to wean from mechanical ventilation
• Therapeutic interventions
• Steroids for mother
• Exogenous surfactant for infant
• Volume guarantee ventilation
• Bronchodilators
• Diuretics (to prevent fluid build-up)
• Nursing care of the infant with bronchopulmonary dysplasia
• Assessment/analysis
■ Pulmonary function tests
■ Monitor oxygen saturation
■ Assess for pulmonary edema
• Planning/implementation
■ Prevention
■ Provide appropriate ventilation
○ Avoid high peak inspiratory pressures
○ Prevent air leaks
○ Use high-frequency ventilation
■ Prevent respiratory infections
■ Avoid hypoxemia
■ Provide appropriate supplemental oxygenation
■ Provide respiratory support
■ Provide adequate nutrition, usually via nasogastric tube
■ Allow child to rest during feedings
■ Provide support to family
• Evaluation/outcomes
■ Child is able to achieve a normal oxygen saturation
■ Child is able to be weaned from mechanical ventilation
■ Child is free of developmental, growth delays
Germinal matrix hemorrhage-intraventricular
hemorrhage
• Hemorrhage into ventricles caused by ruptured vessels; bleed may be
asymptomatic early
• Diagnosed via magnetic resonance imaging, ultrasonography
• Clinical findings
• Sudden deterioration of condition, mental status
• Bulging anterior fontanels
• Twitching
• Stupor
• Seizures
• Irregular breathing
• Therapeutic intervention
• Ventricular shunt or drainage
• Avoid hyperosmolar drugs
• Avoid rapid volume expansion
• Nursing care for infants with germinal matric hemorrhageintraventricular hemorrhage
• Assessment/analysis
■ Assess neurologic status
■ Assess oxygenation
■ Assess blood gasses
• Planning/implementation
■ Provide adequate oxygenation (ventilator support, supplemental
oxygen)
■ Provide seizure control
■ Prevent increased intracranial pressure
■ Elevate head of bed 20 to 30 degrees
■ Provide support for family
■ Monitor for hydrocephalus after bleed
• Evaluation/outcomes
■ Bleeding stops
■ Infant maintains adequate oxygenation
■ Infant experiences normal neurologic development
Necrotizing entercolitis
• Necrotic lesions in intestines resulting from three factors: intestinal
ischemia, presence of pathologic bacteria colonies, excess formula in
intestines
• More common in preterm and formula-fed infants; occurs several weeks
after birth
• Prevention: encouragement of breastfeeding
• Therapeutic interventions: surgical excision, which may lead to short
bowel syndrome; early minimal feedings may be protective
• Nursing care of infants with necrotizing enterocolitis
• Assessment/analysis
■ Abdominal distention, diminished or absent bowel sounds
■ Impaired sucking, vomiting, loss of weight
■ Gastrointestinal bleeding
• Planning/implementation
■ Maintain NPO and nasogastric decompression
■ Administer IV therapy and total parenteral nutrition as prescribed
■ Monitor fluid and electrolyte balance
■ Provide ileostomy or colostomy care if ostomy is created
■ Provide nonnutritive sucking (e.g., pacifier)
• Evaluation/outcomes
■ Maintains fluid and electrolyte balance
■ Gains weight
Late preterm infants
Respiratory distress
• Apnea a common problem in late preterm infants
• Infant may require an apnea monitor
• Parents should be taught cardiopulmonary resuscitation for infants
• Respiratory infections also problematic
• Parents should be taught to limit infant contact with others
• Parents should be taught what to watch for with respiratory infections
Thermoregulation
• Late preterm infants have less body fat than full-term infants
• Difficulty with regulating body temperature
• Stress from being cold can lead to hypoglycemia
• Fluctuating body temperature can be a sign of sepsis
Hypoglycemia
• Caused by inadequate glycogen reserve
• Clinical findings: jitteriness, temperature and respiratory instability
• Risk factors: SGA), LGA, IDMs, birth trauma, congenital anomalies,
endocrine disorders (e.g., hyperinsulism, hypopituitarism,
hypothyroidism)
Nutrition
• Late preterm infants may have difficulty with energy to feed, inadequate
feeding
• Kangaroo care may help promote feeding
• Breast milk (from mother using a breast pump) is the best supplement
• Infant feeding: put to breast or given formula soon after birth; simple
proteins, carbohydrates, fats, vitamins, and minerals needed for
continued cell growth
• Every 3 to 4 hours
• Fluid: 130 to 200 mL/kg or 2 to 3 oz/lb of body weight
• Calories: 110 to 130 calories/kg or 50 to 60 calories/lb of body weight
• Protein: 2.0 to 2.2 g/kg of body weight from birth to 6 months of age; 1.8
g/kg of body weight from 6 to 12 months of age
Postterm/postmature infants
Meconium aspiration syndrome
• Compromised fetus releases meconium into amniotic fluid; fluid is
aspirated during first few breaths after birth, causing pulmonary
obstruction leading to chemical pneumonitis
• Therapeutic interventions
• Amnioinfusion before birth to thin particles of meconium
• Suctioning after head appears outside vaginal orifice
• Surfactant lavages immediately after birth
• Oxygenation and ventilation
• Nursing care of infants with meconium aspiration syndrome
• Assessment/analysis
■ Signs of fetal hypoxia and meconium-stained amniotic fluid during
intrapartum
■ Respiratory distress after birth
■ Signs of sepsis
■ Altered neurologic status (e.g., seizures)
• Planning/implementation
■ Remove meconium and amniotic fluid from nasopharynx and
oropharynx immediately after birth
■ Admit to NICU
■ Maintain patent airway
■ Maintain oxygenation and high humidity; prevent chilling
■ Administer surfactant by aerosol as prescribed
■ Administer antibiotics as prescribed
■ Maintain mechanical ventilation, if used
■ Monitor for respiratory and metabolic acidosis
■ Administer feedings as ordered; attempt to prevent exhaustion
• Evaluation/outcomes
■ Maintains respiratory functioning
■ Remains free from infection
■ Feeds without difficulty
Persistent pulmonary hypertension of the newborn
• Severe pulmonary hypertension; right-to-left through foramen
ovale/ductus arteriosus
• Associated with meconium aspiration, congenital cardiac anomalies
• Clinical findings
• Hypoxia
• Cyanosis
• Tachypnea
• Grunting, retractions
• Decreased capillary refill
• Decreased peripheral pulses
• Shock
• Therapeutic interventions
• Sildenafil to increase pulmonary perfusion
• Inhaled nitric oxide
• Extracorporeal membrane oxygenation (ECMO)
• Surgery to address underlying condition
• Nursing care of newborns with persistent pulmonary hypertension
• Assessment/analysis
■ Monitor arterial blood gases
■ Assess for signs of hypoxemia (cyanosis, rapid breathing, etc.)
■ Monitor oxygen status
• Planning/implementation
■ Maintain acid–base balance
■ Prevent hypoxemia (provide supplemental oxygen, assisted
ventilation as needed)
■ Prevent hypercarbia (excess CO2)
■ Regulate IV fluids
■ Reduce noxious/painful stimuli
• Evaluation/outcomes
■ Infant achieves adequate oxygenation
■ Infant achieves a normotensive state
Large-for-gestational-age infants
• Infant weighs more than 8 lbs (4 kg) at birth or an infant who weighs
>90th percentile for his or her gestational age at birth (may be preterm or
postterm); commonly seen in IDMs
• LGA infants are at increased risk for morbidity, birth injuries; have
increased incidence of congenital anomalies
• Vaginal birth can be risky for LGA infants because of size; cesarean birth
is an alternative if fetal heart rhythm is abnormal or labor progresses
poorly
• Any infant with a gestation >42 weeks should be assessed for
hypoglycemia, birth injuries, congenital anomalies
Answer key: Review questions
1. 3 Because neonates are unable to shiver, they use the breakdown of brown
fat to supply body heat; the preterm infant has a limited supply of brown
fat available for this breakdown.
1 Inability to use shivering is not specific to preterm neonates; all
newborns are unable to use shivering to supply body heat. 2 The
breakdown of glycogen into glucose does not supply body heat. 4
Pituitary hormones do not regulate body heat.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
2. 1 The preterm infant has a reduced glomerular filtration rate and reduced
ability to concentrate urine or conserve water.
2 All systems of the preterm neonate are less developed than in the fullterm neonate. 3 Urine is not concentrated with a higher specific gravity.
The opposite occurs; urine is very dilute. 4 The fluid and electrolyte
balance of preterm infants is easily upset.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis
3. 3 Immaturity of the respiratory tract in preterm infants is evidenced by a
lack of functional alveoli, smaller lumina with increased possibility of
collapse of the respiratory passages, weakness of respiratory musculature,
and insufficient calcification of the bony thorax, leading to respiratory
distress.
1 Hemorrhage is not a common occurrence at the time of birth unless
trauma has occurred. 2 Brain damage is not a primary concern unless
severe hypoxia occurred during labor; it is difficult to diagnose at this
time. 4 Aspiration of mucus may be a problem, but generally the air
passageway is suctioned as needed.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
4. 4 The moisture provided by the humidity liquefies the tenacious
secretions, making gas exchange possible.
1 Caloric intake is increased; the amount, number, and type of feedings
are related to the metabolic rate. 2 Infants should be positioned sidelying rather than prone; the prone position is associated with apnea and
sudden infant death syndrome (SIDS). 3 Maintaining a high-humidity
environment is not a routine action; the concentration of oxygen
depends on the oxygen concentration of the neonate’s blood gases.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Planning/Implementation
5. Answers: 4, 1, 2, 3, 5
4 The bag should be removed, and the mouth checked for secretions and
suctioned, if necessary, to clear the airway. 1 Repositioning the
newborn’s head may open the airway. 2 Opening the mouth slightly
reduces resistance to the positive pressure of the pumped air. 3
Reapplying the mask may create a better seal when the bag is
compressed again. 5 After nursing interventions are implemented, the
neonate should be reassessed for a response.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Planning/Implementation
6. 2 Edema crossing over the suture lines is the sign that differentiates
between these two conditions; cephalohematoma does not extend beyond
the suture line.
1 Pain is not associated with either condition. 3 Edema increasing is
unusual; it should decrease in size. 4 Bruising can occur with either
condition.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
7. 4 A rapid birth does not give the fetal head adequate time for molding;
therefore, pressure against the head is increased and blood vessels may
burst.
1 Brachial palsy results from excessive pulling on the head and shoulders
during a difficult birth. 2 Dislocated hip is more likely to occur in a
footling breech birth. 3 Fractured clavicle result from excessive pulling
on the head and shoulders during a difficult birth.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
8. 4 Intracranial bleeding may occur in the subdural, subarachnoid, or
intraventricular spaces of the brain, causing pressure on vital centers;
clinical signs are related to the area and degree of cerebral involvement.
1 Tetany is caused by hypocalcemia; it is manifested by exaggerated
muscular twitching. 2 Spina bifida is a defect of the spinal column that
is observed at birth. 3 An elevated potassium level causes cardiac
irregularities, not the irritable behavior observable with CNS
involvement.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
9. 4 With Erb-Duchenne paralysis, there is damage to spinal nerves C5 and
C6, which causes paralysis of the arm.
1 The grasp reflex is intact because the fingers usually are not affected; if
C8 is injured, paralysis of the hand results (Klumpke paralysis). 2 There
would be a negative Moro reflex only on the affected side. 3 There is no
interference with turning of the head; usually injury results from
excessive lateral flexion of the head as the shoulder is born.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
10. 3 Gentle massage and manipulation of the arm muscles help prevent
contractures. The parents can perform them at home.
1 Keeping it immobilized is dangerous because it may lead to permanent
contractures. 2 The length of the arm will not change on a daily basis. 4
Passive range-of-motion exercises should be delayed for 10 days to
prevent additional injury to the brachial plexus.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
11. 4 The brachial plexus is injured by excessive pressure during a difficult
birth or during a vaginal breech birth.
1 Erb palsy is an injury that occurs during the birth process; it is not
acquired before or after birth. 2 Erb palsy is a birth injury, not a genetic
problem. 3 Erb palsy is a birth injury to nervous tissue, not a tumor
arising from muscle tissue.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Nursing Process: Assessment/Analysis
12. 4 Injury to the brachial plexus, clavicle, or humerus during birth prevents
abduction and adduction movements of an upper extremity.
1 Children with Down syndrome exhibit the expected Moro reflex. 2
Cranial nerve damage is not considered a cause; however, if the cochlea
were undeveloped or the eighth cranial (vestibulocochlear) nerve were
injured, it would affect equilibrium and response to the test. 3 Cerebral
or cerebellar birth injuries usually cause a symmetric loss of the Moro
reflex.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
13. 3 Opioid withdrawal affects the CNS and respiratory systems.
1 Lethargy and constipation may occur in a newborn with thyroid
deficiency. 2 Grunting and low-pitched cry may indicate that the
newborn is experiencing cold stress or respiratory distress. 4 Watery
eyes and rapid respirations may occur in a newborn affected with
syphilis.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
14. 2 As the opioid is cleared from the newborn’s body, signs of withdrawal
become evident. Tremors, irritability, difficulty sleeping, twitching, and
convulsions result.
1 Dehydration is secondary to inadequate feeding; it is not a direct result
of opioid withdrawal. 3 Muscle hypertonicity, not hypotonicity, occurs.
4 Opioid withdrawal results in signs of excessive stimulation.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
15. 1 This conjunctivitis occurs about 3 to 4 days after birth; if it is not
treated prophylactically with an antibiotic at birth or within 3 days,
chronic follicular conjunctivitis with conjunctival scarring will occur.
2 Human immunodeficiency virus (HIV) in the newborn does not
manifest itself with conjunctivitis. 3 High oxygen concentrations given
to severely compromised preterm infants cause vasoconstriction of
retinal capillaries, which can lead to blindness; there are no data to
indicate that this infant was preterm, severely compromised, or
received oxygen. 4 Chemical conjunctivitis occurs within the first 48
hours and is not purulent.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
16. 1 Chlamydia trachomatis is associated with the development of
pneumonia in the newborn.
2 Purulent conjunctivitis at this time suggests a chlamydia infection, not
an allergic response. 3 Boric acid solution will not treat this problem; a
prescribed antibiotic is required. 4 Teaching the mother to wash her
hands before touching her infant would be done eventually; however,
the priority is to monitor for signs of pneumonia.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
17. 2 Because physical signs of congenital syphilis are difficult to detect at
birth, the infant should be screened immediately to determine whether
treatment is necessary.
1 Cleft palate is a congenital defect that occurs in the first trimester;
Treponema pallidum does not affect a fetus before the 16th week of
gestation. 3 Muscle hypotonicity is found in children with Down
syndrome, not congenital syphilis. 4 Maculopapular lesions of the soles
do not manifest in the infant with congenital syphilis until about 3
months of age.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Planning/Implementation
18. 1 RhoGAM must be given within 72 hours postpartum if the patient has
not been sensitized previously, irrespective of the length of the gestation.
2 Administration of RhoGAM would be useless at the first clinic visit
because antibodies have been produced already. 3 RhoGAM is always
indicated at the termination of a pregnancy, even with a short-term
pregnancy. 4 RhoGAM is always indicated at the termination of a
pregnancy, even with fetal demise.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Planning/Implementation
19. 4 There is an apparent ABO incompatibility because the mother is O and
the infant is B; incompatibility can cause jaundice within the first 24
hours.
1 The information provided does not indicate neonatal sepsis. 2 Rh
incompatibility is not a factor because the mother is Rh positive. 3
Jaundice in the first 24 hours is not physiologic; it is pathologic.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
20. 2 The neonate’s age is critical because the development of jaundice
before 24 to 48 hours after birth may indicate a blood dyscrasia
(pathologic jaundice, hyperbilirubinemia), requiring immediate
investigation. Jaundice occurring between 48 and 72 hours after birth
(physiologic jaundice) is a consequence of the expected breakdown of
fetal red cells and immaturity of the liver.
1 Unless the jaundice was pathologic (occurring in the first 24 hours of
life), this is not necessary. 3 First, the age of the neonate must be
ascertained to determine whether this is physiologic or pathologic
jaundice; then the nurse should obtain a sample of heel blood to
determine the serum bilirubin level. 4 Bilirubin studies should be done
first to determine whether the serum level warrants phototherapy. This
therapy requires a health care provider’s order.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
21. 4 RhoGAM will prevent sensitization from Rh incompatibility that may
arise between an Rh-negative mother and an Rh-positive newborn.
1 Determining the father’s blood type is unnecessary because only the
mother’s and infant’s Rh factors are relevant. 2 Maternal blood
transfusion is unnecessary; if a transfusion were needed, it would be for
the newborn, not the mother. 3 There is no incompatibility;
incompatibility might occur if the mother were O positive and the
newborn had type A, B, or AB blood.
Client Need: Pharmacologic and Parenteral Therapies; Cognitive Level:
Application; Nursing Process: Planning/Implementation
22. 3 Development of jaundice within the first 24 hours indicates hemolytic
disease of the newborn.
1 Neurologic signs may or may not be present during the first 24 hours;
they are dependent on the bilirubin level. 2 Muscular irritability may or
may not be present during the first 24 hours; usually it develops later. 4
Serum bilirubin levels are expected to accumulate in the neonatal
period because of the short life span of fetal erythrocytes, reaching
levels of 7 mg/100 mL the second to third day when jaundice appears
(physiologic jaundice).
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis
23. 2 Choanal atresia is a lack of an opening between one or both of the nasal
passages and the nasopharynx.
1 Rectal atresia involves the rectum ending in a pouch and the anal canal
opening into the other (nonconnected) end of the rectum. 3 Atresias
associated with the gastrointestinal tract include esophageal and
intestinal atresia involving the ileum, jejunum, or colon. 4 An atresia
involving the pharynx and larynx is not commonly seen.
Client Need: Physiologic Adaptation; Cognitive Level: Knowledge;
Nursing Process: Assessment/Analysis
24. 1 There is little or no opening between the nasal passages and the
nasopharynx; therefore, the infant can breathe only through the mouth.
When feeding, the infant cannot breathe without aspirating some of the
fluid; this causes choking.
2 The swallowing reflex is present in these infants. 3 Because it is difficult,
if not impossible, to suck, the infant will be hungry. 4 If choanal atresia
is unilateral, there may be no symptoms, and the infant will be able to
feed; if bilateral, sucking will be almost impossible.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes
25. Answers: 4, 1, 5, 2, 3
4 A patent airway and adequate pulmonary ventilation are always the
priorities; inadequate oxygenation can result in cerebral anoxia. 1 Vital
signs, including heart rate, are called vital because they reflect the
cardiopulmonary and hemodynamic status of a person. 5
Replenishment of body fluids is a significant intervention after surgery;
the patency of the catheter must be maintained and the flow rate
monitored to ensure that an excessive amount is not instilled and affect
the delicate fluid balance in an infant. 2 The operative site should be
monitored for signs of hemorrhage but after the vital signs. An increase
in the heart and respiratory rates and a decrease in blood pressure may
indicate bleeding. 3 The urinary output should be monitored hourly.
This comes after airway, breathing, circulation, signs of bleeding, and
interventions that can influence these vital signs are monitored.
Client Need: Management of Care; Cognitive Level: Analysis; Nursing
Process: Evaluation/Outcomes
26. 3 The bladder membrane is exposed; it must remain moist and, as much
as possible, sterile.
1 Loose diapers will allow the exposed membrane to dry and increase the
risk for infection. 2 Dry gauze dressings will allow the exposed
membrane to dry and increase the risk for infection. 4 The jelly will
adhere to the membrane, causing trauma.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Nursing Process: Planning/Implementation
27. 4 The pubic bone and the bladder form during the same time of
embryonic development.
1 Imperforate anus is not a defect associated with exstrophy of the
bladder. 2 Absence of a kidney is not a defect associated with exstrophy
of the bladder. 3 Congenital heart disease is not a defect associated
with exstrophy of the bladder.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Nursing Process: Assessment/Analysis
28. 1 The greatest problem facing this infant is infection of the bladder
mucosa and excoriation of the surrounding tissue; meticulous hygiene is
necessary, both preoperatively and postoperatively.
2 Dehydration is not a problem because fluid intake and the amount of
urinary output are not affected. 3 Urinary retention is not a problem
because the urine drains continuously. 4 The congenital abnormality
involves the genitourinary system, not the intestines.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
29. 1 Asking an open-ended question about routine provides for collection of
more data.
2 Asking the mother if everything is all right implies that things are not
well and that the mother may be to blame. 3 Asking when the baby was
last fed may make the mother feel guilty about not meeting her baby’s
needs. 4 Commenting to the mother that she is having a bad day is a
negative comment that closes communication.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Caring; Nursing
Process: Planning/Implementation
30. 4 Asymmetry of the gluteal dorsal surface of the thighs and inguinal
folds indicates developmental dysplasia of the hip; folds on the affected
side appear higher than those on the unaffected side.
1 An inguinal hernia is evidenced by protrusion of the intestine into the
inguinal sac. 2 Impaired reflex behavior and a shrill cry indicate central
nervous system damage. 3 Peripheral nervous system damage is
manifested by limpness or flaccidity of extremities.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
31. 4 A foul smell emanating from the cast indicates development of an
infection and requires immediate treatment.
1 Soiling of the cast with excreta, although problematic, is not a serious
complication. 2 Decreasing the number of feedings each day is not
necessary, nor is it desirable. 3 The infant’s position should be changed
frequently.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
32. 1 Standard seat belts and car seats are not readily adapted for use by
children in spica casts; specially designed devices are available to meet
safety requirements.
2 Other strategies in addition to diapers will be necessary to keep the cast
clean. 3 Changing the infant’s position every 8 hours is inadequate; the
position should be changed at least every 2 hours. 4 Using the
abduction bar for lifting or turning can weaken the cast; the bar is
designed to keep the hips in alignment.
Client Need: Safety and Infection Control; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
33. 4 When elevation of the head is desired, the entire mattress or crib
should be raised at the head of the crib.
1 There is no reason to place such a time limit of 1 hour on this position. 2
Pillows under the head or shoulders of a child in a spica cast will thrust
the chest forward against the cast, causing discomfort and respiratory
distress. 3 Padding the edge of the cast will not help elevate the infant’s
head.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Nursing Process: Planning/Implementation
34. 1 Chalasia allows a reflux of gastric contents into the esophagus and
eventual regurgitation. Placing the infant in an upright position keeps the
gastric contents in the stomach by gravity and limits the pressure against
the cardiac sphincter.
2 Preventing the infant from crying probably will have little effect on
chalasia. 3 Keeping the infant in the prone position after feedings will
promote regurgitation; it is an unsafe position because of the danger of
SIDS. 4 Ensuring that the infant drinks a full bottle at every feeding will
promote vomiting; the infant should be allowed to stop feeding when
satiated, not when the bottle is empty.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
35. Answers: 3, 5
3 Paroxysmal pain is related to the peristaltic action associated with
intestinal obstruction. 5 Abdominal distention pushes the diaphragm
upward, causing respiratory distress characterized by grunting
respirations. 1 Weak pulse is unrelated to intestinal obstruction. 2
Hypotonicity is unrelated to intestinal obstruction. 4 A high-pitched cry
is unrelated to intestinal obstruction; it is related to neurologic
problems.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
36. 4 The average respiratory rate for infants is 35 breaths/min. Tachypnea
requires further investigation.
1 A temperature of 99.5° F is within the expected range for infants. 2 A
blood pressure of 75/48 mm Hg is within the expected range for infants.
3 A heart rate of 100 beats/min is within the expected range for infants.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing Process:
Planning/Implementation
37. 3 Heart failure is characterized by a decrease in the blood flow to the
kidneys, causing sodium and water reabsorption, resulting in peripheral
edema. The peripheral edema indicates severe cardiac decompensation.
1 Tachypnea is an early attempt by the body to compensate for decreased
cardiac output. 2 Tachycardia is an early attempt by the body to
compensate for decreased cardiac output. 4 Periorbital edema occurs
most noticeably in children with acute poststreptococcal
glomerulonephritis (APSGN), not heart failure.
Client Need: Physiologic Adaptation; Cognitive Level: Analysis; Nursing
Process: Assessment/Analysis
38. 3 Children with cardiac malformations often require more energy to
achieve the activities of daily living; decreased oxygen utilization and
increased energy output in the developing child result in a slow growth
rate.
1 Cognitive impairment is not a common finding in children with
congenital heart disease. 2 Cardiac anomalies are more often a result of
prenatal, rather than genetic, factors. 4 Clubbing is not characteristic of
most children with cardiac anomalies, only of those with more severe
hypoxia.
Client Need: Physiologic Adaptation; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
39. 3 Polycythemia, reflected in an elevated hematocrit, is a direct attempt of
the body to compensate for the decrease in oxygen to all body cells caused
by the mixture of oxygenated and deoxygenated circulating blood.
1 Proteinuria is not characteristic of heart malformations that cause a
right-to-left shunting of blood. 2 Edema is not a common finding with
heart malformations associated with a right-to-left shunting of blood. 4
Absence of pedal pulses is characteristic of coarctation of the aorta, an
obstructive malformation.
Client Need: Reduction of Risk Potential; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
40. 2 The intrapleural space must be drained of fluid and air to facilitate the
reestablishment of negative pressure in the intrapleural space.
1 The tidal volume increases as the lung reexpands, but it is not the
reason for the insertion of chest tubes. 3 Intrapleural pressure should
be negative, not positive; positive intrapleural pressure causes collapse
of the lung. 4 Closed chest drainage is related to intrapleural pressure,
not pericardial and chest wall pressure.
Client Need: Physiologic Adaptation; Cognitive Level: Comprehension;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation
C H AP T E R 2 0
Perinatal loss, bereavement, and grief
Loss, grief, and bereavement: Basic concepts and
theories
• Loss
• May be actual or perceived and covers a range of changes, the ultimate
being death
• Normal (uncomplicated) grief
• A nearly universal pattern of physical, psychologic, and emotional
responses to bereavement, separation, or loss
• The intensity and duration of grief vary and depend on many factors,
including the culture in which the grieving person was raised and the
meaning of the loss to the grieving person
• Grief cannot be prevented
• Bereavement
• A form of grief with anxiety symptoms that is a common reaction to the
loss of a loved one; the condition of being without a loved one
• Perinatal bereavement
• Grief after the death of an expected child, regardless of the cause:
miscarriage, stillbirth, neonatal death, or termination of pregnancy for
fetal anomalies
• Primary loss of child plus many secondary losses
• Stages of grief
• Important to understand the stages of grief (Box 20.1)
■ Kübler-Ross’ explanation of these stages in 1969 was groundbreaking
■ Clinicians and researchers now understand that grief is not linear, so
stages of grief are not in a particular order
• Parents and siblings will all move through stages of grief
■ Family members may each be at different stages at the same time
■ Individuals may move through the stages in a different order; may
experience a stage multiple times
■ The grief process for parents and close relatives may last for several
years, or parents may never achieve acceptance
• Disenfranchised grief
• Occurs when relationship with the deceased is not openly
acknowledged and honored publically
• Support is limited
• Complicated grief
• In complicated grief, a person has a prolonged or significantly difficult
time moving forward after a loss; it can develop from disenfranchised
grief
■ Loss from death of a child can develop into complicated grief
• Lack of social support, preexisting relationship difficulties, absence of
surviving children, and ambivalent attitudes increase the likelihood
that grief will be complicated
• Reactions can include intrusive thoughts, yearnings, sleep disturbance,
and loss of interest in personal activities
• Referral to a specialist in grief counseling is recommended
• Anticipatory grief
• A person experiences anticipatory grief before the actual loss or death
occurs
• Family is likely to go through anticipatory grief if the death is not
sudden
• Can be considered a chance for people to prepare or complete tasks
related to the impending death
• Grief theories
• Dual-process model (Stroebe & Schut, 1999) identifies two types of
stressors and a dynamic oscillation
■ Loss-oriented activities, with focus on grieving
■ Restoration-oriented activities, with focus on avoiding grieving
■ Oscillation between confronting and avoiding the task of grieving
• Continuing bonds theory
■ Instead of detachment from the deceased, emphasis is on the
incorporation of the deceased into the bereaved person’s life
■ Parents and siblings may experience continuing bonds differently
• Caring theory
• Swanson’s caring theory (Swanson et al., 2009) can be applied to caring
for bereaved families
• The five elements of the nurse–client relationship include knowing,
being with, doing for, enabling, and maintaining belief (in the family’s
ability to grow from the loss)
BOX 20.1
S t a ge s of D ying A ccording t o K üble r- R oss
Denial: “This can’t be true.” “I’ll be just fine after surgery (or radiation or
chemotherapy).” Client and family may search for health care providers
who will give more favorable opinions, or may seek alternative therapies.
Anger: “Why me?” Client and family have feelings of resentment, envy, or
anger directed at client, family, health care providers, God, and others.
Bargaining: “I just want to see my daughter’s graduation, then I’ll be
ready...” Client (or family) asks for more time to reach an important life
event and may make promises to God.
Depression: “I just don’t know how my wife will get along after I’m gone.”
Family and client may grieve and mourn for impending losses.
Acceptance: “I have no regrets—I’ve done everything I’ve wanted to in my
life and am proud of what I’ve accomplished.” Client and family are
neither angry nor depressed.
From Black, J.M. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.).
St. Louis: Mosby.
Types of loss associated with pregnancy
• Definitions
• Miscarriage: in utero death before 20 weeks of gestation (also called
spontaneous abortion) as a result of abnormalities of the conceptus or
maternal environment
• Fetal death: death before birth, but after 20 weeks of gestation
• Stillbirth: fetal death that occurs at 20 weeks or later of gestation
• Neonatal death
■ Early: death in less than 7 days after birth
■ Late: death from 7 to 28 days after birth
■ Infant death: death of a live birth within the first year
• Serious fetal diagnosis
• Grief occurs with any loss, including the perceived loss of the health of a
child
• Increased use of sonography in prenatal care has increased the number
of fetal defects diagnosed before birth (not the number of defects, just
the number of those diagnosed prenatally)
• Creates loss of joy in the pregnancy, loss of the imagined perfect child,
loss of many of the parents’ dreams for the child
• Nurse’s ability to listen as parents process the diagnosis is key
• Pregnancy termination
• Also referred to as termination of pregnancy for fetal anomalies (TOPFA)
• Risk of complicated grief is especially high after termination of a
pregnancy due to fetal abnormality
• Selective reduction is a procedure recommended when a woman has a
multifetal pregnancy to reduce the number of developing embryos
because of high morbidity and mortality of pregnancies with more than
two fetuses
• Elective abortion due to social and financial obstacles is more common
in women with incomes below 200% of the poverty level; sadness is not
uncommon, even though they may also feel relief
• Nurses need to recognize that women experience loss and grief even
when abortion is elective
Miles’ model of parental grief responses
• Three overlapping phases of parental grief (Box 20.2)
• Acute distress includes shock
■ Accepting the reality of the loss
■ Spouses/partners are often grieved at their partner’s grief
■ Some are stoic
• Intense grief: emotional, cognitive, behavioral, and physical responses
• Reorganization is the (attempt to) return to usual level of functioning;
recovery from the loss
■ Consistent with continuing bonds theory in incorporation of the
person who has died into the bereaveds’ lives
BOX 20.2
C once pt ua l M ode l of P a re nt a l G rie f
Phases of acute distress
• Shock
• Numbness
• Depression
Phases of intense grief
• Loneliness, emptiness, yearning
• Guilt
• Anger (including anger at self and/or spouse), resentment, bitterness,
irritability
• Fear and anxiety (especially about getting pregnant again)
• Disorganization
• Difficulties with cognitive processing
• Sadness and depression
• Physical symptoms
Reorganization
• Search for meaning
• Reduction of distress
• Reentering normal life activities with more enthusiasm
• Can make plans, including decision about another pregnancy
Adapted from Miles, M. (1980). The grief of parents...when a child dies. Oak Brook, IL: Compassionate
Friends; Miles, M. (1984). Helping adults mourn the death of a child. In Wass, H., & Orr, C. (eds.).
Childhood and death. New York: Hemisphere; and Christ G.H., Bonanno, G., Malkinson, R., & Simon,
R. (2003). Appendix E: Bereavement experiences after the death of a child. In Institute of Medicine;
Committee on Palliative and End-of-Life Care for Children and Their Families, Board on Health Sciences
Policy; Field, M.J., & Behrman, R.E. (eds.). When children die: Improving palliative and end-of-life care
for children and their families. Washington (DC): National Academies Press.
Family aspects of grief
• Parent’s reactions to a child’s dying
• When child is diagnosed, parents begin to cope with possibility of death
• When care changes to palliative focus, parents must begin to cope with
reality of death
• May have to process grief twice: once for illness and once for impending
death
• Grief is intense, long lasting, and complex
• Grief can encompass losses related to expected life experiences with
deceased child
• May never achieve acceptance
• Loss of a child can lead to marital difficulties
■ Spouses may experience grief differently
■ May feel guilt or shame for being unable to help the dying child
■ May not be able to provide emotional support to spouse or surviving
children
• Sibling’s reactions to a child’s dying
• Grief experience is as significant as that of parents
• Responses and grieving vary by developmental stage
■ Process grief differently than adults
■ May not be able to fully work through the grieving process
■ This can cause unresolved grief
■ Support centers, counselors can help siblings
• Children should be given the choice to say goodbye to siblings
• May experience significant guilt, feelings of having caused the illness
• May be jealous or resentful of attention a sick sibling receives
• May have difficulty in school
• May be afraid for the health of other family members
• Care for grieving families
• Expected death
■ Child and family can plan
■ Grieving can begin earlier
■ Families can seek resolution and may be able to say goodbyes
• Unexpected death
■ No planning is possible
■ Loss of child must be integrated without preparation
■ No opportunity for anticipatory grieving
• Nurses’ role
■ Provide privacy for child and family as much as possible
■ Facilitate time for family to share together
■ Facilitate grieving process
■ The nurse’s function during all phases of parental grief is primarily
supportive, and the degree of intervention depends on the family’s
strengths and weaknesses in coping with the crisis
■ Educate family regarding what to expect regarding impending death
■ Support family through the time they need to be with the body after
death
■ If the child’s body is damaged from trauma or other reasons
○ Prepare family for condition of body
○ Make body as presentable as possible
■ Help families to understand the normalcy of grieving
■ Provide follow-up care after death of child
■ Recognize complicated grief, and assist individual in seeking support
and counseling to resolve it
When a loss is diagnosed: Helping the woman and
her family in the aftermath
• Holding the Infant
• Can help parents face the reality of the loss and facilitate grief
• Parents may feel differently about doing so, or they may want to be the
only ones to see and hold the infant
• Option to see and hold the fetus or infant is the parents’ decision
■ Parents should not be told they “should” see the infant
■ Some studies show less depression in mothers who did not see their
stillborn child
• Nurse’s sensitivity to the situation is key
■ Prepare the parents about what to expect, especially about the
fragility of the skin
■ Prepare the infant by bathing, dressing, including identification
bracelet, and wrapping infant in a blanket
■ Hold the infant as one would if the infant were alive
■ Give parents time alone with the infant, and let them know when the
nurse will return
■ Time spent will vary
• Decision making
• Autopsy
■ Autopsy is always required if death was unexplained, violent, or a
possible suicide
■ Autopsy may be an optional choice if family desires it
■ Results may take weeks, depending on situation
■ Open casket is still an option after autopsy
• Organ or tissue donation
■ Some states have legal requirements to request organ/tissue
donations after death
■ Written consent is required to proceed
■ Healthy children who die unexpectedly or from trauma are
excellent candidates
■ Children who have suffered from a chronic disease may not be
suitable (but this should be determined on a case-by-case basis)
■ If a full-time transplant coordinate is available, he or she will
approach the family; otherwise, staff must decide who should
approach
■ If possible, discussion should be begun before death
■ Be direct and open
■ Have discussion in a quiet location
■ Always keep discussion separate from communication regarding
death
■ Nurse should be prepared to answer common questions
○ Donation does not cause pain or suffering
○ Donation does not mutilate body
○ Funeral does not need to be delayed
○ Open caskets are possible
○ There is no cost associated with donating
○ Many religious faiths allow donation
• Disposition of the body
■ Burial or cremation; decisions include placement of a plot or ashes
■ Memorial or funeral service
■ Families should not be rushed in decision making, although
sometimes family prefers to consider choices in their home instead of
at the hospital
• Expression of feelings
• The skill of caring, showing understanding and patience, is keenly
important
• Nurse can validate the experience and feelings of the parents, listen to
the stories and to parents talk about the loss and its meaning
• Nurses can reflect the parents’ feelings: “I’m sad for you.”; “You sound
angry.”
• Allot enough time to engage with parents without being rushed
• Parent education
• Nurse’s role is to help family understand different responses to loss
• Help families connect to resources, such as Compassionate Friends
• Help partners understand they may not respond in the same way to the
loss: incongruent grieving
• Reinforce positive coping efforts: blogging, support groups, support
from family members
• Creating mementos
• Nurse can offer to provide information for a card or memory: baby’s
measurements, footprints and handprints, identification band
• Parents may want to take photographs
Nurses’ reactions to caring for grieving families
• Although caregiver grief is usually less intense and shorter in duration
than parental and family grief, repeated experiences with child death can
lead to a major grief response; awareness of this possibility can help the
nurse prepare support systems
• Nurses pass through the stages of grieving when caring for grieving
families
• As with families, may not experience all stages
• May experience grief more intensely with patients the nurse has known
longer
• Providing care can be stressful and emotionally exhausting
• Requires skill and personal strength
• Professional boundaries can help a nurse provide care
• It is important for the nurse to have a support system
Application and review
1. The parents of an infant who is dying ask the nurse whether they should
tell their 7-year-old son that his sister is dying. What is the most
appropriate response by the nurse?
1. “Your child cannot comprehend the real meaning of death, so don’t
tell him until the last moment.”
2. “Your son probably fears separation most and wants to know that
you will care for him, rather than what will happen to his sister.”
3. “You should talk this over with your health care provider, who
probably knows best what is happening in terms of your daughter’s
prognosis.”
4. “Your son probably doesn’t understand death as we do but fears it
just the same. He should be told the truth to let him prepare for his
sister’s possible death.”
2. Parents of a stillborn child are trying to cope with the loss and explain to
the siblings, ages 7 and 9, what has happened. The parents take turns
holding the infant in another room. The nurse remains present and
provides emotional support to the parents. What is an important shortterm goal for this family?
1. Identify the problems that they will be facing related to the loss of
the infant.
2. Include the infant’s siblings in the events and grieving after the
infant’s death.
3. Seek out other families who have lost infants to sudden infant death
syndrome (SIDS) and receive support from them.
4. Accept that there was nothing that they could have done to prevent
the infant’s death.
3. A nurse determines that a client who, although ambivalent, is considering
an abortion because of a serious fetal diagnosis and is in crisis. How
should the nurse intervene to alleviate the crisis?
1. Help the client express her feelings.
2. Identify how family members interact.
3. Suggest that the client seek spiritual counseling.
4. Involve the father in the decision-making process.
4. Nurses who care for the terminally ill apply the theories of Kübler-Ross in
planning care. According to Kübler-Ross, individuals who experience a
terminal illness go through a grieving process. Place the stages of this
process in the order identified by Kübler-Ross.
1. _____ Anger
2. _____ Denial
3. _____ Bargaining
4. _____ Depression
5. _____ Acceptance
5. A new mother refuses to look at her newborn who has a severe birth
defect. What is the nurse’s most therapeutic approach?
1. Request that the family try to distract her.
2. Clarify why she should stop blaming herself for the baby’s
handicap.
3. Reinforce the explanation of the handicap and allow time for her to
discuss her fears.
4. Wait until she has sufficiently recovered from the stress of birth and
then bring the baby to her again.
6. A health care provider tells a mother that her newborn has multiple visible
birth defects. The mother seems composed and asks to see her baby. What
nursing action is most helpful to ease the mother’s stress when seeing her
infant for the first time?
1. Bring the infant to her as requested.
2. Describe how the infant looks before bringing the infant to her.
3. Help her verbalize her feelings, bring the infant to her, and stay with
her during this time.
4. Show her pictures of the birth defects, discuss treatment options,
and then bring the infant to her.
7. The result of an amniocentesis performed at 16 weeks’ gestation reveals a
fetus with Down syndrome. The client elects to have the pregnancy
terminated. What should the nurse conclude about an abortion at this
stage of the pregnancy?
1. The client is exhibiting emotional instability.
2. There is a high risk for a postoperative infection.
3. Contraceptive counseling should be deferred to a later time.
4. An opportunity to express feelings about her decision should be
provided.
See Answers on page 330.
Answer key: Review questions
1. 4 Children at early school age are not yet able to comprehend death’s
universality and inevitability; they fear it, often personifying death as a
“bogeyman” or “death angel.” They need an opportunity to prepare for
this.
1 A 7-year-old child needs to know the seriousness of the illness and that
recovery may not be possible. 2 Children at early school age interpret
death as separation and punishment; they fear this, in addition to death
itself. 3 “You should talk this over with your health care provider, who
probably knows best what is happening in terms of your daughter’s
prognosis” only avoids the question.
Clinical Area: Childbearing and Women’s Health Nursing; Client Need:
Psychosocial Integrity; Cognitive Level: Application; Integrated
Process: Caring; Nursing Process: Planning/Implementation
2. 2 The other children need to be involved with the grieving process and
work through their own feelings.
1 Identification of problems is a long-term goal. 3 It is too early to seek
out support groups. 4 Acceptance is premature; also, they may never
achieve this goal.
Clinical Area: Childbearing and Women’s Health Nursing; Client Need:
Psychosocial Integrity; Cognitive Level: Application; Integrated
Process: Caring; Communication/Documentation; Nursing Process:
Planning/Implementation
3. 1 The ability to express one’s feelings is often a first step in the
recognition and resolution of a crisis.
2 Identifying how family members interact is not a priority need; it may
come later in the nurse–client relationship. 3, 4 First, the client must
explore her own feelings; it is she who should decide whether she wants
to seek spiritual counseling and whether the father should be involved
in the decision-making process.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Caring
4. Answers: 2, 1, 3, 4, 5
2 The initial response is shock, disbelief, and denial, and the client seeks
additional opinions to negate the diagnosis. 1 When negating the
diagnosis is unsuccessful, the client becomes angry and negative. 3
Bargaining for wellness follows in an attempt to prolong life. 4 As the
reality of the situation becomes more apparent, depression sets in and
the client may become withdrawn. 5 Acceptance is the final stage of
grieving; this stage may never be achieved.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Caring
5. 3 Reinforcing the explanation of the handicap and allowing time for her to
discuss her fears allow for ventilation of feelings and clarify explanations
that probably were not heard or understood because of anxiety.
1 Distraction prevents the client from facing the problem, thereby
increasing her feelings of loss of control. 2 Clarifying why she should
stop blaming herself for the baby’s handicap closes off communication
by not allowing free expression of grief and assumes that the client
blames herself. 4 Waiting to bring her the baby supports avoidance of
the reality of the situation; it does not solve the problem.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Caring
6. 3 Allowing the client time to talk about her feelings and staying with her
when she sees the infant for the first time provide support, acceptance,
and understanding.
1 Bringing the infant immediately does not allow the mother adequate
time to prepare to see her infant. 2 Anomalies are difficult to describe
accurately in words, especially when the mother has not been given
time to express her feelings. 4 Showing pictures may not be helpful,
and discussing treatment is premature.
Clinical Area: Childbearing and Women’s Health Nursing; Client Needs:
Psychosocial Integrity; Cognitive Level: Application; Nursing Process:
Planning/Implementation; Integrated Process: Caring
7. 4 The client must feel comfortable enough to verbalize her feelings; this
helps to complete the grieving process.
1 It is a false assumption that the client is exhibiting emotional instability.
2 Induced abortion is a sterile procedure and should not predispose the
client to postoperative infection. 3 Studies show that contraceptive
counseling at this time is most important because the client may not
return after the abortion.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis
Bibliography
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Index
A
AAP., See American Academy of Pediatrics (AAP)
Abandonment, avoiding charge of, 224, 229
Abdomen, physical examination of, in pregnant trauma victim, 105–106b
ABO incompatibility, 294–295, 296, 318
Abortion, 26
grieving process and, 329, 330
Abruptio placentae, 72
Abruption, placental, 72
Abused drugs, 129–132
prescription of, 133
Accelerations, in fetal heart rate, 168, 173, 174–175
Acceptance, 324b
Accreta, placenta, 242
Acroesthesia, 15
Active alert, 256, 256b
Active immunity, of newborn, 254
Acupressure, nonpharmacologic pain management and, 154–155
Acupuncture, nonpharmacologic pain management and, 154–155
Acute distress, phase of, 325b
Acute respiratory distress syndrome (ARDS), 86–87
Adaptations, to parenthood and parent-infant interactions, 226. See
also Parenthood, transition to
Adolescent,
pregnancy and, 32
pregnant, 106–107
AFP enzyme blood test., See Alpha-fetoprotein (AFP) enzyme blood test
Age, and transitions to parenthood, 236–237
Agonist-antagonist analgesics, opioid (narcotic), pharmacologic pain
management and, 158
Agoraphobia, 120–121
Airway, primary survey and, 103–104
Alcohol,
consumption, pregnancy and, 22
levels, blood, effects of, 131t
pregnancy and, 37, 43
substance abuse of, 129–132
Aldosterone, changes in pregnancy, 17
Alpha-fetoprotein (AFP) enzyme blood test,
for high-risk pregnancy, 58
for pregnancy, 27
Ambulation,
in labor, first stage of, 179
for prevention of venous thromboembolism, 222
American Academy of Pediatrics (AAP), on infant nutrition, 271, 277
American Dental Association, on fluoride supplementation for breastfed
infants, 277
Amniocentesis, for pregnancy, 27
high-risk, 57–58
Amnioinfusion, in fetal assessment, 171
Amnion, 5, 5f
Amniotic fluid, 5, 5f
decreased, 192
embolus, 205
in high-risk pregnancy, 57
in labor, first stage of, 178, 180, 185
Amniotic fluid index, 55
Amniotic membrane stripping, 200
Analgesia,
epidural, 158–159
nerve block, 158–159
nitrous oxide for, 159
pharmacologic pain management and, 157–159
systemic, pharmacologic pain management and, 157–158
Anaphylactoid syndrome of pregnancy, 205
Anaphylaxis of pregnancy, 205
Anemia, 96–97, 117
clinical findings of, 96
hemolytic, 96
iron-deficiency, 96
megaloblastic, 96
pregnancy and, 37
Anesthesia,
epidural, 158–159
general, 159
local perineal infiltration, 158
pharmacologic pain management and, 157–159
spinal, 158
Anger, 324b
Antacids, pregnancy and, 40
Antagonists (naloxone), opioid (narcotic), pharmacologic pain management
and, 158
Antepartal factors, in predisposing factors for postpartum, infections, 249
Antepartum testing,
for high-risk pregnancy, 55, 56b
using electronic fetal monitoring, 60–61
Antibiotic, for endometritis, 249
Anticipatory grief, 324
Anticoagulants, for deep venous thrombosis, 248
Anticonvulsant therapy, 89
Antidepressant medications, 118
Antithyroid medication, for pregnancy, 79
Anus, in initial assessment of the newborn, 262
Anxiety,
to birth defect, 329, 330
as factors influencing pain response, 151
Anxiety disorders, 119–124
agoraphobia, 120–121
general care management and, 123–124
generalized, 121
obsessive-compulsive disorder, 121–122
panic, 119–120
posttraumatic stress, 122–123
Aortic stenosis, 300
Apgar score, in initial assessment of the newborn, 259, 259t
Appendicitis, 101
ARDS., See Acute respiratory distress syndrome (ARDS)
Areola, breastfeeding and, 278
AROM., See Artificial rupture of membranes (AROM)
Aromatherapy, nonpharmacologic pain management and, 155
Artificial rupture of membranes (AROM), 199
Artificial sweeteners, pregnancy and, 43
ASD., See Atrial septal defect (ASD)
Aspartame, pregnancy and, 43
Aspiration of mucus, of preterm infants, 286, 316
Asthma, 84–85
Asymmetric gluteal folds, developmental dysplasia of the hip and, 309, 320
Asymmetric Moro reflex, 293–294, 317–318
Asymptomatic bacteriuria, 97
Atrial septal defect (ASD), 298
Atrioventricular canal defect, 298
Attachment, 238, 239, 240, 241
factors impeding, 239
promotion of, 227, 231
with multiple births, 234
supportive care in, 239
in transition to parenthood, 233–234
Attitude, fetal, as factors affecting labor, 141
Augmentation, of labor, 200
Auscultation,
of fetal heart, 166–167, 173–174
intermittent, during labor, 165
Autoimmune disorders, 92–95
Autosomal-recessive disorder, affecting exocrine (mucus-producing)
glands, 85
B
Babinski reflex, in newborn, 255
Baby, sleepy/fussy, infant nutrition and, 279
Baby blues, 127b
Bacteriuria, asymptomatic, 97
Bag-and-mask ventilation, in newborns, 293, 317
Bargaining, 324b
Baseline fetal heart rate, during labor, 167–168, 172, 172f, 174
Basophils, in newborn, 265
Bathing,
in newborn, 264
pregnancy and, 29
Bearing-down efforts, in labor, second stage of, 182
Behavioral characteristics, of newborn, 255–257
Bell palsy, 91–92
Bereavement, 323
Biofeedback, nonpharmacologic pain management and, 156
Biophysical profile (BPP), of high-risk pregnancy, 56
Biorhythmicity, in parent-infant communication, 235
Birth,
breech, 194
Cesarean, 201–203
characteristics of, parent-infant relationship and, 233
complications of, 189–208
experience of, effect of, 225–226
labor processes and, 141–149
pain during, 150
postterm, 192–193
preterm, 189–191
vaginal, operative, 200–201
Birth centers, 34
Birth defect,
anxiety to, 329, 330
mother’s stress on, 329, 330
Birth injuries, 287–289
Birth plans, 34
Bladder,
distended, 224, 229
empty, in assessment of uterine fundus, 224, 230
emptying of, during postpartum period, 223, 225, 228, 231
Bladder distention, prevention of, during postpartum period, 221
Bladder patterns, normal, promotion of during postpartum period, 222
Blastocyst, 1
Bleeding,
early pregnancy, 67–71
risk factors of, 68
types/clinical findings of, 68
late pregnancy, 71–74
Bleeding time, in newborn, 265
Blood alcohol levels, effects of, 131t
Blood components, postpartum physiologic changes and, 214
Blood fibrinogen levels, postpartum physiologic changes and, 214
Blood gases, neonatal, 266
Blood pressure,
changes in pregnancy, 13t
postpartum physiologic changes and, 213
Blood volume,
changes in pregnancy, 13t
postpartum physiologic changes and, 213
BMI., See Body mass index (BMI)
Body mass index (BMI), during pregnancy, 38t, 39
Bonding, in transition to parenthood, 233–234
Bony pelvis, 142
Bowel patterns, normal, promotion of during postpartum period, 222
BPP., See Biophysical profile (BPP)
Brachial palsy, 293, 317
Brachial plexus, in Erb-Duchenne paralysis, 293, 317
Bradycardia, 173, 175
puerperal, 214
Breast engorgement,
interventions for, 222
patient teaching for, 224, 230
Breast milk,
expressing and storing, 279
for infant nutrition, 271
Breastfeeding, 271–273
advantages of, 271
care of breasts during, 272–273
contraindications of, 272
feeding schedule for, 273
frequently asked questions on, 273
indicators of effective, 279
prerequisites of, 271–272
steps to successful, 272b
supporting mothers and infants and, 278
techniques for, 272
Breastfeeding, promotion of, during postpartum period, 223
Breastfeeding mothers,
fluid for, 46–47
postpartum, 211
Breasts,
changes in pregnancy, 12
postpartum physiologic changes in, 211
teach care of, breastfeeding and, 272–273
Breathing,
primary survey and, 104
techniques, nonpharmacologic pain management and, 153–154
Breech birth, types of, 194
Bronchopulmonary dysplasia, 312
Brown fat, in preterm infants, 286, 316
C
Caffeine, pregnancy and, 23
intake, 43
Calcium,
for lactation, 47
during pregnancy, 40
Calories, pregnancy and, 38
Cancer, 100
care of pregnant women with, 100
Caput succedaneum, 287, 288f, 293, 317
Carbohydrate, for infants, 277
Cardiac malformations, 297–303
aortic stenosis in, 300
atrial septal defect in, 298
atrioventricular canal defect in, 298
clinical findings in, 300–301
coarctation of the aorta in, 300
nursing care of, 301–303
obstructive defects in, 300
patent ductus arteriosus in, 298
symptomatic, 310, 321
tetralogy of Fallot, 298–299
therapeutic interventions for, 301
total anomalous pulmonary venous connection in, 299
transposition of the great vessels in, 299
tricuspid atresia in, 299
truncus arteriosus in, 299
valvular aortic stenosis in, 300
ventricular septal defect in, 297
Cardiac output,
changes in pregnancy, 13t
postpartum physiologic changes and, 213
Cardiopulmonary resuscitation (CPR), of pregnant woman, 106
Cardiovascular disorders, 83–84
Cardiovascular system, 104t
changes in pregnancy, 12–13, 13t
of newborn, 253
postpartum physiologic changes in, 213–214
Caring theory, 324
CBC., See Complete blood count (CBC)
Cell division, 1
Cephalohematoma, 287, 288f
Cephalopelvic disproportion, additional care for, 225, 230
Certified midwives (CMs), 33
Certified nurse midwives (CNMs), 33
Cervical changes, in pregnancy, 12
Cervical ripening, 200
Cervix,
incompetent, 68–69
in labor, 181, 186
postpartum physiologic changes in, 210
Cesarean birth, 201–203
vaginal birth after, 203
CF., See Cystic fibrosis (CF)
Chalasia, 310, 321
Chest,
circumference, in initial assessment of the newborn, 259
physical examination of, in pregnant trauma victim, 105–106b
Childbirth preparation, nonpharmacologic pain management and, 153
Chlamydia trachomatis infection, in neonate, 294, 318
Choanal atresia, 309, 319
Cholelithiasis/cholecystitis, 101–102
clinical findings of, 102
Cholinergic crisis, 94
ChooseMyPlate pregnancy weight gain calculator, 49
Chorioamnionitis, 192
definition and etiologies of, 192
diagnosis of, 192
risks of, 192
therapeutic interventions for, 192
Chorion, 4–5, 5f
Chorionic villi sampling (CVS),
for high-risk pregnancy, 57, 57f
for pregnancy, 27
Chromosomal alterations, 4
Chromosomes, 4
Circulation, primary survey and, 104–105
CIWA-Ar Scale., See Clinical Institute Withdrawal Assessment for Alcohol
(CIWA-Ar) Scale
Cleavage, in fertilization, 1
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Scale, 131t
Clotting disorders, in pregnancy, 73–74
Clotting factors, postpartum physiologic changes and, 214
Clubfoot, 305–306
CMs., See Certified midwives (CMs)
CNMs., See Certified nurse midwives (CNMs)
Coagulopathies, 245–246
Coarctation of the aorta, 300
Cocaine, 133
Cold, application of, nonpharmacologic pain management and, 154
Coma, myxedema, 80
Comfort, promotion of, during postpartum period, 221–222
Common newborn problems, 264–265
Complete blood count (CBC),
in labor, first stage of, 177–178
for pregnancy, 26
Complicated grief, 323
Conception, 1–2
Conceptus, 4
Congenital, term, 8
Congenital anomalies, 297–309
cardiac malformations in, 297–303
genitourinary anomalies in, 307–309
intestinal obstruction in, 304–305
musculoskeletal anomalies in, 305–307
nasopharyngeal and tracheoesophageal anomalies in, 303–304
Congenital defect, von Willebrand disease (vWD), 246
Congenital disorders, 8
Consolability, 257
Constipation, pregnancy and, 50
Continuing bonds theory, 324
Contraction stress test (CST), for high-risk pregnancy, 60–61
Contractions, assessing, during labor,
first stage of, 181, 186
second stage of, 184, 187
Cord,
compression, in fetal heart rate pattern, 173, 175
insertion, in late pregnancy bleeding, 72–73
risk factors of, 73
traction on, 73
variations of, 73
velamentous insertion of, 73
Cordocentesis, for high-risk pregnancy, 58
Corticosteroids,
for idiopathic thrombocytopenic purpura, 245–246
for preterm labor, 190
Cortisol, changes in pregnancy, 17
Counterpressure, nonpharmacologic pain management and, 154
Cow’s milk, on infant nutrition, 271
CPR., See Cardiopulmonary resuscitation (CPR)
Cranial birth injuries, 287–288
Cravings, pregnancy and, 43
Crawl, in newborn, 255
Crying, 256, 256b
Crystalloid solution, for hemorrhagic (hypovolemic) shock, 244
CST., See Contraction stress test (CST)
Cuddliness, 257
Cultural diversity, effect of, during postpartum period, 226
Cultural factors, in labor, first stage of, 176
Cultural system, in family centered childbearing, 227, 231
Culture,
as factors influencing pain response, 151
infant feeding and, 276
CVS., See Chorionic villi sampling (CVS)
Cystic fibrosis (CF), 85–86
Cystitis, 97–98
Cytomegalic inclusion disease, 291
Cytomegalovirus, 291
D
Daily fetal movement count (DFMC), 55
Daily recommended intake (DRI), for pregnant women,
of calcium, 40
of fiber, 44
of folic acid, 42
of iron, 40
of magnesium, 40
of vitamin B6, 42
of vitamin B12, 42
of vitamin C, 42
of vitamin D, 41
of vitamins, 41
of zinc, 41
DDH., See Developmental dysplasia of the hip (DDH)
Death, neonatal, 324
Decelerations, in fetal heart rate, 168–170, 172, 173, 174, 175
Decidua basalis, 2
Deep sleep, 256, 256b
Deep venous thrombosis, 247
Denial, 324b
Depression, 324b
major, 117–118
paternal postpartum, 125
postpartum, 215
with psychotic features, 127–128
risk factors for, 126b
screening for, 127
without psychotic features, 125–127
signs of, 127b
Desmopressin, for von Willebrand disease, 246
Developmental crises, 23
Developmental dysplasia of the hip (DDH), 306–307
asymmetric gluteal folds and, 309, 320
cast for, foul smell from, 309, 320
Developmental stages, and parent-infant relationships, 233
DFMC., See Daily fetal movement count (DFMC)
Diabetes mellitus, 76–77
pregnancy and, 37, 76
hazards of, 76–77
Diabetic mothers, infants of, 296–297
Diaphoresis, 15
postpartum, 215
Diaphragm position, changes in pregnancy, 14t
“Diastasis recti, ”, 215
DIC., See disseminated intravascular coagulopathy (DIC)
Digestive system, of newborn, 254
Discharge planning, in newborn, 266, 267b
Discharge teaching, during postpartum period, 226–227
content of, 226–227
evaluation/outcomes in, 227
safety in, 227
Disenfranchised grief, 323
Displaced urethral openings, 308–309
Disseminated intravascular coagulopathy (DIC), 73–74
in postpartum hemorrhage, 242
Dizygotic twins, 7
Dizygotic (fraternal) twins, 195
Douching, pregnancy and, 29
Doulas, for pregnant women, 33
DRI., See Daily recommended intake (DRI)
Drowsy, 256, 256b
Drugs, abused, 129–132
prescription of, 133
Dual-process model, 324
Dysfunctional labor, 193–196
definition of, 193
fetal causes of, 194–195
labor patterns, abnormal, 194
maternal complications of, 193
nursing care of women with, 196
pelvic structure, alterations, 194
position, of woman, 195
psychologic responses in, 196
uterine activity, abnormal, 193
Dysplasia,
bronchopulmonary, 312
developmental, of hip, 306–307
asymmetric gluteal folds and, 309, 320
cast for, foul smell from, 309, 320
Dysregulation, neurotransmitter, 117
Dystocia, 193–196
shoulder, 203–204
E
Early decelerations, in fetal heart rate, 168, 169f
Early pregnancy bleeding, 67–71
risk factors of, 68
types/clinical findings of, 68
Eclampsia, hypertension and, 64, 65
Ectoderm, 2, 3f
Ectopic pregnancy, 69–70
tubal pregnancy pattern of, 69
EDD., See Estimated date of delivery (EDD)
Effleurage, nonpharmacologic pain management and, 154
Electronic fetal monitoring, 60–61
during labor, 165–166, 166f
Elimination, in labor, first stage of, 178–179
Embolus, amniotic fluid, 205
Embryo, 2–8, 5f
amniotic fluid, 5, 5f
development of, 4
membranes, 4–5, 5f
yolk sac, 5–6, 5f
Embryonic development, 4
stages of, 2f
Emotional changes, in pregnancy, 15–16
Employment, maternal, infant nutrition and, 280
Endocrine disorders, 76–82
diabetes mellitus, 76–77
hyperemesis gravidarum, 77–78
maternal phenylketonuria, 81–82
thyroid disorders, 78–81
Endocrine system,
changes in pregnancy, 16–17
of newborn, 255
postpartum physiologic changes in, 210–211
Endoderm, 3, 3f
Endometritis, in postpartum infections, 249
Energy,
infant nutrition and, 276
for lactation, 46
during pregnancy, 37–38
Entrainment, in parent-infant communication, 235
Environment, as factors influencing pain response, 152
Eosinophils, in newborn, 265
Epidural analgesia, 158–159
Epilepsy (seizure disorder), 88–90
clinical findings of, 89
types of, 88–89
Episiotomy, 246
comfort for, 222
patient teaching for, 223, 228
Episodic changes, in fetal heart rate, 168–170
Epispadias, 308
Erb-Duchenne paralysis, 293, 317
Erikson’s stage of trust versus mistrust, infant nutrition and, 271
Erythrocytes (RBCs), reduction in concentration of, 96
Estimated date of delivery (EDD), 23
Estrogen, 6
changes in pregnancy, 17
postpartum physiologic changes and, 210
Excessive bleeding, prevention of, during postpartum period, 220
Excretory system, of newborn, 254
Exercise, during pregnancy, 30
Expression, of feeling, 329, 330
Exstrophy, of bladder, 307–308, 309, 320
External fetal monitoring, 165–166, 167, 174
Extrauterine life, transition to, of newborn, 253
Extremities,
in initial assessment of the newborn, 262
physical examination of, in pregnant trauma victim, 105–106b
F
Face-to-face position, in parent-infant communication, 235
False pelvis, 142
Family, nursing care during postpartum period for, 219–232
application and review of, 223–225
discharge in,
criteria for, 219
planning of, 219
discharge teaching in, 226–227
content of, 226–227
evaluation/outcomes in, 227
safety in, 227
physical needs, care management for, 219–223
nursing interventions for, 220–223
physical assessment in, 219–220
routine laboratory tests in, 220
psychosocial needs, care management for, 225–226
adaptations to parenthood and parent-infant interactions in, 226
birth experience in, effect of, 225–226
cultural diversity in, effect of, 226
maternal self-image in, 226
transfer from recovery area in, 219
Fat, in breast milk, for newborns, 276
Father, becoming a, 236
Fat-soluble vitamins, for maternal and fetal nutrition, 41–42
Feeding,
choanal atresia and, 309, 319
frequency of, breastfeeding and, 278
schedule,
for breastfeeding, 273
for formula feeding, 274
techniques,
for breastfeeding, 272
for formula feeding, 274
Fern test, for premature rupture of membranes, 191
Fertilization, 1
Fetal assessment, during labor, 165–175
client and family teaching in, 172
documentation of, 172
heart rate patterns in, 167–170
monitoring in, 165
other methods of, 171
Fetal attitude, 141
Fetal circulation, 7
Fetal compromise, monitoring of, during labor, 165
Fetal development, 6–7
Fetal head, as factors affecting labor, 141
Fetal heart rate (FHR), during labor,
baseline, 167–168, 172, 172f, 173, 174, 175
episodic changes in, 168–170
patterns of, 167–170
categorization of, 170
cord compression in, 173, 175
first stage, 177
second stage, 182
periodic changes in, 168–170
Fetal heart tones,
auscultate, Doppler in, 167, 174
maximum intensity of, 165, 166f
Fetal hemoglobin, 265
Fetal hypoxia, preventing, 185, 188
Fetal lie, 141
Fetal maturation, 6–7
Fetal monitoring, during labor,
considerations for, 167, 174
electronic, 165–166, 166f
external, 165–166, 167, 174
internal, 166, 167, 174
Fetal nutrition, 37–54
care management for, 47–50
assessment in, 47–48
laboratory testing in, 48
nutritional care and patient education in, 48
physical examination in, 48
nutrient needs for,
before conception, 37
during lactation, 46–47
during pregnancy, 37–44
Fetal position, 141, 142f
Fetal presentation, 141
Fetal response, monitoring of, during labor, 165
Fetal scalp blood sampling, in fetal assessment, 171
Fetal skull bones, 141
Fetal viability, 7
Fetus, 2–8
fetal maturation of, 6–7
multifetal pregnancy and, 7–8
placenta and, 5f, 6
umbilical cord and, 5f, 6
Fever, after postpartum period, 224, 229
FHR., See Fetal heart rate (FHR)
Fibrinogen, in newborn, 265
First stage, of labor, 176–180, 185
ambulation in, 179
assessment of, 176–178
cultural factors in, 176
diagnostic tests in, 177–178
elimination in, 178–179
fluid intake for, 178
general hygiene for, 178
interview in, 176
laboratory tests in, 177–178
nursing interventions for, 178–180
nutrient intake for, 178
physical examination in, 176–177, 177f
positioning in, 179
prenatal data in, 176
psychosocial factors in, 176
stress in, 176
supportive care during, 179–180
transition of, 180, 185
First trimester, energy needs during, 38
Fluid intake, in labor, first stage of, 178
Fluid loss, postpartum physiologic changes and, 212
Fluids,
amount excretion of, after birth, 223, 228
for infants, 276
for lactation, 46–47
during pregnancy, 39–40
Fluoride supplementation, for breastfed infants, 277
Folate,
for maternal and fetal nutrition, 42
pregnancy and, 23
Folic acid,
for lactation, 47
for pregnancy, 23, 37
Follicle-stimulating hormone (FSH), 211
Food plan, during lactation, 45t, 46
Food poisoning, pregnancy and, 50
Food safety, pregnancy and, 50
Forced Cesarean birth, 201
Forceps assisted, vaginal birth, 200
Formula feeding, 273–274
Formulas,
iron-fortified commercial, for infant nutrition, 271
types of, for formula feeding, 273
Fourth stage, of labor, 183–184
Fractured clavicle, as birth injury, 317
Fraternal twins, 195
FSH., See Follicle-stimulating hormone (FSH)
Fundal height, changes in, with pregnancy, 12f
Fussy baby, infant nutrition and, 279
G
Gag, in newborn, 254
Gallbladder,
changes in pregnancy, 16
inflammation of, 101
Gametogenesis, 1
Gastric lavage, 134
Gastrointestinal disorders, 95
Gastrointestinal system,
changes in pregnancy, 16, 16f
postpartum physiologic changes in, 214
GDM., See Gestational diabetes mellitus (GDM)
General anesthesia, 159
General nursing care of clients, with anxiety disorders, 123
Generalized anxiety disorder, 121
Generalized seizures, 89
Genes, 4
Genitalia, in initial assessment of the newborn, 262
Genitourinary anomalies, congenital, 307–309
Genitourinary disorders, 97–99
Germ layers, primary, 2–3, 3f
Germinal matrix hemorrhage-intraventricular hemorrhage, 313
Gestational age assessment, in newborn, 259, 260f
Gestational diabetes mellitus (GDM), 76
pregnancy and, 43–44
Gestational hypertension, 64, 65
Gland secretions, mucous, organs affected by, 85
Gluteal folds, asymmetric, developmental dysplasia of the hip and, 309, 320
Goodell sign, 12
Grandparent adaptation,
to pregnancy, 24
transition to parenthood and, 237–238
emotional and role changes in, 237
practical considerations, 238
Grasp, in newborn, 254
Gravida, 10
Gravidity, 10
Grief, 323–330
anticipatory, 324
complicated, 323
disenfranchised, 323
family aspects of, 326–327, 328–329, 330
normal (uncomplicated), 323
nurses’ reactions to caring for, 328
parental,
Miles’ model of, 325–326
phases of, 325–326, 325b
stages of, 323, 324b, 329, 330
theories of, 324
Group B streptococcus culture, pregnancy and, 27
Grunting respirations, intestinal obstruction and, 310, 321
Gynecomastia, in newborn, 255
H
Habituation, 257
Haploid, 1
hCG., See Human chorionic gonadotropin (hCG)
hCS., See Human chorionic somatomammotropin (hCS)
Head,
fetal, as factors affecting labor, 141
physical examination of, in pregnant trauma victim, 105–106b
Head circumference, in initial assessment of the newborn, 259
Health disorders, mental,
during pregnancy, 117–118
substance abuse and, 117–140
anxiety, 119–124
perinatal substance abuse, 128–135
postpartum mood disorders, 125–128
Hearing, of newborn, 256
Hearing-impaired parent, and transition to parenthood, 237
Heart, location of, changes in pregnancy, 13t
Heart disease, during pregnancy, functional (therapeutic) classification of, 83
Heart failure, in infants and children, 310, 321
Heart rate, changes in pregnancy, 13t
Heartburn, pregnancy and, 49
Heat, application of, nonpharmacologic pain management and, 154
Heavy lifting, pregnancy and, 30
Heel-stick sites, 258f
HELLP syndrome, 65
Hematocrit,
in newborn, 265
postpartum physiologic changes and, 214
Hematologic disorders, 96–97
Hematologic system, 104t
Hematomas, in postpartum hemorrhage, 242
Hemodynamics, pregnancy, adverse effects of, 83
Hemoglobin,
in newborn, 265
reduction in concentration of, 96
Hemolytic anemia, 96
Hemolytic disorders, 294–295
Hemorrhage,
Cesarean birth and, 225, 231
signs of, assessment of patient for, 225, 230
Hemorrhagic disorders, 67–74
Hemorrhagic (hypovolemic) shock, 244–245
Hepatic system, of newborn, 254
Herpes culture, pregnancy and, 26
Herpes genitalis (herpesvirus), 292
High-risk newborns, nursing care of, 284–286
High-risk pregnancy, assessment of, 55–63
antepartum testing for, 55, 56b
using electronic fetal monitoring, 60–61
biochemical assessment for, 57–58
biophysical assessment for, 55–56
nurses’ role in, 61
psychologic considerations related to, 61
risk factors in, assessment of, 55
HIV., See Human immunodeficiency virus (HIV)
Home birth, 34
Hospital, delivery in, 34
hPL., See Human placental lactogen (hPL)
Human chorionic gonadotropin (hCG), 6, 10
changes in pregnancy, 17
Human chorionic somatomammotropin (hCS), 6, 17
Human immunodeficiency virus (HIV),
in newborn, 290
pregnant woman with, 108
Human milk, uniqueness of, 277–278
Human placental lactogen (hPL), 17. See also Human chorionic
somatomammotropin (hCS)
Hydatidiform mole, 70–71
Hydrotherapy, nonpharmacologic pain management and, 155
Hygiene, in labor, first stage of, 178
Hyperactivity, in opioid withdrawal, 294, 318
Hyperbilirubinemia (pathologic jaundice), 296, 319
Hypercoagulation, 247
Hyperemesis gravidarum, 77–78
Hypertension, transient, 64
Hypertensive disorders, 64–66
classification of, 64
guidelines for prevention, 65
risk factors of, 64
therapeutic interventions, 65
Hyperthyroidism, 78–80
Hypnosis, nonpharmacologic pain management and, 155
Hypoglycemia,
in late preterm infants, 314
in newborn, 265
Hypospadias, 308
Hypotension, orthostatic, 214
Hypothyroidism, 80–81
I
Ice packs, for breast discomfort, 224, 229
ICP., See Intrahepatic cholestasis of pregnancy (ICP)
Identical twins, 195. See also Monozygotic twins
Idiopathic thrombocytopenic purpura (ITP), 245–246
IDM., See Infant of diabetic mother (IDM)
Immature white blood cells, in newborn, 265–266
Immediate stabilization, trauma and, 103–106
Immune system,
of newborn, 254
postpartum physiologic changes in, 215–216
Immunization, pregnancy and, 26
Immunoglobulin G (IgG), in newborn, 254
Immunoglobulin M (IgM), in newborn, 254
Implantation, 2
Incompetent cervix, 68–69
Indigestion, pregnancy and, 49
Infant feeding,
breastfeeding and, 271–273
cultural influences on, 276
factors influencing decision for, 271
formula feeding and, 273–274
Infant nutrition, 271–283
Infant of diabetic mother (IDM), 77
Infants,
basic needs of, 233
breastfeeding contraindications for, 272
hemolytic disorders of, 294–295
large-for-gestational-age, 316
multiple, infant nutrition and, 279
nutrient needs for, 276–277
postterm/postmature, 314–316
preterm, 284–285
infant nutrition and, 279
late, 314
nursing care of, 285–286
supporting breastfeeding, 278
Infections,
of Chlamydia trachomatis, in neonate, 294, 318
exstrophy of the bladder and, 309, 320
in newborn, 289–292
postpartum, 248–250
endometritis in, 249
predisposing factors for, 249b
urinary tract infection in, 250
wound infections in, 249–250
prevention of, during postpartum period, 221
Inflammatory bowel disease, 95
Integumentary disorders, 87–88
Integumentary system,
changes in pregnancy, 15
of newborn, 254
postpartum physiologic changes in, 215
Intense grief, phase of, 325b
Intermittent auscultation, during labor, 165
Internal fetal monitoring, 166, 167, 174
Interview,
for assessment of attachment behaviors, 234
in labor, first stage of, 176
Intestinal obstruction, in congenital anomalies, 304–305
Intoxication, substance, 128
Intracranial hemorrhage, as birth injuries, 287, 293, 317
Intradermal water block, nonpharmacologic pain management and, 155
Intrahepatic cholestasis of pregnancy (ICP), 88
Intrapartal factors, in predisposing factors for postpartum infection, 249
Intrapleural space, drainage of, 310–311, 322
Iron,
for lactation, 47
during pregnancy, 40
supplement, infant nutrition and, 277
Iron-deficiency anemia, 96
pregnancy and, 40
Iron-fortified commercial formulas, for infant nutrition, 271
Irritability, 257
ITP., See Idiopathic thrombocytopenic purpura (ITP)
J
Jaundice, in newborn, 264–265, 296, 319
Joint Commission Standards, 150
K
Kegel exercises, during postpartum period, 228, 232
Kick count, 55
Kidney function, of preterm infants, 286, 316
L
La Lache League International, infant nutrition and, 280
Labor,
augmentation of, 200
birth processes and, 141–149
characteristics of, and parent-infant relationship, 233
clinical findings preceding, 143–144
complications of, 189–208
dysfunctional, 193–196
factors affecting, 141–143
family during, nursing care of, 176–188
first stage of, 176–180, 177f
fourth stage of, 183–184
induction of, 198–200
pain during, 150
patterns, abnormal, 194
postterm, 192–193
precipitous, 196–197
preterm, 189–191
process of, 143–145
second stage of, 181–183
stages of, and maternal changes, 144–145
third stage of, 183
trial of, 203
true, clinical findings of, 144
Laboratory and diagnostic tests, for newborn, 265–266
Laboring woman,
maximizing comfort for, 150–164
care management of, 159–160
factors influencing pain response in, 151–152
nonpharmacologic pain management for, 153–156
pain during labor and birth, 150
pharmacologic pain management for, 157–159
position of, factors affecting labor and, 143
Lactation, anatomy and physiology of, 277–278
Lactogenesis, 277
Lactose intolerance, pregnancy and, 43
Lanugo, 254
Large-for-gestational-age infants, 316
Latch, breastfeeding and, 278
Late decelerations,
in fetal heart rate, 168, 169f
in fetus, during labor, 184, 187
Late pregnancy bleeding, 71–74
Late preterm infants, 314
Left occipitoanterior (LOA) position, 142f, 181, 186
Leopold maneuvers, 177, 177f
Let-down, breastfeeding and, 278
Leukocytosis, postpartum physiologic changes and, 214
Light sleep, 256, 256b
Lightening, in uterus, 11
Living children, 26
LOA position., See Left occipitoanterior (LOA) position
Local perineal infiltration anesthesia, 158
Lochia, 209
patient teaching for, 228, 232
Loss, 323–330
aftermath of, 327–328
associated with pregnancy, 324–325
Low birth weight, preterm labor versus, 189
Lower back, physical examination of, in pregnant trauma victim, 105–106b
Lymphocytes, in newborn, 265
M
Magnesium, for maternal and fetal nutrition, 40
Magnetic resonance imaging, of high-risk pregnancy, 56
Malnutrition, pregnancy and, 48
Malposition, dystocia and, 194
Malpresentation, dystocia and, 194–195
Marijuana, 132
“Mask of pregnancy, ”, 215
Massage, nonpharmacologic pain management and, 154
Maternal adaptation, to pregnancy, 23–24
Maternal ambivalence, 24
Maternal assays, for high-risk pregnancy, 58
Maternal death, 251
Maternal employment, infant nutrition and, 280
Maternal nutrition, 37–54
care management for, 47–50
assessment in, 47–48
laboratory testing in, 48
nutritional care and patient education in, 48
physical examination in, 48
nutrient needs for,
before conception, 37
during lactation, 46–47
during pregnancy, 37–44
Maternal phenylketonuria, 81–82
mBPP., See Modified biophysical profile (mBPP)
Meconium, stools, 254
Meconium aspiration syndrome, 314–315
Medical-surgical disorders, 83–99
autoimmune, 92–95
cardiovascular, 83–84
gastrointestinal, 95
genitourinary, 97–99
hematologic, 96–97
integumentary, 87–88
neurologic, 88–92
pulmonary, 84–87
Megaloblastic anemia, 96
Meiosis, 1
Melanocyte-stimulating hormone, 215
Melasma, 215
Membranes, of embryo, 4–5, 5f
Menstrual calendar, 23
Menstruation, postpartum physiologic changes and, 210
Mental health disorders,
during pregnancy, 117–118
substance abuse and, 117–140
anxiety, 119–124
perinatal substance abuse, 128–135
postpartum mood disorders, 125–128
Mesoderm, 3, 3f
Metabolic changes, postpartum physiologic changes and, 210
Metabolic disorders, 76–82
diabetes mellitus, 76–77
hyperemesis gravidarum, 77–78
maternal phenylketonuria, 81–82
thyroid disorders, 78–81
Methamphetamine, 133
MG., See Myasthenia gravis (MG)
Mild preeclampsia, hypertension and, 65
Miles’ model of parental grief responses, 325–326, 325b
Milia, 254
Milk ejection, breastfeeding and, 278
Minerals,
for infants, 277
for lactation, 47
during pregnancy, 40–41
Minute ventilation, changes in pregnancy, 14t
Miscarriage (spontaneous abortion), 67–68
Mitosis, 1
Modified biophysical profile (mBPP), of high-risk pregnancy, 56
Molar pregnancy, 70
Mongolian spots, 254
Monocytes, in newborn, 265
Monozygotic twins, 7, 195
Mood disorders,
perinatal, 117
postpartum, 125–128
paternal postpartum depression, 125
postpartum blues/maternal blues, 125
postpartum depression without psychotic features, 125–127
Moro reflex,
asymmetric, 293–294, 317–318
in newborn, 255
Mother-infant relationship, supportive nursing care in, 238, 240
Mothers,
becoming a, 235–236
breastfeeding contraindications for, 272
exploration of infant of, 238, 240
parenting role of, development of, 239, 240
supporting breastfeeding, 278
talking to her baby, encouragement for, 238
Mucous gland secretions, organs affected by, 85
Mucus, aspiration of, of preterm infants, 286, 316
Multifetal pregnancy, 7–8, 32–33, 195
woman with, 108
Multigravida, 10
Multipara, 10
Multiple alleles, 4
Multiple genes, 4
Multiple infants, infant nutrition and, 279
Multiple sclerosis, 90–91
Multivitamin-multimineral supplements, during pregnancy, 42
Musculoskeletal anomalies, congenital, 305–307
Musculoskeletal system, 104t
changes in pregnancy, 15
postpartum physiologic changes in, 215
Music, nonpharmacologic pain management and, 155
Mutations, 4
Myasthenia gravis (MG), 93–95
clinical findings of, 94
Myasthenic crisis, 94
Myxedema coma, 80
N
Naegle’s rule, in pregnancy, 23
Naloxone, 134
Nasopharyngeal and tracheoesophageal anomalies, 303–304
Nausea, pregnancy and, 49
Neck, physical examination of, in pregnant trauma victim, 105–106b
Necrotizing enterocolitis, 313–314
Neonatal abstinence syndrome, 292–293
Neonatal death, 324
Neonatal intensive care unit (NICU), respiratory distress in, 287, 316
Neonate, care of, 77
Nerve block analgesia, pharmacologic pain management and, 158–159
Neurobiology, of PTSD, 122
Neurologic disorders, 88–92
Neurologic system,
changes in pregnancy, 15–16
of newborn, 255
postpartum physiologic changes in, 215
Neuromuscular system, of newborn, 254–255
Neuromusculoskeletal birth injuries, 288–289
Neurosurgery, 89
Neurotransmitter dysregulation, 117
Neutrophils, in newborn, 265
Newborn,
acquired problems of, 287–293
birth injuries, 287–289
infections, 289–292
respiratory distress syndrome, 287
substance dependence (neonatal abstinence syndrome), 292–293
care management for, 258–263, 264–266
complications of, 284–322
feeding, 271–283
high-risk, nursing care of, 284–286
nursing care for, 253–270
nutrition, 271–283
persistent pulmonary hypertension of, 315–316
physiologic and behavioral adaptations of, 253–257
behavioral characteristics in, 255–257
physiologic adjustment in, 253–255
transition to extrauterine life in, 253
special care for, 262–263
states of sleep and activity of, 256b
NICU., See Neonatal intensive care unit (NICU)
Nitrazine test, for premature rupture of membranes, 191
Nitrous oxide, for analgesia, 159
Nonbreastfeeding mothers, postpartum, 211
Nonfood substances, 43
Nonpharmacologic interventions, nursing care during, 159
Nonpharmacologic pain management, 153–156
Nonsteroidal antiinflammatory drugs, for superficial venous thrombosis, 247
Nonstress test, for high-risk pregnancy, 60
Normal (uncomplicated) grief, 323
Nulligravida, 10
Nullipara, 10
Nurse, interventions performed by, during postpartum period, 228, 232
Nursing care,
for endometritis, 249
for episiotomy, 246
in labor, third stage of, 183
for postpartum depression, 126–127
for postpartum hemorrhage, 243
for shock, 244–245
for urinary tract infection, 250
for venous thromboembolic disorders, 248
for wound infection, 250
Nursing care of clients,
with agoraphobia, 120–121
general, with anxiety disorders, 123
with generalized anxiety disorder, 121
with obsessive-compulsive disorders, 122
with panic disorder, 120
with posttraumatic stress disorder, 123
receiving analgesic/anesthetic agents, 159–160
who abuse alcohol,
assessment/analysis, 130
evaluation/outcomes, 132
planning/implementation, 131–132
who abuse drugs, 134–135
Nursing care of family, during pregnancy, 22–36
adaptation to, 23–24
age differences in, 32
birth plans in, 34
birth setting choices in, 34
care management for, 25–27
follow-up visits in, 28
initial visit in, 25–27
prenatal care in, goals of, 25
collaborative care in, 31
cultural influences in, 32
diagnosis of, 23
estimating date of birth in, 23
evaluation/outcomes in, 31
expectant parents in, classes for, 33
multifetal pregnancy in, 32–33
nursing interventions in, 28–30
patient teaching in, 22–23
perinatal and childbirth education in, 33
perinatal care choices in, 33–34
preconception care in, 22
provider choices in, 33
variations in prenatal care in, 32–33
Nursing care of women,
with abruptio placentae, 72
with acute respiratory distress syndrome (ARDS), 87
with anemia, 97
with appendicitis, 101
with asymptomatic bacteriuria, 97
with Bell palsy, 91–92
with cystic fibrosis, 86
with cystitis, 98
with developing disseminated intravascular coagulopathy, 73–74
with ectopic pregnancy, 69–70
with epilepsy (seizure disorder), 89–90
with hydatidiform mole, 70–71
with hyperemesis gravidarum, 78
with hypertensive disorders, 65–66
with hyperthyroidism, 79–80
with hypothyroidism, 81
with incompetent cervix, 69
with miscarriage (spontaneous abortion), 68
with multiple sclerosis, 91
with myasthenia gravis, 94
with placenta previa, 71–72
pregnant,
with asthma, 84–85
with cardiovascular disorders, 83–84
with diabetes mellitus, 77
with special needs, 106–108
with pyelonephritis, 99
with systemic lupus erythematosus, 92–93
with trophoblastic disease, 70–71
Nutrient intake, in labor, first stage of, 178
Nutrient needs, for infants, 276–277
Nutrition,
of late preterm infants, 314
maternal, inadequate, 8
promotion of, during postpartum period, 222
O
Obesity, pregnancy and, 197
Observation, in assessment of attachment behaviors, 234
Obsessive-compulsive disorder, 121–122
Obstetric emergencies, 203–205
Obstetric procedures, 198–203
Obstetricians, for pregnant women, 33
Obstructive defects, in cardiac malformations, 300
Older pregnant woman, 107
Oligohydramnios, 192
Omega-3 fatty acids, for maternal and fetal nutrition, 39
Oogenesis, 1
Open-ended question, for data collection, 309, 320
Ophthalmia neonatorum, 289
Opioid (narcotic) agonist-antagonist analgesics, pharmacologic pain
management and, 158
Opioid analgesics, pharmacologic pain management and, 157
Opioid (narcotic) antagonists (naloxone), pharmacologic pain management
and, 158
Opioid withdrawal, in newborn, 294, 318
Opioids, 133–134
Organogenesis, period of, 4
Orthostatic hypotension, 214
Ostium primum defect (ASD1), 298
Ostium secundum defect (ASD2), 298
Ovarian function, postpartum physiologic changes and, 210–211
Ovaries, changes in pregnancy, 11
Ovulation, postpartum, 211
Oxygen consumption, changes in pregnancy, 14t
Oxytocin, 199
lactogenesis and, 277
Oxytocin challenge test, for high-risk pregnancy, 60
P
Pain,
expression of, 150
gate-control theory of, 151
during labor and birth, 150
management of,
nonpharmacologic, 153–156
pharmacologic, 157–159
perception of, 150
in preterm infants, 311
response, factors influencing, 151–152
Pancreas, changes in pregnancy, 17
Panic disorders, 119–120
Panting, during labor, second stage of, 184, 187
Pap test, pregnancy and, 26
Parental grief,
Miles’ model of, 325–326
phases of, 325–326, 325b
Parenthood, transition to, 233–241
attachment and bonding in, 233–234
behaviors of, assessment for, 234
care management in, 238
communication between parent and infant, 234–235
biorhythmicity in, 235
entrainment in, 235
reciprocity and synchrony in, 235
senses in, 234–235
diversity in, 236–237
age and, 236
personal aspirations in, 237
in same-sex couples, 236–237
socioeconomic conditions in, 237
grandparent adaptation and, 237–238
emotional and role changes in, 237
practical considerations, 238
parental role after birth and, 235–236
adjustment for the couple in, 236
becoming a father and, 236
becoming a mother and, 235–236
tasks and responsibilities in, 235
parental sensory impairment in, 237
hearing-impaired parent, 237
visually impaired parent, 237
parent-infant contact in, 234
early, 234
extended, 234
sibling adaptation in, 237
Parent-infant contact, 234
early, 234
extended, 234
Parent-infant interactions, adaptations to, 226
Parent-infant love, development of, 233
Parent-infant relationships,
concepts basic to, 233
influences in, 233–234
Parenting,
ability, 239, 241
basis for, 233
Parity, 10
Paroxysmal pain, in intestinal obstruction, 310, 321
Partial molar pregnancy, 70
Partial seizures, 88
Passageway, as factors affecting labor, 142–143
Passenger, factors affecting labor and, 141
Passive immunity, in newborn,
after birth, 254
in utero, 254
Patent ductus arteriosus, 298
Paternal adaptation, to pregnancy, 24
Paternal postpartum depression, 125
Pathologic jaundice., See Hyperbilirubinemia (pathologic jaundice)
Pelvis,
bony, 142
classification of, 142
true, 142
Percreta, placenta, 242
Percutaneous umbilical blood sampling (PUBS), for high-risk pregnancy, 58
Perinatal bereavement, 323
Perinatal considerations, perinatal substance abuse and, 128
Perinatal mood disorders, 117
Perinatal substance abuse, 128–135
Perineal pad, changing of, patient embarrassment in, 225, 230–231
Perineal trauma, in labor, second stage of, 183, 185, 187
Perineum, postpartum physiologic changes in, 210
Periodic changes, in fetal heart rate, 168–170
Peripartum depression, without psychotic features, 125–127
Persistent pulmonary hypertension, of newborn, 315–316
Personal aspirations, in transition to parenthood, 237
Pharmacologic pain management, 157–159
Phenylketonuria (PKU),
maternal, 81–82
testing, for newborn, 255
Physical examination, in labor, first stage of, 176–177
Physical status, of infant, parent-child relationships and, 238, 240
Physicians, for pregnant women, 33
Physiologic adjustment, in newborn, 253–255
Physiologic factors, influencing pain response, 151
Pica, pregnancy and, 43
Pituitary gland, changes in pregnancy, 17
Pituitary hormones, postpartum physiologic changes and, 210–211
PKU., See Phenylketonuria (PKU)
Placenta, 5f, 6
premature separation of, 72
clinical findings of, 72
Placenta previa, 71–72
clinical findings of, 71
types of, 71
Placental abnormalities, in postpartum hemorrhage, 242
Placental abruption, 72
Placental separation, expulsion and, in labor, third stage of, 183
indications of, 184, 187
Placental variations, in late pregnancy bleeding, 72–73
Platelet count, in newborn, 265
Pneumonia, Chlamydia trachomatis infection and, 294, 318
Polycythemia, in congenital cardiac malformation, 310, 321
Polysubstance abuse, 129
Positional changes, nonpharmacologic pain management and, 153
Positioning,
for breastfeeding, 278
in labor,
first stage of, 179
second stage of, 182
Postpartum blues/maternal blues, 125
signs of, 127b
Postpartum complications, 242–252
coagulopathies as, 245–246
episiotomy and, 246
hemorrhagic (hypovolemic) shock as, 244–245
maternal death as, 251
postpartum hemorrhage as, 242–243
postpartum infections as, 248–250
venous thromboembolic disorders as, 247–248
Postpartum depression, 127b, 215
with psychotic features, 127–128
risk factors for, 126b
screening for, 127
without psychotic features, 125–127
Postpartum diaphoresis, 215
Postpartum hemorrhage, 242–243
Postpartum infections, 248–250
endometritis as, 249
predisposing factors for, 249b
urinary tract infection as, 250
wound infections as, 249–250
Postpartum mood disorders, 125–128
paternal postpartum depression, 125
postpartum blues/maternal blues, 125
postpartum depression without psychotic features, 125–127
Postpartum period, nursing care of family during, 219–232
application and review of, 223–225
discharge in,
criteria for, 219
planning of, 219
discharge teaching in, 226–227
content of, 226–227
evaluation/outcomes in, 227
safety in, 227
physical needs, care management for, 219–223
nursing interventions for, 220–223
physical assessment in, 219–220
routine laboratory tests in, 220
psychosocial needs, care management for, 225–226
adaptations to parenthood and parent-infant interactions in, 226
effect of birth experience in, 225–226
effect of cultural diversity in, 226
maternal self-image in, 226
transfer from recovery area in, 219
Postpartum physiologic changes, 209–218
Postpartum psychosis, 127b, 215
Postterm labor, 192–193
nursing care of women during, 193
Postterm pregnancy, 192–193
assessment of, 192
risk factors of, 192
therapeutic intervention for, 192
Postterm/postmature infants, 314–316
Posttraumatic stress disorder, 122–123
Potassium, for maternal and fetal nutrition, 41
Potentiation, 129
Powers, as factors affecting labor, 143
PP., See Primary progressive (PP) multiple sclerosis
PR., See Progressive-relapsing (PR) multiple sclerosis
Precipitous labor, 196–197
Preconception, in predisposing factors for postpartum infection, 249
Preeclampsia,
hypertension and, 64
mild, hypertension and, 65
Pregestational, 76
Pregnancy,
adaptations to, 11–17
anaphylactoid syndrome of, 205
anatomy of, 10–21
antithyroid medication for, 79
clotting disorders in, 73–74
with diabetes,
nursing care of, 77
physiology of, 76
diabetes mellitus during, 76
health promotion for, vaccines in, 223
heart disease during, functional (therapeutic) classification of, 83
hemodynamics, adverse effects of, 83
high-risk, assessment of, 55–63
antepartum testing for, 55, 56b
biochemical assessment for, 57–58
biophysical assessment for, 55–56
nurses’ role in, 61
psychologic considerations related to, 61
risk factors in, assessment of, 55
high-risk complications of, 64–116
cancer, 100
endocrine and metabolic disorders, 76–82
hemorrhagic disorders, 67–74
hypertensive disorders, 64–66
medical-surgical disorders, 83–99
nursing care of pregnant women with special needs, 106–108
reasons for, 107
trauma, 103–106
hypertensive disorders of, nursing care of women with, 65–66
medication during, 124
mental health disorders during, 117–118
multifetal, 195
woman with, 108
nature of, and parent-infant relationship, 233
nursing care of family during, 22–36
adaptation to, 23–24
age differences in, 32
birth plans in, 34
birth setting choices in, 34
care management for, 25–27
collaborative care in, 31
cultural influences in, 32
diagnosis of, 23
estimating date of birth in, 23
evaluation/outcomes in, 31
expectant parents in, classes for, 33
multifetal pregnancy in, 32–33
nursing interventions in, 28–30
patient teaching in, 22–23
perinatal and childbirth education in, 33
perinatal care choices in, 33–34
preconception care in, 22
provider choices in, 33
variations in prenatal care in, 32–33
pattern, tubal, 69
physiology of, 10–21
postterm, 192–193
readiness for, and parent-infant relationship, 233–234
signs of, 11
surgical emergencies during, 101–102
termination, 325
Pregnant adolescent, 106–107
Pregnant woman, cardiopulmonary resuscitation of, 106
Premature rupture of membranes, 191
definition and implications of, 191
nursing care of women with, 191
therapeutic interventions in, 191
Prematurity, retinopathy of, 311–312
Prenatal data, in labor, first stage of, 176
Preterm birth, 26, 189–191
spontaneous versus indicated, 189
Preterm infants, 284–285
infant nutrition and, 279
late, 314
nursing care of, 285–286
Preterm labor, 189–191
definition of, 189
interventions in, 189–191
versus low birth weight, 189
nursing care of women during, 189
testing of, 189
Previous experience, as factors influencing pain response, 151
Primary progressive (PP) multiple sclerosis, 90
Primary survey, 103–105
Primigravida, 10
Primipara, 10
Progesterone, 6
changes in pregnancy, 17
postpartum physiologic changes and, 210
Progressive-relapsing (PR) multiple sclerosis, 90
Prolactin, postpartum, 210–211
Prolapsed umbilical cord, 204
Propylthiouracil (PTU), 79
Prostaglandin, 199
Protein,
for infants, 277
for lactation, 47
during pregnancy, 39
Pruritic urticarial papules and plaques of pregnancy (PUPPP), 15, 88
Pruritus gravidarum, 87–88
Pseudomenstruation, in newborn, 255
Psychosis,
postpartum, 215
signs of, 127b
Psychosocial factors, in labor, first stage of, 176
Psychotic features,
postpartum depression with, 127–128
postpartum depression without, 125–127
PTU., See Propylthiouracil (PTU)
Pubic bone malformation, 309, 320
PUBS., See Percutaneous umbilical blood sampling (PUBS)
Pudendal nerve block, 158
“Puerperal bradycardia, ”, 214
Puerperium, 209
Pulmonary disorders, 84–87
Pulmonary embolism, 247
Pulmonary (pulmonic) stenosis, 300
Pulse rate, postpartum physiologic changes and, 214
Pumping, breastmilk and, 279
PUPPP., See Pruritic urticarial papules and plaques of pregnancy (PUPPP)
Pyelonephritis, 98–99
Q
Quadruplets, 8
Quiet alert, 256, 256b
R
Radioactive iodine, 79
Reciprocity, in parent-infant contact, 235
Red blood cells, in newborn, 265
Redness, edema, ecchymosis, discharge, approximation (REEDA), for
episiotomy, 246
REEDA., See Redness, edema, ecchymosis, discharge, approximation
(REEDA)
Relapsing-remitting (RR) multiple sclerosis, 90
Relaxation techniques, nonpharmacologic pain management and, 153–154
Relaxin hormone, 215
Renal system, 104t
Reorganization, 325b
Reproductive system, 104t
postpartum physiologic changes in, 209–210
Respiratory distress,
in late preterm infants, 314
in neonatal intensive care unit, 287, 316
syndrome, 287
Respiratory rate,
assessment of, 310, 321
changes in pregnancy, 14t
Respiratory system, 104t
changes in pregnancy, 13–14, 14t
of newborn, 253
postpartum physiologic changes in, 214
Reticulocytes, in newborn, 265
Retinol, for maternal and fetal nutrition, 41
Retinopathy of prematurity, 311–312
Reva Rubin’s phases of maternal adjustment, 235
Rh immune globulin, 223
Rh incompatibility, 294, 296, 319
RhoGAM, administration of, 295–296, 318
Right occipitoanterior (ROA) position, 142f
Right ventricular hypertrophy, in tetralogy of Fallot, 298–299
ROA position., See Right occipitoanterior (ROA) position
Rooming-in, 234
Rooting, in newborn, 254
RR., See Relapsing-remitting (RR) multiple sclerosis
Rubella, 291
vaccination for, during postpartum period, 223
Rubella titer, for pregnancy, 26
Rupture of membranes,
artificial, 199
premature, 191
S
Same-sex couples, parenting in, 236–237
Schedule, feeding,
for breastfeeding, 273
for formula feeding, 274
Second stage, of labor, 180, 181–183, 186
additional interventions for, 182
assessments of, 181
bearing-down efforts in, 182
birth room for, 182
description of, 181
equipment for, 182
father or partner in, support of, 182
fetal heart rate and pattern in, 182
newborn in, immediate care of, 182–183
perineal trauma in, 183
positioning in, 182
Second trimester, energy needs during, 38
Secondary progressive (SP) multiple sclerosis, 90
Secondary survey, 105–106
Sedatives, pharmacologic pain management and, 157
Seizures,
partial, 88
tonic-clonic, 89
Selective serotonin reuptake inhibitors (SSRIs), 118
Self-image, maternal, during postpartum period, 226
Senses, in parent-infant communication, 234–235
Sensory impairment, parental, and transition to parenthood, 237
Sensory organ, in initial assessment of the newborn, 261
Sepsis, in newborn, 291
Serious fetal diagnosis, 325
Serum glucose,
level, pregnancy and, 27
in newborn, 266
Severe preeclampsia, hypertension and, 65
Sex determination, of embryo, 4
Sex-linked genes, 4
Sexual counseling, pregnancy and, 30
Shoulder dystocia, 203–204
Sibling adaptation,
to pregnancy, 24
transition to parenthood and, 237
Side-lying position, during labor, 181, 186
in uteroplacental insufficiency, 185, 188
Single father, 24
Single mother, 24
Sinus venosus defect, 298
Skin-to-skin contact, 234
Skull bones, fetal, 141
SLE., See Systemic lupus erythematosus (SLE)
Sleep-wake states, in newborn, 255–256
Sleepy baby, infant nutrition and, 279
Smell, of newborn, 256
Smoking, pregnancy and, 22
SNAP., See Supplemental Nutrition Assistance Program (SNAP)
Socioeconomic conditions, in transition to parenthood, 237
Sodium, for maternal and fetal nutrition, 41
Soft tissues, passageway and, 142–143
Sonogram,
for high-risk pregnancy, 57
for pregnancy, 27
SP., See Secondary progressive (SP) multiple sclerosis
Spermatogenesis, 1
Spica cast,
car seats for, 310, 320
foul smell from, 309, 320
position for, 310, 321
Spinal anesthesia, 158
Splenectomy, for idiopathic thrombocytopenic purpura, 246
Spontaneous abortion., See Miscarriage
Spontaneous preterm labor, 189
causes of, 189
SSRIs., See Selective serotonin reuptake inhibitors (SSRIs)
Stages of grief, 323, 324b, 329, 330
Startle reflex., See Moro reflex
Station, as factors affecting labor, 141, 143f
Stillbirth, 324, 329, 330
Stork bites, 254
Stress,
disorder, posttraumatic, 122–123
in labor, first stage of, 176
Striae gravidarum, 15
Subinvolution, of uterus, 209
Substance abuse,
definitions, 128–129
perinatal, 128–135
Substance dependence, 129, 292–293
Substance intoxication, 128
Substance tolerance, 129
Substance withdrawal, 128–129
Succenturiate placenta, 73
Sucking, in newborn, 254
Superficial venous thrombosis, 247
Supine hypotension, 13, 14f
Supplemental Nutrition Assistance Program (SNAP), 49
Synchrony, in parent-infant contact, 235
Syphilis, 290, 294, 318
Systemic analgesia, pharmacologic pain management and, 157–158
Systemic lupus erythematosus (SLE), 92–93
T
Tachypnea, assessment of, 310, 321
Taking-hold phase, 239, 241
Taking-in phase, 239, 241
Taste, of newborn, 256
Tdap., See Tetanus-diphtheria-acellular pertussis (Tdap)
Telangiectatic nevi, 254
Telogen effluvium, 215
Temperature, of newborn, 254
Teratogens, 8
Terbutaline sulfate, 206
Termination of pregnancy for fetal anomalies (TOPFA), 325
Tetanus-diphtheria-acellular pertussis (Tdap), vaccination for, during
postpartum period, 223
Tetralogy of Fallot, 298–299
Therapeutic interventions,
in abused drugs, 130, 134
in acute respiratory distress syndrome, 87
in agoraphobia, 120
in anemia, 96–97
in appendicitis, 101
in asthma, 84
in asymptomatic bacteriuria, 97
in Bell palsy, 91
in cancer, 100
in cholelithiasis/cholecystitis, 102
in cystic fibrosis, 86
in cystitis, 98
in DIC, 73
in early pregnancy bleeding, 68
in ectopic pregnancy, 69
in epilepsy (seizure disorder), 89
in generalized anxiety disorder, 121
in hydatidiform mole, 70
in hyperemesis gravidarum, 78
in hyperthyroidism, 79
in hypothyroidism, 81
in incompetent cervix, 69
in inflammatory bowel disease, 95
in intrahepatic cholestasis of pregnancy, 88
in major depression, 118
in multiple sclerosis, 90
in myasthenia gravis, 94
in obsessive-compulsive disorder, 122
in panic disorder, 119–120
in placenta, 72
in placenta previa, 71
in postpartum depression,
with psychotic features, 128
without psychotic features, 126
in posttraumatic stress disorder, 123
in pruritic urticarial papules and plaques of pregnancy, 88
in pyelonephritis, 99
in systemic lupus erythematosus, 92
Thermoregulation, in late preterm infants, 314
Third stage of labor, 183
Third trimester, energy needs during, 38
Thrombus, during postpartum period, 224, 229
Thrush, 289
Thyroid,
changes in pregnancy, 17
postpartum physiologic changes in, 211
Thyroid disorders, 78–81, 117
Thyroidectomy, care for, 80
Thyroxine (T4) screening, for newborn, 255
Tidal volume, changes in pregnancy, 14t
Time, concerns in, 227, 231
Tobacco, substance abuse of, 129
Tocolysis, in fetal assessment, 171
Tocolytic therapy, for preterm labor, 190
Tolerance, substance, 129
Tonic neck, in newborn, 255
Tonic-clonic seizures, 89
TOPFA., See Termination of pregnancy for fetal anomalies (TOPFA)
Total anomalous pulmonary venous connection, 299
Total lung capacity, changes in pregnancy, 14t
Touch,
in newborn, 257
nonpharmacologic pain management and, 154
Toxoplasmosis, 291
Tracheoesophageal anomalies, 303–304
Transcutaneous electrical nerve stimulation, nonpharmacologic pain
management and, 155
Transient hypertension, 64
Transposition, of great vessels, 299
Trauma, 103–106
maternal adaptations during pregnancy to, 104t
physical examination of pregnant, 105–106b
Traumatic event, 122
Travel, pregnancy and, 30
Trial of labor, 203
Tricuspid atresia, 299
Triplets, 8
Trisomy 21, during high-risk pregnancy, 58
Trophoblastic disease, 70–71
True labor, clinical findings of, 144
True pelvis, 142
Truncus arteriosus, 299
Trust versus mistrust, infant nutrition and, 271
Tubal pregnancy pattern, 69
Tuberculosis, pregnancy and, 26
Typical behaviors, of newborn, 239, 240–241
U
Ultrasonography, for high-risk pregnancy, 55–56
Umbilical cord, 5f, 6
assessing, in labor, first stage of, 180, 186
prolapsed, 204
Umbilical cord blood acid-base determination, in fetal assessment, 171
Upper muscular uterine segment, 142
Urinalysis, neonatal, 266
Urinary system,
changes in pregnancy, 14–15
postpartum physiologic changes in, 212
Urinary tract infections, in postpartum infections, 250
Urine specimen analysis, in labor, first stage of, 177
Uterine activity,
abnormal, 193
monitoring of, during labor, 165
Uterine atony, in postpartum hemorrhage, 242
Uterine ligaments, trauma to, prevention of, 184, 187
Uterine tone, maintenance of, during postpartum period, 220–221, 221f
Uteroplacental blood flow, changes in pregnancy, 11
Uteroplacental insufficiency, 173, 175
side-lying position in, 185, 188
Uterus, 5f
changes in pregnancy, 11–12
contracted, patient teaching for, 224, 229
postpartum physiologic changes in, 209
rupture of, 204–205
V
Vaccinations, health promotion for planning future pregnancies, 223
Vacuum assisted, vaginal birth, 200–201
Vacuum extraction, 200
Vagina,
changes in pregnancy, 12
physical examination of, in pregnant trauma victim, 105–106b
postpartum physiologic changes in, 210
Vaginal birth,
after Cesarean, 203
operative, 200–201
Vaginal bleeding, immediate investigation of, 225, 230
Valvular aortic stenosis, 300
Varicella, vaccination for, during postpartum period, 223
Varicosities, postpartum physiologic changes and, 214
Vegetarianism, pregnancy and, 44
Venous stasis, 247
Venous thromboembolic disorders, 247–248
Ventricular septal defect, 297
after open heart surgery, 309, 319–320
Vernix caseosa, 254
Version, as obstetric procedure, 198
Vibroacoustic stimulation, for high-risk pregnancy, 60
Vibroacoustic stimulation, in fetal assessment, 171
Vision, of newborn, 256
Visiting hours, in birthing unit, 227, 231
Visually impaired parent, and transition to parenthood, 237
Vital signs, postpartum physiologic changes and, 213–214
Vitamin A,
for lactation, 47
during pregnancy, 41
Vitamin B6, for maternal and fetal nutrition, 42
Vitamin B12,
for breastfed infants, 277
for lactation, 47
during pregnancy, 42
Vitamin C,
for lactation, 47
during pregnancy, 42
Vitamin D,
infant nutrition and, 277
for maternal and fetal nutrition, 41
Vitamin E, for maternal and fetal nutrition, 42
Vitamin K, for newborns, 277
Vitamins,
for infants, 277
for lactation, 47
during pregnancy, 41–42
Vomiting, pregnancy and, 49
von Willebrand disease (vWD), 246
vWD., See von Willebrand disease (vWD)
W
Warfarin, for deep venous thrombosis, 248
Water, for newborns, 276
Water block, intradermal, nonpharmacologic pain management and, 155
Water therapy, nonpharmacologic pain management and, 155
Water-soluble vitamins, for maternal and fetal nutrition, 42
Weaning, infant nutrition and, 280
Weight gain,
for maternal and fetal nutrition, 38–39, 38t
slow, infant nutrition and, 279
Weight loss,
postpartum physiologic changes and, 211–212
during pregnancy, 23
Wharton jelly, 6
White blood cells,
in newborn, 265
postpartum physiologic changes and, 214
WIC., See Women, Infants, and Children (WIC)
Witch’s milk, in newborn, 255
Withdrawal,
substance, 128–129
symptoms, treatment for, 134
Women, Infants, and Children (WIC), 49
Work, pregnancy and, 29–30
Wound infections, in postpartum infections, 249–250
Y
Yolk sac, 5–6, 5f
Z
Zinc,
for lactation, 47
during pregnancy, 41
Zygote, 1