OB KNOWLEDGE CHECKS

3. What methods are effective for teaching pregnant teenagers? 4. What should prospective teenage parents be taught about infant growth and development?

. A variety of teaching methods such as visual aids, videos, group classes with other teens, and one-to-one counsel- ing may be effective for teenagers.Prospective teenage parents should be taught that infants develop a sense of trust, which is necessary for future development, when their needs are met promptly and gently. Crying indicates a need and does not mean the infant is "spoiled."

1. Why is a preconception visit important? 2. Why are medical, surgical, psychological and obstetric his— tories necessary? 3. Why is it important for all caregivers to be consistent when measuring BP? 4. What are major risk factors during pregnancy?

1. A preconception visit identifies factors that may cause harm to the fetus or the mother so that steps can be taken before pregnancy occurs to avoid problems. 2. Medical, surgical, psychological, and obstetric histories are necessary to identify chronic conditions or past difliculties that might affect the outcome of the pregnancy. 3. All caregivers should use the same techniques to mea- sure blood pressure because position and how the blood pressure is taken affect the results. Monitoring changes in blood pressure during pregnancy is an important component of prenatal care. 4. Major risk factors during pregnancy are age under 16 or over 35 years; low socioeconomic status; nonwhite race; multiparity; obesity; previous problem pregnancies; pre- existing medical disorders or infections; and use of sub- stances such as alcohol, tobacco, or illicit drugs.

1.What are the signs of threatened abortion, and how do they differ from those of inevitable abortion? 2.What are the major causes of recurrent spontaneous abortion? 3. What interventions can nurses provide for families experiencing grief as a result of early pregnancy loss?

1. Bleeding is the most common sign of threatened abortion. It may be accompanied by rhythmic cramping, backache, or feelings of pelvic pressure. Gross rupture of membranes and subsequent cervical dilatation and bleeding make the abortion inevitable. 2. Recurrent spontaneous abortions (also called miscarriages) most often occur as a result of genetic or chromosomal abnormalities of the embryo or anomalies of the maternal reproductive tract. Additional causes are believed to be hormonal and immunologic factors or systemic diseases or infections. 3. Nurses can facilitate the grief response by being aware that although many couples grieve over an early pregnancy loss, they often feel a lack of support from family, friends, and health care personnel. Grief often includes feelings of guilt and speculation about whether the woman could have done something to prevent the loss. Nurses may help by emphasizing that abortions usually occur as the result of factors or abnormalities that can- not be avoided. When nurses demonstrate empathy and unconditional acceptance of the feelings expressed, they support the grief response. Providing information about the grieving and referrals to additional support groups also may be helpful.

1. What are characteristics of a functional family? 2. What factors may interfere with family functioning?

1. Characteristics of a functional family include open communication, flexibility in role assignments, agreement of adults on the basic principles of parenting, and resiliency and adaptability. 2. Factors interfering with healthy family functioning include lack of financial resources, absence of adequate family support, birth of an infant who requires specialized care, presence of unhealthy habits such as substance abuse or lack of anger management, and the inability to make mature decisions that are necessary to provide care to an infant.

1. What is the relationship among DNA, genes, and chromosomes? 2. Can genes be studied by examining them under a micro— scope? Why or why not? What methods are used to study them? 3. Why do cell specimens for chromosomal analysis have to be alive, regardless of the tissue used? 4. What do each of these abbreviations mean: 46XY and 46XX? How are chromosome abnormalities described?

1. DNA is the building block of genes. A varying number of genes makes up each chromosome. 2. Genes are too small to be seen under a microscope. They can be studied by analysis of the products they instruct cells to produce, by direct study of the DNA, or through their close association with another gene that can be studied by one of these other methods. 3. Chromosomes can be seen under a microscope when living nucleated cells are dividing. Cell division during the metaphase is a common time for analysis because each chromosome is compact. Fluorescent in situ hybridization (FISH) identifies chromosomal abnormalities in more than one stage of cell division, allowing rapid test results. 4. 46,XY describes the chromosome makeup of a normal human male. 46,XX describes the chromosomes of a normal human female. Abnormalities are described

3. How can differences in Western and traditional cultural values to be reconciled? 4. How can nurses show respect for traditional cultural practices that are harmless?

1. Differing cultures and lack of understanding of cultures (between the nurse and the childbearing family) may create difficulties related to communication style, decision making, touch, spirituality and religiosity, and time orientation. Nurses should attempt to reconcile these differences by taking the opportunity to learn about the uniqueness of each woman and her cultural beliefs and practices. 2. Integrating harmless traditional cultural practices into the care of the childbearing woman demonstrates respect for her culture

1. How does weight gain in the mother relate to the birth weight of the infant? 2. How much weight should the average woman gain during pregnancy? What factors might change this? 3. What pattern of weight gain is recommended for the average woman?

1. Maternal weight gain helps determine fetal growth. Too little weight gain may be associated with low neonatal birth weight, and too much gain may be associated with large infants. 2. The average woman should gain 11.5 to 16 kg (25 to 35 lb). Underweight women and those carrying more than one fetus should gain more, and overweight women should gain less. 3. The average woman should gain approximately 0.5 to 2 kg (1.1 to 4.4 lb) the first trimester and 0.35 to 0.5 kg (0.8 to 1lb) per week in the second and third trimesters.

7.Why do many low—income women delay seeking health care until the second or third trimester? 8. How do the attitudes of health care workers affect the care of poor families?

1. Poverty is the underlying factor that causes problems such as inadequate access to health care. The lack of access to health care includes the inability to pay for it, lack of transportation, lack of care for other children, inaccessible hours for appointments, and language barriers. 2. An important barrier to health care results from the unsympathetic attitude of some health care workers toward those who are unable to pay for prenatal care. Poor families may experience long delays, hurried examinations, rudeness, and arrogance from some members of the health care team. Staff may be overworked and frustrated with the workloads they carry. Women may wait hours for an examination that lasts only a few minutes. Many never see the same health care provider more than once. These women may not keep clinic appointments because they do not see the importance of the hurried, impersonal examinations.

1. How does pregnancy affect the developmental tasks of adolescence? 2.What are the major problems associated with teenage pregnancy in terms of maternal and fetal health?

1. Pregnancy interrupts developmental tasks such as the achievement of a stable identity, development of a per- sonal value system, completion of educational goals, and achievement of independence from parents. 2 . Teenage mothers have an increased chance of peri- natal complications, including death, pregnancy- associated hypertension, anemia, preterm labor and birth, depression, substance abuse, intimate partner violence, poor nutrition and self-care, perineal lacer- ations, and striae gravidarum with itching. They are also at risk for another teenage pregnancy. Infants are at greater risk for preterm birth, low birth weight, and neonatal death.

1.What is the primary objective of prenatal screening and diagnosis? 2. What are three categories of obstetric ultrasound? What are the two routes used for obstetric ultrasound? 3. What information is obtained with a basic ultrasound? 4. Why is ultrasound transmission gel used during obstetric ultrasounds?

1. The primary objective of prenatal screening and diagnosis is to detect disorders or abnormalities that could affect the woman, fetus, and newborn. 2. The three categories of obstetric ultrasound are standard (or basic), limited, and specialized (detailed or targeted). The two routes used for obstetric ultrasound are trans- vaginal and transabdominal. 3. Basic obstetric ultrasound provides the following information: . Maternal anatomy (cervix, uterus, adnexa) . Number of fetuses . Biometry (fetal measurements of specific structures) that estimates gestational age and fetal weight or determines whether a structure is a normal or abnormal size Presence of fetal cardiac activity Placental location Amniotic fluid volume Survey of fetal anatomy Fetal presentation 4. A water-soluble transmission gel or lotion is used to increase transmission of sound waves.

1. What is the expected uterine growth at 16 weeks, 20 weeks, and 36 weeks of gestation? 2. How does uterine blood flow change during pregnancy? 3. What is the purpose of the cervical mucous plug? 4. What is the major purpose of progesterone in early pregnancy? 5. How do the breasts change in size and appearance during pregnancy?

1. The uterine fundus is midway between the symphysis and the umbilicus at 16 weeks, at the level of the umbilicus by 20 weeks, and to the xiphoid process at 36 weeks of gestation. 2. In late pregnancy, 17% of the cardiac output goes to the uterus and placenta, with almost 90% of it going to the placenta. 3. The cervical mucus plug blocks ascent of bacteria from the vagina into the uterus, thereby providing additional protection of the fetus from possible infection. 4. The major purpose of progesterone in early pregnancy is to stop contractions, help prevent fetal tissue rejection, and, with estrogen, prevent ovulation. 5. During pregnancy the breasts enlarge and become more vascular; the areolae increase in size and become more pigmented; the nipples darken, enlarge, and become more erect; and Montgomery's tubercles become more prominent.

10. Why do some women experience dyspnea during pregnancy? 11. How does the respiratory system compensate for upward pressure exerted on the diaphragm by the enlarging uterus? 12. How does pregnancy affect the gastrointestinal system? 13. Why are pregnant women at increased risk for urinary tract infection?

10. Progesterone causes slight hyperventilation and increases sensitivity of the respiratory center to carbon dioxide, leading to a feeling of dyspnea. 11. Flaring of the ribs, widening of the substernal angle, and increased circumference of the chest allow adequate intake of air with each breath. 12. Estrogen causes hyperemia of the gums that may lead to bleeding or gingivitis. Vascular hypertrophy of the gums (epulis) may occur. Excessive salivation (ptyalism) is a problem for some. Progesterone relaxes smooth muscle in the gastrointestinal tract, which slows gastric empty- ing time and intestinal motility and may lead to heart- burn and constipation. Emptying time of the gallbladder is increased, and thicker bile and gallstones may result. 13. Expectant mothers are at increased risk for urinary tract infection because compression of the ureters between the uterus and the pelvic bones and dilation of the ureters and kidney pelvis cause stasis of urine, allowing time for bacteria to multiply.

10. What are second and third trimester indications for amniocentesis? 11. What risks are associated with early amniocentesis? 12. Why is surfactant important for fetal lung maturity?

10. Second trimester indications for amniocentesis include prenatal diagnosis of chromosomal, genetic, and metabolic disorders. Third-trimester indications are to test for fetal lung maturity (FLM), identification of fetal infection, and therapeutic amniocentesis for amniotic fluid volume disorders such as hydramnios and oligo hydramnios. 11. Risks of early amniocentesis (before 15 weeks of gestation) include increased degree of difliculty of the procedure with an increased failure rate, inadequate amniotic fluid volume for sampling, increased rates of pregnancy loss, and amniotic fluid leakage that has been linked to talipes equino varus (clubfoot) deformity in the infant. 12. Surfactant is important for fetal lung maturity because it reduces surface tension on the inner walls of the alveoli, allowing them to stay slightly open during exhalation. Additionally, surfactant stabilizes lung volume, alters lung mechanics, and maintains gas exchange in the lung. Without adequate surfactant, lung walls adhere to one another, making alveoli inflation during inhalation difficult, which in turn increases the amount of pressure required to keep alveoli open. If this situation is not corrected, impaired oxygenation eventually leads to respiratory distress syndrome (RDS) and other neonatal complications, increasing the rates of neonatal morbidity and mortality.

10. What are the goals of perinatal education? 11. What information is typically covered in preconception classes? Early pregnancy classes? Second—trimester classes? 12. What techniques are commonly taught in childbirth preparation classes during the third trimester? 13. How is the woman in labor helped by having a labor partner? 14. What are the various roles the support person might take?

10. The goals of perinatal education are to help women and their support persons become knowledgeable consumers; to be active participants in pregnancy and childbirth; and to provide coping techniques for pregnancy, birth, and parenting. 11. Preconception classes generally include information about nutrition before conception, healthy lifestyle, signs of pregnancy, and choosing a caregiver. The emphasis is on the benefits of early and regular prenatal care to reduce risk factors for poor pregnancy outcome. The effects of pregnancy and childbirth on a woman's relationships and career may also be discussed.Early pregnancy (first trimester) classes cover infor- mation on adapting to pregnancy and understanding what to expect. Emphasis is on regular prenatal care and avoiding hazards to promote a healthy pregnancy. Second-trimester classes focus on changes occurring during middle pregnancy and what to expect during the third trimester. Teachers discuss childbirth choices and information to help students become more knowledge- able consumers. 12. Childbirth preparation classes during the third trimester focus on self-help measures, what to expect during birth, and how to prepare for the birth of the baby. Specific techniques include pharmacologic and non pharmacologic pain control. 13. Having a support person during labor increases a woman's satisfaction by helping her cope with stress, focus on her learned techniques, and feel that her experience is being shared. 14. Various support roles include active assistance and physical care, verbal encouragement, minimal physical assistance, and presence without active involvement.

11. What is the effect of pregnancy on battering behavior? 12. How can nurses alter their practice to help prevent violence against women?

11. Battering may start or become worse during pregnancy. The face, arms, buttocks, abdomen, and breasts are frequent targets for battery. Women may start prenatal care late and miss appointments. They have an increased risk for uterine rupture, placental abruption, preterm birth, low-birth-weight infant, maternal and fetal death, sexually transmitted diseases (STDs), and postpartum depression. 12. Nurses can examine their own biases to determine whether they accept a common myth that blames the victim. In addition, nurses can consciously practice in ways that empower women and make it clear that the woman owns her body and no one deserves to be beaten.

11. How do "morning sickness" and HEG compare in terms of onset, duration, and effect on the woman? 12. What are the nursing goals in therapeutic management of HEG? 13. Why is critical thinking particularly important in the care of the woman with HEG?

11. Both morning sickness and hyperemesis gravidarum begin in the first trimester. Morning sickness is self- limiting and causes no serious complications. Hyperemesis is persistent, uncontrollable vomiting that may cause excessive weight loss, dehydration, and electrolyte or acid-base imbalance. 12. Goals of management are to maintain hydration, replace electrolytes and vitamins, maintain nutrition, and pro- vide emotional support. 13. Nurses must use critical thinking to examine personal biases that may result in lack of comfort and support for women with hyperemesis. Helping the woman identify any reluctance to accept her pregnancy may lead to solutions that can reduce the intensity of hyperemesis.

12. When the nurse assesses cultural influences on nutrition during pregnancy, what factors should be considered? 13. For what nutritional problems should the nurse assess when caring for low—income women?

12. The nurse should consider traditional foods from the woman's culture, the degree to which she follows the traditional diet, and her inclusion of nontraditional foods in her diet. 13. The nurse should assess the woman's financial resources for food purchase, need for financial assistance, and edu- cation about nutrition.

13. What are the usual characteristics of multifactorial disor— ders? 14. What factors can vary the likelihood that a multifactorial disorder will occur or recur? 15. How can a woman avoid exposing her fetus to terato— gens? 16. Why should a woman with phenylketonuria adhere to a low—phenylalanine diet before and during pregnancy? 17. Why is adequate folic acid intake before conception important?

13. Multifactorial disorders are typically present and detect- able at birth. They are usually isolated defects rather than being present with other unrelated defects. However, sometimes the primary multifactorial defect alters further development and results in other related defects. 14. Factors that may affect the likelihood that a multifactorial disorder will occur or recur include the following: the number of affected close relatives, severity of the defect in those affected, gender of the affected person, geographic location, and seasonal variations. 15. The woman may be able to prevent exposing her fetus to teratogens by being immunized against infections such as rubella at least 28 days (1 month) before pregnancy, eliminating the use of non therapeutic drugs such as alcohol and illicit drugs, changing therapeutic drugs to those having a lower risk to the fetus, and avoiding radiation exposure when she may be pregnant. 16. A pregnant woman who has phenylketonuria should return to her low-phenylalanine diet when she is pregnant to prevent buildup of toxic products that would damage the developing fetus. 17. Adequate folic acid intake of at least 0.4 mg (400 mcg) has been associated with a lower incidence of neural tube defects. Because the neural tube begins closure at 4 weeks of gestation, the woman should have adequate intake beginning before conception to ensure the best outcome.

13. What major cues indicate a woman has been physically abused? 14. How can nurses intervene to help women protect their safety if they choose to remain in a home situation with a partner who physically abuses them? 15. What are possible indicators that a woman is a victim of human trafficking?

13. The physically abused woman often appears hesitant, embarrassed, or evasive. She may avoid eye contact and appear ashamed, guilty, or frightened. Signs of present and past injury may be present, such as bruising, swell- ing, lacerations, burns, scars, and old fractures, as well as genital injuries. 14. Nurses can help establish short-term goals by helping the woman acknowledge the abuse, develop a plan for pro- tecting herself and her children, and identify community resources that provide protection. 15. Victims of human trafficking may have a pattern of "red flags." One red flag may not be indicative of the patient being a victim of trafficking in persons (TIP); the nurse should assess for the patterns of possible indicators, which include being accompanied by an individual who insists on answering all questions for the woman; reluctance or inability of the victim to reveal their true situation; signs and symptoms of phys- ical and mental abuse; evidence of being controlled; fearfulness; submissiveness; fear of authority figures; lack of identification documents; the woman cannot communicate her physical address; inconsistencies in stories and/or histories; a woman who is foreign or non-English speaking; homelessness; a history of previous and/or current prostitution charges or sexual abuse; possession of expensive electronics, jewelry, and other luxury items; a history of substance abuse; markings on the body that appear to be branding; and a high number of sex partners relative to age.

14. What are the effects of maternal vasospasm on the fetus? 15. What are the signs and symptoms of preeclampsia? Why is reduced activity a part of management? 16. What is the effect of vasospasm on the brain? 17. What are the effects of magnesium sulfate, including the primary adverse effect? 18. What are the major complications of eclampsia?

14. Persistent vasospasm of uterine arterioles may result in fetal hypoxemia, intrauterine growth restriction, or even fetal death. 15. Classic signs of preeclampsia include hypertension and possibly proteinuria. Nonspecific edema that is severe and generalized is often seen but is no longer considered a classic sign of preeclampsia. Headache, hyperreflexia, Visual disturbances, and epigastric pain indicate the disease is worsening. Rest, especially in a lateral position, increases maternal cardiac return and circulatory volume, thus improving perfusion of vital organs. 16. Vasospasms cause rupture of cerebral capillaries and small cerebral hemorrhages.Symptoms of arterial vasospasm include headache and visual disturbances such as blurred vision, "spots" before the eyes, and hyperactive deep tendon reflexes (DTRs). 17. Magnesium sulfate prevents seizures by reducing central nervous system irritability and decreasing vasoconstriction. The primary adverse effect is central nervous system depression, which includes depression of the respiratory center. 18. Pulmonary edema, circulatory or renal failure, aspiration of gastric contents, and cerebral hemorrhage are complications of eclampsia. HELLP syndrome, which demonstrates coagulation and liver function abnormalities, is more likely to occur when a woman has severe preeclampsia oreclampsia. Disseminated intravascular coagulation (DIC) may cause unexpected bleeding as levels of coagulation factors decline.

14. What causes the progressive changes in posture and gait during pregnancy? 15. What are the reasons that women do not ovulate and have menstrual periods during pregnancy? 16. Why do maternal needs for insulin change during pregnancy?

14. Relaxation of pelvic connective tissue and joints by relaxin and progesterone creates instability and results in a wide stance and "waddling" gait. Lordosis occurs when the large uterus causes the woman to lean backward to maintain her balance. 15. The hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are suppressed during pregnancy by high levels of estrogen and progesterone to prevent ovulation. Progesterone maintains the endometrium and prevents menstruation 16. Maternal hormones create increasing resistance of maternal tissues to insulin to provide glucose for the fetus. Normally, the mother produces more insulin to meet her needs.

14.What suggestions can the nurse give the vegan about diet during pregnancy? 15. How can lactose—intolerant women increase their intake of calcium? 16. What other conditions present nutritional risk factors during pregnancy? 17. What nutritional problems may the adolescent have during pregnancy?

14. The vegan can include non animal sources of iron; calcium; zinc; riboflavin; and vitamin B6, B12, and D and combine incomplete protein foods to ensure intake of all essential amino acids. She may also need to take supplements. 15. Lactose-intolerant women can choose calcium-containing foods such as leafy green vegetables, broccoli, peanuts, tofu, salmon, and sardines. 16. Other nutritional risk factors during pregnancy are excessive nausea and vomiting, anemia, abnormal pre- pregnancy weight, eating disorders, food cravings and aversions (including pica), multiparity, closely spaced pregnancies, multifetal pregnancy, and substance abuse. 17. The adolescent may skip meals and vitamin-mineral supplements and eat snacks and fast foods of low nutrient value to be like her peers.

15. What criteria are used to determine whether an NST is reactive or nonreactive? 16. Why are contractions necessary for CST interpretation? 17. Identify the four results of CST interpretation and explain each one.

15. Reactive NSTs contain two or more FHR accelerations within a 20-minute period. Accelerations are defined as visually apparent increases in the FHR that reach a peak of 15 beats per minute (bpm) above the baseline, with the entire acceleration lasting a minimum of 15 seconds but less than 2 minutes ("15 x 15"). Before 32 weeks of gestation, accelerations are defined as visually apparent increases in the FHR that reach a peak of 10bpm above the baseline with the entire acceleration lasting at least 10 seconds ("10 X 10"). 16. Contraction stress tests (CSTs) determine fetal well-being by monitoring FHR responses to contractions. Healthy, well oxygenated fetuses can physiologically tolerate the interrupted placental blood flow which occurs during contractions and maintain FHR with normal characteristics such as a stable baseline rate and accelerations. In compromised fetuses, brief interruptions of oxygen trans- fer during contractions can result in late decelerations. 17. The interpretation criteria for CST are as follows: Negative—No late decelerationsPositive—Late decelerations are present with a minimum of 50% of the contractions even when fewer than three contractions occur in 10 minutes Equivocal—suspicious—Intermittent late decelerations or significant variable decelerations (sudden decreases in the FHR that quickly return to the baseline) Equivocal—FHR decelerations in the presence of con- tractions that are more frequent than every 2 minutes or last longer than 90 seconds Unsatisfactory—Fewer than three contractions in 10 minutes or a tracing that cannot be interpreted

16. What is the difference between ethics and bioethics? 17. How do the deontologio, utilitarian, and human rights models differ within ethical theories? 18. When might two ethical principles conflict? 19. How do the steps of the nursing process relate to ethical decision making?

16. Ethics examines conduct and distinctions between right and wrong to determine the best course of action. Bio- ethics applies specifically to the ethics of health care. 17. The deontologic model applies ethical principles to determine what is right. It does not vary the solution according to individual situations. The utilitarian model analyzes the benefits and burdens to determine a course of action that provides the greatest amount of good in a given situation. Belief that every patient has basic human rights is the basis for the human rights model. 18. Ethical principles may conflict when the application of one principle violates another. 19. Assessment is used to gather data from all concerned persons. Ethical theories and principles are analyzed to determine whether an ethical dilemma exists. Planning involves identifying as many options as possible and choosing a solution. Interventions must be identified to implement the chosen solution, and the results are evaluated.

17. How do presumptive and probable indications of pregnancy differ? 18. Why is "fetal" movement felt by the pregnant woman not a positive sign of pregnancy? 19. What are the most common causes of inaccurate pregnancy test results?

17. Most, but not all, presumptive signs are subjective. Prob- able signs are objective. Both can have causes other than pregnancy. Positive indicators of pregnancy have no other possible causes. 18. Many things such as gas, peristalsis, or pseudocyesis (false pregnancy) can be mistaken by the woman for fetal movement. 19. Common causes of inaccurate pregnancy test results include a urine specimen that is too dilute or contains protein or blood; maternal ingestion of certain drugs such as some diuretics, anticonvulsants, antiparkinson drugs, hypnotics, or tranquilizers; incorrect testing procedure; or testing too early in the pregnancy.

18. What are the four biophysical characteristics evaluated with ultrasound during a BPP and what do they reflect? 19. Why is amniotic fluid volume an important parameter in BPPs and MBPPs? 20. Describe the process of shunting in relationship to fetal oxygenation?

18. The four biophysical characteristics evaluated with ultra- sound during a biophysical profile (BPP) are fetal move- ment, fetal tone, fetal breathing movement, and amniotic fluid amount. Biophysical characteristics are a reflection of the central nervous system (CNS) and provide an indi- rect means of evaluating fetal oxygenation. 19. Amniotic fluid volume is an important parameter in bio- physical profiles (BPPs) and modified biophysical pro- files (MBPPs) because it is the only long-term indicator of fetal oxygenation. 20. Shunting occurs because the fetus redirects blood from areas not critical to fetal life, such as the kidneys, gastro- intestinal tract, and extremities, to the vital organs, which include the heart, brain, and adrenal gland. If changes in oxygenation are prolonged, blood flow to the fetal kidneys ceases. Therefore oligo hydramnios in fetuses with normal renal structures and intact amniotic membranes suggests prolonged fetal hypoxia and is a strong indication of fetal compromise.

18. How do the nutritional needs of the lactating mother compare with those of the woman who is not lactating? 19. What changes should the woman who is not breastfeed— ing make after the birth of her baby

18. The lactating woman needs more of many nutrients than does the woman who is not pregnant. She needs to eat 330 more calories than her non pregnant needs during the first 6 months of lactation, and 170 calories will be drawn from her fat stores. During the second 6 months the lactating woman needs 400 calories daily more than the non pregnant woman does. 19. The woman who is not breastfeeding should decrease calories to her pre pregnant level, continue to eat a well balanced diet including enough protein and vitamin C, and plan to lose extra weight slowly.

19. What nursing assessments should be made for the woman with preeclampsia? Why? 20. What measures may be initiated to prevent or manage seizures? 21. How can injury during seizure be prevented? 22. What are the signs of magnesium toxicity? How should it be managed?

19. Assessments for the woman with preeclampsia include daily weights; location and degree of edema; vital signs; hourly urinary output; urine for protein; deep tendon reflexes; and subjective signs such as headache, visual disturbances, and epigastric pain. The fetal heart rate should be assessed for nonreassuring patterns. Respira- tory rate; oxygen saturation level; consciousness level; and laboratory data such as creatinine, liver enzymes, and magnesium levels should be evaluated. Psychosocial assessment should include the reaction of the woman's family and support system. Nursing assessment helps determine whether the condition is responding to med- ical management, if the condition is stable, or if the dis- ease is worsening. 20. To prevent seizures, maintain a quiet environment, reduce environmental stimuli, and maintain a therapeutic level of magnesium. Nurses must remain with the woman and call for help if a seizure occurs. Attempt to turn the woman on her side before the onset of a seizure. Note the sequence and time of the seizure. Insert an air- way after the seizure, and suction the woman's nose and mouth, administer oxygen, administer medications, and prepare for additional medical interventions. 21. To prevent seizure-related injury, the side rails should be padded and raised. The bed should be in the lowest position with the wheels locked. Oxygen and suction should be readily available. Necessary equipment and medications should be immediately available. 22. Signs of magnesium toxicity include respiratory rate below 12 breaths per minute, hyporeflexia, sweating or flushing, altered sensorium (lethargy, drowsiness, disorientation), and serum magnesium level beyond the therapeutic range. If toxicity occurs, discontinue the drug and notify the physician. Calcium gluconate is an antidote for magnesium toxicity and should be immediately available.

20. How did the Roe v. Wade ruling affect state laws related to abortion in the United States? 21. What are the major conflicting beliefs about abortion?

20. The Supreme Court decision in Roe v. Wade declared that abortion was legal anywhere in the United States and that existing state laws prohibiting abortion were unconstitutional because they interfered with a woman's right to privacy. Stipulations in terms of the trimester of pregnancy were part of Roe v. Wade. 21. The belief that abortion is a private choice conflicts with the belief that abortion is taking a life.

20. Why might an expectant mother say, "I am pregnant" during the first trimester and "I am going to be a mother" late in pregnancy? 21. How might pregnancy affect the sexual responses of the mother and the father?

20. The fetus seems vague and unreal during the first trimester. Gradually, physical changes (uterine growth, weight gain, quickening) confirm that a fetus is developing, and the expectant mother begins to perceive the fetus as a separate though dependent being. 21. The pregnant woman may have increased interest in sex during the first trimester unless she has nausea or fears miscarriage. Interest is often increased in the second trimester because of pelvic vaso congestion and a general feeling of well-being. The discomforts of the third trimester may decrease sexual responsiveness. Some expectant fathers are more interested in sex during pregnancy, but others find the pregnant woman unattractive and fear harming the fetus.

22. What dangers are involved in punitive approaches to ethical and social problems? 23. What problems are involved in the use of advanced reproductive techniques? 24. Describe precautions the nurse should take to ensure the privacy of a person's medical records.

22. Punitive approaches are against the ethical principles of autonomy, bodily integrity, and personal freedom. Although the intended plan may be to protect the fetus, such a plan can have unexpected outcomes, causing the woman to avoid prenatal care or be dishonest with care providers, causing greater harm to her fetus. 23. Problems involved in the use of advanced reproductive techniques include high cost, low success rate, limitation to the affluent, control of unused embryos, and problem or unexpected pregnancy outcomes. 24. Log off of computer terminals when access is complete. Maintain secret identity codes that access private information. Maintain a low volume in phone reports. Direct reports to another professional should be done on a "need to know" basis rather than reporting to those who do not need to know. Verbal reports should be done in a private area. Care must be taken not to violate patient or institutional confidentiality when having any discussion on the Internet.

22. What does "looking for a fit" mean in role transition? 23. Why is grief work part of maternal role transition? 24. How does the pregnant woman seek safe passage for herself and the baby?

22. The pregnant woman explores the role of mother to develop a sense of herself in the role and selects behaviors that confirm her idea of fulfilling the role. 23. Pregnancy brings the realization that the woman will have to give up certain aspects of her previous life. This causes a temporary sadness and the need for grief work. 24. Seeking safe passage involves going to a health care provider and following recommendations of the provider and of her culture.

23. What does the acronym HELLP stand for? What are the prominent signs and symptoms of HELLP syndrome? Why should the liver not be palpated in a woman with HELLP syndrome? 24. Compare preeclampsia with chronic hypertension in terms of onset and treatment.

23. H, Hemolysis; EL, elevated liver enzymes; LP, low plate- lets. Major symptoms are pain and tenderness in the right upper quadrant. Additional signs and symptoms may include nausea, vomiting, and severe edema. Laboratory data include a low hematocrit level, abnormal liver studies, coagulation abnormalities, and often abnormal renal studies. Palpating the liver could cause trauma, including rupture of a subcapsular hematoma. 24. Preeclampsia occurs only during pregnancy and the early postpartum period. Chronic hypertension is present before pregnancy or before the twentieth week of gestation and persists after the postpartum period. Hypertension that remains several weeks postpartum suggests that the woman has chronic hypertension even if her blood pressure measurements were normal when she entered care. Treatment may be similar during pregnancy; however, chronic hypertension may be treated with antihypertensive medications before and during pregnancy. Preeclampsia may further complicate chronic hypertension.

25. Why do unsensitized Rh—negative expectant mothers receive RhoGAIVI during pregnancy and after an abortion, amniocentesis, and childbirth? 26. What are the effects on the fetus of maternal Rh sensitization? 27. Why is the first fetus sometimes affected if ABO incompatibility occurs? Why are the effects of ABO incompatibility milder than those of Rh sensitization?

25. Administration of Rho(D) immunoglobulin prevents development of maternal anti-Rh antibodies and is recommended after any procedure that includes the pos- sibility of maternal exposure to Rh-positive fetal blood. 26. A mother who is sensitized has developed antibodies to the Rh antigen. Maternal anti-Rh antibodies cross the placental barrier. If the fetus is Rh positive, the antibodies destroy fetal Rh-positive red blood cells. The fetus becomes anemic, bilirubin concentration increases, and in extreme cases severe neurologic dis- ease can result. 27. Many women with blood type 0 have anti-A or anti-B antibodies before they become pregnant, so the first pregnancy can be affected. The effects of ABO incompatibility are milder than Rh sensitization because the primary antibodies of the ABO system are IgM, which do not readily cross the placenta.

25. What are reality boosters? Why are they important for the expectant father's adjustment? 26. How can nurses help men in their struggle for recognition as parents? 27. Why should information relating to newborn care presented in prenatal classes be repeated after the infant is born?

25. Reality boosters include seeing the fetus via ultrasound, hearing the fetal heart, and feeling the fetus move. They are important in making the coming child seem real. 26. Nurses can help men gain recognition as parents by focusing on the father as well as the mother, encouraging the father's questions, and including him in the plan of care. 27. Information about infant behavior and care is more relevant and therefore more useful after the infant is born.

25. How do state boards of nursing safeguard patients? 26. How do standards of care and agency policies influence judgments about malpractice? 27. How can standards of care be used to help defend mal— practice claims against nurses?

25. State boards of nursing administer the individual states' nurse practice acts, which establish what the nurse is allowed and expected to do when practicing nursing in that state. 26. Standards of care and agency policies influence judgment about malpractice because they describe the level of care that can be expected from practitioners at the time of care. 27. Nursing actions that help defend malpractice claims include securing informed consent appropriately, keep- ing documentation that provides evidence that the standard of care has been maintained, acting appropriately as a patient advocate in terms of taking a problem through the chain of command, and maintaining expertise.

28. What concerns do nurses have about unlicensed assistive personnel? 29. Why is early discharge a concern for nurses? 30. What are the important points in follow—up phone call

28. Concerns about the use of unlicensed assistive personnel include whether this use compromises the quality of care and if the high workload of the nurse restricts the time available to supervise unlicensed personnel adequately. 29. Short lengths of stay lead to concerns about the woman's ability to care for herself and her infant, potential complications that new parents may not identify, and the fact that parents will not have had time to absorb the necessary teaching. Follow-up phone calls help alleviate some concerns and identify some problems that develop after discharge. In non maternity medical situations, many older women are often discharged early from the hospital. Because the cognitive abilities of a woman may decline with advanced age, in these situations it is important to also provide teaching to the woman's care provider. 30. Facilities that use phone call follow-up should have regularly reviewed and updated protocols, good documentation forms, and specific instructions to the patient about actions to take if further problems develop.

28. What determines the response of grandparents to the pregnancy? 29. How does the response to pregnancy differ for a toddler, a preschool child, and an adolescent? 30. How can parents prepare siblings for the addition of a newborn to the family?

28. The age of the grandparents, the number and spacing of other grandchildren, and their perceptions of their role help shape the way grandparents respond to an expected grandchild. 29. Toddlers do not understand that a birth is expected and should be told shortly before the expected date. Pre- schoolers may expect the infant to be a playmate near their age. School-age children may like to be involved and to help prepare for the birth. Adolescents may be embarrassed by evidence of their parents' sexuality, indifferent to the pregnancy, or very involved in preparations. 30. Parents can make any changes in sleeping arrangements several weeks before the infant is born so that other children do not feel displaced by the newborn. They can increase time and attention to older children and reassure them of their love and acceptance.

28. What effects do the hormones of pregnancy have on maternal glucose metabolism? 29. What are the maternal effects of type 1 diabetes mellitus? What are possible fetal and neonatal effects? 30. How do insulin needs vary from the first trimester through the postpartum period?

28. The hormones of pregnancy cause resistance of maternal cells to insulin, which increases the availability of glucose for the fetus. 29. The mother is at risk to develop preeclampsia, urinary tract infections, ketoacidosis, and preterm labor. Possible fetal and neonatal effects include congenital malformations; small or large fetal size, depending on the placental vascular supply; fetal hypoxemia; and polycythemia. Neonatal effects include hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. 30. Insulin needs decrease during the first trimester and increase sharply during the second and third trimesters (when placental hormones initiate insulin resistance). During the muscular exertion and reduced oral intake associated with labor, insulin needs must be determined by frequent checks of blood glucose levels to keep the maternal glucose level within normal limits. In the post- partum period, insulin needs decrease as levels of placental hormones decline.

31. What is the importance of the glycosylated hemoglobin (Hbmc) measurement in monitoring diabetes mellitus? 32. How does GDIVI compare with type 1 and type 2 diabetes mellitus in terms of onset and treatment? 33. What is the difference between GCT and OGTT? 34. How do the maternal, fetal, and neonatal effects of gestational diabetes differ from those of preexisting diabetes?

31. Glycosylated hemoglobin gives an accurate evaluation of blood glucose level for the past 2 to 3 months and is not affected by recent intake or restriction of food. 32. Gestational diabetes mellitus is first diagnosed during pregnancy with none of the classic signs of type 1 diabetes: thirst, heavy urine excretion, and weight loss despite heavy food intake. Type 1 diabetes mellitus usually emerges during childhood or early adulthood and requires insulin for control. Type 2 diabetes usually occurs in adulthood and is usually managed by diet and/ or oral hypoglycemics if not pregnant. Gestational diabetes is often managed by diet and exercise, although insulin may be needed if fasting or post prandial capillary blood glucose values are persistently high. Oral hypoglycemics are not commonly used. 33. A glucose challenge test (GCT) is a screening procedure only and requires no fasting before the woman drinks a 50-g glucose solution and has a serum glucose drawn 1 hour later. A 3-hour oral glucose tolerance test (OGTT) is performed to diagnose diabetes mellitus, including gestational diabetes. The OGTT requires measurement of a fasting blood glucose level followed by intake of 100 g of glucose solution. Blood glucose levels are determined hourly after the solution is taken, at 1, 2, and 3 hours. 34. Maternal effects of gestational diabetes mellitus include increased incidence of urinary tract infections, hydram- nios (excessive amniotic fluid), premature rupture of membranes, and development of hypertension. Fetal effects may include macrosomia, which can result in shoulder dystocia or cesarean birth. The newborn is at risk for hypoglycemia. Preexisting diabetes has similar maternal effects as gestational diabetes, but fetal and infant effects may be more severe if the disease is not well controlled. The infant may have intrauterine growth restriction (IUGR) if the woman's diabetes has caused vascular impairment, or macrosomia if her glucose level is poorly controlled and no vascular impairment exists. Congenital anomalies are increased in preexisting diabetes, especially if the diabetes is poorly controlled at conception and during early gestation.

35. How do the cardiovascular changes of pregnancy affect the condition of the woman who has a cardiac defect? 36. What are the two major categories of heart disease? What are the functional classifications of heart disease? 37. What are the primary goals for management of heart disease in terms of diet, activity, and weight gain? 38. Why should the administration of fluids, both oral and intravenous, be monitored closely during labor? 39. Why is the fourth stage of labor particularly dangerous for the woman with heart disease?

35. Increased intravascular volume and increased cardiac output (particularly stroke volume) place an added bur- den on the heart of a woman who has a cardiac defect. 36. Acquired and congenital heart disease are the two major categories of heart disease during pregnancy. Acute problems such as myocardial infarction or conduction disorders may also occur during pregnancy. Functional classification depends on the person's ability to toler- ate activity. Class I indicates no limitation on activity. Class II indicates slight restriction if necessary. Class III is associated with marked limitation. Class IV indicates that the person has symptoms such as dyspnea at rest. 37. Goals of treatment are to prevent anemia with adequate iron and folic acid intake so the supply of red blood cells is adequate to transport oxygen and thus reduce the demands on the heart, limit physical activity so cardiac demand does not exceed the capacity of the heart, and limit weight gain, which would add further demands on the heart. 38. With every contraction, blood is shifted from the uterus and placenta into the central circulation. This can lead to fluid overload if fluids are administered rapidly. 39. An additional 500 mL of blood is returned to the central circulation with delivery of the placenta. Also, the compression of the vena cava that characterized much of pregnancy is gone. This increases the load on the heart and can lead to further compromise of the heart.

4. How many additional calories should a woman consume each day during pregnancy? 5. How much protein is recommended during pregnancy? 6. Which vitamins are in the fat—soluble and water—soluble groups? What is the difference in the way the body stores them? 7. Why should all women of childbearing age consume 400 mcg of folic acid daily?

4. Although no additional calories are needed during the first trimester, the recommendation for the second and third trimesters is 340 calories and 452 calories. 5. Approximately 71 g of protein per day, an increase of 25 g above pre pregnancy needs, is recommended during pregnancy. 6. Fat-soluble vitamins (A, D, E, K) are stored in the fat and are available longer than the water-soluble vitamins (such as B6, B12, folic acid, thiamine, riboflavin, niacin, C), which must be replenished daily. Excessive intake of fat-soluble vitamins is more likely to cause toxicity. 7. Because many pregnancies are not planned and the neural tube forms early in gestation, all women of childbearing age should have 400 mcg (0.4 mg) of folic acid daily to prevent birth of infants with neural tube defects from folic acid deficiency. Once pregnancy occurs, 600 mcg (0.6 mg) of folic acid should be taken daily.

4. Why is ectopic pregnancy sometimes called a "disaster of reproduction"? 5. Why is the incidence of ectopic pregnancy increasing in the United States? How is ectopic pregnancy treated? 6. What is a hydatidiform mole, and why are two phases of treatment necessary?

4. Ectopic pregnancy remains a significant cause of maternal death because of hemorrhage, and it can reduce the woman's chance of subsequent pregnancies because of damage to a fallopian tube. Also, the condition that caused the ectopic pregnancy in the tube may be present in the opposite tube. 5. The increase in incidence of ectopic pregnancy may occur as a result of pelvic inflammatory disease that may complicate untreated sexually transmitted infections. Scarring of the fallopian tubes that may result from the infection may make it diflicult for the fertilized ovum to pass through the obstructed tube. Ectopic pregnancy is also more likely to occur in women who have assisted reproduction for infertility, ovulation disorders, contraceptive devices, and use of progesterone agents. Treatment for ectopic pregnancy may be medical (chemotherapeutic agent) or surgical (sal- pingostomy or salpingectomy). 6. Hydatidiform mole is a form of gestational tropho blastic disease that involves abnormal development of the placenta as the fetal part of the pregnancy fails to develop. The first phase of treatment is evacuation of the molar pregnancy from the uterus. The second phase is follow-up to detect malignant changes in remaining tro- phoblastic tissue.

40. How much should the pregnant obese patient gain during pregnancy? 41. What complications should the nurse assess during the intrapartum period?

40. The obese woman should gain 11 to 20 lb during pregnancy. 41. During the intrapartum period, the nurse caring for an obese patient should assess for signs of dysfunctional labor (abnormal contraction pattern, slow or no cervical change, inadequate fetal descent).

42. Why is supplemental iron needed by most women who are pregnant? 43. What are the neonatal effects of iron deficiency anemia? 44. What are the fetal and neonatal effects of folic acid deficiency?

42. Most women begin pregnancy with marginal iron stores, do not have adequate iron stores to meet the demands of pregnancy, and have difliculty meeting the high iron needs of pregnancy with diet alone. 43. The fetus usually receives adequate iron, even at a cost to the mother. Therefore neonatal effects of moderate maternal anemia are rare. With very severe maternal anemia, however, the fetus may become hypoxic. 44. The fetal and neonatal effects of folic acid deficiency are increased risk of spontaneous abortion, abruption of the placenta, and fetal anomalies, particularly neural tube defects.

45. What are the maternal effects of sickle cell disease? 46. How is sickle cell disease treated during pregnancy? 47. Why is iron supplementation often not recommended for women with thalassemia?

45. Pregnancy may worsen sickle cell disease, and the risk of "sickle cell crisis" is increased. 46. Frequent measurements of hemoglobin, blood count, serum iron, and iron-binding capacity, as well as folate, are necessary to determine the degree of anemia. Frequent fetal surveillance and monitoring for signs of sickle cell crisis are also necessary. The nurse should also be aware that the woman's pain could be a pregnancy complication rather than a result of sickle cell crisis. 47. Thalassemia is associated with increased iron absorption and storage, making women with this disorder susceptible to iron overload.

48. What are the maternal and fetal effects of SLE? 49. In what ways does pregnancy affect RA? 50. How can Hashimoto's thyroiditis affect the newborn? 51. What is the major concern about administering anticonvulsant drugs for the pregnant woman with epilepsy? 52. What is the recommended supportive care for pregnant women with Bell's palsy?

48. The maternal and fetal effects of systemic lupus erythematosus are increased incidence of abortion, fetal death, and preterm delivery. Congenital heart block, often permanent, is a serious complication for the newborn. Pregnancy can exacerbate the disease, and renal complications pose a special risk. 49. Rheumatoid arthritis often markedly improves during pregnancy. However, relapse often occurs soon after childbirth. 50. Hypothyroidism in the woman may cause adverse effects on the mental development of the fetus through birth and childhood. A greater risk for miscarriage, preterm birth, and preeclampsia exists if it is not corrected. 51. Anticonvulsant drugs may be teratogenic. Many have probable or known adverse effects on the fetus. However, generalized seizures may also have adverse fetal effects, so maintaining the anticonvulsant dose as low as possible is important. Newer anticonvulsants have less data related to their possible fetal effects. 52. The recommended supportive care for women with Bell's palsy includes eye patching, applying ointment or drops to prevent trauma to the cornea, facial massage, and psychological support. Corticosteroids may be given.

5. What is an NT measurement? What aneuploidy is associated with an increased NT measurement? 6. What conditions are associated with elevated AFP levels? 7. What is multiple—marker screening? Why is it performed?

5. Nuchal translucency (NT) is a first-trimester ultrasound measurement of the fluid-filled space measured at the back of the fetal neck. An enlarged NT, often defined as 3.0 mm or greater or above the 99th percentile for gestational age, is associated with trisomy 21 as well as structural abnormalities such as congenital heart defects. 6. Neural tube defects (NTDs) are most commonly associated with elevated alpha-fetoprotein (AFP) levels. Other conditions include underestimation of gestational age, undiagnosed multiple gestation, fetal demise, conditions associated with fetal edema such as cystic hygroma, and abdominal wall defects such as gastroschisis. 7. Multiple-marker screening, sometimes called a triple or quad screen, is a maternal blood test for three or four substances (human chorionic gonadatropin [hCG], alpha-fetoprotein [AFP], unconjugated estriol [uE3], and, in the quad screen, inhibin A). It is performed to evaluate a woman's risk for trisomy 21, trisomy 18, and open neural tube defects (NTDs).

5. Why is it important for nurses to examine their own cultural beliefs and values? 6. What is meant by the term "cultural negotiation?"

5. Nurses should examine their own cultural values and beliefs to determine ways in which their beliefs may generate conflict with those who hold different cultural beliefs. 6. Cultural negotiation involves providing information while acknowledging that the woman may hold views that are different from those of the nurse.

5. If a parent has an autosomal dominant disorder, what are the chances the child will have the same disorder? 6. Why would parents who are first cousins be more likely to have a child with an autosomal recessive disorder? 7. If each member of a couple carries the gene for an autoso— mal recessive disorder, what are the chances the children will have the disorder? What are the chances the children will be carriers? What are the chances the children will not receive the abnormal gene from either parent? 8. Why are males more often affected by X—linked recessive dis— orders? If a female carries an X—linked recessive disorder such as hemophilia, what are the chances her sons will have the disorder? What are the chances her daughters will be carriers?

5. The child of a parent with an autosomal-dominant disorder has a 50% chance of having the same disorder. 6. Blood relationship (consanguinity) of parents increases the likelihood that both share some of the same abnormal autosomal-recessive genes, increasing the chance that their offspring will be affected with a disorder. The closer the parents' blood relationship, the more genes they are likely to share. 7. If both parents carry an abnormal gene for an autosomal-recessive disorder, each child has a 25% chance of receiving both copies of the defective gene and having the disorder. Each child also has a 50% chance of receiving only one copy of the defective gene and being a carrier like each parent. Each child also has a 25% chance of receiving the normal gene from each parent, thereby being neither a carrier nor affected and having no chance of passing the gene to future generations. 8. Males are more likely to have X-linked recessive disorders because they do not have a compensating X chromosome with a normal gene. Each son of a female carrier has a 50% chance of having the trait and a 50% chance of being unaffected. Each daughter of the female carrier has a 50% chance of being a carrier and a 50% chance of being unaffected.

5. What is the recommended schedule for antepartum visits? 6. How does fundal height relate to gestational age? 7. How does maternal adaptation differ in multifetal pregnancies?

5.The usual schedule of antepartum visits begins in the first trimester and continues every 4 weeks until 28 weeks, then every 2 weeks until 36 weeks, and weekly from 37 weeks to birth. 6. A gradual, predictable increase in uterine size occurs as gestation advances. From approximately 16 weeks until 38 weeks, fundal height in centimeters is nearly equal to gestational age in weeks. 7. In multifetal pregnancies, increased blood volume results in additional work for the heart of the mother. The greatly increased size of the uterus causes greater elevation of the diaphragm and more compression of the large vessels, ureters, and bowel. Nausea and vomiting are more frequent.

53. What are the fetal and neonatal effects of CIVIV infection? 54. Why is rubella infection most dangerous in the first tri— mester? 55. How can rubella be prevented? 56. How are infants born to mothers with varicella treated? 57. How does vertical transmission of the herpesvirus occur?

53. Primary maternal infection is more likely to result in fetal and neonatal infection. About 90% of newborns are not affected, but about 10%will have symptoms at birth. About 10% of this group will show full cytomegalovirus (CMV) inclusion disease. Another 10% of this birth group will show late-onset signs. Problems include enlarged spleen and liver, central nervous system (CNS) abnormalities, developmental delay, dental defects, jaundice, chorioretinitis, hearing loss, and growth impairment. 54. The first trimester is the time of organogenesis, when damage can be done to all developing organ systems. 55. A vaccine is available to prevent rubella, but it cannot be given during pregnancy. During pregnancy a woman can only avoid situations in which she is likely to con- tract rubella. Rubella immunization should be given to the woman before discharge after birth, and she should be taught that pregnancy should be avoided for 4 weeks (1 month) after the immunization. 56. Immunization with varicella-zoster immune globulin is recommended. Because of viral shedding, infected mothers and infants must be isolated from those who are not immune 57. Vertical transmission of herpesvirus occurs when organ- isms ascend after rupture of membranes and during birth when the fetus comes into contact with infectious tissue and secretions.

58. What are the fetal and neonatal effects of parvovirus 819 infection? 59. How is HBV transmitted? How are newborns treated? 60. How can HIV infection be prevented? 61. What is the medical management for a pregnant woman with HIV infection?

58. The fetal and neonatal effects of parvovirus B19 infection are failure of red blood cell production, severe fetal anemia, hydrops, and heart failure. 59. Hepatitis B virus is transmitted by contact with infected blood, saliva, vaginal secretions, semen, or breast milk. A newborn whose mother is known to carry the hepatitis B surface antigen should receive hepatitis B immune globulin soon after birth, followed by hepatitis B vaccine. The infant should receive the second and third doses of vaccine at regularly scheduled times. 60. Avoid sexual transmission by abstinence, avoiding inter- course with infected persons, or using recommended barrier methods such as a condom. Intravenous drug users who refuse rehabilitation must avoid transmission that occurs when needles are shared with those who are infected. Use standard precautions to avoid contact with secretions that may carry the virus. 61. Several combinations of antiretroviral medication regimens may be administered to delay replication of the virus. Opportunistic diseases are treated. Good hygiene reduces transmission of infectious organisms to the susceptible person, and nutritious meals reduce the risk for opportunistic infection. Antiretroviral therapy reduces vertical transmission of HIV to the infant and ideally begins during the second trimester of pregnancy. Additional treatment continues after birth for the infant. Individualized maternal therapy may include multiple antiretrovirals.

6.Why is expanded blood volume important during pregnancy? 7. How does physiologic anemia or pseudoanemia differ from iron deficiency anemia? 8. Why might some pregnant women feel faint when they are in a supine position? 9. Why is circulation to the kidneys and skin increased during pregnancy?

6. Expanded blood volume is needed for the added maternal tissues of pregnancy, to provide blood flow to the placenta, and to allow for loss of blood at childbirth. 7. Physiologic anemia of pregnancy is caused by a greater increase in plasma volume than in red blood cells (RBCs), resulting in a dilution of, but not inadequate, hemoglobin concentration. Iron-deficiency anemia is caused by a true lack of iron that affects hemoglobin levels. 8. In the supine position, the weight of the uterus on the vena cava and aorta impedes blood flow to and from the lower extremities, resulting in decreased cardiac output and supine hypotensive syndrome. 9. During pregnancy, increased circulation through the kidneys is needed to remove metabolic wastes generated by the mother and the fetus. Increased circulation through the skin is necessary to dissipate heat that is generated by accelerated metabolism.

62. How can toxoplasmosis be prevented? 63. What are the risk factors for colonization of the newborn with (388 during the intrapartum period? How is coloniza— tion prevented? 64. How is TB treated in the mother? How is it diagnosed and treated in the newborn?

62. Toxoplasmosis can be prevented by cooking meat thoroughly, not touching mucous membranes while handling raw meat, washing kitchen surfaces and hands thoroughly after handling raw meat, avoiding uncooked eggs and unpasteurized milk, washing vegetables and fruit before consumption, and avoiding contact with materials that may be contaminated with cat feces. 63. Risk factors for the mother transmitting group B Strep- tococcus (GBS) to her infant include a prior infant with GBS infection, presence of GBS organisms in the urine in the present pregnancy, preterm birth (before 37 weeks), maternal fever in labor, and prolonged membrane rup- ture (218 hours). Intravenous antibacterial therapy is used to prevent colonization in the newborn of the GBS-positive mother or if her status is unknown. 64. Isoniazid, rifampin, and ethambutol are given for 2 months followed by isoniazid and rifampin daily or twice per week for 7 months to treat tuberculosis in the mother. Pyridoxine (vitamin B6) is added to prevent neu- rotoxicity. The infant is skin-tested at birth and may be prescribed isoniazid. Isoniazid is usually continued for the infant until the mother's tuberculosis has been inac- tive for at least 3 months. Infant tuberculosis medication may stop if the mother and family members are well treated and show no additional disease. If the skin test result shows conversion to positive, a full course of drug therapy should be given to the infant.

7. What are the signs and symptoms of placenta previa? How is it managed in the home? 8. What are the signs and symptoms of placental abruption? 9. What are the major dangers to the mother and the fetus during the placental abruption? 10. What is DIC?

7. Painless vaginal bleeding in the latter half of pregnancy is the classic sign of placenta previa. Bed rest, no sexual intercourse, an adult caregiver present at all times, and availability of emergency transportation to the hospi- tal are essential for home care. The woman must also be taught to monitor fetal movement and to report a decrease in movement or increase in vaginal bleeding. 8. The five classic signs of placental abruption are (a) bleeding, which may be evident vaginally or concealed behind the placenta; (b) uterine tenderness; (c) uterine irritability, with poor relaxation between contractions; (d) abdominal pain; and (e) a highuter ineresting tone if an intrauterine pressure catheter is being used. Additional symptoms include a "boardlike" abdomen, firm to the touch; "port wine"—colored amniotic fluid, and non reassuring fetal heart rate (FHR) pattern and signs of hypovolemic shock. 9. Hemorrhagic shock is the major danger of placental abruption for the mother; anoxia, excessive blood loss, and delivery before maturity are major dangers for the fetus. 10. Disseminated intravascular coagulation is a life-threatening disorder in which procoagulation and anticoagulation factors are activated simultaneously, resulting in profuse bleeding from any vulnerable area. It may occur with missed abortion (primarily if the pregnancy had reached the second trimester when fetal death occurred), placental abruption, severe pregnancy-induced hypertension, amni- otic fluid embolism, and other conditions such as sepsis.

8. Which minerals are often below the recommended amounts in the diets of pregnant women? 9. Why is excessive use of vitamin—mineral supplements unnecessary and possibly dangerous? 10. How much fluid should a woman drink each day during pregnancy? 11. How much of each food group is recommended during pregnancy?

8. Iron, calcium, and folic acid are often below the recom- mended amounts in the diets of pregnant women. 9. Excessive intake of vitamins and minerals may result in toxicity and interfere with absorption of other vitamins and minerals. 10. During pregnancy a woman should drink 8 to 10 cups (or approximately 3 liters) of fluids (mostly water) daily. 11. During pregnancy the woman should eat 7 to 9 oz of whole grains, 3 to 31/2 cups of vegetables, 2 cups of fruits, 3 or more cups or the equivalent from the dairy group, and servings equal to 6 to 61/2 oz from the protein group.

8. What are some relief methods for morning sickness? 9. How can backache be decreased during pregnancy?

8. Relief methods for morning sickness include eating dry carbohydrates (crackers, dry toast, dry cereal) before get- ting out of bed in the morning. Small frequent meals and high-protein snacks my help alleviate nausea and vomiting during the day. If necessary, the provider may prescribe vitamin B6 (pyridoxine), doxylamine, or phenothiazines. 9. Correct posture and body mechanics and exercises such as pelvic rocking can help alleviate backache during pregnancy. Wearing low-heeled shoes and application of heat or acupuncture may also help.

8. What is the major advantage of CVS compared with amniocentesis? 9. What risk is associated with CVS when the procedure is performed at less than 10 weeks?

8. The major advantage of chorionic villi sampling (CVS) compared with amniocentesis is that it is done in the first trimester (10 to 13 weeks gestation) and provides faster results. This prevents a long delay between screening and diagnosis and provides results before the mother perceives fetal movement. This may ease the decision-making process regarding continuation of the pregnancy and decrease emotional distress on the patient and family. 9. There is an increased risk of limb reduction defects associated with chorionic villi sampling (CVS) when the procedure is performed before 10 weeks gestation.

9. What is a chromosomal trisomy? Describe a common trisomy. 10. What is a chromosomal monosomy? Which monosomy is compatible with life? 11. Why are structural chromosomal abnormalities often harmful? 12. What are the possible outcomes of the offspring of a par— ent who has a balanced chromosomal translocation?

9. A trisomy exists when each body cell contains an extra copy of one chromosome. Down syndrome is the most common trisomy and involves three copies of chromo- some 21, for a total of 47 chromosomes in each cell. 10. A monosomy exists when each body cell is missing a chromosome. Turner syndrome (a female with a single X chromosome) is the only monosomy compatible with postnatal life. 11. Genetic material can be lost or duplicated when a chromosome has a structural abnormality. Also, the position of genes on the chromosome may be altered, preventing them from functioning normally. 12. A parent with a balanced chromosomal translocation may have a child with completely normal chromosomes, or the child may have a balanced chromosomal trans- location like that of the parent. The offspring may also receive an unbalanced amount of chromosomal material (too much or too little), which often results in spontaneous abortion or birth defects.

9. How do poverty and inadequate prenatal care affect infant mortality and morbidity? 10. What is the effect of health care disparities in the United States?

9. Poverty is the underlying factor that causes problems such as inadequate access to health care. The lack of access to health care is a major reason for the large number of low-birth-weight infants and the high infant mortality rate. 10. Health care disparities in the United States across racial, geographic, socioeconomic status, age, and gender result in differences in the health outcomes for different groups of people.

5. What special resources do mature gravidas often have? 6. Why is it important to offer prenatal testing to the mature gravida? 7. What anticipatory guidance should the nurse provide the older mother for the first weeks at home after childbirth?

Mature gravidas often have maturity, problem-solving skills, and emotional and financial resources that may be unavailable to younger women.The fetus of amature woman is at increased risk for chro- mosomal anomalies that may be detected by prenatal screening. The older mother may have less energy than younger mothers, and conserving her energy for care of herself and her infant is important.

22. What is meant by the phrase "Adoption is an act of love"? 23. What are the nurse's responsibilities to the adoptive parents?

Mothers see adoption as an act of sacrifice and love when they give up the infant to those who can provide a better life. Adoptive parents must be taught how to care for an infant 4. and what to expect in terms of growth and development.

8. How does smoking affect the neonate? What are the long—term effects on the child? 9. What problems are associated with fetal alcohol syndrome? 10. What are the effects of maternal cocaine use on the infant? 11. Why are women who use heroin encouraged to use methadone during pregnancy?

Neonatal effects of maternal smoking include risk for low birth weight, increased risk for sudden infant deathsyndrome (SIDS), and an increased risk of colic, asthma, and childhood obesity.Fetal alcohol syndrome is characterized by slow growth, central nervous system impairment, and cranial and facial anomalies. Effects of maternal cocaine use on the infant include increased risk for preterm birth, preterm rupture of the membranes, intrauterine growth restriction, and low birth weight. Pregnant heroin users are placed on methadone to pro- vide a long-acting, steady drug dose to the fetus to avoid the problems of intrauterine overdosage and withdrawal. The dosage is gradually decreased to wean the pregnant woman off of the drug. Buprenorphine may also be used.

18. How do nurses promote bonding in families of an infant with congenital anomalies? 19. What should be included in discharge planning for the family of an infant with congenital anomalies?

Nurses can promote bonding by handling the infant gently, emphasizing normal traits, helping parents hold and cuddle the infant, and using communication skills to help parents come to terms with their feelings.Discharge planning should include special feeding and other techniques that the infant may require, the follow-up care needed, and referral to agencies and organizations that may be helpful.

15. When should parents be told that the infant has anomalies? 16. What types of defects most affect parenting? 17. How can the reaction of parents to birth anomalies be described?

Parents experience less anxiety when they are gently told about the condition of the infant and allowed to hold their newborn as soon as possible. Facial, genital, and irreparable defects are likely to affect parenting most. The reaction of parents can be described in terms of a grief response. Initial reactions include shock and disbe- lief. Denial, anger, and guilt are common.

12. What prenatal behaviors may indicate substance abuse? 13. What signs and symptoms indicate recent cocaine use? 14. How does nursing care differ during the intrapartum period when the woman has recently taken illicit drugs?

Prenatal behaviors that suggest substance abuse include prenatal care sought late in pregnancy, failure to keep appointments, inconsistent follow-through with recom- mended regimens, poor grooming, inadequate weight gain, needle punctures, thrombosed veins, signs of cel- lulitis, defensive or hostile reactions, and severe mood swings. Signs and symptoms of recent cocaine use include pro- fuse sweating, high blood pressure, tachycardia, irregular respirations, lethargic response to labor, dilated pupils, increased body temperature, sudden onset of severely painful uterine contractions, fetal tachycardia, and exces- sive fetal activity. Emotional signs include anger, caustic or abusive reactions to the caregiver, emotional lability, and paranoia. Interventions are focused on preventing maternal or fetal injury and may require setting limits in a firm, nonjudg- mental manner with a woman who may be abusive and in great pain.

24. What are the symptoms of postpartum depression, and how does it differ from postpartum blues? 25. How can nurses intervene for postpartum depression? 26. What is the therapeutic management for postpartum psychosis?

The symptoms of postpartum depression differ from those of postpartum "blues" in their intensity and per- sistence. In postpartum depression, the symptoms are present daily for at least 2 weeks. They include anxi- ety, feelings of guilt, agitation, fatigue, sleeplessness, feeling unwell, irritability, difficulty concentrating or making decisions, confusion, appetite changes, loss of pleasure in normal activities, crying, sadness, depres- sion, suicidal thoughts, and being less responsive to the infant. Nurses can demonstrate caring, provide anticipatory guidance, help the mother verbalize her feelings, and make appropriate referrals. Postpartum psychosis usually requires hospitalization, psychotherapy, and appropriate medication.

20. How should the stillborn infant be presented to the parents? why? 21. What is a memory packet, and what should it include?

The way in which the stillborn infant is presented creates memories that the parents will retain. The infant should be washed and taken to the parents while still warm and soft, wrapped in a soft, warm blanket. A memory packet that includes photographs of the baby, handprints, footprints, a birth identification band, crib card, blanket, cap, and, if possible, alock of hair help par- ents grieve.