Maternal and Child Nursing

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Maternal and Child Nursing

  1. 1. Misamis University Ozamiz City Graduate School MASTER IN NURSING (MN) FINAL EXAMINATION Major in Maternal and Child NursingName: Reynel Dan L. Galicinao Date: April 30, 2011I. Psychological and Physiological Changes of Pregnancy The psychological changes occur in response to the physiologic changes. Though the physiological changes of pregnancy are dynamic and extensive they are considered an extension of normal physiology. The nurse uses this concept when preparing teaching plans and developing care plans. Complete the following: A. What is the significant health care goal that the nurse promotes when teaching a pregnant woman from any culture? Providing care to childbearing families is aimed at the ideal of having every pregnancyresult in a healthy mother, baby, and family unit. Consider cultural practices because they haveimportant implications for the provision of nursing care. The primary goal is to providecomprehensive family-centered care to the pregnant client, the family and the baby throughoutpregnancySafe, effective care environment  Provide education and counselling regarding environmental safety for the expectant woman and a safe intrauterine environment for the fetus.  Provide opportunities for expectant couple to tour birthing facilities.  Discuss progress of couple in childbirth education program.Physiological integrity  Promote maternal-fetal well-being.  Discuss changes in third trimester and during birth process.  Demonstrate methods of assessing fetal activity.Psychosocial integrity  Promote psychosocial adaptation.  Provide opportunities for counselling and discussion of psychosocial aspects.Health promotion and maintenance  Promote, encourage, and review self-care activities.  Provide opportunities to discuss parenting activities that will promote infant health. B. You are caring for a pregnant client in the third trimester. What are two physiological reasons why you would advise her in the lateral recumbent position while sleeping? With the progression of pregnancy, the fetal weight increases with the compression of themajor blood vessels, especially the inferior vena cava. With this compression comes return ofinsufficient blood to the heart and subsequent onset of symptoms such as pain, dizziness,cramping, and shortness of breath. Because of the anatomy of the IVC in relation to the aorta
  2. 2. and the vertebral column, lying on the left side relieves the pressure and symptoms associatedwith this condition. To promote placental perfusion, the woman should not lie flat on her back:left lateral position provides the best placental perfusion; however, either side is acceptable. C. Explain why it is important that pregnancy be diagnosed as early as possible and how this diagnosis may impact upon the woman’s physiological and psychological health status. When a woman misses her menstrual period, she must visit the physician to check forpregnancy. The earlier the client begins prenatal care, the better. This includes assessing thepatient, performing prenatal testing, providing nutritional care, and minimizing the discomforts ofpregnancy. Prenatal education should focus on nutrition, sexuality, stress reduction, lifestylebehaviors, and hazards at home or work.II. The Growing Fetus The development of the fetus is a complex phenomenon which originates form the union of an ovum and a sperm. When united, the ovum and the sperm form a single cell which is called zygote. This concept enables the nurse to explore these stages of development with the childbearing family to help them understand some of the changes taking place in the woman’s body. Complete the following: A. Explain how the nutrients are exchanged from the mother to the fetus during pregnancy. The placenta is a large, flat organ that is attached to the inside of the uterus of a pregnantwoman. It is attached to the fetus through the umbilical cord. The placenta has many importantfunctions during pregnancy, including nutrient exchange between mother and baby through theirblood streams. This transfer is vital in enabling nutrition be transported from the mother throughthe placenta to the fetus and expelling waste produced by the fetus back through the placentaand into the maternal blood stream, which is then released by the mother. The placenta is composed of numerous blood vessels. These blood vessels are filled withfetal blood, while the placenta is rich in maternal blood. As these blood vessels carry fetal bloodthrough the placenta, they come into contact with the mothers blood, which transfers nutrientsinto and removes waste from the fetal blood through the walls of the blood vessels. It isimportant to note that during this interaction, the blood does not mix. Separation is maintainedby the blood vessel walls. The substances that are transported from the mother to the fetus include glucose, aminoacids, maternal antibodies, oxygen and waste products such as carbon dioxide and bilirubinfrom the liver. Glucose acts as the energy powerhouse for fetal development. Amino acids arethe building blocks of the developing baby. Maternal antibodies provide immunity to the fetusbefore it is able to produce its own antibodies as its immune system matures. B. Why should a pregnant woman avoid lying in the supine position? Lying on the right side does not give as much relief as lying on the left.Lying on your back would understandably give you symptoms. Lying on the back especially asthe pregnancy progresses causes Vena Cava Sydrome and renders the woman extremelyhypotensive and prone to dizzy spells having compressed her major arteries and veins with thebulging fetus against the spine. To promote placental perfusion, the woman should not lie flat onher back: left lateral position provides the best placental perfusion; however, either side isacceptable. 2|Page
  3. 3. C. Explain why the continued assessment of the eyes is important when administering oxygen to premature infant. Oxygen relieves neonatal respiratory distress which can be caused by cyanosis,tachypnea, nasal flaring, bradycardia, retractions, hypotonia, hyporeflexia, or expiratory grunting.No matter how it’s administered, oxygen therapy can be hazardous to a neonate. Whan givenfor prolonged periods, it can cause retrolental fibroplasia, which may result in blindness inpreterm neonates, and can contribute to bronchopulmonary dysplasia. Because of theneonate’s size and special respiratory requirements, oxygen administration commonly requiresspecial techniques and equipment.III. Assessing Fetal and Maternal Health: The First Prenatal Visit When a woman visits a healthcare facility for the first prenatal visit, an assertive effort should be made by the healthcare providers to validate the pregnancy, determine the woman’s health status and initiate the strategies that will encourage the woman and her family to establish positive behavior patterns of health promotion during the pregnancy and throughout their lives. This concept will allow the nurses to review the anatomical structures of the female’s body and demonstrate knowledge of how to appropriately intervene to provide nursing care, education, and guidance during the mother’s pregnancy. A. Identify the four types of pelvis and illustrate how the anatomy of the pelvis may accommodate or hamper the fetus as it progresses the birthing process.There are four main types of pelvic shapes.Gynecoid  typical female pelvis in which inlet is round instead of oval  normal female pelvis  optimal diameters in all three planes  50% of all womenAndroid  male-type pelvis  normal male pelvis  posterior segments are decreased in all three planes  deep transverse arrest of descent of the fetus and failure of rotation of the fetus are common  20% of all womenAnthropoid  pelvis in which anteroposterior diameter is equal to or greater than the transverse diameter  apelike pelvis with long anteroposterior diameter  may allow for easy delivery of an occiput-posterior presentation of the fetus  25% of all womenPlatypelloid  broad pelvis with shortened anteroposterior diameter and flattened, oval, transverse shape 3|Page
  4. 4.  flat female pelvis with wide transverse diameter  arrest of fetal descent at the pelvic inlet is common  labor progress can be poor  5% of all women B. Ms. X had delayed her first pre-natal visit. She visited the prenatal clinic after she experienced edema of the feet and hands. As a nurse, you take the history and physical assessment to begin Ms. X’s care. Explain history taking of a pregnant woman, assessment and planning of care.HEALTH HISTORYAge  Adolescents (younger than age 19) have an increased incidence of anemia, gestational hypertension, preterm labor (PTL), small-for-gestational-age (SGA) infants, intrauterine- growth-restricted infants, cephalopelvic disproportion, and dystocia.  Women of advanced maternal age (over age 35) have an increased incidence of hypertension, pregnancies complicated by underlying medical problems such as diabetes, multiple gestation, and infants with genetic abnormalities.Family History  Includes maternal and paternal history  Congenital disorders, hereditary diseases, multiple pregnancies, diabetes, heart disease, hypertension, mental retardation, renal disease, use of diethylstilbestrolWomans Medical History  Childhood diseases, especially rubella, measles and chickenpox  Major illnesses, surgery (especially of the reproductive tract, spinal surgery or appendectomy), blood transfusions  Chronic medical conditions, such as epilepsy, diabetes mellitus  Drug, food, and environmental sensitivities  Urinary tract infections (UTIs), heart disease, hypertension, endocrine disorders, anemias  Menstrual history (onset of menarche, length, amount, regularity, and pain [dysmenorrhea] of menstrual cycle). Also, assess bleeding between periods  Gynecologic history (sexually transmitted diseases, contraceptive use, sexual history)  Use of medications (prescription and over-the-counter [OTC]), recreational drugs, alcohol, nicotine, tobacco, and caffeine  History of tuberculosis, hepatitis, group B beta-hemolytic streptococcus, or human immunodeficiency virus (HIV)Womans Nutritional History  Adherence to special dietary practices (religious, social or cultural preferences)  Eating disorders (obesity, bulimia, anorexia nervosa)Womans Past Obstetric History  Problems of infertility, date of previous pregnancies, and deliveries’ dates; infant weights; length of labors; types of deliveries; multiple births; abortions; and maternal, fetal, and neonatal complications  Womans perception of past pregnancy, labor, and delivery for herself and effect on her familyWomans Present Obstetric History  Gravidity, parity  Date of last menstrual period  Estimated date of birth/expected date of confinement  Signs and symptoms of pregnancy: amenorrhea, breast changes, nausea and vomiting, fetal movement, fatigue, urinary frequency, skin pigment changes. Expectations for her 4|Page
  5. 5. present pregnancy, labor, and delivery. Expectations for her health care providers and her perception of her relationship between herself and her nurse  Rest and sleep patterns: length, quality, and regularity of rest and sleep  Activity and employment: exercise patterns, type and hours of employment, exposure to hazardous material (occupational hazards), plans for continued employment  Sexual activity: sexual satisfaction, frequency and positions during intercourse, alternative practices used to achieve sexual satisfaction  Diet history: weight gain, eating patterns (times and frequency of eating daily), number of servings of food from the five food groups, calories, protein, vitamins, and minerals consumed daily  Psychosocial status: emotional changes she is experiencing, womans and familys reactions to present pregnancy, support system - familys and friends willingness to provide support, womans present coping with lifestyle changes caused by the pregnancyLABORATORY DATAUrinalysis  Urine is tested for glucose, ketones, and protein. Urine is usually collected by way of clean catch midstream  Glucose (glucosuria) may be present in small amounts because the glomerular filtration rate is increased without the same increase in kidney tubular reabsorption. Glucosuria should be investigated to rule out diabetes  Protein in the urine that exceeds 250 mg/dL should be reported because it may be a sign of preeclampsia, renal problems, or UTI  Ketones in the urine should be reported because ketonuria may be a sign of excessive weight loss, dehydration, or electrolyte imbalance. Ketonuria is commonly secondary to nausea and vomiting of pregnancy  If the urine is cloudy and bacteria or leukocytes are present (> 4 leukocytes per high- powered field), a urine culture is performed  The presence of bilirubin is indicative of liver or gallbladder disease or breakdown of RBCs  The presence of blood in the urine (hematuria) is suggestive of UTI, kidney disease, or vaginal contaminationBlood  Determination of hematocrit and hemoglobin levels and description of the morphology of the RBCs are done to find evidence of anemias, such as sickle cell or Mediterranean anemia  Hemoglobin levels average 12 to 16 g/dL  Blood type, Rh factor, and antibody screen: if the woman is found to be Rh negative or to have a positive antibody screen, her partner is screened and a maternal antibody titer is drawn as indicated o Coombs test - retested at 28 weeks in the Rh-negative woman for detection of antibodies. o RhO(D) immune globulin (RhoGAM) given at 28 weeks as indicated. Also administered following chorionic villus sampling (CVS), percutaneous umbilical sampling (PUBS), amniocentesis, trauma or placental separation (abruptio placentae or placenta previa) o Given within 72 hours of birth of RhO(D) mom or Du- and without antibodies and neonate is Rh1(D) or Du+ with a negative Coombs test  Glucose- diabetic screening for women who are at average risk conducted at 24 to 28 weeks using a 1-hour 50-g glucose load test. According to the American Diabetes Association, average risk includes: age 25 or older; obese women of any age; family history of diabetes mellitus in a first-degree relative; member of an ethnic group with a high prevalence of diabetes (Hispanic, Black, Native American, Asian-American); history of abnormal glucose tolerance; history of poor obstetric outcome  Alpha-fetoprotein (AFP) - done at 15 to 18 weeks. High maternal levels may indicate an open neural tube defect in the fetus; low levels have been associated with Down syndrome. Inaccurate pregnancy dating is the most common cause for an abnormal AFPInfection 5|Page
  6. 6.  Venereal Disease Research Lab (VDRL) test or Fluorescent Treponemal Antibody Absorption Test for syphilis is done on the initial visit; repeat VDRL at 32 weeks as indicated  Gonorrhea - cervical cultures are usually done at the initial visit and when symptoms are present  Herpes - all visible lesions are cultured, and the cervix is cultured weekly beginning 4 to 8 weeks before delivery  Chlamydia - done at the initial visit and when symptoms are present  Rubella titer - if nonimmune, less than 1:8, immunize postpartum  Hepatitis B surface antigen  HIV - screen is done on high-risk womenOther Tests  Toxoplasmosis - done as indicated for women at risk  Tuberculin skin tests - done as indicated  Papanicolaou (Pap) smear - done unless recent results available  Maternal serum alpha-fetoprotein (MS-AFP) - done to detect open neural tube defects or open abdominal wall defects; offered to all women and usually drawn between 16 and 18 weeks gestation  Sickle cell screen - done to detect presence of sickle hemoglobin in at-risk women.  Group B beta streptococcus (cervical and pharyngeal swabs) - done to detect carriers or active group B beta streptococcusPHYSICAL ASSESSMENTGeneral Examination  The woman is asked to empty her bladder before the examination to enhance her comfort and to facilitate palpation of her uterus and pelvic organs during the vaginal examination  Evaluation of the womans weight and blood pressure.  Examination of the eyes, ears, and nose - nasal congestion during pregnancy may occur as a result of peripheral vasodilatation  Examination of the mouth, teeth, throat, and thyroid - the gums may be hyperemic and softened because of increased progesterone  Inspection of breasts and nipples - the breasts may be enlarged and tender; nipple and areolar pigment may be darkened  Auscultation of the heart  Auscultation and percussion of the lungsAbdominal Examination  Examination for scars or striations, diastasis (separation of the rectus muscle), or umbilical hernia  Palpation of the abdomen for height of the fundus (palpable after 13 weeks of pregnancy); measurement recorded and used as guideline for subsequent calculations  Palpation of the abdomen for fetal outline and position (Leopolds maneuvers) - third trimester  Check of FHTs - FHTs are audible with a Doppler after 10 to 12 weeks and at 18 to 20 weeks with a fetoscope  Record fetal position, presentation, and FHTsPelvic Examination  The woman is placed in lithotomy position  Inspection of external genitalia  Vaginal examination - done to rule out abnormalities of the birth canal and to obtain cytologic smear (Pap and, if indicated, smears for gonorrhea, vaginal trichomoniasis, candidiasis, herpes, group B beta streptococcus, and chlamydia)  Examination of the cervix for position, size, mobility, and consistency. Cervix is softened and bluish (increased vascularity) during pregnancy  Identification of the ovaries (size, shape, and position)  Rectovaginal exploration to identify hemorrhoids, fissures, herniation, or masses  Evaluation of pelvic inlet - anteroposterior diameter by measuring the diagonal conjugate  Evaluation of midpelvis - prominence of the ischial spines 6|Page
  7. 7.  Evaluation of pelvic outlet - distance between ischial tuberosities and mobility of coccyxSubsequent Prenatal Assessments  Uterine growth and estimated fetal growth o Fundus at symphysis pubis indicates 12 weeks gestation o Fundus at umbilicus indicates 20 weeks gestation o Fundal height corresponds with gestational age between 22 and 34 weeks o Fundus at lower border of rib cage indicates 36 weeks gestation o Uterus becomes globular, and drop indicates 40 weeks gestation  A greater fundal height suggests: o Multiple pregnancy o Miscalculated due date o Polyhydramnios (excessive amniotic fluid) o Hydatidiform mole (degeneration of villi into grapelike clusters; fetus does not usually develop) o Uterine fibroids  A lesser fundal height suggests: o Intrauterine fetal growth restriction o Error in estimating gestation o Fetal or amniotic fluid abnormalities o Intrauterine fetal death o SGA  FHTs - palpate abdomen for fetal position o Normal - 110 to 160 beats per minute (bpm)  Weight - major increase in weight occurs during second half of pregnancy; usually between 0.5 lb (0.2 kg)/week and 1 lb (0.5 kg)/week. Greater weight gain may indicate fluid retention and hypertensive disorder  Blood pressure - should remain near womans prepregnant baseline  Complete blood count at 28 and 32 weeks gestation; VDRL - rechecked at 36 to 40 weeks gestation  Antibody serology screen if Rh negative at 36 weeks gestation  Culture smears for gonorrhea, chlamydia, group B beta-hemolytic streptococcus, and herpes, as indicated; usually at 36 and 40 weeks gestation  Urinalysis - for protein, glucose, blood, and nitrates  AFP - done at 15 to 20 weeks  Diabetic screening - done as indicated at 24 to 28 weeks  Administer RhoGAM as indicated at 28 weeks  Edema - check the lower legs, face, and hands  Evaluate discomforts of pregnancy - fatigue, heartburn, hemorrhoids, constipation, and backache  Evaluate eating and sleeping patterns, general adjustment and coping with the pregnancy  Evaluate concerns of the woman and her family  Evaluate preparation for labor, delivery, and parentingIV. Promoting Fetal and Maternal Health A. Describe health practices important for a positive pregnancy outcome.PATIENT EDUCATION GUIDELINESPrenatal Care  It is important to keep scheduled prenatal care appointments: o Weeks 1-28: Every month o Weeks 28-36: Every 2 weeks o Weeks 36-delivery: Every week  Expect the following discomforts of pregnancy, and speak with your nurse or health care provider about strategies for relief: o Back pain, leg cramps, breast tenderness o Morning sickness, heartburn 7|Page
  8. 8. o Frequent urination o Constipation o Swelling of legs, varicose veins o Fatigue  Follow a healthy, balanced diet with three meals per day, and take prenatal vitamin as directed by your health care provider  Get regular exercise, and use proper body mechanics to avoid injury  Be aware of danger symptoms of pregnancy; these must be reported to your health care provider promptly: o Vision disturbances - blurring, spots, or double vision o Vaginal bleeding, new or old blood o Edema of the face, fingers, and sacrum o Headaches - frequent, severe, or continuous o Fluid discharge from vagina; unusual or severe abdominal pain o Chills, fever, or burning on urination o Epigastric pain (severe stomach ache) o Muscular irritability or convulsions o Inability to tolerate food or liquids, leading to severe nausea and hyperemesis B. Utilize the nursing process to address the concerns and potentially harmful health practices of a woman during pregnancy.HEALTH EDUCATION AND INTERVENTIONNursing Diagnoses  Acute Pain (backache, leg cramps, breast tenderness) related to physiologic changes of pregnancy  Imbalanced Nutrition: Less Than Body Requirements related to morning sickness and heartburn and lack of knowledge of requirements in pregnancy  Impaired Urinary Elimination (frequency) related to increased pressure from the uterus  Constipation related to physiologic changes of pregnancy and pressure from the uterus  Impaired Tissue Integrity related to pressure from the uterus and increased blood volume  Anxiety or Fear related to the birth process and infant care  Ineffective Role Performance related to the demands of pregnancy  Activity Intolerance related to physiologic changes of pregnancy and enlarging uterusNursing InterventionsMinimizing Pain  Teach the woman to use good body mechanics: wear comfortable, low-heeled shoes with good arch support; try the use of a maternity girdle.  Instruct the woman in the technique for pelvic rocking exercises.  Encourage the woman to take rest periods with her legs elevated.  Inform the woman that adequate calcium intake may decrease leg cramps.  Instruct the woman to dorsiflex the foot while applying pressure to the knee to straighten the leg for immediate relief of leg cramps.  Instruct the woman to wear a fitted, supportive brassiere.  Instruct the woman to wash her breasts and nipples with water only.  Instruct the woman to apply vitamin E or lanolin cream to the breast and nipple area. Lanolin is contraindicated for women with allergies to lambs wool.Minimizing Morning Sickness and Heartburn and Maintaining Adequate Nutrition  Encourage the woman to eat low-fat protein foods and dry carbohydrates, such as toast and crackers.  Encourage the woman to eat small, frequent meals.  Advise the woman to eat slowly.  Instruct the woman to avoid brushing her teeth soon after eating.  Instruct the woman to get out of bed slowly. 8|Page
  9. 9.  Encourage the woman to drink soups and liquids between meals to avoid stomach distention and dehydration.  Instruct the woman in the use of antacids; caution against the use of sodium bicarbonate because it results in the absorption of excess sodium and fluid retention.  Instruct the woman to avoid offensive foods or cooking odors that may trigger nausea.  Encourage the woman to eat a few bites of soda cracker or dry toast before getting out of bed in the morning.  Teach the woman the importance of good nutrition for herself and her fetus. Review the basic food groups with appropriate daily servings. o Seven servings of protein-rich foods, including one serving of a vegetable protein o Three servings of dairy products or other calcium-rich foods o Seven servings of grain products o Two or more servings of vitamin C-rich vegetable or fruit o Three servings of other fruits and vegetables o Three servings of unsaturated fats o Two or more servings of other fruits and vegetables  If the woman is a vegetarian, inform her of appropriate intake. Assess type of vegetarian and food intake. o Partial vegetarians may exclude a specific type of animal food, usually meat, but may consume fish and poultry. o Recommend iron and folic acid supplements.  Inform the woman that average weight gain in pregnancy is 25 to 35 lb (11 to 16 kg). About 2 to 5 lb (0.9 to 2.3 kg) are gained in the first trimester and about 1 lb (0.5 kg) per week for the remainder of the gestation. o Average weight gain for obese women is 15 lb (6.8 kg). o Adolescent weight gain should be about 5 lb more than for adult women if within 2 years of starting menses. o Women with a multiple pregnancy should gain between 35 and 45 lb (15.9 and 20.5 kg). o Average weight gain for underweight women is 28 to 40 lb (12.7 to 18.1 kg).  Advise the woman to limit the use of caffeine.  Inform the woman that alcohol should be limited or eliminated during pregnancy; no safe level of intake has been established.  Inform the woman that smoking should be eliminated or severely reduced during pregnancy; risk of spontaneous abortion, fetal death, low birth weight, and neonatal death increases with increased levels of maternal smoking.  Inform the woman that ingesting any drug during pregnancy may affect fetal growth and should be discussed with her health care provider.Minimizing Urinary Frequency and Promoting Elimination  Instruct the woman to limit fluid intake in the evening.  Instruct the woman to void before going to bed.  Encourage the woman to void after meals.  Encourage the woman to void when she feels the urge and after sexual intercourse.  Encourage the woman to wear loose-fitting cotton underwear.  Cranberry or blueberry juice may be recommended to help prevent UTIs. Caffeine should be avoided.Avoiding Constipation  Instruct the woman to increase fluid intake to at least eight glasses of water per day. One to two quarts of fluid per day is desirable.  Teach the woman that foods high in fiber should be eaten daily.  Encourage the woman to establish regular patterns of elimination.  Encourage daily exercise such as walking.  Inform the woman that OTC laxatives should be avoided and that bulk-forming agents may be prescribed if indicated.Maintaining Tissue Integrity  Encourage the woman to take frequent rest periods with her legs elevated.  Instruct the woman to wear support stockings and wear loose-fitting clothing for leg varicosities. 9|Page
  10. 10.  Instruct the woman to rest periodically with a small pillow under the buttocks to elevate the pelvis for vulvar varicosities.  Instruct the woman to avoid constipation, apply cold compresses, take sitz baths, and use topical anesthetics, such as Tucks, for the relief of anal varicosities (hemorrhoids).  Provide reassurance that varicosities will totally or greatly resolve after delivery.Reducing Anxiety and Fear and Promoting Preparation for Labor, Delivery, and Parenthood  Encourage the woman or couple to discuss their knowledge, perceptions, cultural values, and expectations of the labor and delivery process.  Provide information on childbirth education classes, and encourage them to attend.  Provide information on sibling and grandparent preparation as indicated.  Encourage a tour of the birth facility.  Discuss coping and pain control techniques for labor and birth.  Inform the woman or couple of common procedures during labor and birth.  Provide guidelines for coming to the birth facility.  Encourage the woman or couple to discuss their perceptions and expectations of parenthood and their “idealized child”.  Discuss the infants sleeping, eating, activity, and response patterns for the first month of life.  Discuss physical preparations for the infant, such as a sleeping space, clothing, feeding, changing, and bathing equipment.  Discuss plans for returning to work and childcare arrangements.  Discuss the importance of planning time for themselves and each other apart from the newborn.  Provide information and encourage attendance at baby care, breast-feeding, and parenting classes.  Answer any questions the woman/couple may have.Enhancing Role Changes  Encourage discussion of feelings and concerns regarding the new role of mother and father.  Provide emotional support to the woman/couple regarding the altered family role.  Discuss physiologic causes for changes in sexual relationships, such as fatigue, loss of interest, and discomfort from advancing pregnancy. Some women experience heightened sexual activity during the second trimester.  Teach the woman or couple that there are no contraindications to intercourse or masturbation to orgasm provided the womans membranes are intact, there is no vaginal bleeding, and she has no current problems or history of premature labor.  Teach the woman or couple that female superior or side-lying positions are usually more comfortable in the latter half of pregnancy.Minimizing Fatigue  Teach the woman reasons for fatigue, and have her plan a schedule for adequate rest. o Fatigue in the first trimester is due to increased progesterone and its effects on the sleep center. o Fatigue in the third trimester is due mainly to carrying increased weight of the pregnancy. o About 8 hours of rest are needed at night. o Inability to sleep may be due to excessive fatigue during the day. o In the latter months of pregnancy, sleeping on the side with a small pillow under the abdomen may enhance comfort. o Frequent 15- to 30-minute rest periods during the day are important to avoid overfatigue. o Whenever possible, the woman should work while sitting with her legs elevated. o The woman should avoid standing for prolonged periods, especially during the third trimester.  To promote placental perfusion, the woman should not lie flat on her back: left lateral position provides the best placental perfusion; however, either side is acceptable.  Help the woman plan for adequate exercise. o In general, exercise during pregnancy should be in keeping with the womans prepregnancy pattern and type of exercise. 10 | P a g e
  11. 11. o Activities or sports that have a risk of bodily harm (skiing, snowmobiling, ice- skating, inline skating, horseback riding) should be avoided. o During pregnancy, endurance during exercise may be decreased. o Exercise classes for pregnant women that concentrate on toning and stretching have resulted in enhanced physical condition, increased self-esteem, and greater social support as a result of being in the exercise group.Evaluation: Expected Outcomes  Verbalizes understanding of proper body mechanics and wears low-heeled shoes  Identifies the basic food groups and describes meals to include needed servings for pregnancy  Reports limited fluid intake in the evening  Describes foods high in fiber  Wears support stockings and loose-fitting clothing  Discusses expectations for labor, delivery, and parenthood and attends educational classes  Verbalizes an understanding of the physiologic causes that may change the sexual relationship  Reports engaging in regular exercise C. Discuss the categories of potential terratogens. Terratogens are any drug, virus or irradiation, the exposure to such may cause damageto the fetus. A wide range of different chemicals and environmental factors are suspected or areknown to be teratogenic in humans.Drugs and medications:  Tobacco, caffeine, drinking alcohol (ethanol), coccaine, isotretinoin, temazepam, nitrazepam, nimetazepam, amino pterin or methotrexate, androgenic hormones, busulfan, captopril, enalapril, coumadin, cyclosphamide, diethylstilbestrol, phenytoin, etretinate, lithium, methimazole, penicillamine, tetracyclines, thalidomide, trimethadione, methoxyethyl esthers, flusilazole, valproic acid, streptomycin, quinine, Vitamin K, iodides, steroidsEnvironmental chemicals:  Polychlorinated biphenyls (PCBs), polychlorinated dibenzodioxins (dioxin), polychlorinated dibenzofurans (PCDFs), hexachlorobenzene, organic mercury, ethidium bromideIonizing radiation:  Atomic weapons fallout (Iodine-131, uranium), background radiation, diagnostic x-rays, radiation therapyInfections:  Cytomegalovirus, herpes virus, parvovirus B19, rubella virus (German measles), syphilis, toxoplasmosis, Venezuelan equine encephalitis virus  TORCH: Toxoplasmosis, Other agents, Rubella, Cytomegalovirus, Herpes simplex virus.  Group of infections caused by organisms that can cross the placenta or ascend through the birth canal and adversely affect fetal growth and developmentMetabolic imbalance:  Alcoholism, endemic cretinism, diabetes, folic acid deficiency, iodine deficiency, hyperthermia, phenylketonuria, rheumatic disease, congenital heart block, virilising tumors D. Make a teaching plan for working women that addresses their needs and problems. Nurses specializing in obstetrics understand the importance of ensuring a healthymother and a healthy baby. In order to design a tailored pregnancy nursing care plan, it is 11 | P a g e
  12. 12. necessary to have a baseline of the pregnant or post-partum patients condition, whether that behemorrhage, preeclampsia or ectopic pregnancy, to name a few. An effective nursing care planfor pregnancy patients should include assessment, promoting autonomy and patient teaching.Assessment Assessment, the first element in the nursing process, is what nurses use to establishbaseline information for patients. This begins with a thorough head-to-toe overview. Assess thepatients head and neck, noting any enlarged lymph nodes, thyroid or other abnormalities.Moving down, check the patients heart rate and breathing, and report any signs of shortness ofbreath. Also document the patients fundal height and fetal assessment. Pay special attention toany edema in the extremities or subjective reports of pain in the calves. Laboratory results arealso reviewed and documented.Promoting Autonomy As the pregnant patient watches their body change, she may begin to feel at a loss ofcontrol of her body or well-being. A pregnancy nursing care plan acknowledges and respectsthose feelings, while focusing on promoting patient autonomy. Interventions that the patient canperform for themselves should be included in the nursing care plan. For example, if a particulargoal on the nursing care plan states that the patient will be free of nausea and vomiting by theirthird trimester, a patient intervention might include avoiding areas with strong or offensivesmells and eating crackers. This allows the patient to feel proactive and more involved in theirown health care maintenance.Patient Education Pregnancy nursing care plans most often include patient education listed as a goal andas a nursing intervention. Teaching the pregnant patient how to recognize normal and abnormalsymptoms in her body provides an extra line of defense against fetal health risks that mightotherwise go unnoticed or addressed too late. It also helps mothers-to-be feel more comfortableabout the birthing process and post-partum life. This may include information about proper diet,the risks and benefits of medications and activities that should be avoided during pregnancy andimmediately post-partum. Patient teaching also should include information on birthing options,breastfeeding and bottle feeding. 12 | P a g e

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