Chapter 24

Determine the teenagers cognitive development, the three most important areas are

1.Egocentrism(interest centered on self) which involves the ability to defer personal satisfaction to respond to the needs of the infant: "What will you do when the baby is sick?" 2.Present-future orientation, which involves the ability to make long-term plans: "What are your plans for finishing high school?" 3.Abstract thinking, which involves identifying cause and effect: "Why is it important to keep clinic appointments?" "Why should condoms be used even though you are pregnant?"

Type of defect

Accepting an infant with facial or genital anomalies is particularly difficult for the family and the community. Parents are often concerned how the rest of the family and peers will accept the child. Gender is at the core of a person's identity, and any defect of the genitals arouses deep concern in both parents. Some anomalies, such as hypospadias (opening of the urethra on the underside of the penis), are repaired in early childhood. Other genital anomalies, such as ambiguous genitalia, when assignment of gender is in doubt, cause extreme concern in the family and affect such basic issues as what to name the infant, how to dress the infant, and how to respond to questions about the infant's gender.

Impact of Teenage Pregnancy on Parenting

Adolescent mothers are at risk of becoming non-nurturing parents. Whether this risk results from adolescence per se, the higher incidence of premature births, the lower socioeconomic status, or the particular home environment is difficult to determine.

Counseling

Allow time to counsel teenagers about their specific problems, such as nutrition, stress reduction, and infant care.

irreparable defect

Although the initial impact of any defect is deep disappointment and concern, when the defect is irreparable, the parents must grapple with the knowledge that the infant will have a lifelong disability. Examples of irreparable defects include Down syndrome, microcephaly, and amelia (absence of an entire extremity).

Delayed pregnancy

An increasing number of women are waiting late into their reproductive lives to become pregnant

post partum period

Assess the mother-infant interaction so that bonding and attachment can be promoted. Encourage the woman to continue her efforts to stop taking substances. Women who stop or reduce use during pregnancy may return to using at previous levels after pregnancy and need support to continue abstinence. Referral to social services and child protective agencies may be necessary for follow-up care of the mother and infant.

Providing ongoing care

At each antepartum visit, consider the current status of substance use, social service needs, education needs, and compliance with treatment referrals. Verify compliance with recommended treatment regimens such as antepartum clinics and chemical-dependence referral programs. Coordinate care among various service providers such as group therapy and prenatal classes. Provide continuing prenatal education about the anatomy and physiology of pregnancy and consequences of prenatal substance abuse. Describe how the newborn benefits when the mother abstains from drugs, including tobacco and alcohol. Praise any attempts at abstinence, and encourage the expectant mother to try again if she relapses. Assess maternal attachment to the fetus because it may help her reduce or eliminate her substance use. Fetal movement often increases the woman's awareness of the fetus and may lead to a discussion about her plans for the infant and changes in her life that have occurred and will occur.

most helpful interventions related to loss of a baby, the baby's rights

Be recognized as a person who was born and died Be named Be seen, touched, and held by the family Have life-ending acknowledged Be put to rest with dignity

Helping the woman identify strengths

Because she generally has a poor self-image, assist the substance-abusing pregnant woman in identifying personal strengths. Acknowledge her actions when she abstains from drugs or alcohol for even a short time. Praise for maintaining an adequate weight gain, and attending prenatal classes may increase her confidence and compliance with the recommended regimen of care.

early pregnancy loss

Comments such as "You shouldn't have any problems getting pregnant again" discount the parents' feelings. When ectopic pregnancy is the reason for the loss, the woman must cope with the loss of the pregnancy as well as with the loss or damage of a fallopian tube.

Concurrent Death and Survival in Multifetal Pregnancy

Contrary to common belief, parents do not grieve less for the dead infant because of the joy they experience in the surviving infant. They may have fears about the health of the surviving infant, especially if the infant is preterm or ill. They may be unable to grieve for the dead child because of their concerns for the surviving child. They may also have problems with attachment to the surviving infant because of grieving and fear that they will lose that infant, too. In addition, they may receive less support from others than parents who have lost the only child in a single gestation.

Medical and Obstetric History

Determine whether the woman has medical conditions that are prevalent among women who use drugs, such as hepatitis, STDs, cellulitis, seizures, hypertension, depression, or suicide attempts. Evaluate for past and current complications of pregnancy. Spontaneous abortions, premature deliveries, abruptio placentae, and stillbirths are associated with substance abuse. Current complications may include vaginal bleeding, an inactive or hyperactive fetus, or FGR. Identify emotional responses regarding the pregnancy. Anger or apathy is particularly significant during the latter half of the pregnancy, when normal feelings of ambivalence are usually resolved. Negative feelings toward the pregnancy may interfere with compliance with recommended care.

Pain Control

If pain medication can be administered safely, do not withhold it under the false assumption that the woman does not need it or medication will contribute to her chemical dependence. Include nonpharmacologic comfort measures such as sacral pressure, back rubs, a cool cloth on the head, and continual support and encouragement as for any woman in labor.

Nursing Diagnosis related to substance abuse

Ineffective Health Maintenance related to lack of knowledge of the effects of substance abuse on self and fetus and inability to manage stress without the use of drugs.

Because perinatal death affects the whole family, an appropriate nursing diagnosis for families is:`

Interrupted Family Processes related to grief over newborn (or fetal) death.

Cocaine

Maternal: Hyperarousal state, euphoria, generalized vasoconstriction, hypertension, tachycardia, increased STDs, increased spontaneous abortion, abruptio placentae, preeclampsia, PROM, preterm labor, precipitous delivery Fetal: Tachycardia, stillbirth, prematurity, irritability, sleep followed by agitation, poor response to comforting or interaction, possible attention and language problems

Tobacco

Maternal: Decreased placental perfusion, abruptio placentae, anemia, PROM, preterm labor, spontaneous abortion Fetal: Prematurity, LBW, neurodevelopmental problems, increased incidence of SIDS

Opioids (heroin, methadone, morphine)

Maternal: Malnutrition, anemia, increased incidence of STDs, HIV exposure, hepatitis, thrombosis, cardiac disease, spontaneous abortion, preterm labor Fetal: FGR, LBW, perinatal asphyxia, meconium aspiration syndrome, neonatal abstinence syndrome, fetal or neonatal death, SIDS, child abuse and neglect, long-term developmental effects unclear

Marijuana

Maternal: Often used with other drugs: alcohol, cocaine, tobacco; exact effects undetermined Fetal: Unclear, more study needed, may be related to neurobehavioral problems; increased risk of anomalies or mortality unproven

Antidepressants such as selective serotonin reuptake inhibitors

Maternal: Relief of anxiety and depression, risk of anomalies with paroxetine, small risk of anomalies for other antidepressants Fetal: Transient respiratory distress, irritability, poor tone, persistent pulmonary hypertension

Alcohol

Maternal: Spontaneous abortion, abruptio placentae Fetal: Fetal demise, FGR, fetal alcohol spectrum disorders, FAS (facial and cranial anomalies, developmental delay, intellectual impairment, short attention span)

Caffeine (coffee, tea, cola, chocolate, cold remedies, analgesics)

Maternal: Stimulates CNS and cardiac function, causes vasoconstriction and mild diuresis; half-life triples during pregnancy Fetal: Crosses placental barrier and stimulates fetus; teratogenic effects are undocumented

Amphetamines and methamphetamines ("speed," "crystal," or "ice"; ecstasy)

Maternal: Vasoconstriction, tachycardia, hypertension, spontaneous abortion, preterm labor, abruptio placentae, preeclampsia, and retroplacental hemorrhage Fetal: Increased risk for FGR, prematurity, cleft palate, abnormal sleep patterns, agitation, poor feeding, vomiting

Advantages of delayed birth

Mature primigravidas come to the parenting role with a range of personal resources: psychosocial maturity, self-confidence, and a sense of control over their lives. they can usually solve complex problems and because of their age are usually more financially secure

Assisting with the grieving process

Nurses must recognize that grief responses vary among individuals, and cultural and religious beliefs affect the expression of grief. Members of some groups express grief openly by crying, becoming angry, or seeking comfort from a support group. Those in other cultures (e.g., Chinese, Japanese, Native American) do not. They may appear stoic and may not reveal the depths of their grief. In some cultures (such as Latino), it is acceptable for women, but not for men, to grieve publicly. The mother should be offered a private room, if possible. The infant should be examined in front of the parent so they can ask questions. Information about the normal needs of this newborn should be given at the same time as other information.

providing accurate information

Nurses who work in perinatal settings are responsible for becoming informed about follow-up treatment and timing of surgical procedures for common anomalies so they can clarify and reinforce information provided by the physician. if possible it is good for one nurse to work with the family during their entire stay

History of Substance Abuse

Obtaining an accurate history of substance abuse is difficult and depends in large part on the way the health care worker approaches the woman. A sincere, nonjudgmental, empathic approach promotes an open exchange of information. Ask about all forms of drug use, including cigarettes, over-the-counter drugs, prescribed medications, alcohol, and illicit drugs such as marijuana, amphetamines, cocaine, and heroin. Examine patterns of drug use, which can range from occasional recreational use to weekly binges to daily dependence on a particular drug or group of drugs.

Adoption option for teenage pregnancy

Only 2% to 4% of unmarried adolescents relinquish their newborns for adoption Adolescents who choose abortion or adoption receive less assistance in dealing with their experience than those who keep their infants. They need help in coping with their feelings about their decision

participating in infant care

Parents should be involved in giving care to the infant as soon as possible to increase bonding and to help them feel they can be real parents to the infants. Providing care for the infant also helps reduce parental anxiety as they get to know their baby

Preventing Substance Abuse

Participate in campaigns to prevent substance abuse throughout the community. Use posters, diagrams, pamphlets, and other visual aids to describe the effects of tobacco, alcohol, and other drugs on the fetus. Post visual aids in schools, supermarkets, shopping centers, and other areas where women of childbearing age will be exposed to them.

Implications of Fetal- Neonatal Health

Prematurity and low birth weight (less than 2500 g or 5.5 lb) are more likely to occur in infants born to adolescent mothers. These infants also have a higher infant mortality rate Low birth weight may result from a variety of causes, such as poor placental perfusion, which occurs during preeclampsia, or the underdeveloped vasculature of the uterus in young primigravidas. Cigarette smoking is another cause of low birth weight. Teens are more likely to smoke during pregnancy than other maternal age-groups

Preparing a memory box or packet

Prepare a memory box or packet that may include a photograph; the crib card with the infant's name, weight, and length; identification band with the time and date of birth; blanket and cap used for the baby; and anything else used in care of the infant. Make paper handprints or soft modeling material impressions of the infant's hands and feet. If possible and with the parents' permission, cut a lock of hair from the nape of the neck where it won't be noticeable. Some facilities offer commercial remembrance materials to give parents. The packets or boxes may contain clothing for the baby to wear or provide a place to keep baby items. Take photographs of the infant to help the parents remember the baby's features and assist them in their grieving. Take photos of the infant dressed and undressed, wrapped and unwrapped, and of the parents and other family members with the infant. Professional photographs may be available from Now I Lay Me Down To Sleep Foundation, a nonprofit organization that provides bereavement photos to families. A list of photographers and their locations is available at www.nowilaymedowntosleep.org. A website that offers help for caregivers who take pictures for the family is www.toddhochberg.com. Keep the memory packet and photos on file if the parents do not want to take them home, because they may want them at a later time.

One of the most relevant nursing diagnosis for expectant teenage mothers

Risk for Ineffective Health Maintenance related to lack of knowledge of measures to promote health during pregnancy and increased family stress.

Preconception Counseling

Smoking cessation, attaining optimum weight, folic acid intake, and screening for violence are all topics that should be discussed with all young women so that a future pregnancy has the most positive outcome

Planning for discharge

Teach parents the special feeding, holding, and positioning techniques that their infant needs. Early participation in infant care fosters feelings of attachment and responsibility for the infant as well as increasing feelings of confidence. Young children, who are often jealous of the attention and care the infant requires, may regress to infantile behaviors, such as bed-wetting or thumb-sucking. Remind parents that this response indicates a need for attention rather than naughtiness. Although grandparents can be a great source of strength and support, they may also have difficulty adjusting to the infant with an abnormality. When appropriate and if the parents are willing, include interested grandparents when teaching special care the infant will need.

Adoption

The decision to place the infant for adoption is a painful one that can produce long-lasting feelings of ambivalence and chronic sorrow. On the one hand, the expectant mother may be satisfied that the infant is going into a stable home where the child is wanted and will receive excellent care. On the other hand, the social pressures against giving up one's child are often intense. First, the nursing staff who come into contact with the woman must be informed of her decision to place the infant for adoption. This information prevents inadvertent comments that could cause distress. Second, nurses must remember that adoption is an act of love, not one of abandonment, because the woman relinquishes the newborn to a family that is better able to provide financial and emotional support. The nurse should try to establish rapport and a trusting relationship with the birth mother. It is helpful to acknowledge the situation at the initial contact with the woman: "Hello, I'll be your nurse today. I understand the adoptive family is coming this morning. What can I do to help you get ready?" This is much more helpful than providing care without reference to an event that is of utmost concern to the mother. It also provides an opening for her to express feelings that may include attachment to the infant, ambivalence about her decision, and profound sadness. Nurses also teach adoptive families how to care for the newborn and what to expect in growth and development. Teaching requires adequate time and a private place. The family benefits from all the teaching provided to other new parents. They may be anxious, and demonstrations as well as return demonstrations are appropriate.

Initiating seizure precautions

The laboring woman who has recently used cocaine is at risk for seizures. Take seizure precautions to protect her from injury in case of seizures. Keep the bed in a low, locked position. Pad the side rails and keep them up at all times. To prevent aspiration, make sure suction equipment functions properly. Reduce environmental stimuli (lights, noise) as much as possible.

Facilitating Communication

The most helpful course of action is to answer questions as honestly as possible. If unsure of information, say so: "I'm not sure about that, but I'll find out for you." In addition to answers, parents need kindness, support, and genuine concern.

Presenting the infant to the parents

The way in which the infant is presented to the parents is extremely important because these are the memories they will retain. If necessary, wash the infant and apply baby lotion or powder. Wrap the infant in a soft, warm blanket. Some parents wish to participate in bathing and dressing the baby. If possible, bring parents and infant together while the infant is still warm and soft. It may be necessary to keep the infant in a warmed incubator if some time elapses before the parents have contact with the infant. If this is not possible, tell the parents that the skin may feel cool. Call the infant by name and allow parents to keep the infant as long as they wish. Tell them to feel free to unwrap the infant if they wish. When the stillborn infant has severe deformities, explain the defect briefly and gently. Wrap the infant to expose the most normal aspect. Use diapers to cover genital defects, and booties and mittens to cover abnormalities of the hands and feet so the parents do not see those areas first. It is not advisable, however, to try to hide the defects completely. Allow parents to progress at their own speed in inspecting the infant. Parents may look at the abnormality or choose to leave the infant wrapped. Some parents provide infant care before their baby dies. If death is near, ventilators and other equipment may be removed so the parents can feel closer to the infant. They may hold the infant during the dying process. Many feel this is very helpful to them because it provides a chance to say goodbye and is the only opportunity they will have to parent their baby. Other family members may also be present at this time. Stay with the family, if they wish, to help them at this difficult time. Allow as much privacy and time as the parents and other family members need to be together. Remain sensitive to cues that members of the family want to talk or prefer silence. A sympathetic smile and a promise to return in a specific time and then returning at that time are equally important. It is all right to ask, "Do you want to talk?" Then, listening quietly and reflecting the mother's or father's feelings are all that are required. Although many parents want to spend time caring for or holding their baby before or after death, others may not. It is important not to make the parents feel guilty or that they should behave in a certain way. Nurses must accept that each family needs to go through this difficult experience in their own way (Limbo & Kobler, 2010).

preventing heroin withdrawl

To prevent or stabilize heroin withdrawal during labor, give methadone to the woman who usually takes it at a chemical-dependence center if she did not receive her daily dose. Administer methadone intramuscularly as ordered if the woman is nauseated or vomiting. Avoid narcotic agonists-antagonists, such as butorphanol (Stadol), because they may cause acute withdrawal signs and symptoms in the woman and the fetus.

Eliminating Barriers to Health Care

Two major barriers to health care are scheduling conflicts and negative attitudes of some health care workers. locate closet clinic to where she lives, provide information about public transportation if necessary Nurses can be instrumental in finding ways to overcome these negative attitudes, thus encouraging pregnant women, including teenagers, to return for needed follow-up care.

attachment to the fetus

attachment starts during pregnancy helping the pregnant teen begin this process as early as possible is important hearing the fetal heartbeat, seeing the ultrasound, and feeling the fetus's movement all help in this process

maintain effective communication

avoid confrontation, acknowledge her feelings, when the woman is abusive be careful to not return the abuse, but keep therapeutic communication

reinforcing and clarifying information

because the fetus is at more risk for chromosomal anomalies information about available diagnostic tests are given The tests most often recommended are multiple marker screening, chorionic villus sampling, amniocentesis, and ultrasonography.

Nutrition

counseling about nutrition is one way to help reduce low birth rate occurrence Determine the adolescent's general nutritional status, and assess for eating disorders that would reduce caloric intake and possibly affect fetal growth. put emphasis on the fact that the fetus is still growing and discuss nutritional needs during lactation refer teen to assistance programs if necessary

grief

describes the emotional response to the loss

grief and mourning

early emotions are denial and disbelief, usually followed by anger Other emotions include fear, which may be expressed as concern about what must be done in the immediate or distant future (surgical procedures, complicated care, the infant's potential for a normal life). Sadness and depression, manifested by crying, withdrawal from relationships, lack of energy, inability to sleep, and decreased appetite, may precede acceptance and resolution. Gradually, often after a prolonged period, feelings of sadness abate and the family is able to adapt to the loss and resolve their grief.

breastfeeding

for teens in particular they maybe embarrassed when it comes to breast feeding, educate on how to keep privacy and the position to hold the infant, also discuss possible problems that may arise, such as the infant not latching on check frequently during feeding to see if any intervention is needed

Assisting with other needs

help the parents prepare how to tell the rest of the family about the loss of the baby Offer to call clergy and discuss plans for a funeral or memorial service. Parents may wish to discuss this with their own clergy, or a hospital chaplain may assist them. Discuss the normal grieving process and explain that a considerable amount of time is involved. Describe common reactions that family members and friends may have and that grandparents will also experience grief because of the loss as well as the pain their children must endure. Parents may find that friends and relatives expect them to recover quickly from perinatal loss and cannot understand their continued grief. Suggest they allow the parents to "tell the story" of the infant as often as they want because this helps them in the grief process. Suggest that they help the parents collect and talk about mementos to help establish memories of the infant. Explain that some young children think they have done something to cause the death and need reassurance. Young children may have questions (such as "Is the baby still dead?" or "Is the baby alive?") that should be answered simply but truthfully

stress reduction

identify the various stressors in the teen's life Stress may be related to basic needs such as food, shelter, and health care. Fear of labor and delivery and fear of being single, alone, and unsupported all create stress. Meeting the developmental tasks of adolescence while working on the developmental tasks of pregnancy is another stressor. many teens have not told their parents or the father of the baby, that she is pregnant, and this is a source of stress, the nurse can help by role playing the encounter

timing of communication to parents

if anomaly is present it needs to be communicated as soon as possible to the parents

diagnosis and management of substance abuse

in addition to toxicology screening women who use illicit drugs need to be assessed for STDs, hepatitis, and exposure to HIV Nurses monitor weight and provide guidance in nutrition to prevent maternal anemia and inadequate weight gain.

methadone

is a synthetic opiate drug prescribed to women who use heroin Methadone can be taken orally once daily and is long acting, providing consistent blood levels to decrease the adverse fetal effects of wide swings in blood level found with heroin use. At therapeutic levels, it does not produce the euphoria or sedation of heroin and allows the woman to live a relatively normal lifestyle. The woman in a drug treatment program who receives a daily dose of methadone is more likely to receive prenatal care. The newborn, however, must withdraw from methadone after birth. Some women taking methadone also use other illicit drugs such as cocaine or marijuana. Buprenorphine may be used instead of methadone with less severe neonatal withdrawal Treatment is aimed at establishing abstinence and preventing relapse. Outpatient or residential treatment provides education, individual and group therapy sessions, and peer support groups (Narcotics Anonymous, Alcoholics Anonymous, or Cocaine Anonymous). Written contracts that focus on abstinence for 1 day at a time are often used to help the woman who has relapsed and experiences feelings of guilt and self-blame.

mourning

is the process of going through the phases of grief until the loss can be accepted and resolved.

preconception care for the older mother

is vital so that any potential risk factors can be identified early

Implications of maternal health in teen pregnancy

majority of teen pregnancies have no medical complications, although they have increased risk for anemia, preeclampsia, and preterm birth high incidence of STDs among pregnant teenagers is another concern

infants born to mothers dependent on opioids have NAS

physical signs that affect all body systems as a result of fetal exposure to opioids

Disadvantages of delayed birth

pregnancy complications can result in missed work that was not anticipated because they are older need more time to recover than that of younger mothers may have less peer support

promoting bonding and attachment

priority nursing intervention is to promote bonding and attachement To promote bonding, the nurse handles the newborn gently and presents the infant as someone precious. Parents are particularly sensitive to facial expressions of shock or distress. The infant should be called by name. Many nurses emphasize the normal aspects of the infant's body: "She's so alert, and she has beautiful eyes." Perhaps it is most important to help the parents hold their infant as soon as possible. Touching and cuddling are essential to caring.

self care

provide the same information you would to an older adult

Pregnancy Loss Assessment

requires great sensitivity n the case of infant death, collect as much information as possible before meeting the woman and her family for the first time so that hurtful mistakes can be avoided. Knowing the child's gender, weight, length, gestational age, and whether any abnormalities were noted will help the nurse communicate effectively. Many perinatal units design a sticker or symbol to place on the door, chart, and Kardex so that all staff who come in contact with the family, including auxiliary, housekeeping, and laboratory personnel, will be alerted that the infant has not survived. Designs include a fallen leaf, flower, teardrop, butterfly, or rainbow Evaluate the availability of a support system that includes family members or clergy. Ask whether a spiritual adviser would help the family cope with their grief, if appropriate. The family may want the infant baptized or blessed. Assess the father's needs too, because they are sometimes perceived as needing less support than the mother, and they may not receive the support they need. Many fathers feel a need to appear strong so that they can support their partners. As a result, they often hold back their own feelings of grief and pain in an attempt to avoid increasing the mother's grief.

Maternal and Fetal Implications of delayed pregnancy

she may experience some delay in becoming pregnant most pregnancies are normal but there are higher risks The risks may be genetic, a result of preexisting medical conditions, or from obstetric complications. Advanced maternal age is associated with an increased risk for fetal chromosome abnormalities such as trisomy 21 (Down syndrome). Genetic abnormalities also increase when the father is older than 55 years The most common examples of preexisting diseases that can cause maternal or fetal jeopardy are hypertension and diabetes mellitus. The older woman is also at increased risk for obstetric complications such as spontaneous abortion, gestational diabetes, cesarean birth, preterm delivery, stillbirth, preeclampsia, multifetal gestation, placenta previa, abruptio placentae, and low-birth-weight infants

providing parenting information

the older mother that is used to mental stimulation of work may feel isolated if at home with the baby and may experience guilt if at work they are particularly receptive to prenatal classes

Socioeconomic Implications of Teenage Pregnancy

the public cost of teenage pregnancy in the US is approximately 9 billion per year Children born into this situation do not escape unscathed. They may show a higher incidence of impaired intellectual functioning and poor school adjustment. The negative cycle is often repeated: daughters of teenage mothers are three times more likely to become teen mothers than daughters of older mothers

Applying Teaching or Learning Principles

try to arrange a support group for the pregnant teenager, so she can be surrounded by peers with similar concerns when educating avoid using the words "should" or "ought" or making decisions for the teenagers

Communicating with the woman

try to identify stressors in her life that may be contributing to the substance abuse maintain nonjudgemental attitude Allow her to express guilt, and reassure her that abstinence is possible and that she can and must begin again.

Physical Assessment of the pregnant teenager

very similar to that of the adult at the initial visit, obtain a thorough health and family history to determine whether conditions such as diabetes or infectious diseases increase the risk for the mother and fetus Monitor closely for signs of iron deficiency anemia, preeclampsia, or STDs try to identify behavioral risk factors, such as poor nutrition, smoking, alcohol or drug use, or unprotected sex Screen for physical or sexual abuse, which is more common in pregnant teenagers treat the interview like a normal conversation, asking about their interests if possible

Evaluation during antepartum period

• Can the expectant mother identify the effects of substance abuse on herself and her infant? • Does she discuss her feelings about continued substance abuse? • Does she identify her own strengths and work with the health care team to stop using drugs?

signs and symptoms of recent cocaine use

• Diaphoresis, hypertension, tachycardia, irregular respirations • Dilated pupils, increased body temperature • Sudden onset of severely painful contractions • Fetal tachycardia • Excessive fetal activity, late decelerations • Angry, caustic, abusive reactions and paranoia

BOX 24-1 FACTORS THAT CONTRIBUTE TO TEENAGE PREGNANCY

• Peer pressure to begin sexual activity • High rate of sexual activity • Limited access to contraceptive devices • Lack of accurate information about how to use contraceptives correctly • Incorrect or lack of use of contraceptives • Fear of reporting sexual activity to parents • Ambivalence toward sexuality; intercourse not "planned" • Feelings of invincibility • Low self-esteem and consequent inability to set limits on sexual activity • Desire to attain love or escape present situation • Lack of appropriate role models

Behaviors associated with substance abuse

• Seeking prenatal care late in pregnancy • Failure to keep prenatal appointments • Inconsistent follow-through with recommended care • Poor grooming, inadequate weight gain • Needle punctures, thrombosed veins, cellulitis • Defensive or hostile reactions • Anger or apathy regarding pregnancy • Severe mood swings

One of the most relevant nursing diagnoses during the intrapartal period is:

•Risk for Injury related to physiologic and psychological effects of recent drug use.