HESI Remediation Packet Maternity

Environmental Management: Attachment Process/Manipulation of Individual's surroundings to facilitate the development of the parent-infant relationship

-Create an environment that fosters privacy. -individualize daily routine to meet parents' needs. -Permit father or significant other to sleep in room with mother. -Develop policies that permit presence of significant others as much as desired.

Parent Education: Infant: Instruction on nurturing and physical care needed during first year of life.

-Determine parents' knowledge, readiness, and ability to learn about infant care. -Provide anticipatory guidance about developmental changes during first year of life. -Teach parent or parents skills to care for newborn. -Demonstrate ways in which parent or parents can stimulate infant's development. -Discuss infant's capabilities for interaction. -Demonstrate quieting techniques.

The client has been prescribed a 4 gram bolus of magnesium sulfate to run over 20 minutes. It arrives from the pharmacy diluted in 250 mL of normal saline. What rate does the nurse set the IV pump to run the bolus? (Enter a whole number, round as needed. ) mL/hour

750 mL/h

Table 22-3: Examples of Parent-Infant Attachment Interventions

Attachment Promotion Facilitation of development of parent-infant relationship Provide opportunity for parent or parents to see, hold, and examine newborn immediately after birth. Encourage parent or parents to hold infant close to body. Assist parent or parents to participate in infant care. Provide rooming-in while in hospital.

Dural Puncture==Headache.

Because the tough dura and the fragile web-like arachnoid membranes lie close together, dural puncture also punctures the arachnoid. If the dura is unintentionally punctured with the needle used to introduce the catheter, substantial leakage of cerebrospinal fluid can occur, which may result in a spinal headache. Dural puncture and spinal headache also can occur without obvious cerebrospinal fluid leakage.

If the client had HELLP syndrome, which lab results would the nurse expect to see?

Decrased hemoglobin and hematocrit with burr cells, elevated liver enzhymes, and decreased platelets.

Visiting Twelve Step meeting

Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. In pregnant women, alcohol withdrawal tends to begin within 6 to 24 hours after the last drink. Alcohol withdrawal treatment during pregnancy consists of the administration of benzodiazepines. Chlordiazepoxide (Librium) and diazepam (Valium) are considered the benzodiazepine agents of choice for treatment of pregnant women. Since the 1970s, methadone maintenance therapy (MMT) has been considered the standard of care for pregnant women who are dependent on opioids. MMT is recommended because it reduces drug craving and promotes better adherence to prenatal care and drug abuse counseling visits. Buprenorphine (SBuutex or Buvoxone) is another medication approved for opioid addiction treatment hat s being sued increasingly during pregnancy. It appears to be as effective ad methadone. Neither buprenorphine nor methadone is associated with an increased risk for birth defects. Anywhere for 30% to 80% of infants exposed to opioids, including methadone or buprenorphine, in utero require treatment for neonatal abstinence syndrome (NAS). Neither the incidence nor the severity of NAS correlates directly with the maternal methadone dose at birth. Therefore, limiting the methadone dose to minimize the risk for NAS is not warranted. Detoxification from opioids during pregnancy is currently not recommended, because of fears of maternal relapse and a potential risk for fetal distress or fetal demise. however, a study of more that 600 pregnant women who were detoxified from opioids reported no fetal harm during the process. these data highly suggest that detoxificaiotn of pioid-addicted pregnant women is not harmful. in addition, the rate of treatment for nAS is less if long-term behavioral health management is provided once women are completely off opioids. Pregnant women who use cocaine should be advised to sop usig immediately and be referred for substance abuse tratment. Effective psychosocial and behavioral treatments have been develoed for pregnant substance abusers. Communication between obstetrics are provided and substance abuse treatment staff is necessary for treatment success. As is the case with cocaine users, methamphetamine users are urged to immediately stop all during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is very high. The most effective treatments for methamphetamine addiction at this time are behavioral therapies, such as cognitive-behavioral and contingency-management interventions. There are currently no medications that counteract the specific effects of methamphetamine or that prolong abstinence from and reduce the abuse of methamphetamine. Two-step method for diagnosing gestational diabetes mellitus (GDM), recommended by the American College of Obstetricians and Gynecologists. An international consensus group the International Association of Diabetes and Pregnancy Study Groups, consisting of representatives from multiple obstetric and diabetic organizations including the ADA, recommends a different (one-step) method of screening and diagnosis. If the tests done early in pregnancy for preexisting diabetes are normal, a 75-g OGTT diagnostic test is administered between 24 and 28 weeks of gestation. The 75-g OGTT requires a fasting blood glucose level, which is drawn before giving the glucose load. Blood glucose levels are then drawn 1 and 2 hours later. A diagnosis of GDM is made if only one glucose value is exceeded. The one-step method of screening and diagnosis significantly increases the incidence of GDM because the upper limit of normal for the blood glucose value at each sampling time is lower than in the two-step method. Therefore, more cases of GDM are diagnosed. Most practitioners in the United States continue to use the two-step approach to screening for GDM. However, many countries in Europe and Asia, as well as some healthcare providers in the United States, have adopted the IADPSG recommendations for screening and diagnosing GDM. High serum glucose in pregnancy is associated with complications such as preeclampsia, macrosomia, operative vaginal birth, shoulder dystocia, birth injury, cesarean birth, neonatal intensive care, respiratory distress, and neonatal hyperbilirubinemia. A commonly accepted method of diagnosing gestational diabetes mellitus (GDM) has been a non-fasting glucose challenge test at 24-28 weeks of gestation. For a 50-g glucose challenge test, the most common cutoff was 140 mg/dL, a level that was associated with macrosomia and gestational hypertension. An elevated result triggered a fasting 2 or 3-hour oral glucose tolerance test (OGTT). A second abnormal result yielded a diagnosis of GDM. Using this approach, about 5% to 6% of pregnant women received treatment, including diet, exercise, glucose monitoring, and possibly oral hypoglycemic medication or insulin use. Conflicting Guidelines ACOG: In 2006, at least nine different criteria were used to identify gestational diabetes, using 50-100 g of glucose as the challenge. The American College of Obstetricians and Gynecologists' approach used two-step screening, clinical criteria, and history. Critics of this approach questioned its reliance on maternal, rather than newborn, outcomes; its acceptance of clinical criteria or history alone for diagnosis; and its ambiguous screening cutoffs. ADA: In 2008, the International Association of Diabetes in Pregnancy Study Group (IADPSG) set out to identify levels at which treatment would benefit the baby. They proposed a one-step approach, consisting of a 75-g OGTT. Abnormal levels were set based on their association with macrosomia and cord blood C-peptide =, a marker for fetal insulin levels. One abnormal result was enough to trigger a diagnosis of GDM. This approach is estimated to identify GDM in nearly 18% of all pregnant women. The American Diabetes Association (ADA) endorsed this approach. NIH Consensus Conference Criticism of the one-step approach includes reliance on just one abnormal result and the unintended consequences of labeling women with GDM: increase in cesarean birth and possibly labor induction, additional fetal assessments, more intensive newborn assessments, significantly increased patient costs, life disruptions, and psychological stress. To resolve the differences between the ACOG and ADA approaches, the National Institutes of Health (NIH) convened a Consensus Conference. The NIH conference found some advantages for convenience of diagnosis within the context of one visit; however, there was insufficient evidence of clear improvement in patient outcomes to recommend the one-stop approach. Therefore, the NIH group recommended continuing the current two-step approach and called for further targeted research.

Family Integrity Promotion: Childbearing Family. Facilitation of growth of individuals or families who are adding infant to family unit.

Prepare parent or parents for expected role changes involved in becoming a parent. Prepare parent or parents for responsibilities of parenthood. Monitor effects of newborn on family structure. Reinforce positive parenting behaviors.

The client's spouse is at the bedside helping her use relaxation breathing through each contraction. The client is in the right lateral position with the head of the bed slightly elevated. She asks why the magnesium sulfate was increased. What explanation should the nurse provide? The anxiety caused by labor contractions is affecting the drug's efficacy. The HCP increased the dosage to achieve the level that prevents seizures. The oxytocin is having an adverse interaction with the magnesium sulfate. The HCP increased the level because your blood pressure keeps going up.

The HCP increased the dosage to achieve the level that prevents seizures.

Breastfeeding reduces the amount of insulin needed.

The need for additional insulin falls during the postpartum period. Breastfeeding is encouraged not only for the newborn's benefit but also because the added calorie intake by the mother helps lower the amount of insulin needed in women with types 1 and 2 diabetes mellitus. The woman with gestational diabetes mellitus (GDM) usually needs no insulin after birth but the greater risk for later development of type 2 diabetes should be emphasized with teaching before discharge.

Smoking can interfere with the milk ejection (let-down) reflex.

Women who smoke and breastfed should avoid smoking for 2 hours before a feeding to minimize the amount of nicotine in the milk and improve the milk-ejection reflex. All smokers should be discouraged from smoking in the same room with the infant because exposure to second-hand smoke can increase the likelihood that the infant will experience behavioral and respiratory health problems.

Which technique should the nurse use when evaluating the client's blood pressure while she is on bed rest? a) Have the client lie supine and take the blood pressure on the left arm. b) Have the client lie in a lateral position and take the blood pressure on the dependent arm. c) Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level. d) Have the client stand briefly and take the blood pressure on the right arm.

b) Have the client lie in a lateral position and take the blood pressure on the dependent arm.

The client's sister is very concerned about the swelling in her sister's face and hands because it seems to be worsening rapidly. She asks the nurse if the healthcare provider (HCP) will prescribe some water pills (diuretics) to help get rid of the excess fluid.

"I would be happy to explain to you about the effect of diuretics on pregnancy." (The sister may have seen diuretics used for treating fluid retention before (for example, in cardiac disease), but may not be aware of how diuretics affect pregnancy. Diuretics decrease blood flow to the placenta by decreasing blood volume. In the case of the preeclamptic client, this is particularly dangerous because the disease has already caused a volume deficit. In addition, the diuretics disrupt normal electrolyte balance and stress kidneys that are already compromised by preeclampsia. The only time they are used is if the preeclamptic client also has heart failure, but this client has no symptoms of heart failure.)

The client asks the nurse why she is getting magnesium sulfate. What is the the nurse's best response? "It is a diuretic and it is being given to help get the fluid off." "It is a tocolytic, which means it is being given to stop your labor." "It is a central nervous system depressant given to prevent seizures." "It is an antihypertensive and it will help bring your blood pressure down."

"It is a central nervous system depressant given to prevent seizures."

The client's spouse offers to sign the consent forms for her since she isn't feeling well right now. Which response by the nurse is correct? "The client does not have to sign the informed consent." "That would be fine. Please read over the forms before you sign." "If the client does not feel like signing, we just wait until she feels better." "The client should sign the consent forms herself since she is the one receiving the care."

"The client should sign the consent forms herself since she is the one receiving the care."

Lactation Counseling: Use of interactive helping process to assist in achieving and maintaining successful breastfeeding.

-Correct misconceptions, misinformation, and inaccuracies about breastfeeding. -Assess feeding techniques and assisted as needed. -Evaluate parents' understanding of infant's feeding cues (e.g., rooting, sucking, alertness). -Determine frequency of feedings in relation to infant's needs. -Demonstrate breast massage and discuss its advantages to increasing milk supply. -Provide education, encouragement, and support.

Risk Identification: Childbearing Family: Identification of individual or family likely to experience difficulties in parenting and assigning priorities to strategies to prevent parenting problems

-Determine developmental stage of parent or parents. -Reviewing prenatal history for factors that predispose individuals or family to complications. -Ascertain understanding of English or other language used in community. -Monitor behavior that may indicate problem with attachment. -Plan for risk-reduction activities in collaboration with individual or family.

Women Want to Know How to use a Diaphragm

-Follow instructions carefully when using your diaphragm. Skill at insertion and removal increases with practice. Plan to insert the diaphragm up to 6 hours before intercourse. -Empty your bladder before insertion. Spread about a tablespoon of spermicidal cream or gel inside the dome and around the rim. -Insert the diaphragm into the vagina with the spermicide toward the cervix. A squatting position or placing one foot on the tub or toilet seat makes insertion and removal easier. -Be sure that the front rim fits behind your pubic bone and that you can feel the cervix through the center of the diaphragm. If more than 6 hours pass between insertion and intercourse or if you have intercourse again, insert more spermicide into the vagina without removing the diaphragm. -Leave the diaphragm in place for at least 6 hours after the last intercourse. Leaving it in place for more than 24 hours increases the risk of toxic shock syndrome. -Douching with the diaphragm in place is unnecessary and lessens the effectiveness. -To remove the diaphragm, assume a squatting position and bear down. Hook a finger around the front rim to break the suction, and pull down. -Wash the diaphragm with mild soap and dry well after each use. Inspect it for holes by holding it up to a light or filling it with water. If you find a hole, use another contraceptive method and go to your health care provider for a new diaphragm.

While the nurse is awaiting the lab results to determine if the client has elevations in liver function, diminished kidney function, or altered coagulopathies, which questions should the nurse ask her? (Select all that apply. One, some, or all options may be correct.) a) "Do you have any dizziness?" b) "Do you have blurry vision?" c) "Do you have abdominal pain?" d) "Do you have cramping in your calf when you flex your leg?" e) "Do you have shortness of breath or chest discomfort?"

1. "Do you have any dizziness?" 2. "Do you have blurry vision?" 3. "Do you have abdominal pain?" 5. "Do you have shortness of breath or chest discomfort?"

Parental Behaviors Affecting Infants Attachment.

1. Looks; gazes; takes in physical characteristics of infant; assumes en face position; eye contact. 1a. Turns away from infant; ignores infant's presence. 2. Hovers' maintains proximity; directs attention to points to infant. 2a. Avoids infant; does not seeks proximity; refuses to hold infant when given opportunity. 3. Identifies infant as unique individual. 3a. Identifies infant with someone parent dislikes; fails to recognize any of infant's unique features. 4. Claims infant as family member; names infant. 4a. Fails to place infant in family context or identify infant with family member; has difficulty naming. 5. Touches; progresses from fingertip to fingers to palms to encompassing contact. 5a. Fails to move from fingertip to palmar contact and holding. 6. Smiles at infant. 6a. Maintains bland countenance or frowns at infant. 7. Talks to, coos, or sings to infant. 7a. Wakes infant when infant is sleeping; handles roughly; hurries feeding by moving nipple continually. 8. Expresses pride in infant. 8a. Expresses disappointment, displeasure in infant. 9. Assigns meaning to infant's actions and sensitively interprets infant's needs. 9a. Makes no effort to interpret infant's actions or needs. 10. Views infant's behaviors and appearance in positive light. 10a. Views infant's behavior as exploiting, deliberately uncooperative; views appearance as distasteful, ugly.

Dealing With Pregnant Substance Abusers

1. Realize that the decision to become and remain sober can only be made by he substance abuser. 2. Understand that nurses do not have the power to cure anyone. They only serve as educators, supporters, and advocates. 3. Educate yourself about the effects of drug use in general and effects on pregnancy and the newborn specifically. 4. Treat substance abusers with the same respect and consideration that you show other people. 5. Become familiar with your local treatment centers. Learn which of them accept pregnant women. Keep an up to date list of groups meeting in your community. 6. Remember that there are no "hopeless cases." It is never too late to quit! 7. Practice patience and persistence. It may take months or years to see the effects of your work.

The HCP prescribes an IV infusion of magnesium sulfate of 1 gram/hour after the bolus has been completed. The pharmacy sends an IV bag with 40 grams/1000 mL. What rate should the nurse set the IV pump? (Enter a whole number, if needed, round to a whole number.) mL/hour

25

After the nurse establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000 mL D5LR. The prescription from the HCP is oxytocin 2 mU/min to augment labor. What is the drip rate for the oxytocin? (Enter the numerical value only. If rounding is required, round to the whole number.)

6

Which client should be assigned to the most experienced nurse? A 15-year-old gravida 1, para 0, with mild preeclampsia. A 35-year-old gravida 3, para 2, with HELLP syndrome. A 23-year-old gravida 2, para 0, with gestational diabetes. A 16-year-old gravida 1, para 0, with preterm labor.

A 35-year-old gravida 3, para 2, with HELLP syndrome.

Increasing effective Communication

A woman often does not volunteer information about her feelings and concerns, especially if she has negative feeling about their care. In addition, the woman and the nurse both may be unaware of any misunderstanding or conflict regarding the plan of care. Nurses must ask specifically about the feelings and concerns that woman and her family have about the pregnancy.

AntePartum-Identifying Gestational Diabetes Mellitus

All pregnant women should be screened by identification of history or risk factors that are consistent with GDM or by blood glucose testing. A common prenatal screening test is the glucose challenge test (GCT) administred between 24 and 28 weeks. An oral glucose tolerance test may be used as the initial test if a woman is at high reisk for GDM but is more likely to be used as a diagnostic test when abnormally high GCT results occur. Women with a fasting glucose level greater than 126 mg/dL or a nonfasting level of more than 200 mg/dL meet the criteria for GDM, and no added testing is needed. Glucose challenge test. Fasting is not necessary for a GCT, and the woman is not required to follow any pretest dietary instructions. The woman should ingest 50 g of oral glucose solution; 1 hour later, a blood sample is taken. If the blood glucose concentration is 140 mg/dl or greater, a 3 hour oral glucose tolerance test (OGTT) is recommended. Some practitioners use a lower cutoff of 130 or 1135 mg/dL to identify more women at risk. Oral glucose tolerance test. The OGTT is the gold standard for diagnosing diabetes, but this test is more complicated. After the fasting plasma glucose level is determined, the woman should ingest 100 g of oral glucose solution. Plasma glucose levels are then determined at 1, 2, and 3 hours. GDM is the diagnosis of the fasting blood glucose level is abnormal or if two or more of the following values occur on the OGTT. Fasting greater than 95 mg/dL 1 hour, greater than 180 mg/dL. 2 hours, greater than 155 mg.dL 3 hours, greater than 149 mg.dL

Advice regarding breastfeeding must be individualized.

Although all abused substances appear in breast milk, some in greater amounts than others, breastfeeding is definitely contraindicated in women who use methamphetamine, alcohol, cocaine, heroin, or marijuana.a However, methadone used is not a contraindication to breastfeeding. The baby's nutrition and safety needs are of primary importance in this consideration. For some women, a desire to breastfeed can provide strong motivation to achieve and maintain sobriety.

Nursing Interventions

Although substance abusers can be difficult of care for at any time, they are often particularly challenging during the intrapartum and postpartum periods because of manipulative and demanding behavior. typically these women display poor control over their behavior and a low threshold for pain. Increased dependency needs and lack of involvement with infant care may also be apparent. Nurses must understand that substance abuse is an illness and that these women deserve to be treated with patience; kindness, consistency, and firmness when necessary. Even women who are actively abusing drugs experience pain during labor and after giving birth and may need both pharmacologic and nonpharmacologic interventions. Developing a standardized plan of care so patients have limited opportunities to play staff members against one another is helpful. Mother-infant attachment should be promoted by identifying the woman's strengths and reinforcing positive maternal feelings and behaviors. Staffing should be sufficient to ensure strict surveillance of visitors and prevent unsupervised drug use.

The nurse asks the client if the HCP has discussed the labor and delivery processes, potential complications, and the management of those complications with her and if she understands them. The client replies, "I think so," and then asks for a pen. Witness the signatures after the client and her spouse have signed the consent form. Call the HCP to explain all procedures again to the client before asking her to sign. Explain all the procedures and risks, and then ask the client to sign the consent form. Ask the client to explain what she understands about the procedures she is undergoing.

Ask the client to explain what she understands about the procedures she is undergoing.

Assessment of Attachment Behaviors One of the most important areas of assessment is careful observation of specific behaviors thought to indicate the formation of emotional bonds between the newborn and the family, especially the mother. Unlike physical assessment of the neonate, which has concrete guidelines to follow, assessment of parent-infant attachment relies more on skillful observation and interviewing. Rooming-in of mother and infant and liberal visiting privileges for father or partner, siblings, and grandparents providing nurses with excellent opportunities to observe interactions and identify behaviors that demonstrate positive or negative attachment. Attachment behaviors can be easily observed during infant feeding session. Box 22-1 presents guidelines for assessment of attachment behaviors.

Assessing Attachment Behavior -When the infant is brought to the parents, do they reach out for the infant and call the infant by name? (recognize that in some cultures parents may not name the infant in the early newborn period.) -Do the parents speak about the infant in terms of identification--who the infant resembles, and what appears special about their infant over others infants? -When parents are holding the infant, what kind of body contact is seen-do parents feel at ease in changing the infant's position, are fingertips or whole hands used, and does the infant have parents of the body they avoid touching or parts of the body they investigate and scrutinize? -When the infant is awake, what kinds of stimulation do the parents provide--do they talk to the infant, to each other, or to no one, and how do they look at the infant--direct visual contact, avoiding eye contact, or looking at other people or objects? -How comfortable do the parents appear in terms of caring for the infant? Do they express any concern regarding their ability or disgust for certain activities, such as changing diapers? -What type of affection do they demonstrate to the newborn, such as smiling, stroking, kissing, or rocking? -if the infant is fussy, what kinds of comforting techniques do the parents use, such as rocking, swaddling, talking, or stroking?

When evaluating the fetal monitor strip, the nurse notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change? Cord compression is occurring due to oxytocin making the contractions stronger. The fetus' head is descending further into the pelvis and this causes the heart rate to decrease. The fetus has the same magnesium level as the mother's, causing the fetus to be sedated. The mother's hypertension has caused an acute stress incident in the fetus.

At 0930 the client'a spouse rings the call bell and yells, "Come quickly, she is shaking all over!" The nurse determines that the client is experiencing an eclamptic seizure. Make a note of the time and sequence of the eclampsia seizure. Observe fetal monitor for non-reassuring patterns of fetal heart rate. Turn the client onto her side and place a pillow behind her to stabilize the position. Suction the mouth and oropharynx, and apply oxygen at 10 liters/minute by facemask. Submit

Follow-Up Care

Before a known substance abuser is discharged with her baby, the home situation must be assessed to determine the environment is safe and that someone will be available to meet the infant's needs if the mother is unable to do so. the social services department of the birthing facility is usually involved in interviewing the mother before discharge to ensure that the infant's needs will be met. Family members or friends are sometimes asked to become actively involved with the mother and infant after discharge. A home care or public health nurse may be asked to make home visits to assess the mother's ability to care for the baby and provide guidance and support. If serious questions about the infant's well-being exist, the case is likely to be referred to the state child protective services agency for further action.

Blood Glucose Monitoring

Blood glucose levels should be evaluated to determine whether levels are normal. A common method is measurement of fasting blood glucose level (no food for the previous 4 hours) and postprandial blood glucose level (2 hours after each meal). If fasting capillary blood glucose levels repeatedly exceed 120 mg/dL, insulin therapy is started. Additional tests for glucose levels may be performed, as needed.

If the nurse observes that a client on magnesium sulfate has 40 mL in the urimeter in 2 hours, her respiratory rate is 10 breaths/minute and her DTR's are 4, which medication should the nurse prepare to administer? Vitamin K. Corticosteroid. Calcium gluconate. Polystyrene sulfonate.

Calcium gluconate

What is the pathophysiology responsible for the client's complaint of a pounding headache and the elevated DTRs?

Cerebral edema

Fostering Bonding in Women of Varying Ethnic and Cultural Groups

Childbearing practices and rituals of other cultures are not always congruent with standard practices associated with bonding in the Anglo-American culture. For example, Chinese families traditionally use extended family members to care for the newborn so that the mother can rest and recover, especially after a cesarean birth. Some Native-American, Asian, and Hispanic women do not initiate breastfeeding until their breast milk comes in. Haitian families do not name their babies until after the confinement month. The amount of eye contact varies among cultures as well. Yup'ik Eskimo mothers almost always position their babies so that they can make eye contact. Nurses should become knowledgeable about the childbearing beliefs and practices of diverse cultural and ethnic groups. Because individual cultural variations exist within groups, nurses need to clarify with the client and family members or friends what cultural norms they follow. Incorrect judgements can be made about parent-infant bonding if nurses do not practice culturally sensitive care.

Therapeutic Management of GDM

Diet. Ideally, a registered dietitian, registered dietary technician, or diabetes educator determines the dietary need of the woman with GDM. The diet should provide the calories and nutrients needed for maternal and fetal health, result in euglycemia, avoid ketosis, and promote appropriate weight gain. Calories should be distributed in a way similar to that for preexisting diabetes. Simple sugars, found in concentrated sweets, should be eliminated from the diet based on a non-obese prepregnancy weight, an average of 30 kcal/kg/day is recommended. Calorie restriction to 25 kcal/kg each day may be recommended for women who are obese. These may be prescribed a diet wit ha smaller percentage of carbohydrates than that for women of normal weight to limit hyperglycemia. Carbohydrates at breakfast may be limited to 30 g during pregnancy because of increased levels of cortisol and growth hormones at that time of day. Protein foods at breakfast help satisfy early morning hunger. An evening snack is usually needed to prevent ketosis at night. Calories should be divided among three meals and at lest three snacks.

Assessing Attachment Behavior

During pregnancy, and often even before conception occurs, parents develop an image of the "ideal" or "fantasy" infant. At birth the fantasy infant becomes the real infant. How closely the dream child resembles the real child influences the bonding process. Assessing such expectations during pregnancy and at the time of the infant's birth allows identification of discrepancies in the parents' view of the fantasy child versus the real child. The labor process significantly affects the immediate attachment of mothers to their newborn infants. Factors such as a long labor, feeling tired or "drugged" after birth, and problems with breastfeeding, preterm birth, and being separated from the infant at birth can delay the development of initial positive feelings toward the newborn. Referral to groups such as La Leche League International or Postpartum Support International can be helpful.

Table 22.1--Infant Behaviors Affecting parental Attachment

Facilitating Behaviors and Inhibiting Behaviors. 1. Visually alert; eye-to-eye contact; tracking or following parent's face. 1a. Sleepy; eyes closed most of the time; gaze aversion. 2. Appealing facial appearance; randomness of body movement reflecting helplessness. 2a. Resemblance to person parent dislikes; hperirritability or jerky body movements when touched. 3. Smiles. 3a. Bland facial expression; infrquent smiles. 4. Vocalization; cryign only when hungry or wet. 4a. Crying for hours on end; colicky. 5. Grasp reflex 5a. Exaggerated motor reflex. 6. Anticipatory approach behaviors for feedings; sucks well; feeds easily 6a. Feeds poorly; regurgitates; vomits often 7. Enjoys being cuddled and held 7a. resists holding and cuddling by crying, stiffening body. 8. Easily consolable 8a. Inconsolable; unresponsive to parenting, care-taking tasks. 9. Activity and regularity somewhat predictable 9a. Unpredictable feeding and sleeping schedule. 10. Attention span sufficient to focus on parents 10a. Inability to attend to parent's face or offered stimulation 11. Differential crying, smiling, and vocalizing; recognizes and prefers parents. 11a. Shows no preference for parents over others. 12. Approaches through locomotion 12a. Unresponsive to parent's approaches. 13. Clings to parent; puts arms around parent's neck. 13a. Unresponsive to parent's approaches. 14. Clings to parent; puts arms around parent's neck. 14a. Seeks attention form any adult in room 15. Lifts arms to parents in greeting 15a. Ignores parents.

Diagnosis and Management of Substance Abuse

In addition to toxicology screening, the pregnant woman who uses illicit drugs must be assessed throughout pregnancy for STIs, hepatitis, and exposure to HIV. Fetal diagnostic tests such has ultrasonography, nonstress tests, and biophysical profiles help identify problems. Nurses monitor weight and provide guidance in nutrition to prevent maternal anemia and inadequate weight gain. Therapeutic management depends on the type of drug used and the problems presented. In the case of opioids, withdrawal during pregnancy has been associated with significant fetal stress, fetal seizures, and even fetal death. The pregnant woman who uses heroin is often prescribed an alternative drug, such as methadone, a synthetic opiate. Methadone, can be taken orally once daily and is long acting, providing consistent blood levels to decrease the adverse fetal effects of wide wings in blood level found with heroin use. At therapeutic levels, methadone does not produce the euphoria or sedation of heroin and allows the woman to live a relatively normal life. The woman in a drug-treatment program who receives a daily dose of methadone is more likely to receive prenatal care. However, the newborn must withdraw from methadone after birth. Some women taking methadone also use other illicit drugs such as cocaine or marijuana. Buprenorphine can be used instead of methadone, with less severe neonatal withdrawal. Treatment is aimed at establishing abstinence and preventing relapse. Outpatient or residential treatment provides education, individual and group therapy sessions, and peer support groups. Written contracts that focus on abstinence for one day at a time are often used to help the woman who has relapsed and experiences feelings of guilt and self-blame.

Hypovolemic Shock Interventions

Interventions -Notify the health care provider. -If the uterus is atonic, massage gently and expel clots to cause it to contract; compress uterus manually, as needed, using two hands. Add oxytocic agent to intravenous drop, as ordered. -Give oxygen by non-rebreather face mask at 10 L/min -Tilt the woman onto her side or elevate the right hip; elevate her legs to at least a 30-degree angle. -Provide additional or maintain existing intravenous (IV) infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume (woman should have patent IV lines' insert second IV using 16 to 18 gauge IV catheter). -Administer blood or blood products, as ordered. -Monitor vital signs. -Insert an indwelling urinary catheter to monitor kidney perfusion. -Administer emergency drugs, as ordered. -Prepare for possible surgery or there emergency treatments or procedures. -Document the incident, medical and nursing interventions instituted, and the woman's response to interventions.

Ante Partum Interventions

Interventions with substance-abusing pregnant women is best accomplished by an interprofessional health care team. Team members should include, at a minimum, an obstetrician, mental health provider, substance abuse counselor, nurse, and social worker. Medical Management Intervention with the pregnant substance abuser begins with education about specific effects on pregnancy, the fetus, and the newborn for each drug used. Consequences of perinatal drug use should be clearly communicated, and abstinence recommended as the safest course of action unless the woman is abusing opioids. Women are often more receptive to making lifestyle changes during pregnancy than at any other time in their lives. The casual, experimental, or recreational drug user is frequently able to achieve and maintain sobriety when she receives education, support, and continued monitoring throughout the remainder of the pregnancy. Periodic screening throughout pregnancy of women who have admitted to drug use may help them to continue abstinence. Treatment for substance abuse is individualized for each woman. Specific recommendations will vary depending on the type of drug used and the frequency and mount of use. Women are more likely to attempt to stop smoking during pregnancy than at any other time in their lives. Women who quit smoking by the first trimester have infants whose growth is comparable to those born to nonsmokers. Smoking-cessation programs during pregnancy are effective and should be offered to all pregnant smokers. These programs should continue throughout the postpartum period as well, because women who quit smoking during pregnancy tend to relapse within 1 year of giving birht. ACOG recommends the use of nicotine replacement patches in pregnant women who have been unable to stop smoking using nopharmacologic therapy. Many smoking-cessation resources are available, both in print and online, and smoking "quitlines" for example 1-800-QUIT0NOW are effective in assiting pregnant women to quit smoking. For more infomation on smokign cessation, vist the American Lung Association website. detoxification, short term inpatient or outpatient treamtnet, long term residential treatment, aftercare services, and self help support groups are all possible teratment options fo ralcohol and drug abuse. Women for sobrity may be more helpful organzization for women than Alcoholics Anonymous or Narcotics Anonymous, which were originally developed for male substance abusers. In general, long term treatment of any sort is becoming incresingly difficult to obtain, partcualrly for women who lack insruance coverage. Althoug hsome programs allow a woman to keep her children with her at the treatment facility, far too few of them are available to meet the demand.

The nurse performs a nonstress test to evaluate fetal well-being. The client is getting nervous and anxious with the situation. She asks the nurse why she is doing a nonstress test. What is the nurse's best response? It measures the oxygen levels of the fetus. Accelerations of the fetal heart rate in response to uterine contractions. It evaluates the heart rate of the fetus in response to its own movements. Late decelerations of the fetal heart rate in response to uterine contractions.

It evaluates the heart rate of the fetus in response to its own movements.

What information should be included in the client and family teaching about magnesium sulfate? This medication will be given intramuscular every four hours for 24 hours. Magnesium sulfate may cause hyperactivity, leg cramps, and difficulty sleeping. Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. Magnesium sulfate increases the risk of having seizures and we will need to watch her closely.

Magnesium is excreted in the urine, so the nurse will closely monitor the urine output.

Neurologic System that result from trauma during labor. Pregnancy induced neurologic discomforts disappear after_______? Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing the compression of the median nerve. Headache requires careful assessment. Postpartum headaches can be caused by various conditions, including postpartum-onset preeclampsia stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia. Depending on the cause and effectiveness of the treatment, the duration of the headaches can vary from 1 to 3 days to several weeks.

Neurologic changes during the puerperium are those that result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labor and childbirth. Pregnancy-induced neurologic discomforts disappear after birth. Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing the compression of the median nerve. The periodic numbness and tingling of fingers that afflict 5% of pregnant women usually disappear after childbirth unless lifting and carrying the baby aggravates the condition. Headache requires careful assessment. Postpartum headaches can be caused by various conditions, including postpartum-onset preeclampsia, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia. Depending on the cause and effectiveness of the treatment, the duration of the headaches can vary from 1 to 3 days to several weeks.

Metabolic Changes Associated with Pregnancy: Increased metabolism.

Normal pregnancy is characterized by comlex alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis. During normal pregnancy, adjustments in maternal metabolism allow for adequate nutrition for the mother and the developing fetus. Glucose, the primary fuel used by the fetus, is transported across the placenta through the process of carrier-mediated facilitated diffusion, meaning that the glucose levels in the fetus are directly proportional to maternal levels. Although glucose crosses the placenta, insulin does not. Around the tenth week of gestation, the fetus begins to secrete its own insulin at levels adequate to use the glucose obtained from the mother. Therefore, as maternal glucose levels rise, fetal glucose levels are increased resulting in increased fetal insulin secretion. During the first trimester of pregnancy, the pregnant woman's metabolic status is significantly influenced by the rising levels of estrogen and progesterone. These hormones stimulate the beta cells in the pancreas to increase insulin production, which promotes increased peripheral use of glucose and decreased blood glucose, with fasting levels being reduced by approximately 10%. At the same time, an increase in tissue glycogen stores and a decrease in hepatic glucose production occur, which further encourage lower fasting glucose levels. As a result of these normal metabolic changes of pregnancy, women with insulin-dependent diabetes are prone to hypoglycemia during the first trimester. Changing insulin needs during pregnancy. A, First trimester: Insulin need is reduced because of increased insulin production by pancreas and increased peripheral sensitivity to insulin; nausea, vomiting, and decreased food intake by mother ang glucose transfer to embryo or fetus contribute to hypoglycemia. B, Second trimester: insulin needs begin to increase as placental hormones, cortisol, and insulinase act as insulin antagonists, decreasing effectiveness of insulin. C, Thirst trimester: Insulin needs may double or even quadruple but usually level off after 36 weeks of gestation. D, Day of birth: maternal insulin requirements decrease drastically to approach prepregnancy levels. E, Breastfeeding mother maintains lower insulin requirements, as much as 25% less than those of prepregnancy; insulin needs of non-breastfeeding mother return to prepregnancy levels in 7 to 10 days, F, Weaning of breastfeeding infant causes mother's insulin needs to return to prepregnancy levels. During the second and third trimesters, pregnancy exerts a "diabetogenic" effect on the maternal metabolic status. Because of the major hormonal changes, decreased tolerance to glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose occur. Rising levels of human chorionic somatomamotropin, estrogen , progesterone, prolactin, cortisol, and insulinase increase from approximately 18 to 24 weeks of gestation to approximately 36 weeks of gestation. Maternal insulin requirements may double or quadruple by the end of the pregnancy. At birth, expulsion of the placenta prompts an abrupt drop in levels of circulating placental hormones, cortisol, and insulinase. Maternal tissues quickly regain their prepregnancy sensitivity to insulin. For the non-breastfeeding mother, the prepregnancy insulin-carbohydrate balance usually return in approximately 7 to 10 days. Lactation uses maternal glucose; therefore the breastfeeding mother's insulin requirements remain lower during lactation. On completion of weaning, the mother's prepregnancy insulin requirement is reestablished.

An important part of attachment is an acquaintance.

Parents use eye contact, touching, talking, and exploring to become acquainted with their infant during the immediate postpartum period. Adoptive parents undergo the same process when they first meet their new child. During this period families engage in the claiming process, which is the identification of the new baby. The child is first identified in terms of "likeness" to other family members, when in terms of "differences," and finally in terms of "uniqueness." The unique newcomer is thus incorporated into the family. Mothers and fathers examine their infant carefully and point out characteristics that the child shares with other family member and that are indicative of a relationship between them. Maternal comments such as the following reveal the claiming process: "Everyone says, "he's the image of his father," but I found one part like me--his toes are shaped like mine.

(hemoglobin and hematocrit). Hematomas--Vulvar hematomas are the most common. Pain is the most common symptom, and most vulvar hematomas are visible. Viganial hematomas occurs more commonly in association with a forceps-assisted birth, and episiotomy, or primigravidity. Retroperitoneal hematomas are the least common but life-threatening. They are caused by laceration of one of the vessels attached to the hypogastric artery, usually associated with rupture of a cesarean scare during labor. During the postpartum period, the if the woman reports persistent perineal or rectal pain or a feeling of pressure in the vagina, a careful examination is made. However, a retroperitoneal hematoma can cause minimal pain and the initial symptoms can be signs of shock. Hematomas are usually surgically evacuated. Once the bleeding has been controlled, usual postpartum care is provided with careful attention to pain reliefs, monitoring the amount of bleeding, replacing fluids, and reviewing the laboratory results (hemoglobin and hematocrit).

Pelvic hematomas (i.e., a collection of blood in the connective tissue) can be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most common. Pain is the most common symptom, and most vulvar hematomas are visible. Vaginal hematomas occur more commonly in association with a forceps-assisted birth, an episiotomy, or primigravidity (Francois & Foley, 2017). Retroperitoneal hematomas are the least common but life-threatening. They are caused by laceration of one of the vessels attached to the hypogastric artery, usually associated with rupture of a cesarean scar during labor. During the postpartum period, if the woman reports persistent perineal or rectal pain or a feeling of pressure in the vagina, a careful examination is made. However, a retroperitoneal hematoma can cause minimal pain and the initial symptoms can be signs of shock (Francois & Foley, 2017). Hematomas are usually surgically evacuated. Once the bleeding has been controlled, usual postpartum care is provided with careful attention to pain relief, monitoring the amount of bleeding, replacing fluids, and reviewing laboratory results (hemoglobin and hematocrit).

Preventing Excessive Bleeding All women are at risk. The most frequent cause of hemorrhaging is uterine atony. The most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention. If uterine atony occurs, the relaxed uterus distends with blood clots, blood vessels, in the placental site are not clamped off, and excessive bleeding results. Although the cause of uterine atony is not always clear, it often results from retained placental fragments. Excessive blood loss after birth can also be caused by vaginal or vulvar hematomas or unrequited lacerations of the vagina or cervix. These potential sources might be suspected if excessive vaginal bleeding occurs in the presence of a firmly contracted uterus. A perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, and notification of the primary health care provider. More objective estimates of blood loss include measuring serial hemoglobin or hematocrit values, weighing blood clots and items saturated with blood (1 ml equals 1 g), and establishing how many milliliters are required to saturate the perineal pads being used. Any estimation of lochial flow is inaccurate and incomplete without considering the time factor. The woman who saturates a perineal pad in 1 hour or less is bleeding much more heavily than the woman who saturates one perineal pad in 8 hours. Nurses in general tend to overestimate rather than underestimate blood loss. Different brands of perineal pads vary in their saturation volume and soaking appearance. For example, blood placed on some brands tends to soak down into the pad, whereas on other brands it tends to spread outward. Nurses should determine saturation volume and soaking appearance for the brands used in their institution, so they can improve the accuracy of blood loss estimation. The nurse always checks for blood under the mother's buttocks as well as on the perineal pad. Although the amount on the perineal pad can appear to be small, blood can flow between the buttocks onto the linens under the mother. When this happens, excessive bleeding can go undetected. When excessive bleeding occurs, vital signs are monitored closely. Blood pressure is not a reliable indicator of impending shock from early postpartum hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the woman has lost 30% to 40% of her blood volume. Respirations, pulse, skin condition, urinary output, and level of consciousness are more sensitive means of identifying hypovolemic shock. The frequent physical assessments performed during the fourth stage of labor are designed to provide prompt identification of excessive bleeding. Nurses maintain vigilance for excessive bleeding throughout the hospital stay as they perform a periodic assessment of the uterine fundus and lochia.

Preventing Excessive Bleeding All women who have given birth are at risk for excessive bleeding that can progress to postpartum hemorrhage (see Chapter 33). The most frequent cause of excessive bleeding after birth is uterine atony (i.e., failure of the uterine muscle to contract firmly). The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention. If uterine atony occurs, the relaxed uterus distends with blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results. Although the cause of uterine atony is not always clear, it often results from retained placental fragments. Excessive blood loss after birth can also be caused by vaginal or vulvar hematomas or unrepaired lacerations of the vagina or cervix. These potential sources might be suspected if excessive vaginal bleeding occurs in the presence of a firmly contracted uterus. SAFETY ALERT A perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, and notification of the primary health care provider. Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy (profuse). Figure 21-3 shows examples of perineal pad saturation corresponding to each of these descriptions. FIG 21-3Blood loss after birth is assessed by the extent of perineal pad saturation as (from left to right) scant (<2.5 cm), light (<10 cm), moderate (>10 cm), or heavy (one pad saturated within 2 hours). Although postpartal blood loss can be estimated by observing the amount of drainage on a perineal pad, judging the amount of lochial flow is difficult if based only on observation of perineal pads. More objective estimates of blood loss include measuring serial hemoglobin or hematocrit values, weighing blood clots and items saturated with blood (1 ml equals 1 g), and establishing how many milliliters are required to saturate the perineal pads being used. Any estimation of lochial flow is inaccurate and incomplete without considering the time factor. The woman who saturates a perineal pad in 1 hour or less is bleeding much more heavily than the woman who saturates one perineal pad in 8 hours. Nurses in general tend to overestimate rather than underestimate blood loss. Different brands of perineal pads vary in their saturation volume and soaking appearance. For example, blood placed on some brands tends to soak down into the pad, whereas on other brands it tends to spreads outward. Nurses should determine saturation volume and soaking appearance for the brands used in their institution so that they can improve accuracy of blood loss estimation. SAFETY ALERT The nurse always checks for blood under the mother's buttocks as well as on the perineal pad. Although the amount on the perineal pad can appear to be small, blood can flow between the buttocks onto the linens under the mother. When this happens, excessive bleeding can go undetected. When excessive bleeding occurs, vital signs are monitored closely. Blood pressure is not a reliable indicator of impending shock from early postpartum hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the woman has lost 30% to 40% of her blood volume (see Chapter 33). Respirations, pulse, skin condition, urinary output, and level of consciousness are more sensitive means of identifying hypovolemic shock (see the Emergency box). The frequent physical assessments performed during the fourth stage of labor are designed to provide prompt identification of excessive bleeding. Nurses maintain vigilance for excessive bleeding throughout the hospital stay as they perform periodic assessment of the uterine fundus and lochia. EMERGENCY Hypovolemic ShockSigns and Symptoms • Persistent significant bleeding occurs—perineal pad is soaked within 15 minutes; may not be accompanied by a change in vital signs or maternal color or behavior. • The woman states she feels weak, lightheaded, "funny," or nauseated or that she "sees stars." • The woman begins to act anxious or exhibits air hunger. • The woman's skin color turns ashen or grayish. • Skin feels cool and clammy. • Pulse rate increases. • Blood pressure decreases. Interventions • Notify the primary healthcare provider. • If the uterus is atonic, massage gently and expel clots to cause it to contract; compress uterus manually, as needed, using two hands. Add oxytocic agent to intravenous drip, as ordered. • Give oxygen by nonrebreather face mask at 10 L/min. • Tilt the woman onto her side or elevate the right hip; elevate her legs to at least a 30-degree angle. • Provide additional or maintain existing intravenous (IV) infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume (woman should have two patent IV lines; insert second IV using 16- to 18-gauge IV catheter). • Administer blood or blood products, as ordered. • Monitor vital signs. • Insert an indwelling urinary catheter to monitor kidney perfusion. • Administer emergency drugs, as ordered. • Prepare for possible surgery or other emergency treatments or procedures. • Document the incident, medical and nursing interventions instituted, and the woman's response to interventions.

Exercise for GDM

Research results have been mixed about whether exercise reduces the need for insulin in the woman with GDM. Nevertheless, exercise and an active lifestyle can improve cardiorespiratory fitness. A graduated physical exercise program should be recommended by a physician, taking into account each woman's risk factors, but exercise has been shown to be safe for women with GDM.

Gestational Diabetes Mellitus

Risk Factors GDM is a carbohydrate intolerance of variable severity that develops or is first recognized during pregnancy. Some women diagnosed with gestational diabetes may actually have unrecognized type 2 diabetes. GDM is an added risk factor that a woman will develop type 2 diabetes later in life, often well after she has finished bearing children. Factors such as obesity, inactivity, abnormal cholesterol levels, vascular disease, or family members with type 2 diabetes further increase a woman's risk to develop type 2 diabetes. Diagnosis begins with history taking to identify the woman at risk to develop gestational diabetes. Factors known to increase the risk include the following. • Overweight (body mass index [BMI] ≥25 to 25.9) or obesity (BMI ≥30 or morbidly obese (BMI ≥ 40 or higher) • Maternal age older than 25 years • Previous birth outcome often associated with GDM (neonatal macrosomia, maternal hypertension, infant with unexplained congenital anomalies, previous fetal death) • Gestational diabetes in previous pregnancy • History of abnormal glucose tolerance • History of diabetes in a close (first-degree) relative • Member of a high-risk ethnic group (African-American, Hispanic or Latino, American Indian, Asian American, or Pacific Islanders)

Assist the Bereaved parents in Communicating and Establishing Support from Family Members

Sensitive care of bereaved parents may involve their own parents. A couple's parents and other children are particularly important when a perinatal loss has occurred. However, it is up to the parents to decide to what extent they want family involved in the acute phases of their grief. If it is the parents' desire, nursing staff should allow a couple's children, parents, extend family members, and friends to be involved in the rituals surrounding the death, such as seeing and holding the baby. Such visits afford other the opportunity to become acquainted with the baby, to understand the parents' loss, to offer their support, and to say goodbye (see Fig. 3-2). This experience helps parents explain to their children about their brother or sister and what death means, offers the children answers to their questions in a concrete manner, and helps the children in pressing their grief. Involving extended family and friends enables the parents to mobilize their social support system of people who will support the family, not only at the time of loss but also the future. Parents also need information about how grief affects a family. They may need help in understanding and coping with the potential differing responses of various family members. Frustrations can arise because of the insensitive or inadequate responses of other family members. Parents may need help in determining ways to let family members know how they feel and what they need.

Hypovolemic Shock

Signs and Symptoms -Persistent significant bleeding occurs-perineal pad is soaked within 15 minutes; may not be accompanied by a change in vital signs or maternal color or behavior. -The woman states she feels weak, lightheaded, "funny." or nauseated or that she "sees stars." -The woman begins to act anxious or exhibits air hunger. -The woman's skin color turns ashen or grayish. -Skin feels cool and clammy. -Pulse rate increases. -Blood pressure decreases.

Mothers react negatively

Some mothers react negatively. They "claim" the infant in terms of the discomfort or pain the baby causes. The mother interprets the infant's normal responses as being negative toward her and reacts to her child with dislike or indifference. She does not hold the child close or touch the child in a comforting way. For example, "The nurse put the baby into Lydia's arms. She promptly laid him across her knees and glanced up at the television. "Stay still until I finish watching; you've been enough trouble already" Nursing interventions related to the promotion of parent-infant attachment are numerous and varied. (Table 22-3). they can enhance positive parent=infant contacts by heightening parental awareness of an infant's responses and ability to communicate. As the parent attempt to become competent and loving in that role, nurses can bolster the parent's self-confidence and ego. Nurses can identify actual and prevention of problems and collaborate with other health care professionals who will provide care for the parents after discharge. Nursing considerations for fostering maternal-infant bonding among special populations can vary (see the Cultural considerations box).

Hemoglobin, hematocri 12-16. With preeclampsia is may increase with HEELP it may decrease. Platelets normal 150,000. Preeclampsia would decrease below 100k. LDH values differ according to the test or assays being performed.

TABLE 12.3 -- Common Laboratory Changes in Preeclampsia NORMAL NONPREGNANTPREECLAMPSIAHELLPHemoglobin, hematocrit12-16 g/dL, 37%-47%May ↑↓Platelets (cells/mm3)150,000-400,000/mm3<100,000/mm3<100,000/mm3Prothrombin time (PT), partial thromboplastin time (PTT)12-14 sec, 60-70 secUnchangedUnchangedFibrinogen200-400 mg/dL300-600 mg/dL↓Fibrin split products (FSPs)AbsentAbsent or presentPresentBlood urea nitrogen (BUN)10-20 mg/dL↑↑Creatinine0.5-1.1 mg/dL>1.1 mg/dL↑Lactate dehydrogenase (LDH)*45-90 units/L↑↑ (>600 units/L)Aspartate aminotransferase (AST)4-20 units/L↑↑ (>70 units/L)Alanine aminotransferase (ALT)3-21 units/L↑↑Creatinine clearance80-125 mL/min130-180 mL/min↓Burr cells or schistocytesAbsentAbsentPresentUric acid2-6.6 mg/dL>5.9 mg/dL>10 mg/dLBilirubin (total)0.1-1 mg/dLUnchanged or ↑↑ (>1.2 mg/dL)

Fetal Surveillance

Testing to identify fetal compromise may begin as earl as 28 weeks of gestation if the woman has poor glycemic control or by 34 weeks of gestation in lower-risk women with GDM. The surveillance testing often includes "kick counts", ultrasonography for fetal growth and amniotic fluid volume, biophysical profile, nonstress test, contraction stress test, or amniocentesis for fetal lung maturity.

Preeclampsia==pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition

The 2013 ACOG Task Force on Hypertension in Pregnancy eliminated several criteria that had traditionally been used to diagnose severe features of preeclampsia. These include proteinuria, oliguria, presence of intrauterine growth restriction (IUGR), or fetal growth restriction as a requirement for the diagnosis of preeclampsia. In the absence of proteinuria, preeclampsia may be defined as hypertension along with either thrombocytopenia, impaired liver function, new onset renal insufficiency, pulmonary edema, or new onset cerebral or visual disturbances.

Diaphragm

The diaphragm is a latex dome surrounded by a spring or coil. The woman places spermicidal cream or gel into the dome and around the rim and then inserts the diagram over the cervix. Because it covers the cervix, the diaphragm prevents passage of sperm while holding spermicide and place for additional protection. Diaphragms must be fitted by a health care provider. The correct size may not be available for all women. The woman should be checked for size changes yearly, after a weight gain or loss of 10 lb (4.5 kg) or more, and after each pregnancy. Pressure on the urethra may cause irritation and urinary tract infections. Voiding after intercourse may help prevent infections. An allergy to latex or a history of toxic shock syndrome precludes use. The diaphragm may be damaged by oil-based lubricants and some medications used for vaginal infections.

Parental Attachment, Bonding, and Acquaintance

The process by which a parent comes to love and accept a child and a child comes to love and accept a parent is known as attachment. Attachment occurs through teh process of bonding. In their bonding theory, Klaus and Kennall (1982), later revised their theory of parent-infant bonding, modifying their claim of the critical nature of immediate contact with the infant after birth. They acknowledged the adaptability of human parents, stating that more than minutes or hours are needed for parents to form an emotional relationship with their infants. The terms attachment and bonding continue to be used interchangeably. Attachment is developed and maintained by proximity and interaction with the infant, through which the parent becomes acquainted with the infant, identifies the infant as an individual, and claims the infant as a member of the family. Positive feedback between the parent and the infant through social, verbal, and nonverbal responses (whether real or perceived) facilitates the attachment process. Attachment occurs through a mutually satisfying experience. A mother commented on her son's grasp reflex, "I put my finger in his hand, and he grabbed right on. It is just a reflex, I know, but it felt good anyway."

Treatment and Nursing Care: Care focuses on identifying the substance-abusing woman early in pregnancy, educating her about the effects of substance abuse, and encouraging her to reduce or eliminate use. Appropriate referrals should be made.

Treatment and Nursing Care Care focuses on identifying the substance-abusing woman earl in pregnancy, educating her about the effects of substance abuse, and encouraging her to reduce or eliminate use. Appropriate referrals should be made. A single episode of consuming two alcoholic drinks during pregnancy can lead to the loss of some fetal brain cells. One drink is defined as 12 oz of beer, 5 oz of wine, of 1.5 oz of hard liquor. A partnership should be created with the woman, and a plan for compromises and treatment should be developed. Dietary support, monitoring of the woman's weight gain, and fetal assessment promote better pregnancy outcomes. In the case of therapeutic drugs, the woman's need for the drug is weighed against the potential for fetal harm it may cause and the fetal or maternal harm that may occur if the woman is not treated. In general, the health care provider will choose the least teratogenic drug that is effective and prescribe in the lowest effective dose. Educating female about the effect of drugs on a developing fetus is best done before pregnancy. Because drug use is prevalent in schools, preadolescence is not too soon to begin this education. Women should be taught to eliminate the use of any unnecessary substance before becoming pregnant. A woman is encouraged to tell her health care provider if she thinks she is pregnant (or is trying to conceive) before having a non-emergency radiograph, being prescribed a drug, or taking herbal or food supplements. A trusting, therapeutic nurse-patient relationship makes it more likely that a woman wil lbe truthful abotu the use of substances, both legal and illicit. The nurse who collects data must use a non-judgemental approach and treat the issue as a health problem rather than a moral problem. The nurse should support the woman who is trying to reduce her drug use. The nurse should praise her efforts to improve her overall health and to have a successful pregnancy. A multidisciplinary approach is needed to plan for the care of a mother and newborn that includes referral to community agencies after discharge or child protective services if needed. Drugs that are contraindicated for use in women who are breastfeeding are identified in various drug references. These references should be used as a guide in counseling mothers concerning breastfeeding. See Chapter 14 for discussion of neonatal abstinence syndrome.

Screening at 24 to 28 weeks of Gestation

Two different blood glucose screening methods for GDM are used in the United States. ACOG still recommends the two-step screening method that has been used for many years. The first step is a screen consisting of a 50 g oral glucose load followed by a plasma glucose measurement 1 hour later. The woman need not be fasting when the screen is done. A glucose value of 130 to 140 mg/dL is considered a positive screen. An initial positive screening result is followed by step 2, a 3-hour oral glucose tolerance test (OGTT_ on another day. ACOG recommends use of the two-step screening procedure because there is no evidence that the one-step screening procedure because there i no evidence that the one-step method (see later discussion) leads to clinically significant improvement in maternal or newborn outcomes. Use of the one-step method does, however, significantly increase health care costs because more women will be diagnosed with GDM and thus will require more visits, tests, and procedures than pregnant women who do not have this disease. The OGTT is administered after an overnight fast and at least 3 days of unrestricted diet (at least 150 g of carbohydrate) and physical activity. The woman is instructed to avoid caffeine because it increases glucose levels and to abstain from smoking for 12 hours before the test. The 3-hour OGTT requires a fasting blood glucose level, which is drawn before giving a 100-g glucose load. blood glucose levels are then drawn 1, 2, and 3 hours later. The woman is diagnosed with GDM if two or more values are met or exceeded. Two different sets of glucose values are commonly used to diagnose GDM following the 100-g OGTT. At this time, use of one set of glucose values cannot be clearly recommended over the other. Therefore, providers are urged to select one set of blood glucose values and use it consistently in their practice.

Additional Signs

When the retina is examined, vascular constriction and narrowing of the small arteries are obvious in most women with preeclampsia. The vasoconstriction visible in the retina is occurring throughout the body. Deep tendon reflexes may be very brisk (hyperreflexia), suggesting cerebral irritability secondary to decreased circulation and edema. Upper extremity reflexes should be assessed if the woman has epidural analgesia in place because lower extremity reflexes may be depressed by the epidural medication. Edema may impede ideal DTR assessment. Laboratory studies may identify liver, renal, and hepatic dysfunction if preeclampsia is severe. Coagulation may be impaired as evidenced by a fall in platelets, which are often in the high-normal range in a pregnant woman without preeclampsia. Although generalized edema is a nonspecific sign that may have many causes, it often occurs with preeclampsia and can be severe. Edema may first present as a rapid weight gain caused by fluid retention. Edema may be present in the lower legs, which is common in pregnancy, and in the hands and face. Edema may be so massive that the woman's appearance is distorted. However, edema is not present in all women who develop preeclampsia, and it can be severe in women who do not have the disorder. Pulmonary edema is also more common in women with massive edema from any cause, including drug therapy given to stop preterm labor. Generalized edema is a possible sign identified with preeclampsia, although it may occur in both normal pregnancy or in a pregnancy complicated by another disorder. Facial edema may be subtle. Minimal edema of lower extremities. +1 Marked Edema of lower extremities +2 Edema of lower extremities, face, hands, and sacral area +3 Generalized massive edema that include ascites (accumulation of fluid in peritoneal cavity) +4

IV Calculations Using Ratio and Proportion to Calculate Dosages

When you know three of the four values of a proportion, you can solve the proportion to determine the unknown quantity. In dosage calculation, it is often necessary to find only one unknown quantity. As you recall from Chapter 3, the proportion can be set up stating the terms using colons (ratio format) or as a fraction. Recall to that a proportion is an equation of two ratios of equal value. Before solving for the unknown quantity, it is essential to be competent in setting up the ratio and proportion correctly. If you set up the ratio and proportion incorrectly, you could calculate the dose incorrectly and administer the wrong dose, which could have serious consequences for the patient. Suppose that you have a medication with a dosage strength of 50 mg per mL, and the prescriber orders a dose of 26 milligrams (mg). Ratio and proportion can be used to determine how many milliliters (mL_ to administer. Remember to include the units of measurement when writing a ratio and proportion to avoid errors. When setting up the ratio and proportion using the fraction format to calculate dosages, the known ratio is what you have available (what is on hand) or the information on the medication label. It is stated first (placed on the left side of the proportion). The desired dosage, or what is ordered to be administered, is the unknown (placed on the right side). Therefore, the ratio and proportion would be stated as follows.

Maternal, Fetal, and Neonatal Effects

With a few important exceptions, the effects of GDM are similar to those associated with preexisting diabetes. the exceptions are that GDM is not associated with an increased risk for maternal ketoacidosis or spontaneous abortion. Because GDM develops after the first trimester, the critical period of major fetal organ development (organogenesis), it usually not associated with an increase in major congenital malformation. Nevertheless, poorly controlled GDM, characterized by maternal hyperglycemia during the third trimester, is associated with increased neonatal morbidity and mortality. the major fetal complications are macrosomia, leading to birth injuries or cesarean birth, and neonatal hypoglycemia. Other problems such as hypocalcemia, hyperbilirubinemia, and respiratory distress also may occur. Breastfeeding may reduce later development of type 2 diabetes in the infant.

Nursing Considerations

the care of a pregnant woman with diabetes mellitus focuses primarily on maintaining normal blood glucose levels. As stated earlier, this maintenance involves a rather rigid schedule of controlling the diet, performing blood glucose test, administering insulin, and performing regular fetal surveillance. Some women respond calmly to intense medical supervision. Others respond with anxiety, fear, denial, or anger and may feel inadequate or unable to control the diabetes to the degree expected by the health care team. These feelings may not be shared spontaneously, but they may affect the woman's ability to achieve the desired outcomes. Also, nurses should remember to provide for normal pregnancy care in addition to monitoring the pregnant woman's diabetes. Fleming and Corbett identified evidence-based and theory-based strategies that a nurse might use both before and during pregnancy.