Nursing Care of the Family During Pregnancy - Reviewing key concepts/Thinking critically

Prevention of injury is an important goal for nurses as they teach pregnant women about how to care for themselves during pregnancy. A. DESCRIBE three principles of body mechanics that a pregnant woman should be taught to prevent injury. B. IDENTIFY five safety guidelines that the nurse should include in a pamphlet titled "Safety During Pregnancy" that will be distributed to pregnant women during prenatal visits.

• Use leg muscles to reach objects on or near the floor. Bend at the knees, not from the back. Knees are bent to lower the body to squatting position. Keep feet 12 to 18 inches apart to provide a solid base and maintain balance. • Lift with the legs. To lift a heavy object (e.g., a young child), one foot is placed slightly in front of the other and kept flat while lowering the body to one knee. Lift the weight, holding it close to the body and never higher than the chest. To stand up or sit down, place one leg slightly behind the other while raising or lowering the body. • For prolonged standing (e.g., ironing, employment), place one foot on a low footstool or box; change position often. • Move car seat forward so that your knees are bent and higher than your hips. If needed, use a small pillow to support the low back area. • Sit in chairs low enough to allow both feet to rest on the floor, preferably with knees higher than hips. • Consult your HCP to discuss your current exercise routine and exercises you would like to continue during pregnancy. • Exercise regularly every day, if possible, to improve muscle tone and increase or maintain your stamina. Thirty minutes of moderate physical exercise is recommended. This activity can be broken up into shorter segments with rest in between. • Consider decreasing jogging or running; substitute walking or non-weight-bearing activities such as swimming, cycling, or stretching. • Consider decreasing your exercise intensity as your pregnancy progresses to adjust for normal changes in pregnancy that can reduce your exercise tolerance. • Avoid risky activities such as contact sports, scuba diving, and sports that require precise balance and coordination. Avoid activities that require holding your breath and bearing down (Valsalva maneuver). • You should be able to hold a conversation while exercising. If you cannot talk, you need to slow down. • Avoid becoming overheated by limiting your activity to 30 minutes, especially in hot, humid weather. Do not use hot tubs and saunas. • Perform warmup and stretching exercises to prepare your joints for exercise and lessen the likelihood of injury to your joints. After the 4th month of pregnancy, you should not perform exercises flat on your back. • Include a cool-down period of mild activity involving your legs at the end of an exercise activity. • Rest for 10 minutes after exercising, lying on your side, which helps to increase blood flow to your placenta and fetus. You should get up slowly from the floor to prevent dizziness or fainting. • Drink water as needed during exercise and two or three 8-ounce glasses of water after you exercise to replace the body fluids lost through perspiration. • Increase your food intake with healthy snacks to replace the calories burned during exercise and to provide the extra energy needs of pregnancy. • Take your time. This is not the time to be competitive or train for activities requiring speed or long endurance. • Wear a supportive bra. Your increased breast weight can cause changes in posture and put pressure on the ulnar nerve. • Wear supportive shoes. As your uterus grows your center of gravity shifts making you feel off balance and more likely to fall. • Stop exercising immediately and call your HCP if you experience shortness of breath, dizziness, numbness, tingling, pain of any kind, more than four uterine contractions per hour, decreased fetal activity, or vaginal bleeding. • Recognize signs of danger, including vaginal bleeding; blurred vision; nausea; dizziness; fainting; breathlessness; heart palpitations; increased swelling in your hands, feet, and ankles; sharp pain in the abdomen and chest; and sudden change in body temperature.

OUTLINE the assessment measures that should be used and the data that should be collected during each component of the initial prenatal visit and the follow-up prenatal visits. Initial prenatal visit Health History Interview Physical Examination Laboratory and Diagnostic Testing Follow-up prenatal visits Updating History Interview Physical Examination Fetal Assessment Laboratory and Diagnostic Testing

* The health history includes physical conditions or surgical procedures that can affect the pregnancy or that can be affected by the pregnancy * The initial physical examination provides the baseline for assessing subsequent changes. The nurse should determine the woman's need for basic information regarding reproductive anatomy and provide this information, along with a demonstration of the equipment that may be used and an explanation of the procedure itself. * Urine, cervical, and blood samples are routinely obtained during the initial visit for a variety of recommended screening and diagnostic tests for infectious diseases and metabolic conditions that can affect the mother and/or developing fetus. * Follow-up visits are briefer and less intensive than the initial prenatal visit. At each follow-up visit, the woman is asked to summarize relevant events that have occurred since the previous visit. She is asked about her emotional and physical well-being and any concerns, problems, and questions she may have. Family needs are also identified and explored. * Physiologic changes are documented as the pregnancy progresses and reviewed for possible deviations from normal progress. At each visit physical parameters are measured. The woman's BP and weight are assessed, and the appropriateness of the gestational weight gain is evaluated in relation to her BMI. Urine may be checked by dipstick, and the presence and degree of edema are noted. For examination of the abdomen, the woman lies on her back with her arms by her side and head supported by a pillow. A small wedge is placed under her right hip to tilt her slightly to the left. Abdominal inspection is followed by measurement of the height of the fundus * Gestational age • First uterine evaluation: date, size • Fetal heart first heard: date, method (Doppler stethoscope) • Date of first feelings of fetal movements (quickening) • Current fundal height, estimated fetal weight (EFW) • Current week of gestation by history of LMP and/or ultrasound examination Fetal heart tones Health status Fundal height * Laboratory Tests Genetic Screening Routine Fetal Ultrasound Examination

During an early-bird prenatal class, a nurse teaches a group of newly diagnosed pregnant women about their emotional reactions during pregnancy. What topics should the nurse discuss with the women? (Circle all that apply.) A. Sexual desire (libido) usually increases during the second trimester of pregnancy. B. A referral for counseling should be sought if a woman experiences conflicting feelings about her pregnancy in the first trimester. C. Rapid, unpredictable mood swings reflect gestational bipolar disorder. D. A quiet period of introspection is often experienced around the time a woman feels her baby move for the first time. E. A woman's own mother is usually her greatest source of emotional support during pregnancy. F. Attachment to her baby begins late in the third trimester, when she begins attending childbirth preparation classes and realizes that the baby will arrive soon.

A, D during this normal quiet period a woman focuses on her fantasy child as the attachment process is occurring; sexual desire is decreased during the first and third trimesters and increased in the second; ambivalence and mood swings are common responses when preparing for a new role and reacting to hormonal changes; safe passage and birth preparation are primary concerns during the third trimester; a woman's partner is usually the most important person.

The nurse evaluates a pregnant woman's knowledge about prevention of urinary tract infections (UTIs) at the prenatal visit following a class on infection prevention that the woman attended. The nurse recognizes that the woman needs further instruction when she tells the nurse about which measures that she now uses to prevent urinary tract infections. (Circle all that apply.) A. "I drink about one quart of fluid a day." B. "I have stopped using bubble baths and bath oils." C. "I have started wearing panty hose and underpants with a cotton crotch." D. "I have intercourse with my husband only once a week now because it could lead to bladder infections." E. "If I drink cranberry juice at least twice a day, I will not get an infection."

A,D,E intake of at least 2 to 3 L per day is recommended; she does not have to reduce frequency of intercourse but rather void before and after intercourse and then drink a large glass of water; the effectiveness of cranberry juice has not been proven; additional methods of preventing UTIs include frequent, regular urination; good genital hygiene; and avoiding wearing tight-fitting jeans for long periods.

Terry is a primigravida in her first trimester of pregnancy. She is accompanied by her husband, Tim, to her second prenatal visit. ANSWER each of the following questions asked by Terry and Tim. A. "At the last visit I was told that my baby's estimated date of birth is December 25, 2014! Can I really count on my baby being born on Christmas Day?" B. "Before I became pregnant, my friend told me I should be doing Kegel exercises. I was too embarrassed to ask her about them. What are they, and is it safe for me to do them while I am pregnant?" C. "What effect will pregnancy have on our sex life? We are willing to abstain during pregnancy if we must to keep our baby safe." D. "This morning sickness I am experiencing is driving me crazy. I become nauseated in the morning and again late in the afternoon. Occasionally I vomit or have the dry heaves. Will this last for my entire pregnancy? Is there anything I can do to feel better?"

A. Accuracy of EDB: reliability depends on the accuracy of date used and the regularity of woman's menstrual cycles; most women give birth within 1 week before or 1 week after the expected date of birth. B. Kegel exercises: use pelvic muscle exercises to maintain muscle tone and ability to support pelvic organs; see Kegel Exercises section; see Chapter 4: Teaching for Self-Management—Kegel Exercises box. C. Effect of pregnancy on sexuality: see Sexual Counseling section, Teaching for Self-Management—Sexuality in Pregnancy; emphasize that intercourse is safe as long as pregnancy is progressing normally and it is comfortable for the woman; sexual expression should be in tune with the woman's changing needs and emotions; inform that spotting can normally occur related to the fragility of the vaginal mucosa and cervix and that changes in positions and activities may be helpful as pregnancy progresses. D. Morning sickness: see Table 14-2 (first trimester section), Nursing Care Plan; fully assess what she is experiencing, then discuss why it happens, how long it will likely last, and relief measures that are safe and effective, including complementary and alternative approache

Tony and Andrea are considering the possibility of giving birth to their second baby at home. They have been receiving prenatal care from a certified nurse-midwife who has experience with home birth. Their 5-year-old son and both sets of grandparents want to be present for the birth. A. DISCUSS the decision-making process that Tony and Andrea should follow to ensure that they make an informed decision that is right for them and their family. B. Tony and Andrea decide that home birth is an ideal choice for them. OUTLINE the preparation measures you would recommend to them to ensure a safe and positive experience for everyone.

A. Discuss decision-making process. ■ Fully review advantages and disadvantages of home birth so that an informed decision can be made and appropriate arrangements can be devised to enhance the advantages and offset the disadvantages. ■ Recommend speaking to couples who have experienced a home birth. B. Preparation measures. ■ Preparation of home, including obtaining supplies and equipment and arranging for medical backup and transportation in the event of an emergency; measures to increase safety should be emphasized. ■ Choosing and preparing the persons who will be attending, including children and grandparents.

Jane is a primigravida in her second trimester of pregnancy. ANSWER each of the following questions asked by Jane during a prenatal visit. A. "Why do you measure my abdomen every time I come in for a checkup?" B. "How can you tell if my baby is doing okay?" C. "I am going to start changing the way that I dress now that I am beginning to show. Do you have any suggestions I could follow, especially because I have a limited amount of money to spend?" D. "What can I do about gas and constipation? I never had much of a problem before I was pregnant." E. "Since yesterday I have started to feel itchy all over. Do you think I am coming down with some sort of infection?" F. "I will be flying to Chicago to visit my father in 1 month. Is airline travel safe for me when I am 5 months pregnant?"

A. Purpose of fundal height measurement: indirect assessment of how her fetus is growing. B. Determining fetal health status: discuss fetal heart rate (FHR) and let her listen; discuss fetal movement assessments and tell her how they are done. C. Clothing choices during pregnancy: see Clothing section; consider safety and comfort in terms of low-heeled shoes and nonrestrictive clothing. D. Gas and constipation: see Table 14-2 (second trimester section); assess problem and lifestyle factors that may be contributing to the problem; determine what she has tried so far; discuss why it occurs and appropriate relief measures (fluids, roughage, activity). E. Itchiness: if the woman is experiencing noninflammatory pruritus, use Table 14-2 (second trimester section) for basis of discomfort and relief measures; be sure to rule out rashes related to infection or allergic reactions. F. Travel during pregnancy: see Travel section; tell her that she may travel if her pregnancy is progressing normally; emphasize importance of staying hydrated, wearing seat belt and shoulder harness, doing breathing and lower extremity exercises, ambulating every hour for 15 minutes, and voiding every 2 hours.

A health history interview of the pregnant woman by the nurse is included as part of the initial prenatal visit. A. STATE the purpose of the health history interview. B. WRITE two questions for each component that is included in the initial health history interview. Questions should be clear, concise, and understandable. Most of the questions should be open-ended to elicit the most complete response from the client. C. WRITE four questions that should be included when doing an updating health history interview during follow-up visits.

A. Purpose of the health history interview: ■ Establish therapeutic relationship. ■ Planned time for purposeful communication to gather baseline data related to the woman's subjective appraisal of her health status and to gather objective information based on observation of the woman's affect, posture, body language, skin color, and other physical and emotional signs. ■ Update information and compare with baseline information during follow-up interviews.

Tanisha, a pregnant woman at 26 weeks of gestation, and her husband, George, tell the nurse at a prenatal visit that their friends who live in another state had a baby 2 months ago and employed a doula to help them during childbirth. Their friends recommended that they do the same because the doula was wonderful. Tanisha and George are unsure whether they should spend the extra money, asking the nurse exactly what doulas do and where they could find one. A. DESCRIBE what the nurse should tell this couple about the role of the doula during labor and birth, including how it could be of benefit to them. B. STATE what the nurse should tell this couple about how to find a doula and the importance of interviewing her before they make a commitment to ensure that she is a good "fit" for them.

A. Role of doula: describe what a doula does; cite research that illustrates the benefits of using a doula for labor support; emphasize that the doula's role is to provide physical, emotional, and informational care and that her role does not involve the performance of clinical tasks. B. Finding a doula: community contacts, other health care professionals especially those involved in childbirth care or education, organizations such as DONA, and persons who have used a doula; emphasize the importance of starting early so that there is time to make the right choice; discuss questions to ask during an interview with a prospective doula and put these questions in writing so that the woman can refer to them during the interview.

Doris, who is 23 weeks pregnant, tells you that she is beginning to experience more frequent lower back pain. You note that when she walked into the examining room, her posture exhibited a moderate degree of lordosis and neck flexion. She was wearing shoes with 2-inch-high narrow heels. Nursing Diagnosis Expected Outcome Nursing Measures

Acute pain in lower back related to neuromuscular changes associated with pregnancy at 23 weeks of gestation. ■ Woman will experience lessening of lower back pain following implementation of suggested relief measures. ■ Explain basis for lower back pain and relief measures, including back massage, pelvic rock, and posture changes

Lisa, a primigravida at 32 weeks of gestation, comes for a prenatal visit accompanied by her partner, the father of the baby. They both express anxiety about the impending birth of the baby and how they will handle the experience of labor. Lisa is especially concerned about how she will survive the pain, and her partner is primarily concerned about how he will help Lisa to cope with labor and ensure that she and the baby are safe. Nursing Diagnosis Expected Outcome Nursing Measures

Anxiety related to lack of knowledge concerning the process of labor and birth and appropriate measures to cope with the pain and discomfort. ■ Couple will enroll in a childbirth education program in the seventh month of pregnancy. ■ Explain the childbirth process and describe the many nonpharmacologic and pharmacologic measures to relieve pain; discuss role of coach and possibility of hiring a doula; make a referral to a childbirth education program and assist with the preparation of a birth plan; discuss childbirth options and prebirth preparations

During the third trimester, parents often make a decision concerning the method they will use to feed their newborn. LIST reasons cited for choosing to bottle-feed rather than breastfeed. As a nurse, how might you address these reasons to help the parents to consider the possibility of breastfeeding?

Benefits of Breastfeeding • Reduced infant and child mortality • Reduced risk for: • Nonspecific gastrointestinal infections • Celiac disease • Childhood inflammatory bowel disease • Necrotizing enterocolitis in preterm infants • Asthma • Atopic dermatitis • Lower respiratory tract infection • Otitis media • SIDS • Obesity in childhood, adolescence, and adulthood • Type 2 diabetes • Acute lymphocytic and myeloid leukemia • Dental malocclusions • Enhanced neurodevelopmental outcomes, including higher intelligence Modesty issues, lack of support from the partner and family, incompatibility with lifestyle, and lack of confidence are among the reasons cited by women who decide to formula-feed their infants

A woman's last normal menstrual period (LNMP) began on November 9, 2019, and ended on November 14, 2019. Using Nägele's rule, the estimated date of birth is: A. July 2, 2020 B. July 7, 2020 C. August 16, 2020 D. August 21, 2020

C use Nägele's rule by subtracting 3 calendar months and adding 7 days and 1 year (if appropriate) to the first day of the last normal menstrual period, which in this case is November 9, 2019.

CALCULATE the expected date of birth (EDB) for each of the following pregnant women using Nägele's rule. A. Diane's last normal menses began on May 5, 2019, and ended on May 10, 2019. B. Sara had intercourse on February 21, 2019. She has not had a menstrual period since the one that began on January 14, 2019, and ended 5 days later. C. Beth's last normal menstrual period began on September 4, 2019, and ended on September 10, 2019. Beth noted that her basal body temperature (BBT) rose on the morning of September 28, 2019.

Calculate expected date of birth: use Nägele's rule: subtract 3 months and add 7 days and 1 year (if appropriate) to the first day of the last normal menstrual period. A. February 12, 2019 B. October 21, 2019 C. June 11, 2019

IMAGINE that you are a nurse working in a prenatal clinic. You have been assigned to be the primary nurse for Martha, an 18-year-old, who has come to the clinic for confirmation of pregnancy. She tells you that she knows she is pregnant because she has already missed three periods and a home pregnancy test that she did last week was positive. Martha states that she has had very little contact with the health care system and the only reason she came today is because her boyfriend insisted that she "make sure" she is really pregnant. DESCRIBE the approach that you would take regarding data collection and the nursing intervention that is appropriate for this woman.

Care of woman at initial visit who is anxious and unsure about prenatal care: answer should emphasize: ■ Establishing a therapeutic, trusting relationship so woman will feel comfortable continuing with prenatal care. ■ Teaching the woman about the importance of prenatal care for her health and that of her baby; determine if barriers are present that may limit participation in prenatal care. ■ Involving her boyfriend in the care process so he will encourage her participation in prenatal care; consider that the father of the baby is often considered to be the most significant support person. ■ Following guidelines for health history interview, physical examination, and laboratory testing; ensure privacy and comfort during the examination and teach her about how her body is changing and will continue to change with pregnancy. ■ Evaluating the desire for this pregnancy and the need for community agency support.

Marie asks the nurse what can be done during a prenatal visit to ensure that her baby is healthy and doing well. IDENTIFY and DESCRIBE what the nurse could tell Marie about the components of fetal assessment that will determine her baby's health status.

Components of fetal assessment: see Follow-up Visits section, which describes several assessment measures of the mother and fetus directly; include what a mother can do to assess her fetus, such as daily fetal movement counts beginning at approximately 27 weeks of gestation.

Carol is 4 months pregnant and is beginning to "show." She asks the nurse what she should expect as a reaction from her 13-year-old daughter and 3-year-old son. DESCRIBE the response the nurse would make.

emphasize importance of considering each child's developmental level; prepare children for prenatal events, time during hospitalization, and homecoming of the new baby; refer to sibling classes and encourage sibling visitation after birth; suggest books, DVDs, and Internet sites that parents could use to prepare their children for birth.

IDENTIFY four factors that a nurse should use to estimate the gestational age of a fetus.

• First uterine evaluation: date, size • Fetal heart first heard: date, method (Doppler stethoscope) • Date of first feelings of fetal movements (quickening) • Current fundal height, estimated fetal weight (EFW) • Current week of gestation by history of LMP and/or ultrasound examination

Nurses working in a prenatal clinic become concerned that the fundal height measurement technique they used was inconsistent and resulted in variations in findings. They decide to create a protocol for fundal measurement that will facilitate accuracy. DISCUSS what they should include in the protocol that they create.

Creating a protocol for fundal measurement: see Fundal Height section and Fig. 14-6; consider woman's position, type of measuring device used, measurement method, and conditions of the examination, such as an empty bladder and relaxed or contracted uterus. Document any variations from the protocol when recording a measurement.

Cultural beliefs and practices are important influencing factors during the prenatal period.

Cultural beliefs and practices: see Variations in Prenatal Care—Social and Cultural Influences section. A. Describe how cultural beliefs affect participation in prenatal care: consider beliefs regarding pregnancy and health care during pregnancy, finances, transportation, communication difficulties, and concerns regarding modesty. B. Prescriptions and proscriptions: see specific sections for emotional response, clothing, physical activity and rest, sexual activity, and diet.

Doulas are becoming important members of a laboring woman's health care team. Which activity should be expected as part of the doula's responsibilities? A. Monitoring hydration of the laboring woman, including adjusting intravenous (IV) flow rates B. Interpreting electronic fetal monitoring tracings to determine the well-being of the maternal-fetal unit C. Eliminating the need for the husband or partner to be present during labor and birth D. Providing continuous support throughout labor and birth, including explanations of labor progress

D continuous support is critical and involves praise, encouragement, reassurance, comfort measures, physical contact, and explanations; the doula does not get involved in clinical tasks; she is not a substitute for the father but rather encourages his participation as a partner in supporting the laboring woman.

A woman at 30 weeks of gestation assumes a supine position for a fundal measurement and Leopold maneuvers. She begins to complain about feeling dizzy and nauseated. Her skin feels damp and cool. The nurse's first action is to: A. Assess the woman's blood pressure and pulse B. Provide the woman with an emesis basin C. Elevate the woman's legs 20 degrees from her hips D. Turn the woman onto her left side

D supine hypotension related to compression of the aorta and vena cava is being experienced; the first action is to remove the cause of the problem by turning the woman onto her side; this should alleviate the symptoms being experienced, including nausea; assessment of vital signs can occur after the woman's position is changed.

Your neighbor, Jane Smith, is in her second month of pregnancy. Knowing that you are a nurse, her husband, Tom, confides in you that he just "cannot figure Jane out. One minute she is happy and the next minute she is crying for no reason at all! I do not know how I will be able to cope with this for 7 more months." A. WRITE a nursing diagnosis and expected outcome that reflects Tom's concern. B. DISCUSS how you would respond to his concern.

Expectant father concerned about wife's mood swings. A. Nursing diagnoses: deficient knowledge regarding pregnant spouse's mood changes related to lack of experience with pregnancy; Tom will explain basis for wife's mood swings and strategies he can use to cope with these changes and support his spouse. B. Nurse's response: see Maternal Adaptation section and Table 14-2 (first trimester section); discuss the basis for the mood swings and experiences during the first trimester, including ambivalence; identify measures he can use to support her.

A. Beth is 6 weeks pregnant. During the health history interview, she tells you that she has limited her intake of fluids and tries to hold her urine for as long as she can because "I just hate having to go to the bathroom so frequently." Nursing Diagnosis Expected Outcome Nursing Measures

Risk for urinary tract infection related to lack of knowledge regarding changes of the renal system during pregnancy. ■ Woman will drink at least 2 to 3 L of fluids per day; will empty bladder at first urge. ■ Explain changes that occur in the renal system during pregnancy; increase fluid intake; use acid-ash-forming fluids; void frequently, including before going to bed to keep bladder empty; void before and after intercourse, then drink a full glass of water; perform good perineal hygiene and wear appropriate clothing; use lateral position to enhance renal perfusion and urine formation.

Nurses responsible for the care management of pregnant women must be alert for warning signs of complications that women could develop as pregnancy progresses from trimester to trimester. A. LIST the signs of potential complications (warning signs) for each trimester of pregnancy. INDICATE possible cause(s) for each sign listed. B. DESCRIBE the approach a nurse should take when discussing potential complications with a pregnant woman and her family.

Warning signs of potential complications during pregnancy. A. List signs of complications: * Severe Vomiting * Chills, fever * Burning on urination * Diarrhea * Abdominal cramping, vaginal bleeding * PROM * Vaginal Bleeding, severe abdominal pain * Severe backache or flank pain * Change/Absence of fetal movements * Uterine contractions, pelvic pressure, craming because 37 * Visual disturbances * Edema (Face, fingers, etc) * Headaches (severe, frequent, or continous) * Seizures B. Nursing approach when discussing signs of complications with pregnant woman and her family: see Recognizing Potential Complications section. ■ Discuss the signs, possible causes, and when and to whom to report. ■ Present the signs verbally and in written form. ■ Provide time to answer questions and discuss concerns; make follow-up phone calls. ■ Gather full information of signs that are reported; use information as a basis for action. ■ Document all assessments, actions, and responses, including the date(s) that information regarding these signs was given, the methodology used, and the woman's reaction to the information.

Kelly is a primigravida in her third trimester of pregnancy. ANSWER each of the following questions asked by Kelly during a prenatal visit. A. "My husband and I have decided to breastfeed our baby but friends told me it is very difficult if my nipples do not come out. Is there any way I can tell now if my nipples are okay for breastfeeding?" B. "My ankles are swollen by the time I get home from work late in the afternoon (Kelly teaches second grade). I have been trying to drink about 3 liters of fluid every day. Should I reduce the amount of liquid I am drinking or ask my doctor for a water pill?" C. "I woke up last night with a terrible cramp in my leg. It finally went away but my husband and I just did not know what to do. What if this happens again tonight?"

Woman during third trimester—questions and concerns. A. Nipple condition for breastfeeding: see Preparation for Breastfeeding section and Figs. 14-7 and 14-8 for several measures she can use and what to avoid. B. Ankle edema: see Table 14-2 (third trimester section); discuss basis of the edema and encourage use of lower extremity exercises and elevation of legs periodically during the day; emphasize importance of fluid intake and sleeping in a lateral position (Fig. 14-13) to enhance kidney function, increasing the amount of excess fluid mobilized and excreted in urine. C. Leg cramps: see Table 14-2 (third-trimester section); discuss basis of leg cramps, then demonstrate relief measures such as pressing weight onto foot when standing or dorsiflexing the foot while lying in bed; avoid pointing the toes; ensure adequate intake of calcium.

Jim's partner, Mary, is 5 months pregnant. He tells you that sometimes he feels "left out" of Mary's pregnancy and asks you if he is important to Mary as her partner and the father of the baby. SPECIFY how you would answer his question.

Woman experiencing introspection: see Reordering Personal Relationships section; explain that she is concentrating on having a baby and forming a relationship with the fetus; emphasize her partner's important role as a caregiver and nurturer.

While a nurse is measuring a pregnant woman's fundus, the woman becomes pale and diaphoretic. The woman, who is at 23 weeks of gestation, states that she feels dizzy and lightheaded. A. STATE the most likely explanation for the assessment findings exhibited by this woman. B. DESCRIBE the nurse's immediate action.

Woman experiencing supine hypotension syndrome: see Emergency—Supine Hypotension box. A. Explanation of assessment findings: supine hypotension. B. Immediate action: turn her onto her side and maintain the position until vital signs stabilize and signs and symptoms diminish; place wedge to maintain a lateral tilt, then continue the assessment; when completed, help her to rise slowly to an upright position and observe for signs of postural hypotension.

Tara is 2 months pregnant. She tells the nurse at the prenatal clinic that she is used to being active and that she exercises every day. Now that she is pregnant she wonders if she should shorten or stop her exercise routine. DISCUSS the nurse's response to Tara.

assess her usual pattern of exercise and activity and consider their safety during pregnancy; discuss precautions and guidelines for safe, effective exercise; emphasize that moderate physical activity benefits her and her baby and will prepare her for the work of labor and birth; caution her to take note of the effects of exercise in terms of her temperature, heart rate, and feeling of well-being.

Jennifer (2-1-0-0-1) and her husband, Dan, are beginning their third trimester of a low-risk pregnancy. As you work with them on their birth plan, they tell you that they are having trouble making a decision about their choice of a birth setting. They experienced a delivery room birth with their first child. Jennifer states, "My first pregnancy was perfectly normal just like this one but the birth was disappointing, so medically focused with monitors, IVs, and staying in bed." They ask you for your advice about the different birth settings they have heard and read about—namely, labor, delivery, recovery, and postpartum (LDRP) rooms at their local hospital, the birthing center a few miles from their home, and even their own home. DESCRIBE the approach you would take to guide Jennifer and Dan in their decision making regarding a birth setting.

■ Purpose of birth plan: means of open communication about the childbirth process between the woman and her partner and with the health care providers in an effort to have a childbirth experience that meets their expectations and wishes as closely as possible; it is a tool that couples can use to stay in control and in this case to experience a more satisfying childbirth. ■ Guidelines for formation of birth plan: begin discussion early in pregnancy so that full consideration can be given to each option; identify components that should be included in the plan; facilitate decision making concerning the options available; recognize risk status implications for care options. ■ Topics for discussion and decision making: partner's role during childbirth and who will be present; setting for the birth; labor management measures, including pain control, comfort measures, positions, events at the birth, and newborn and postpartum care (e.g., celebratory activities, breastfeeding, mother-baby care). ■ Birth setting choice is an essential component of a birth plan. ■ Descriptions of each option, along with the criteria for use and the advantages and disadvantages. ■ Onsite visits and interaction with health care providers responsible for care at each site should be encouraged. ■ Recommend speaking to couples who gave birth in these settings to get their impressions. ■ Emphasize that the decision is theirs and that they should choose what is comfortable for them; their decision should be based on a full understanding of each option.